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Therapeutics > SSTI > Flashcards

SSTI Flashcards

1
Q

Name some protecting factors of the skin

A
  1. Dry surface
  2. Fatty acids
  3. Acidic pH (5.6)
  4. Renewal of epidermis (bacteria fall out)
  5. Low temperature (inhibits bacterial growth)
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2
Q

Some predisposing factors of SSTI

A
  1. High bacterial innocul
  2. Excessive moisture
  3. Reduced blood supply (hence less WBC flow)
  4. Presence of bacterial nutrients (e.g. diabetes)
  5. Poor hygiene ans sharing of personal items
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3
Q

What are the five ways in which SSTIs are classified?

A
  1. Severity or extent (mild vs moderate vs severe)
  2. Depth of infection (superficial vs deep)
  3. Presence/absence of discharge (purulent vs non-purulent)
  4. Microbiology (single pathogen or polymicrobial)
  5. Anatomical site (epidermis vs dermis vs hair follicles, etc.)
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4
Q

List the anatomical site and the type of SSTI(s) associated with it

A
  1. Epidermis: impetigo
  2. Dermis: Ecthyma, Erysipelas
  3. Hair follicles: Furuncles, Carbuncles
  4. SC fat: Cellulitis
  5. Fascia: Necrotising fasciitis
  6. Muscle: Myositis
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5
Q

The culture of skin from a patient with a severe case of impetigo contains MSSA. What is the appropriate culture-directed treatment, assuming that Cloxacillin was started 3 days prior to culture results?

A

PO Cloxacillin 250-500mg QDS, 4 more days (total 7 days)

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6
Q

What are the SIRS criteria

A
  • Fever >38 deg C
  • Hypothermia <36 deg C
  • Tachycardia > 90 bpm
  • Tachypnea > 20 breath/min
  • Leukocytosis > 12 *10^9 /L
  • Leukopenia < 4*10^9 /L
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7
Q

The culture of skin from a patient with Ecthyma contains S.pyogenes. What is the best culture-directed treatment, assuming that Cloxacillin was started 3 days prior to culture results?

A

PO Penicillin VK 250-500mg PO QDS for 4 more days

because pen VK has narrower spectrum than cloxacillin

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8
Q

The only condition that can be treated with topical antibiotics

A

Impetigo (muprocin BD for 5 days)

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9
Q

Oral antibiotics used for severe impetigo and ecthyma, and duration of treatment

A
  • Cephalexin/cloxacillin
  • Penicillin VK
  • Clindamycin

Treatment for 7 days

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10
Q

Common causative organisms of Impetigo and Ecthyma

A
  1. S.aureus

2. Streps

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11
Q

Must a culture be obtained before treating Impetigo and Ecthyma?

A

Not necessary, it is usually mild and does not require hospital admission

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12
Q

Treatment for Impetigo

A

Topical Mupirocin BD for 5 days

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13
Q

Empirical treatment of Ecthyma for a patient with Penicillin allergy

A

PO Clindamycin 300mg PO QDS, 7 days

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14
Q

The culture of skin from a patient with a severe case of impetigo contains MSSA. What is the appropriate culture-directed treatment, assuming that Cloxacillin was started 3 days prior to culture results?

A

PO Cloxacillin 250-500mg QDS, 4 more days

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15
Q

What are the indications for adjunctive systemic antibiotics in purulent SSTIs?

A
  1. I&D: unable to drain completely, or lack response
  2. Extensive disease involving multiple sites
  3. Extremes of age
  4. Immunosuppressed
  5. Signs and sx of systemic illness
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16
Q

The culture of skin from a patient with Ecthyma contains S.pyogenes. What is the best culture-directed treatment, assuming that Cloxacillin was started 3 days prior to culture results?

A

PO Penicillin VK 250-500mg PO QDS for 4 more days

because pen VK has narrower spectrum than cloxacillin

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17
Q

Distinguish between Furuncles Carbuncles

A
  • Furuncles: infection of a single hair follicle, extending through dermis
  • Carbuncles: Involes a few adjacent follicles, and forms small abscess
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18
Q

Causative organisms for Cellulitis and Erysipelas

A
  1. S.aureus, usually causing purulent infections
  2. B-hemolytic Strep
    - Almost always the cause of erysipelas
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19
Q

What are some risk factors for purulent SSTIs

A
  1. Close physical contact
  2. Crowded living quarters
  3. Sharing personal items
  4. Poor hygiene
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20
Q

The most common causative organism for purulent SSTIs

A

S.aureus

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21
Q

Main treatment for purulent SSTI

A

Incision & Drainage (I&D)

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22
Q

What is considered “Severe, non-purulent Cellulitis/erysipelas”? What are the organisms to cover?

A

> 2 SIRS criteria with:

  • Hypotension
  • Rapid progression
  • Immunosuppression
  • Comorbidities

Need to cover:
- streps, S. aureus, gram negs (includes P. aeruginosa)

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23
Q

What could cellulitis be caused by in patients who are immunosuppressed?

A

S. aureus, B hemolytic streptococci, Streptococcus pneumoniae, E. Coli, Serratia marcescens, P. aeruginosa

24
Q

For adjunctive systemic antibiotics in purulent SSTIs, PO is adequate in most cases. However, when will IV antibiotics be necessary?

A

In systemic illness (usually those that are admitted to hospitals, or may be required to do so)

25
Q

What are the antibiotics options for severe, non-purulent cellulitis/erysipelas in a patient with MRSA risk factors?

