Skin & Soft Tissue Infections

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Cellulitis Facts

Acute spreading "nonnecrotizing infection affecting the dermis and subcutaneous tissue but does not involve the deep fascia or muscles. May mimic DVT. Often associated with fever, chills, and leukocytosis.

Cellulitis pathogens

Streptococcus pyogenes and/or S. aureus.
Children: H. influenzae possible

Celluitis Treatment

Healthy outpatient: Dicloxicillin, oral cephalasporin, clindamycin, erythromycin, azithromycin, clarithromycin, amxoicillin-clavulanate

IV: clindamycin, vancomycin, cefazolin, nafcillin, or oxacillin

Erysipelas Facts

Superficial skin infection, usually lower extremities or face, involving lymphatics. Bright red and painful indurated lesion with sharply demarcated border

Erysipelas pathogen

Group A streptococci, rarely S. aureus

Erysipelas Treatment

NonDM: Penicillin G
DM: Nafcillin, oxacillin, ceftriaxone, amoxicillin-clavulanate

Impetigo Contagiosa Facts

Superficial, vesiculopustular lesion, contagious, usually children. Small, fluid-filled vesicles, pus-filled blisters.

Impetigo Contagiosa Treatment

Azithromycin
Clarithromycin
Erythromycin
Oral cephalasporin
Clindamycin
Mupirocin

Bollous Impetigo Facts

Starts as vesicles that turn into flaccid bullae containing clear yellow fluid

Bollous Impetigo Pathogen

S. aureus

Bollous Impetigo Treatment

Dicloxacillin
Amoxicillin-clavulanate
Cephalasporin
Mupirocin
TMP/SMZ
Clindamycin

Lymphangitis Facts

Inflammation of lymphatic channels. Characterized by visible red streaking which stems from the inflammatory process in the walls of dilated lymphatic channels ("blood poisoning")

Lymphangitis Pathogen

Usually group A streptococci; rarely S. aureus or Pasturella multocida (bite infection)

Lymphangitis Treatment

Penicillin G IM
Ceftriaxone IM
Penicillin V PO
Amoxicillin PO
Dicloxacillin PO

Lymphadenitis Facts

Infection of a lymph node. Characterized by a tender, swollen node usually at least 3 cm in diameter. Fever is common and the overlying skin is red.

Lymphadenitis Pathogen

Group A streptococci or S aureus

Lymphadenitis Treatment

Penicillin G IM
Clindamycin (IV/PO)
Penicillin V PO
Amoxicillin PO
Erythromycin (IV/PO)

Cutaneous abscesses pathogens

Scalp, trunk and extremity: Staph aureus

Oral and nasal mucosa: Streptococci

Intertriginous/perineal: gram negative aerobes, S. aureus, anaerobes

Axila- P. mirabilis, Ps.aeruginosa, S. aureus

Perirectal/genital: anaerobic (bacteroides sp) and gram negative anaerboes

Cutaneous abscesses pathogens specifics

Foreign bodies- S. aureus

Cat/dog bites: Pasturella multicida, S. aureus, Viridans streptococci, oral anaerobes

Human bites- Eikenella corrodens, oral anaerobes, staph aureus, viridans streptococci

IV drugs- staph aureus, rare pseudomonas aeruginosa

Abx treatment of Cutaneous abscesses

TMP/Sulfa DS PO BID
Clindamycin IV/PO
Clindamycin
Dicloxacillin
Nafcillin
Cefazolin
Amoxicillin Clavulanate
Vancomycin

Necrotizing soft tissue infx facts

Constant, severe pain
Bullae- big blisters
Skin necrosis or ecchymosis
Gas in the tissue (crepitus)

Necrotizing Fasciitis (NF)

Rapidly progressive soft tissue infection characterized by inflammation and necrosis confined to deep subQ fascial tissue. Superficial nerve and deep muscle usually spared.

Type 1- polymicrobial: S. aureus, Enterobacteriacea, Bacteroides sp, other anaerobes, non-group A strep

Type II- Group A strep

Type III- marine Vibrios- V. vulnificus

Risk factors for NF

Type 1 (Polymicrobial): DM, PVD
Type II (Group A strep): exposure to children w/ strep pharyngitis, HIV, IVDA, corticosteroid use, African American, antecedent VZV
Type III(vibrio): chronic liver disease, immunocompromise, iron storage disease

Treatment of NF

Prompt debridement of devitalized tissue

Type I NF (polymicrobial): Carbapenem or Piperacillin-tazobactam PLUS Vanco or Dapto OR
Aztreoname+Ciprofloxacin + (Clindamycin) or (Vancomycin in combination with metronidazole)

Type II NF (Group A strep): Pen G or Ceftriaxone + Clindamycin

Type III NF (Vibrio): Ceftazadime + Doxy OR Cefotaxime + Cipro

Necrotizing Cellulitis

Clostridial cellulitis- C. pefringes- Gas found within skin (crepitus); but fascia and muscle are spared

Non-clostridial: polymicrobial with anaerobics and gram+ves and gram-ves

Marine vibrios-wound infection or ingestion of raw seafood

Necrotizing Cellulitis Treatment

Clostridial- Pen G + Clindamycin or Ceftriaxone + Erythromycin

Polymicrobial- Carbapenem or Piperacillin-tazobactam PLUS Vanco or Dapto OR
Aztreoname+Ciprofloxacin + (Clindamycin) or (Vancomycin in combination with metronidazole)

Marine vibrios- Ceftazadime + Doxy OR Cefotaxime + Cipro

Fournier's Gangrene

Occurs primarily in male diabetics and usually effects the scrotum

Treatment: surgical debridement +
Carbapenem or Piperacillin-tazobactam PLUS Vanco or Dapto OR
Aztreoname+Ciprofloxacin + (Clindamycin) or (Vancomycin in combination with metronidazole)

Gas Gangrene (Clostridium myonecrosis)

Rapidly progressive and life threatening caused by gram+ve spore forming anaerobic bacilli

Pain out of proportion to clinical findings. Heaviness of affected part.

Clinical features: metabolic acidosis, leukocytosis, anemia, thrombocytopenia, coagulopathy

Gas Gangrene Treatment

Resuscitation: crystalloid, plasma, packed cells

Abx: Pen G plus clindamycin

Surgery: debridement or amputation is a mainstay

Hyperbaric oxygen after debridement

Gas Gangrene (nonclostridial)

Polymicrobial infection. Risk factors include DM and PVD. Pain not as pronounced.

Treatment: Early debridement and HBO &
Carbapenem or Piperacillin-tazobactam PLUS Vanco or Dapto OR
Aztreoname+Ciprofloxacin + (Clindamycin) or (Vancomycin in combination with metronidazole)

Streptococcal Myositis

Rare form of invasive group A strep, no gas production but very virulent. 80-100% mortality.

Treatment: debridement +
Pen G or Ceftriaxone + Clindamycin

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