Cellulitis

Question 1

Cellulitis risk factors:

Answer 1

immune suppression

breaches in skin barrier (trauma to skin)

chronic edema

obesity

tinea pedis

lymphedema

vascular disease

Question 2

what are some examples of immune suppressed states that are at increased risk for cellulitis?

Answer 2

DM2

HIV

chronic steroid therapy

Question 3

what are some examples of breaches in skin that are at increased risk for cellulitis?

Answer 3

dry skin chronic inflammation (eczema, radiation therapy)

chronic wounds (pressure ulcer, venous ulcer)

dermatophyte infection (tinea pedis)

Question 4

what kind of chronic edema that can cause cellulitis:

Answer 4

post surgical lymphedema (lymph node dissection)

chronic venous insufficiency

CHF and CKD

prior cellulitis with lymphatic scarring

Question 5

Tinea pedis can cause

Answer 5

skin breakdown between dose and cause a site for bacterial entry in small area. This can cause cellulitis.

Question 6

Reoccurrence of cellulitis

Answer 6

happens up to 30% in pts due to skin barrier breakdown or lymphatic stasis.

Question 7

clinical features of cellulitis:

Answer 7

increasing pain, swelling fever, lymphangitis, regional adenopathy and see erythema of skin and purulence

Question 8

mild superficial infections like impetigo can be treated with

Answer 8

topical mupirocin

Question 9

systemic abx for cellulitis are needed when:

Answer 9

extensive cellulitis >2 cm from wound margin or infection of deep tissue

Question 10

moderate cellulitis treatment should have abx that

Answer 10

cover staph and strep species.

Question 11

moderate cellulitis treatment with purulence or pustules should have abx that have:

Answer 11

that cover for staph

clindamycin

bactrim

Question 12

moderate cellulitis treatment WITHOUT purulence or pustules should have abx that have:

Answer 12

Cellulitis without purulence THINK Strep

should be treated with : clindamycin, dicloxacillin or cephlexin

Question 13

moderate infection with bite wounds should get abx with

Answer 13

anerobic coverage (amoxicillin/clavulanate)

Question 14

immunocompromised pts with severe wound infections (high fever, HD instability) need to

Answer 14

get hospitalized and IV abx.

Question 15

does hydrogen peroxide have a role in wound healing?

Answer 15

Can be used for initial wound management to remove dried blood and necrotic tissue _but ineffective in treating established wound infectio_ns and doesn’t promote healing.

Question 16

wet to dry gauzes are used for

Answer 16

debridement in wounds with extensive exudate

Question 17

Bite wound treatment

Answer 17

Treat all wounds with irrigation with sterile normal saline - allows for better characterization of wound and signs of inflmmation and infection.

May need XR to look for fracture, other boney involvement, or foreign bodies.

Assessment for tetanus and rabies prophylaxis is essential.

Primary wound closure is not needed unless for facial wounds.

3-5 day course of augmentin (amoxicillin -clavulanate) is needed for immunosuppressed, cirrhosis and asplenia.

Capnocytophagia canimorsus common part of canine microbiota and can cause severe infections with asplenia.

Question 18

Pt gets bitten by cat. why are cat bites bad?

how to prevent complications?

Answer 18

cat bites have deep puncture wounds to hands and can be deep. infections when hear extremiteis can progress to bone or joint infections and so antibiotic prophylaxis can help reduce infection rates

Question 19

when to give antibiotic prophylaxis (doxycycline and metronidazole) after cat bite?

Answer 19

recommended for animal bite wound near lymphatics and blood vessels, on hand and close to joints or bones, AND IN IMMUNOCOMPROMISED PTS AND THOSE THAT NEED SURGERY.

antibiotic prophylaxis can help reduce infection rates

Question 20

What bacteria are seen with cat bites?

What antibiotics are appropriate for antibiotic prophylaxis?

Answer 20

pasturella multicida and streptococcus and other anaerobic bacteria.

Cover infection with amoxicillin/clavulanate for porphylaxis and alternate for penicillin allergy is doxycyline/metronidazole.

Give for 3-5 days and some people give first dose IV then followed by oral

Can use doxycycline or bactrim for those that are at risk for MRSA infections.

Question 21

how to manage a cat bite?

