Module 3: Stewardship in Skin and Soft Tissue Infections

Module 3: Stewardship in Skin and Soft Tissue Infections

Module 3: Stewardship in Skin and Soft Tissue Infections Benjamin Westley MD FAAP FACP 4120 Laurel St Suite 204 Anchorage, AK 99508 Objectives Define classes of uncomplicated skin and soft tissue infection (SSTI) that drive empiric antimicrobial selection Purulent SSTI Non-purulent SSTI

Recognize conditions that suggest complications are likely and may require alteration of usual empiric regimens Identify warning signs and clinical features of necrotizing SSTI Discuss classes of Diabetic Foot Infection (DFI) and appropriate initial approaches to therapy Brief comment on SSTI in IV drug users (IVDU) Skin and soft tissue infection Multiple terms/categories Cellulitis/erysipelas Impetigo Abscess

Skin and soft tissue infection (SSTI) Complicated skin and skin structure infection (cSSSI) Necrotizing fasciitis, Fourniers gangrene Diabetic foot infection (DFI) Used interchangeably, often inappropriately Not mutually exclusive Impetigo Superficial crusting/oozing lesions, sometimes bullous MSSA or GAS RARELY MRSA

Single lesions -> Topical mupirocin Multiple/recurring lesions -> cephalexin 500mg po qid Cellulitis Red, hot, indurated tender skin Multiple causes, not always infectious Can be non-purulent, or can surround a purulent lesion If associated with furuncle, carbuncle, or absess -> STAPHYLOCOCCUS AUREUS If diffuse and unassociated with portal of entry -> BETA-HEMOLYTIC STREPTOCOCCI

Erysipelas = subset of cellulitis Fiery red, tender, painful plaque with well demarcated edges GROUP A STREPTOCOCCUS 2014 IDSA SSTI Guidelines1 Categorized SSTI by purulent/non-purulent to help guide need for empiric MRSA coverage If there is carbuncle/abscess or draining pus = PURULENT : I+D, send culture on first episode MILD = NO ABX MODERATE = Cellulitis > 5 cm diameter

Bactrim DS 1 BID x 5 days Clindamycin 300mg po TID if Sulfa allergic SEVERE = Purulent SSTI plus SIRS criteria Blood cultures x 2 Vancomycin dosed to goal trough of 10-15 PO once source controlled and improved to complete 7d Rx Are antibiotics really needed for uncomplicated abscess? Data are conflicting.4-6 2 prior RCT suggest not NEJM study published 2016 suggests small benefit

1265 patients 12y old with abscess 2cm randomized to TMP/SMX 320/1600 bid vs placebo x7 days4 All received I+D with cultures Average abscess 2.5cm with cellulitis of 6cm 45.3% MRSA Cure rate higher with ABX than placebo by ~7% ABX 80.5% vs. Placebo 73.6% (P=0.005) N Engl J Med 2016;374:823-32. N Engl J Med 2016;374:823-32.

Non-purulent cellulitis MILD Cephalexin or Amoxicillin 1g PO TID MODERATE Cefazolin 1-2g iv q8h If not improving after 48-72h, broaden to Vancomycin and evaluate for evolution of unrecognized purulent focus SEVERE Evaluate for necrotizing infection Broad abx

Randomized controlled trial, 524 patients2 Children and adults Half (46%) with purulent disease Bactrim DS BID vs. Clindamycin 300mg TID x 10 days Equivalent cure rates and complication rates MODERATE DISEASE Excluded T > 38.5C (adults) and 38.0C (children) N Engl J Med 2015;372:1093-103 N Engl J Med 2015;372:1093-103

169 patient pre-guideline vs. 175 postguideline3 Interventions: Selective CRP, x-ray, blood cx use ESR, superficial cultures, CT or MRI imaging DISCOURAGED Vancomycin, total Rx IV + PO 7 days Doxycycline, Clindamycin, or Bactrim on discharge Broad aerobic GNR or anaerobe coverage DISCOURAGED NSAID and elevate legs ntern Med. 2011;171(12):1072-1079. Arch Intern Med. 2011;171(12):1072-1079.

Conditions that increase risk of complications Periorbital cellulitis Occasionally mixed flora due to sinus-process Breast cellulitis May appear non-purulent but often staphylococcal or due to obstructed duct with skin flora and may require surgery Parotid or head/neck abscess Staphylococcal and mixed oral flora Perirectal/perineal/genital infection

Often mixed staphylococcal and GI flora Immune compromise Transplant, chemotherapy, immuno-modulatory agents Seek ID input Necrotizing SSTI1 Necrotizing fasciitis Death of tissues along superficial fascial planes 2 forms Mono-microbial, usually Group A Strep (Type II) 30 80% mortality1,10

Polymicrobial (GNRs and anaerobes) Hallmark features (1 or more) Pain out of proportion to visible lesion Woody subcutaneous tissues rapidly expanding Systemic toxicity (LRINEC score) Crepitus Skin necrosis, ecchymosis, and/or bullous lesions Fourniers gangrene Subtype of polymicrobial necrotizing fasciitis involving the scrotum/vulva Spreads from peri-rectal or perineal lesion Enteric mixed flora including clostridium

LRINEC Score7 Laboratory Risk Indicator in Necrotizing Fasciitis WBC, Na, glucose, creatinine, and CRP Score >6 92% PPV 96% NPV Score 6 in ~90% of patients with necrotizing fasciitis i.e. ~10% with necrotizing fasciitis are <6 Score 6 in 8.4% of patient WITHOUT necrotizing fasciitis

