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PR3151 > Management of SSTI > Flashcards

Management of SSTI Flashcards

1
Q

How does the skin serve as a physical barrier to infection?

A

→ Protects against mechanical injury, UV irradiation, microbial and chemical assaults
→ Prevents excessive water loss and desiccation

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2
Q

How does the skin serve as a chemical barrier to infection?

A

→ Skin pH is maintained at 4-5 by producing free fatty acids from phospholipids – keeps bacteria and Candida low, and regulates desquamation (keeps transient bacteria to a minimum)
→ Resident flora help to keep transient bacteria to a minimum as well

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3
Q

How does the skin serve as an immunological barrier?

A

→ Forms part of the innate immunity – physical barrier, antimicrobial peptides (AMP), cytokines, cells containing pattern-recognition receptors
→ AMPs are produced by the skin during inflammation process – directly kill pathogens, promotes wound healing, initiates adaptive immune response, controls inflammation

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4
Q

What are the risk factors for SSTIs?

A
  • Traumatic disruptions of the skin: Lacerations, recent surgery, burns, abrasions, crush injuries, open fractures, injection drug use, human/animal/insect bites
  • Nontraumatic disruptions of the skin: ulcers, tinea pedis, dermatitis, toe web intertrigo, chemical irritants
  • Impaired venous and lymphatic drainage (Saphenous venectomy, Obesity, Chronic venous insufficiency)
  • Peripheral artery disease
  • Diabetes
  • Cirrhosis
  • Neutropenia
  • HIV
  • Transplantation & immunosuppressive meds
  • Hx of any SSTI - prev use of antibiotics for it
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5
Q

How can SSTIs be prevented?

A
  • Focus on managing predisposing risk factors
  • Good care to maintain skin integrity eg good wound care, treating tinea pedis, preventing dry cracked skin, good foot care for DM patients to prevent wounds and ulcers
  • Predisposing factors should be identified and treated at the time of initial diagnosis to decrease recurrence
  • Copiously irrigate acute traumatic wounds, remove foreign objects, and debride devitalised tissues
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6
Q

When are cultures required for SSTIs?

A

Once patient has systemic symptoms (moderate severity or worse)

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7
Q

Where should a skin wound culture be taken from?

A
  • From deep in the wound after cleaning the surface
  • From base of a closed abscess, where bacteria grows
  • By curettage, rather than wound swab or irrigation
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8
Q

What are the likely pathogens to be found in impetigo?

A

Staphylococci or streptococci
Bullous form: toxin-producing strains of S. aureus

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9
Q

What are the likely pathogens to be found in ecthyma?

A

Most frequently caused by Group A streptococci (partial haemolysis)

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10
Q

What are the likely pathogens to be found in non-purulent skin lesions (cellulitis, erysipelas)?

A

Mainly beta-haemolytic streptococcus, usually group A (eg Streptococcus pyogenes)

S. aureus is much less frequently

Other less common pathogens based on exposure and risk factors – Aeromonas, Vibrio vulnificus, Pseudomonas w water exposure

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11
Q

What are the likely pathogens to be found in purulent skin lesions (cellulitis, erysipelas)?

A

Mainly by S. aureus
Some beta-haemolytic streptococcus
Isolation of multiple organisms (incl gram negatives and anaerobes) more common in patients w skin abscess involving the perioral, perirectal or vulvovaginal areas

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12
Q

What is the empiric regimen for mild impetigo?

A

TOP Mupirocin BD x 5/7

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13
Q

What are the empiric regimens for impetigo or ecthyma, when there are multiple lesions?

A

PO cephalexin or cloxacillin
PO clindamycin

Both used to cover MSSA and Streptococci, for 7 days

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14
Q

What is the culture-directed therapy choice for impetigo or ecthyma that tests positive for Streptococcus pyogenes?

A

PO Penicillin V or amoxicillin for 7/7

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15
Q

What is the culture-directed therapy choice for impetigo or ecthyma that tests positive for MSSA?

A

PO cephalexin or cloxacillin for 7/7

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16
Q

When are antibiotics indicated for purulent SSTIs?

