Article 1. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America (pas fini)

Question 1

Tableau résumé important

Question 2

Queation 1. What Is Appropriate for the Evaluation and Treatment of Impetigo and Ecthyma?

Image: Impetigo

Answer 2

Do we need a culture? recommended to help identify whether Staphylococcus aureus and/or a β-hemolytic Streptococcus is the cause (strong, moderate),
but treatment without these studies is reasonable in typical
cases (strong, moderate).

Oral or topical antibiotics?

• Bullous and nonbullous impetigo:oral or topical antimicrobials, but oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection.
• Echtyma: oral

Appropriate medication/ dosing ?

• Bullous and nonbullous impetigo: mupirocin or retapamulin, BID pour 5 jours
• Oral therapy for ecthyma or impetigo: Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent) (strong, high). Because S. aureus isolates
  from impetigo and ecthyma are usually methicillin susceptible,
  dicloxacillin or cephalexin is recommended. When MRSA is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) is recommended (strong, moderate).

Image: echtyma

Question 3

Tableau résumé intéressant

Question 4

Question 2. What Is the Appropriate Evaluation and Treatment for Purulent SSTIs (Cutaneous Abscesses, Furuncles, Carbuncles, and Inflamed Epidermoid Cysts)?

Answer 4

Culture recommanded ?

• Gram stain and culture of pus from carbuncles and abscesses
  are recommended, but treatment without these studies
  is reasonable in typical cases (strong, moderate).
• Gram stain and culture of pus from inflamed epidermoid
  cysts are not recommended (strong, moderate).

Incision recommanded ?

• Incision and drainage is the recommended treatment for
  inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles,
  mild (Figure 1) (strong, high).

Do we give antibiotics ?

• The decision to administer antibiotics directed against
  S. aureus as an adjunct to incision and drainage should be made based upon presence or absence of systemic inflammatory
  response syndrome (SIRS), such as temperature >38°C or
  <36°C, tachypnea >24 breaths per minute, tachycardia >90
  beats per minute, or white blood cell count >12 000
  or <400 cells/μL (moderate; Figure 1) (strong, low). An
  antibiotic active against MRSA is recommended for patients
  with carbuncles or abscesses who have failed initial antibiotic
  treatment or have markedly impaired host defenses or in patients
  with SIRS and hypotension (severe; Figure 1 and
  Table 2) (strong, low).

Question 5

Tableau résumé médicaments

Answer 5

Question 6

Question 3. What Is the Appropriate Treatment for Recurrent Skin
Abscesses?

Answer 6

Recommendations

• A recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material (strong, moderate).
• Recurrent abscesses should be drained and cultured early in the course of infection (strong, moderate).
• After obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated (weak, low).
• Consider a 5-day decolonization regimen twice daily of intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes for recurrent S. aureus infection (weak, low).
• Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (strong, moderate).

Question 7

Question 4. IV. What Is Appropriate for the Evaluation and Treatment
of Erysipelas and Cellulitis?

Image: Erysipelas

Answer 7

Culture ? Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended (strong, moderate) except should be considered for: in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (weak, moderate).

Oral or topical antibiotics ?

• Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci (mild; Figure 1) (strong, moderate).
• For cellulitis with systemic signs of infection, systemic antibiotics are indicated. Many clinicians could include coverage against methicillin-susceptible S. aureus (MSSA)
• For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (severe nonpurulent; Figure 1), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate). In severely compromised
  patients as defined in question 13 (severe nonpurulent;
  Figure 1), broad-spectrum antimicrobial coverage may be considered
  (weak, moderate). Vancomycin plus either piperacillintazobactam
  or imipenem/meropenem is recommended as a
  reasonable empiric regimen for severe infections (strong,
  moderate)

Dosage/ temps ?

• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period (strong, high).

ATTENTION POUR NOUS

• In lower-extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate

Image: cellulitis

Question 8

Question 5. Should Anti-inflammatory Agents Be Used to Complement
Antibiotic Treatment of Cellulitis?

Answer 8

Recommendation
Systemic corticosteroids (eg, prednisone 40 mg daily for
7 days) could be considered in nondiabetic adult patients with
cellulitis (weak, moderate).

Question 9

Question 6. What Is the Preferred Evaluation and Management of Patients
With Recurrent Cellulitis?

Answer 9

Recommandation

1. Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities (strong, moderate). These practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis (strong, moderate).
2. Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4–52 weeks, or intramuscular benzathine penicillin every 2–4 weeks, should be considered in patients who have 3–4 episodes of cellulitis per year despite attempts to treat or control predisposing factors (weak, moderate).

This program should be continued so long as the predisposing
factors persist (strong, moderate).

Question 10

Question 7. What Is the Preferred Management of Surgical Site Infections?

