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Skin Lesions (OM :meat_on_bone:
Path: infx of bone
hematogenous
or…
Skin Lesions
OM :meat_on_bone:
Path: infx of bone
- hematogenous
- or direct inoculation :hocho:
- penetrating injury to bone
non-toxic: have time to get biopsy
toxic: give Abx, culture will be contaminated
Cellulitis
Path: infx of skin/SubQ
Pt: Red, Hot, Tender skin
- well demarcated (usually)
- site of entry
Dx: completely clinical
Cx
- swabbing skin is not a specific test (polymicrobial)
Tx: Nontoxic
Step 1. treat Strep:
- 1st gen cephalosporin (cheap, PO :pill:)
Step 2. treat Staph:
- TMP-SMX or Clinda (PO :pill:)
Toxic (sepsis) :biohazard_sign:
Strep:
- use Pip/Tazo (Zosyn) ; Amp/Clav (Unisyn)?
- OK, but don't get Staph coverage also
- overkill
Step 3. outpatient failure… Staph:
- IV Vanc, Linezolid, Clinda
- transition to PO :pill: w/ improvement
- :pencil2:Clinda > Vanc for step/shelf
f/u:
- Diabetic Ulcer :candy:
- Start broad spectrum initially
- Big guns: Pip/Tazo and Vanc
- OM r/o :meat_on_bone:
- the person who fails to improve
Left: area of redness around puncture site.
- Staph likes to burrow (Abscess :volcano:)
- Strep likes to spread (no abscess)
Right: there should be a recession after Abx :pill:
- failure? Wrong Abx
- Mark the ring around cellulitis
- 5 hours later…ring of erythema retreats from the marker line
Pt:
- Wound (no other Dx step)
- can probe the bone w/ a stick
- sinus draining tract
- Recurrent/refractory Cellulitis (need more Dx steps)
- cellulitis failure
- cellulitis w/ bone px
Dx:
- XR
- XR are usually not (+) before 2 weeks
- bony changes should be seen later
- MRI
- :stars:Best radiographic test
Tagged WBC scan
Bone scan
- see inflammation activity in bone
- so long as no superficial inflammation (cellulitis)
- get if, suspicion for OM, and no overlying soft tissue inflammation
- this is rarely a good answer
- Biopsy:debridement/punch biopsy
- :stars::stars:Absolute best test
- growing Cx on dead bone :skull_and_crossbones:
Tx: Debridement
- w/ 4-6wk Abx (long time)
- tailor Abx to the biopsy (sensitivities/mics)
-
Vanc&Pip/Tazo is too broad
F/u: ESR & CRP
- fall to normal = :checkered_flag:
- eventually want to switch to PO :pill:
-
- Deeper than skin: Cellulitis, OM, & life-threatening
-
Fungus, Lice (dermatology)
Infection Associations
- OM = S. Aureus (any clinical setting)
- w/ SCD = Salmonella :fish:
- w/ penetrating wound or sneakers :athletic_shoe: = Pseudomonas :bath::skin-tone-2:
- diabetic foot :candy: = polymicrobial
- cover Abx for pseudomonas :bath::skin-tone-2:
- here its ok to give Vanc & Pip/Tazo
- w/ Oysters or Cirrhosis = Vibrio Vulnificus
- this kills people
- cirrhotics should avoid raw oysters
- Gardening = Sporothrix