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Skin and soft tissue infections
study guide exam 2
50
Pharmacology
Graduate
02/23/2012

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Cards

Term
Normal flora of the skin?
Definition

Gram positive basteria:

Staphylococci (S. epidermis, S.aurus)

Streptococci (grp A,B,C,& G), S. pyogenes 

corynobacterium, other diphteroids

propionobacterium (acne)

Fungi:

Malassezia sp

Candida sp 

 

 

Term
What is a common pathogen in SSTI?
Definition
S. Pyogenes 
Term
What is Cellulitis?
Definition

Acute inflamation of the skin and subcutaneous fat.

typically a diffuse, spreading skin infection, most commonly affects extremeties (70%)

Term
Cellulitis is usually confused with what?
Definition
erysipela 
Term
What are the causative organism of Cellulitis?
Definition

Gram +:

grp A Streptococci (S. Pyogenes (most common)

S. Aurus (MSSA)

MRSA (CA & HA) (usually associated w/ purulent cellulitis)

Gram -:

E.Coli 

P. aeruginosa

Klebsiella pneumoniae

Exposure to lake or ocean water (pt hx):

Aeromonas hydrophilia & vibrio vulnificus 

Term
How does a CA MRSA looks like?
Definition

Spider bite 

characterized by necrotic centers 

Term
What is folliculitis?
Definition

Inflammation of hair follicules, superficial infection involved only in the dermis 

itchy red papules appear ~ 48 hrs after exposure 

Evolves into pustules that generally heals without tx in several days 

Systemic symptoms uncomon 

Term
What are furuncles?
Definition

Abscess or boil 

walled of pocket of pus from a hair follicle 

involves deeper layers of skin 

occur (in area of friction perspiration) as single or multiple nodules 

Gradually become red, firm and painful 

Drain by themselves 

Term

What are carbuncles?

 

Definition

Multiple furincles unite into one big mass

Extended into subcutaneous tissues

Masses draines through many sinus tracts

Common in back of neck in diabetics

systemic symptoms often present (chills, fever, malaise)

spread to other tissues/bacteremia (causes serious concern)

Term
What is the most common cause of folliculitis, furuncles and carbuncles?
Definition
S. Aureus
Term
How we treat folliculitis/small furuncles?
Definition
use moist heat to promote drainage 
Term
How we treat large furuncles/all cabuncles/abscesses?
Definition

Incision & drainage 

PO abx not necessary except:

Extensive surrounding cellulitis

Fever

Term
What are local findins for Cellulitis?
Definition

Macular erythema 

Generalized swelling

Warm to the touch 

Tenderness

Tender, regional lymphadenopathy 

Lymphagitis (sometimes)

Abscess (sometimes)

Yellow indicates severe cellulitis 

Term
What are systemic findings for cellulitis?
Definition

Fever, chills

Hypothermia

Increase WBC

Tachycardia

Hypotension

Confusion in elderly 

Septic shock

Term
Mild Cellulitis?
Definition
No evidence of significant infction, no significant comorbidities, uncomplicated 
Term
Moderate cellulitis?
Definition
Evidence of infection, systemic signs limited to fever/increase WBC or infection somewhat localized
Term
Severe cellulitis?
Definition
Diffuse infection, several systemic symptoms, significant comorbidities 
Term
What laboratory values needed for systemic symtpoms?
Definition

CBC w/ differential

C-reactive protein

Creatinine

Bicarbonate

Creatinine phosphokinase

Blood cultures (+<5%)

culture/punch biopsies (5-40% +)

Drug susceptibility 

Term
What are complications associated with cellulitis?
Definition

Osteomyelitis (w/ or w/o amputation)

Bacteremia, sepsis 

Term
Treatment of mild cellulitis?
Definition

Clean site (soap/H2O), irrigate, remove foreign bodies 

No abx needed unless immunocompromises or DM patients use Topical abx:

- Mupirocin (bactroban)

- Neomycin/polymixin/bacitracin (Neosporin)

(weaker activity against S. aureus) (toxic if applied to open wound) 

- Clindamycin, erythromycin or benzoyl peroxide 

Term
Treatment moderate cellulitis?
Definition

Cover S.pyogenes, S. aureus (MSSA):

- Dicloxacillin 

- Cephalexin 

if IV needed: 

- Nafcillin

- Cefazolin 

If PCN allergic:

- Clindamycin, vancomycin, TMP-SMZ

Treat for 5-10 days 

Term
Treatment for CA-MRSA?
Definition

TMP-SMX

Doxycycline

Minocycline

Linezolid

Clindamycin 

Duration: 7-14 days 

Term
What test is used to show resistance to clindamycin?
Definition

D-test uses for MRSA clindamycin resistanceif Positive= MRSA resistant to Clinda 

Negative= MRSA susceptible to Clinda 

Term
Treatment for severe cellulitis?
Definition

IV required:

Coverage for S. pyogenes, MSSA:

- Nafcillin 

- Cefzolin 

Is PCN allergic: Clindamycin, Vancomycin

Duration: 7-10 days 

Term
Therapy for severe MRSA SSTI?
Definition

Vancomycin (dosed based on renal fct)

Linezolid

Daptomycin

Telavancin

Clindamycin

Duration: 7-14 days 

Term
What are 2nd/3rd line alternatives w/ MRSA?
Definition

- Tigecycline (Tygacil)