Answer 10

Recommendations

1. Suture removal plus incision and drainage should be performed for surgical site infections (strong, low).
2. Adjunctive systemic antimicrobial therapy is not routinely indicated, but in conjunction with incision and drainage may be beneficial for surgical site infections associated with a significant systemic response (Figure 2), such as erythema and induration extending >5 cm from the wound edge, temperature >38.5°C, heart rate >110 beats/minute, or white blood cell (WBC) count >12 000/μL (weak, low).
3. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong, low).
4. A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics), is recommended (strong, low). See also Tables 2 and 3.
5. Agents active against gram-negative bacteria and anaerobes,
   such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract (strong, low).

Question 11

Question 8. What Is the Preferred Evaluation and Treatment
of Necrotizing Fasciitis, Including Fournier Gangrene?

Answer 11

Recommendations

1. Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (severe nonpurulent; Figure 1) (strong, low).
2. Empiric antibiotic treatment should be broad (eg, vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem; or plus ceftriaxone and metronidazole), as the etiology can be polymicrobial (mixed aerobic–anaerobic microbes) or monomicrobial (group A streptococci, community-acquired MRSA) (strong, low). See also Table 4.
3. Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis (strong, low). See Figures 1, 2, and Table 4.

Question 12

Question 9. What Is the Appropriate Approach to the Management of
Pyomyositis?

(abcès au niveau du muscle)

Answer 12

Recommendations

1. Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography (CT) scan and ultrasound studies are also useful (strong, moderate).
2. Cultures of blood and abscess material should be obtained (strong, moderate).
3. Vancomycin is recommended for initial empirical therapy. An agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or following open trauma to the muscles (strong, moderate).
4. Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is recommended for treatment of pyomyositis caused by MSSA (strong, moderate).
5. Early drainage of purulent material should be performed
   (strong, high).
6. Repeat imaging studies should be performed in the patient
   with persistent bacteremia to identify undrained foci of infection
   (strong, low).
7. . Antibiotics should be administered intravenously initially,
   but once the patient is clinically improved, oral antibiotics
   are appropriate for patients in whom bacteremia cleared
   promptly and there is no evidence of endocarditis or metastatic
   abscess. Two to 3 weeks of therapy is recommended (strong,
   low).

Question 13

Question 10. What Is the Appropriate Approach to the Evaluation and
Treatment of Clostridial Gas Gangrene or Myonecrosis?

Answer 13

Recommendations

1. Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed (severe nonpurulent; Figure 1) (strong, moderate).
2. In the absence of a definitive etiologic diagnosis, broadspectrum treatment with vancomycin plus either piperacillin/ tazobactam, ampicillin/sulbactam, or a carbapenem antimicrobial is recommended (strong, low). Definitive antimicrobial therapy with penicillin and clindamycin (Figure 1) is recommended for treatment of clostridial myonecrosis (strong, low).
3. Hyperbaric oxygen (HBO) therapy is not recommended because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement (strong, low).

Question 14

Question 11. What Is the Role of Preemptive Antimicrobial Therapy to
Prevent Infection for Dog or Cat Bites?

Answer 14

Recommendations

1. Preemptive early antimicrobial therapy for 3–5 days is recommended for patients who (a) are immunocompromised (b) are asplenic; (c) have advanced liver disease; (d) have preexisting or resultant edema of the affected area; (e) have moderate to severe injuries, especially to the hand or face; or (f ) have injuries that may have penetrated the periosteum or joint capsule (strong, low).
2. Postexposure prophylaxis for rabies may be indicated; consultation with local health officials is recommended to determine if vaccination should be initiated (strong,low).

Question 15

Question 12. What Is the Treatment for Infected Animal Bite–Related
Wounds?

Answer 15

Recommendation
42. An antimicrobial agent or agents active against both aerobic
and anaerobic bacteria such as amoxicillin-clavulanate
(Table 5) should be used (strong, moderate).

Question 16

Question 13. Should Tetanus Toxoid Be Administered for Animal Bite
Wounds?

Answer 16

Recommendation

1. Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years. Tetanus, diptheria, and tetanus (Tdap) is preferred over Tetanus and diptheria (Td) if the former has not been previously given (strong, low).

Question 17

Question 14. In Which Patients Is Primary Wound Closure Appropriate for
Animal Bite Wounds?

Answer 17

Recommendation

• Primary wound closure is not recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics (strong, low). Other wounds may be approximated (weak, low).

Question 18

Question 15. What Is the Appropriate Treatment of Cutaneous Anthrax?

Answer 18

Recommandation

1. Oral penicillin V 500 mg 4 times daily (qid) for 7–10 days is the recommended treatment for naturally acquired cutaneous anthrax (strong, high).
2. Ciprofloxacin 500 mg by mouth (po) bid or levofloxacin 500 mg intravenously (IV)/po every 24 hours × 60 days is recommended for bioterrorism cases because of presumed aerosol exposure (strong, low).

Question 19

Question 16. What Is the Appropriate Approach for the Evaluation and
Treatment of Bacillary Angiomatosis and Cat Scratch Disease?

Answer 19

Recommendations

Azithromycin is recommended for cat scratch disease (strong, moderate) according to the following dosing protocol:

• (a) Patients >45 kg: 500 mg on day 1 followed by 250 mg for 4 additional days (strong, moderate).
• Patients <45 kg: 10 mg/kg on day 1 and 5 mg/kg for 4 more days (strong, moderate).