LRINEC scoring CRP <15 mg/dL = 0 15 mg/dL = 4 WBC <15 x 103 /uL = 0 15 25 x 103 /uL = 1 >25 x 103 /uL = 2 Hemoglobin >13.5 g/dL = 0 11 13.5 g/dL = 1

<11 g/dL = 2 Sodium 135 mmol/L = 0 <135 mmol/L = 2 Creatinine 1.6 mg/dL = 0 >1.6 mg/dL = 2 Glucose 180 mg/dL = 0 >180 mg/dL = 1

Imaging in necrotizing fasciitis CT and/or MRI may show fluid along fascial planes, fascial enhancement, or gas in tissues20,21 Sensitivity and specificity are poor Imaging studies tend to delay surgery Clinical impression should drive surgical decision making Small incisions in area of concern made; if no fascial sloughing, necrosis or dehiscence, extensive debridement is not required Necrotizing Fasciitis ABX

Vancomycin dosed to goal trough 10-15, PLUS Piperacillin/tazobactam per local dosing protocol*, PLUS Clindamycin 600-900mg iv q8h AND Immediate surgical consultation!!! It is NOT appropriate to give the above abx for presumed necrotizing infection WITHOUT emergent surgical evaluation *3.375g iv q8h if extended infusion, 3.375g iv q6h if traditional dosing Clindamycin and Group A Strep

Clindamycin decreases in-vitro streptococcal toxic shock toxin production and improves animal survival12,13 Observational data suggests clindamycin decreases mortality in proven severe Group A Streptococcal infections8-10,14,17 Use WITH a beta-lactam until clinically improved then stop clindamycin and continue beta-lactam E.g. cefazolin 1-2g iv q8h then amoxicillin 1g po TID We generally finish therapy with ~10d total Rx

IV immune globulin Suggestion of mortality benefit in severe group A strep infection with the toxic shock syndrome Multi-organ system dysfunction Shock Often, diffuse erythematous sunburn-like rash Data is limited10,14-16 Dosing not well defined Usually 1 g/kg on day 1 then 0.5 g/kg on days 2 and 3 If felt necessary, suggest clinicians discuss with an infectious disease specialist

Diabetic Foot Infection (DFI) Updated IDSA guideline in 201218 Not all diabetic ulcers are infected!! Signs of infection Redness, warmth, tenderness, pain, induration, or purulent secretions MILD Redness 2 cm around ulcer MODERATE Redness >2cm around ulcer OR deep structures involved WITHOUT sepsis

SEVERE Local infection plus SIRS criteria Diabetic Foot Infection Infected wounds in NON-SEPTIC patients should be cultured BEFORE antibiotics are started Cultures should be sent from deep tissue by biopsy or curettage AFTER wound is cleaned and superficial tissues debrided All should get plain x-ray MRI if x-ray negative and suspicion of osteomyelitis If wound probes to bone, patient has

osteomyelitis ABX for DFI18 MILD to MODERATE severity Target aerobic GPC only Mild = Cephalexin pending cultures Moderate = Vancomycin dosed to goal trough of 10-15 SEVERE Vancomycin PLUS piperacillin/tazobactam Urgent surgical consultation Duration Mild: 1 2 weeks

Moderate severe: 2 3 weeks Osteomyelitis present and not resected: 4+ weeks Osteomyelitis fully resected: 2 5 days DFI Treatment Failure/Recurrence Usually due to inadequate offloading, vascular supply, or resection of poorly-viable tissues SSTI in IV Drug Users Increasing frequency in Alaska Many users lick either needles and/or injection sites Usual presentations: Antecubital fossa abscess

Cellulitis with phlebitis Necrotizing fasciitis22 Flora are the usual gram positives including MRSA PLUS oral flora19,22 Streptococcus anginosus group Haemophilus/Eikenella Prevotella/Fusobacterium Literature suggests use Vancomycin monotherapy 1,19 We often add ampicillin/sulbactam for severe SSTI in IVDUs SSTI in IVDU Consider instructing patients about safe

injection techniques Use chlorhexidine Dont touch site Dont lick site or needles Dont re-use/share needles Make sure they were screened for HIV and HCV If using heroin, should be given a naloxone rescue kit References 1. Clin Infect Dis. 2014 Jul 15;59(2):147-59 2. N Engl J Med 2015;372:1093-103. 3. Arch Intern Med. 2011;171(12):10721079.

4. N Engl J Med 2016;374:823-32. 5. Ann Emerg Med 2010;55: 401-7. 6. Ann Emerg Med 2010; 56: 283-7. 7. Crit Care Med. 2004 Jul;32(7):1535-41. 8. Pediatr Infect Dis J 1999; 18:1096100. 12.J Antimicrob Chemother 1997; 40:275 7. 13.J Infect Dis 1988; 158:238. 14.Clinical Infectious Diseases 2014;59(6):8517 15.Clin Infect Dis 1999; 28:8007. 16.Clin Infect Dis 2003; 37:33340. 17.J Infect Dis 1988; 158:238.

18.Clin Infect Dis 2012;54(12):132173 9. South Med J 2003; 96:96873. 19.Acad Emerg Med. 2015 Aug;22(8):9937. 10.Clinical Infectious Diseases 2014;59(3):35865 20.Clinical Radiology (1996) 51, 429-432 11.Clinical Infectious Diseases 2014;59(3):3668

21.Am J Roentgenol. 1998 Mar;170(3):61520. 22.Clinical Infectious Diseases 2001; 33:6 15

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