- Quinupristin-dalfopristin (synercid)

- Rifampin-not used monotherapy

Term
For moderate/ severe treatment when to convert to PO?
Definition
when afebrile for > 4-5 days, then 10-14 d therapy w/ PO 
Term
Waht does lack of response to therapy indicates?
Definition

- Misdiagnosis

-Abx resistance

-Non-adherence

-Subtherapeutic doses

Term
Special populations treatment?
Definition

IV drug abuser:

Add S. epidermis, P,aeruginosa to causative organisms (if severe)

Abx resistance (MRSA)

Immunocomprimised:

more aggressive tx, may treat longer than 10 d

must consider fungi, viral, atypicals

Term
What therapy is not recommended when MRSA decolonization?
Definition
PO antimicrobial therapy 
Term
Tx for decolonization? 
Definition
Nasal decolonization with mupirocin BID for 5–10 days
Nasal decolonization with mupirocin BID for 5– 10 days & a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths
For dilute bleach baths, 1 tsp per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered
Term
What causes Erysipelas?
Definition
Grp A strep (S. pyogenes)
Term
What distinguish erysipelas from cellulitis?
Definition
Characteristic lesion is raised and clearly dermacated 
Term
Treatment of erysipelas?
Definition

PCN drug of choice

Mild-moderate:

-Procaine PCN G

-PCN VK

PCN allergy:

-Clinda

-Erythromycin

Duration: 7-10 days 

Severe: need hospitalization use aqueous PCN G

Term

What causes impetigo?

Superficial infection

Definition

S. pyogenes/ S.aureus 

Itchy, purulent discharge; dries to golden yellow crusts 

Term

Treatment of impetigo?

 

Definition

Mild: topical mupirocin

numerous lesion/lack of response to topical: PO

-Dicloxacillin

-1st gen cephalosporin

- PCN VK (S.pyogenes)

PCN allergic:

-Clindamycin

Duration: 7-10 d (7 d clinical response)

Term
Necrotizing fasciitis presents like cellulitis except?
Definition
Severe, constant pain, bullae, skin necrosis, gas in soft tissues, edema extending beyond margin, systemic symptoms (fever, increase WBC, delirium, renal failure), rapid spread despite abx 
Term
What cause type 1 poly-microbial necrotizing fasciitis?
Definition

Bacteria:5 organisms at same time common

Gram -, anaerobes (clostridia bacteroides), enterococcus

Assosiated w/:

-abdominal surgery

-Decubitis ulcers

-IV drug use

-Bartholin abscess 

Term

What causes type 2 mono-microbial necrotizing fasciitis?

 

Definition

Bacteria: S.pyogenes, S. aureus (& MRSA), V. vulnificus, A.hydrophilia, anaerobic strep sp, clostridia sp (rare)

Associated w/:

DM, ASCVD, PVD

Term
Treamtent of necrotizing fasciitis?
Definition

Surgery: aggressive surgical exploration/dbridement required

Abx: type1: coverage for anaerobes, S.aureus/S.pyogenes, G-

Type 2: coverage for S.pyogenes/S.aureus, clostridia if gas present

Hemodynamic support: shock tx, etc..

Term
When Hyperbaric oxygen is used?
Definition
Mostly w/ clostridial myonecrosis 
Term
Bite wounds: cat causative organisms?
Definition

Pasteurella multocida (G-) (75%)

S. Aureus/S.yogenes (G+)(40%)

Anaerobes (A) (65%)

Term
Dog causative organisms?
Definition

Pasteurella multocida (G-) (50%)

S.aureus/S.pyogenes (G+) (40%)

Anaerobes (A) (50%)

Term
Human bite causative organisms?
Definition

Viridans Strep (G+) (100%)

Bacteroides sp (G- A)(82%)

S.epidermidis (G+) (53%)

Corynebacterium (G+)(41%)

S.aureus (G+)(29%)

Peptostreptococcus (G+A)(26%)

Eikenella (G-A)(15%)

Term
Treat bite with abx when?
Definition

Wound involves hand/near joint

Deep puncture (cat)/difficult to irrigate

Immuno compromised 

tetanus prophylaxis may be needed 

Consider rabies if in area/unprovoked attack by wild animal 

Term
Drug of choice (cat/dog bite wounds)?
Definition

Amoxicillin/clavulanic acid 875/125 mg BID * 5-10d

PCN allergy:

Doxycycline (not if <8yo)

SMX-TMP

+ Clindamycin

for 5- 10 d

Term
Drug of choice Human bite?
Definition

Augmentin 875/125 mg BID * 5-10 d

if PCN allergic:

Clindamycin + SMX/TMP * 5-10 d 

If severe infection at presentation, then IV may be required 

Term
What are complications of bite wounds?
Definition
Septic arthritis, osteomyelitis, subcutaneous abscess, tendonitis, bacteremia (rare), tetanus, rabies (rare, but life threatening)
Term
What causes tetanus?
Definition

Clostridium tetani (G+ anearobe)

vaccine immunizes against exotoxin C. tetani 

Term
Which wounds are most at risk for tetanus?
Definition
> 6 hrs old, > 1cm deep, contain devitalized tissue, contaminated w/ dirt, saliva, etc... injury d/t crush, burn, frosbite, puncture 
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