-Erythromycin 500 mg qid or doxycycline 100 mg bid for
2 weeks to 2 months is recommended for treatment of bacillary
angiomatosis (strong, moderate).

Question 20

Question 17. What Is the Preferred Treatment for Erysipeloid?

Answer 20

Recommendation

1. Penicillin (500 mg qid) or amoxicillin (500 mg 3 times daily [tid]) for 7–10 days is recommended for treatment of erysipeloid (strong, high).

Question 21

Question 18. What Is the Appropriate Treatment of Glanders?

Answer 21

Recommendation

1. Ceftazidime, gentamicin, imipenem,doxycycline, or ciprofloxacin is recommendedbased on in vitro susceptibility (strong, low).

Question 22

Question 19. What Is the Appropriate Diagnosis and Treatment of Bubonic
Plague?

Answer 22

Recommendation

1. Bubonic plague should be diagnosed by Gram stain and culture of aspirated material from a suppurative lymph node (strong, moderate). Streptomycin (15 mg/kg intramuscularly [IM] every 12 hours) or doxycycline (100 mg bid po) is recommended for treatment of bubonic plague (strong, low). Gentamicin could be substituted for streptomycin (weak, low).

Question 23

Question 20. What Is Appropriate for Diagnosis and Treatment for
Tularemia?

Answer 23

Recommendations

1. Serologic tests are the preferred method of diagnosing tularemia (weak, low).
2. Streptomycin (15 mg/kg every 12 hours IM) or gentamicin (1.5 mg/kg every 8 hours IV) is recommended for treatment of severe cases of tularemia (strong, low).
3. Tetracycline (500 mg qid) or doxycycline (100 mg bid po) is recommended for treatment ofmild cases of tularemia (strong, low).
4. Notify the microbiology laboratory if tularemia is suspected (strong, high).

Question 24

Question 21. What Is the Appropriate Approach to Assess SSTIs in
Immunocompromised Patients?

Answer 24

Recommendations

1. In addition to infection, differential diagnosis of skin lesions should include drug eruption, cutaneous infiltration with the underlying malignancy, chemotherapy- or radiation-induced reactions, Sweet syndrome, erythema multiforme, leukocytoclastic vasculitis, and graft-vs-host disease among allogeneic transplant recipients (strong, high).
2. Differential diagnosis for infection of skin lesions should include bacterial, fungal, viral, and parasitic agents (strong, high).
3. Biopsy or aspiration of the lesion to obtain material for histological and microbiological evaluation should always be implemented as an early diagnostic step (strong, high).

Question 25

Question 22. What Is the Appropriate Approach to Assess SSTIs in
Patients With Fever and Neutropenia?

Answer 25

Recommendations

1. Determine whether the current presentation of fever and neutropenia is the patient’s initial episode of fever and neutropenia, or persistent unexplained fever of their initial episode (after 4–7 days) or a subsequent episode of fever and neutropenia (recurrent) (strong, low).
2. Aggressively determine the etiology of the SSTI by aspiration and/or biopsy of skin and soft tissue lesions and submit these for thorough cytological/histological assessments, microbial staining, and cultures (strong, low).
3. Risk-stratify patients with fever and neutropenia according
   to susceptibility to infection: high-risk patients are those
   with anticipated prolonged (>7 days) and profound neutropenia
   (absolute neutrophil count <100 cells/μL) or with a Multinational
   Association for Supportive Care (MASCC) score of
   <21; low-risk patients are those with anticipated brief (<7
   days) periods of neutropenia and few comorbidities (strong,
   low) or with a MASCC score of ≥21 (strong, moderate).
4. Determine the extent of infection through a thorough
   physical examination, blood cultures, chest radiograph, and additional
   imaging (including chest CT) as indicated by clinical
   signs and symptoms (strong, low).

Question 26

Question 23. What Is the Appropriate Antibiotic Therapy for Patients With
SSTIs During the Initial Episode of Fever and Neutropenia?

Answer 26

Recommendations

1. Hospitalization and empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin or meropenem or doripenem) or piperacillin-tazobactam is recommended (strong, high).
2. Documented clinical and microbiologic SSTIs should be treated based on antimicrobial susceptibilities of isolated organisms (strong, high).
3. It is recommended that the treatment duration for most bacterial SSTIs should be 7–14 days (strong, moderate).
4. Surgical intervention is recommended for drainage of soft tissue abscess after marrow recovery or for a progressive polymicrobial necrotizing fasciitis or myonecrosis (strong, low).
5. Adjunct colony-stimulating factor therapy (granulocyte colony-stimulating factor [G-CSF], granulocyte macrophage colony-stimulating factor [GM-CSF]) or granulocyte transfusions

are not routinely recommended (weak, moderate).
68. Acyclovir should be administered to patients suspected
or confirmed to have cutaneous or disseminated varicella zoster
virus (herpes simplex virus [HSV] or varicella zoster virus
[VZV]) infection (strong, moderate).