A
  • Unable to drain completely
  • Lack of response to I&D
  • Extensive disease involving several sites
  • Extremes of age (weak immune system)
  • Immunosuppressed (chemo, transplant etc)
  • Severe disease
  • Signs of systemic illness
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17
Q

What is the treatment choice for mild purulent lesions?

A

I&D or warm compress to promote drainage

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18
Q

What is the treatment choices for moderate purulent lesions?

A

I&D + PO Abx (cloxacillin or cephalexin or clindamycin) for 5-10 days

Clindamycin is used if patient has penicillin allergy

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19
Q

What are the treatment choices for severe purulent lesions?

A

I&D + IV Abx (cloxacillin or cefazolin or clindamycin or vancomycin) for 5-10 days

Vancomycin used only if patient has allergy to the other 3, or has MRSA risk factors

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20
Q

What are the outpatient treatment choices for potential MRSA SSTIs?

A

PO Clindamycin, Doxycycline or Co-trimoxazole for 5-10 days

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21
Q

What are the inpatient treatment choices for potential MRSA SSTIs?

A

IV Vancomycin, Linezolid, Daptomycin for 5-10 days (Vancomycin usually used, other 2 are expensive)

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22
Q

What is the empiric regimen for SSTIs likely caused by gram negatives and/or anaerobes?

A

PO augmentin for 5-10 days
(if there is risk of resistance, can consider pip-tazo)

23
Q

What is the empiric regimen for mild non-purulent SSTIs?

A

PO Penicillin V, cephalexin, cloxacillin for 5-10 days - mainly cover Streptococcus pyogenes

Can use clindamycin if allergic to penicillin

24
Q

What is the empiric regimen for moderate non-purulent SSTIs?

A

IV Cefazolin or cloxacillin for 5-10 - to cover S.pyogenes and MSSA

Can use clindamycin if allergic to penicillin

25
Q

What is the empiric regimen for severe non-purulent SSTIs?

A

IV Abx for 5-10 days: pip-tazo, cefepime, meropenem
If MRSA risk factors: add IV vancomycin, daptomycin or linezolid

26
Q

When would improvement in SSTI after initiating antibiotics be expected by?

A

48-72h

If it takes any longer, reassess indication and/or choice of Abx

27
Q

Are repeat bacterial cultures required for SSTIs?

A

No, as long as patient responds

28
Q

What is mupirocin effective against?

A
  • Highly effective against aerobic gram-positive cocci (esp S. aureus – 2% is bactericidal to it)
  • Not effective against enterococci and gram negatives
  • Useful for eradication of nasal staphylococcal carriage
29
Q

What is the pathophysiology of diabetic foot infections?

A

→ Peripheral neuropathy: ↓pain sensation and altered pain response
→ Motor neuropathy: muscle imbalance
→ Autonomic neuropathy: ↑dryness, cracks and fissures
→ Early atherosclerosis, Peripheral vascular disease, worsened by hyperglycemia and hyperlipidemia
→ Impaired immune response increases susceptibility to infections, worsened by hyperglycemia

Results in ulcer or wound formation, which get colonized by bacteria, bacteria penetrate and proliferate to result in DFI

30
Q

What is the criteria to consider a DFI to be infected?

A

Purulent discharge AND

≥2 signs or symptoms of inflammation: erythema, warmth, tenderness, pain, induration (thickening or hardening of the skin)

31
Q

What are the possible causative pathogens of diabetic foot infections?

A
  • Typically polymicrobial
  • Staphylococcus aureus and Streptococcus spp most common
  • Gram negatives: particularly if chronic or previously treated w Abx (E.coli, Klebsiella spp, Proteus spp; Pseudomonas aeruginosa less common)
  • Anaerobes (Particularly in ischaemic or necrotic wounds; Peptostreptococcus spp, Veillonella spp, Bacteriodes spp)
32
Q

What features of a DFI would classify it as a mild DFI?

A

Infection of skin and SC tissue AND

Erythema ≤ 2cm around ulcer AND

No systemic infection signs

33
Q

What features of a DFI would classify it as a moderate DFI?

