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SSTIs (Diabetic Foot Infections (Classify Severity (Moderate: local…
SSTIs
Diabetic Foot Infections
Suspect ulcer is infected if 2 or more are present: local swelling or induration, erythema, local tenderness or pain, local, warmth, purulent discharge
Classify Severity
Moderate: local infection with erythema >2cm or infection involving deeper tissues
Severe: local infection with 2 or more systemic signs of infection
Mild: local infection; erythema 0.5-2cm around ulcer
PEDIS = perfusion, extent (size), depth (tissue loss), infection, sensation (neuropathy)
Risk Factors for...
MRSA: MRSA infection or colonization within past year; suspect if local prevalence is high; severe infection
Gram negative Enterobactericaea (ESBLs): prior abx in last month; suspect if local prevalence is high
Pseudomonas: warm climate; frequent exposure of feet to water; failed non-pseudo therapy; severe infection
Treatment
Moderate: Risk for MRSA, Psedo, or Gram Neg? If no, MSSA PO/IV Rx for 1-3 weeks. If yes, see severe.
Severe: Broad spectrum MRSA and Gram neg coverage for 2-4 weeks
Mild: Risk for MRSA? If no, MSSA Oral Rx. If yes, MRSA Oral Rx for 1-2 weeks
Nonpurulent SSTIs
Examples
Erysipelas
superficial infection w/ lymphatic involvement; red, shiny, well-demarcated; lower extremities and face more commonly; abrupt onset (~2days)
Likely pathogens: Group A Streptococcus (GAS), Streptococcus pyogenes; "Don't SIP the GAS"
Cellulitis
skin is red, hot, diffuse, and painful; can exist alone or surround areas of pus; recognize and treat early
Likely pathogens: Streptococcus or S. aureus
Necrotizing Fasciitis
life-threatening; massive and rapid tissue destruction; severe pain disproportionate to clinical findings; fever, systemic toxicity (altered mental status); wooden hard induration; crepitus (gas in tissue); skin necrosis
Likely pathogens: Type 1 = Poly-microbial form, mixed anaerobic and facultative (gram negatives, clostridial spp.), diabetic, elderly; Type 2 = Mono-microbial form, S. pyogenes, S. aureus, "flesh eating disease"
Requires emergent and aggressive surgical debridement and administration of systemic antibiotics; work up with MRI; IV tx including anaerobes add Clindamycin for toxin binding effect if suspecting GAS
Classification of Severity (NP)
Mild
typical cases of cellulitis w/o systemic signs of infection
treat with Oral Abx
Moderate
typical cellulitis/erysipelas WITH systemic signs of infection
treat with IF Abx
Severe
ptns who have FAILED oral abx tx or those WITH systemic signs of infection, immunocompromised, or those with clinical signs of deeper infection, hypotension, or evidence of organ dysfunction
treat with surgical eval and debridement
Treatment Options
Mild
ORAL Rx: Penicillin VK, Cephalosporin, Dicloxacillin, or Clindamycin
Moderate
IV Rx: Penicillin, Ceftriaxone, Cefazolin, or Clindamycin
Severe
emergent Surgical Inspection/Debridement: Rule out necrotizing process; EMPIRIC Rx: Vancomycin AND Pip/tazo
After Culture and Sensitivity:
Defined Rx (necrotizing infections)
Monomicrobial:
S. pyogenes = Penicillin AND Clindamycin; Clostridial = Penicillin AND Clindamycin;
Vibrio = Doxycycline AND Ceftazidime
A. hydrophilia = Doxycycline AND Ciprofloxacin
Polymicrobial: Vancomycin AND Pip/Tazo
"No MOre SEEDy MOVies"
Purulent SSTIs
Examples
Impetigo
pustules and honey-colored crusted lesions; HIGHLY contagious; more common in children 2 to 5 yo; more common on face and extremities
Likely pathogen: S. aureus
Furuncles & Carbuncles
Furuncles: can occur anywhere on hairy skin; usually discrete lesions; start as firm, red, tender nodule that becomes painful; lesions often drain (bullous ones called "boils")
Carbuncles: collection of "boils," painful, swollen; commonly on back of neck; associated with mild chills, fever, and malaise
Likely pathogen: S. aureus
Abscess
general collection of pus in deep layers; tender mass with pointed region, with erythema and edema; mistaken as spider bite; systemic symptoms like fever, chills, malaise; possible lymphatic spread through bloodstream
Likely pathogen: S. aureus; MRSA
Classification of Severity
Moderate
purulent SSTI WITH systemic signs of infection
Incision and Drainage; Culture and Susceptibility
Severe
SSTI that FAILED I&D plus antibiotic tx or those with 2 or more systemic signs of infection
Incision and Drainage; Culture and Susceptibility
Mild
purulent SSTI w/o systemic signs of infection
Incision and Drainage
Treatment:
Incision and Drainage is the PRIMARY tx
Mild: Incision and Drainage
Moderate: Incision and Drainage; Culture and Sensitivity
Empiric Rx: TMP/SMX or Doxycycline; (neither cover Strep, so add Cephalexin if needed)
Defined Rx: MRSA = TMP/SMX; MSSA = Dicloxacillin or Cephalexin
Severe: Incision and Drainage; Culture and Sensitivity
Empiric Rx: Vancomycin, Daptomycin, Linezolid, Televancin, or Ceftaroline
Defined Rx: MRSA = see Empiric; MSSA = Nafcillin, Cefazolin, or Clindamycin
"MR. San Antonio (MRSA) severely needs a Va(n)cay."
Systemic signs of infection:
temperature > 38 C;
tachycardia (HR > 90);
tachypnea (RR > 24); or
abnormal WBC ( >12,000 or < 400)