Answer 21

wash wound (irrigate) and have debris removal and should be left open to heal by secondary intention rather than primary closure.

Give antibiotic prophylaxis.

Needs careful follow up for deeper wound infection that may require extended antibiotic therapy. primary closure can be done at hte time if no signs of infeciton. non healing wounds need surgical debridement.

SHould also get a tetanus booster and be considered for rabies vaccine.

Question 22

other considerations after a cat bite?

Answer 22

Should also get a tetanus booster and be considered for rabies vaccine.

Question 23

when to give tetanus immunoglobulin after a cat bite?

Answer 23

high risk bites who have not been recently immunized <5 yrs

Question 24

skin abscess need to have I and D but when should you add antibiotic treatment

Answer 24

abscess >2 cm

extensive surrounding cellulitis

systemic symptoms of infection (fever, chills, tachycardia and WBC)

neutropenia

multiple abscesses

extremes of age

lack of response to I&D

Question 25

What antibiotics should be given for abscess?

Answer 25

bactrim or doxycyline is generally curative IV antibiotics should be given in those with systemic symptoms or rapidly progressive symptoms or persistent symptoms after 48 hrs of oral antibiotic tx or inability to tolerate therapy.

Question 26

clostridium septicum is associated with what to get after infection?

Answer 26

**spontaneous gas gangrene.** History of trauma is not needed for infection can spread hematologenously from GI tract - can have underlying **colonic malginancy** or **IBS** or **diverticulitis** all pts who have Clostrium septicum infection should have a **colonoscopy**

Question 27

non purulent cellulitis without signs of systemic fever can be treated with

Answer 27

cephalexin for 5 to 10 days

Question 28

when should someone get prophylactic antibiotics to prevent cellulitis?

Answer 28

**more than 3 episodes of cellulitis per year** consider penicillin or erythromycin.

Question 29

when to get blood cultures for someone who has cellulitis?

Answer 29

_not routinely indicated_ for erysipelas and celulitis get blood cultures on: **immunocompromised,** **exhibit severe sepsis or unusual precipitating circumstances (immersion injury)** **animal bites** culture of skin tissue aspirate or biopsy should also be considered.

Question 30

primary treatment for abscesses, furncles and carbuncles

Answer 30

**Incision and drainage** Antibiotics after I and D? **mild lesions without SIRS -** no **moderate infections with SIRS**-yes also need abx in: **immune compromised** **those with hypotension** **severe SIRS** **in whom I&D or oral antibiotics fail** **carbuncle=** several furncles that coalesce together. **Furncles** are boils or follicle associated abscesses that extend into the dermis.

Question 31

multiple recurrences of cellulitis by MRSA

Answer 31

consider decolonization with t**opical intranasal mucpirocin and chlorhexidine washes** also consider hidradenitis suppurativa, pilonidal cysts, or foreign body.

Question 32

someone gets bitten by a human. what to do?

Answer 32

all pts should get short course of prophylactic antibiotic therapy with **amoxicillin-clavulanate.** assess for tetanus prophylaxis, and exposure to hep B and C, HIV, and other bodily fluid transmitted pathogens.

Question 33

diabetic foot infection treatment and duration for Mild infection moderate to severe infections:

Answer 33

**Mild infections** - if they are infected treat with MRSA and strep coverage can be treated with **empiric short course of 7-14 days of oral antibiotics**: cephalexin, clindamycin, amoxicillin-clavulanate or dicloxacillin Would cultures should be by curettage or biopsy of deep tissue before initiating antiobtics - can also use doxycycline or bactrim. **Severe infections:** - need polymicrobial coverage with staphyloci, streptococci, and aerobic gram negative bacilli and anaerobes **can treat with 2-4 weeks of antibiotics**

Question 34

necrotizing skin infections like aeromonas hydrophilia (gram neg bacilli) should be treated with

Answer 34

**ciprofloxacicin and doxycycline** this is a seen in aquatic environments with freshwater and brackish water and grows best in warmer months it can cuase soft tissue and blood stream infections with underlying immunocompromising conditions like cirrhosis or cancer.

Question 35

Treatment of group A (strep pyogenes) necrotizing fasciitis

Answer 35

**penicillin and clindamycin** - suppress streptococcal toxin production)