A

Infection of deeper tissue (eg bone, joints) OR
Erythema >2cm around ulcer AND

No systemic infection signs

34
Q

What features of a DFI would classify it as a severe DFI?

A

Infection of deeper tissue (eg bone, joints) OR
Erythema >2cm around ulcer AND

Sign(s) of systemic infection

35
Q

What severities of DFI should cultures be done for?

A

Moderate to severe - Deep tissue culture after cleansing and before starting antibiotics (if possible)

36
Q

What organisms need to be covered empirically for mild DFI?

A

Streptococcus spp + S.aureus

37
Q

What are the empiric regimen choices for mild DFI?

A

PO Abx
* Cephalexin
* Cloxacillin
* Clindamycin (for pts allergic to penicillins)

If MRSA risk factors, use PO:
* Co-trimoxazole
* Clindamycin
* Doxycycline

38
Q

What organisms need to be covered empirically for moderate DFI?

A

Streptococcus spp + S.aureus + gram negatives
(±P.aeruginosa) + anaerobes

39
Q

What are the empiric regimen choices for moderate DFI?

A

Initial IV Abx
* Augmentin
* Cefazolin/Ceftriaxone + Metronidazole

If MRSA risk factors, add IV:
* Vancomycin
* Daptomycin
* Linezolid

40
Q

What organisms need to be covered empirically for severe DFI?

A

Streptococcus spp + S.aureus + gram negatives (incl P.aeruginosa) + anaerobes

41
Q

What are the empiric regimen choices for severe DFI?

A

Initial IV Abx
* Piperacillin-Tazobactam
* Cefepime + Metro
* Meropenem
* Cipro + Clinda

If MRSA risk factors, add IV:
* Vancomycin
* Daptomycin
* Linezolid

42
Q

How long should a mild DFI with no bone involvement be treated for?

A

1-2 weeks

43
Q

How long should a moderate DFI with no bone involvement be treated for?

A

1-3 weeks

44
Q

How long should a severe DFI with no bone involvement be treated for?

A

2-4 weeks

45
Q

How long should antibiotics be continued for after an amputation for a DFI?

A

2-5 days

46
Q

How long should antibiotics be continued for after a surgery to remove infected bone for a DFI?

A

1-3 weeks

47
Q

How long should antibiotics be continued for after a surgery leaving only viable bone for a DFI?

A

4-6 weeks

48
Q

How long should antibiotics be continued for after a surgery leaving only dead bone for a DFI?

A

≥ 3 months

49
Q

How long should antibiotics be used for a DFI where the bone was involved but no surgery was done?

A

≥ 3 months

50
Q

Should antibiotics be continued until complete wound healing?

A

No

51
Q

What are the adjunctive measures used in DFI management?

A
  • Wound care: debridement, “off-loading”, dressings that promote healing & control excess exudate
  • Foot care: daily inspection, prevent wounds and ulcers
  • Optimal glycemic control
52
Q

What are the risk factors for pressure ulcers?

A

Generally, if the person is unable to shift/reposition their body to avoid the shearing forces, pressure and friction, they will be at higher risk for pressure ulcers

  • Reduced mobility
  • Debilitated by severe chronic diseases
  • Reduced consciousness
  • Sensory and autonomic impairment (esp incontinence)
  • Extremes of age
  • Malnutrition
53
Q

Describe the 4 stages of clinical presentation of a pressure ulcer.

A

Stage 1: Abrasion of epidermis, Irregular area of tissue swelling, No open wound
Stage 2: Extends through the dermis, Open wound
Stage 3: Extends deep into subcutaneous fat, Open sore or ulcer
Stage 4: Involves muscle and bone, Deep sore or ulcer

54
Q

What are the adjunctive measures for pressure wound management?

A

→ Debridement of infected or necrotic tissue
→ Local wound care: Normal saline preferred, avoid harsh chemicals
→ Relief of pressure: turn or reposition every 2 hours (also for prevention)

PR3151 (14 decks)

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