A

On top of the treatment for patients w/o MRSA risk factors, ADD:

  • Vancomycin
  • Daptomycin
  • Linezolid

Make sure there is coverage for P.aeruginosa as well

26
Q

Organisms to cover for severe, non-purulent cellulitis/erysipelas

A
  1. Streps
  2. S.aureus
  3. Gram negs (incl. P.aeruginosa)
27
Q

The main difference in the treatment of purulent cellulitis and non-purulent cellulitis/erysipelas?

A

For purulent cellulitis, always consider coverage for S.aureus, and MRSA coverage in patients with MRSA risk factors

28
Q

Whan are cultures considered in cellulitis and erysipelas?

A
  1. Purulent infections AFTER I and D
  2. Immunosuppressed
  3. Signs of severe systemic illness
29
Q

What are the organisms to cover for non-purulent mild cellulitis and Erysipelas, and the antibiotics preferred?

A

Organism: Streptococcus
Antibiotics: PO Penicillin VK/ Cloxacillin/Cephalexin/ Clindamycin

30
Q

What is considered “Moderate, non-purulent Cellulitis/erysipelas”? What are the organisms to cover?

A

When patient has ≥1 SIRS criteria

Organisms: Streps and/or S.aureus

31
Q

Treatment for moderate, non-purulent cellulitis/erysipelas for a patient with ≥2 SIRS criteria

A

IV Antibiotics:

  • Cefazolin
  • Pen G
  • Clindamycin
32
Q

What is considered “Severe, non-purulent Cellulitis/erysipelas”?

A

> 2 SIRS criteria with:

  • Hypotension
  • Rapid progression
  • Immunosuppression
  • Comorbidities
33
Q

Treatment for severe, non-purulent cellulitis/erysipelas in an otherwise normal patient

A

IV antibiotics:

  • Piperacillin/Tazobactam
  • Cefepime
  • Meropenem
34
Q

What are the three factors that calls for MRSA coverage in treating cellulitis and Erysipelas?

A
  1. Immunosuppression
  2. Severely ill (e.g. hypotension < 100/60)
  3. Failure of previous therapy that does not cover MRSA
35
Q

What are the antibiotics options for severe, non-purulent cellulitis/erysipelas in a patient with MRSA risk factors?

A

On top of the treatment for patients w/o MRSA risk factors, ADD:

  • Vancomycin
  • Daptomycin
  • Linezolid
36
Q

Organisms to cover for severe, non-purulent cellulitis/erysipelas

A
  • Streps
  • S.aureus
  • Gram negs (incl. P.aeruginosa)
37
Q

The main difference in the treatment of purulent cellulitis and non-purulent cellulitis/erysipelas?

A

For purulent cellulitis, always consider coverage for S.aureus, and MRSA coverage in patients with MRSA risk factors

38
Q

Antibiotic treatmet duration for Cellulitis and Erysipelas in immunosuppressed patients

A

7 to 14 days

39
Q

Antibiotic treatment duration for Cellulitis & Erysipelas in an otherwise healthy patient?

A

At least 5 days

40
Q

Additional organism to consider for cellulitis from bite wounds

A

Anaerobes and gram negatives

41
Q

A patient presents to the pharmacy for a wound infection caused by a cat by. Her vitals are normal and she has NKDA. What is the most appropriate MONOTHERAPY to manage her infection?

A

PO Amoxicillin/clavulanate 625mg BD-TDS for at least 5 days

42
Q

A patient who recently undergone a liver transplant surgery was admitted into a hospital for non-purulent cellulitis. He was started with IV Piperacillin/Tazobactam.

3 days later, his skin culture results test positive for MSSA. He is afebrile, able to swallow and his vitals have returned to normal. He has NKDA

What changes to the management of infection will you suggest?

A
  1. Culture available: Change to culture-directed therapy:
    - PO Cloxacillin
  2. Immunocompromised: 7 - 14 days antibiotic
    - Hence continute PO Cloxacillin for 4 to 11 days
43
Q

Pathophysiology of DFIs?

A
  1. Neuropathy
  2. Vasculopathy
  3. Immunopathy
  • Which leads to ulcer formation/wounds, bacterial invasion hence DFIs
44
Q

In DFIs, what are the indicators that confirms infection?

A 
Purulent discharge
OR
≥2 of the following sx of inflammation:
- Erythema
- Warmth
- Tenderness
- Pain
- Induration
45
Q

What are the causative organisms for DFIs, and are DFIs typically mono or polymicrobial?

A
  • Usually Polymicrobial
  • Commonly S.aureus and Streps
  • Gram-negs usually in chronic wounds or previously treated with antibiotics (e.g. E.coli, Klebsiella, P.aeruginosa)
  • Anaerobes particularly in ischaemic tissue
46
Q

When should coverage of P.aeruginosa be considered in DFIs?

A
  1. Severe cases

2. Previous antibiotic therapy which did not cover P.aeruginosa failed to show improvement

47
Q

What is considered mild DFI?

A

Infection of skin and SC tissue:

  • Erythema ≤ 2cm around ulcer
  • No systemic sx (no SIRS)
48
Q

What is considered moderate DFI?

A

Infection of deeper tissue like bones and joints:

  • Erythema > 2cm
  • No systemic sx (no SIRS)
49
Q

What is considered severe DFI?

A

Systemic symptoms

50
Q

Name the organisms to be covered in mild DFI and what is the treatment for patient with no MRSA risk factors?

A
  • Organisms: Streps, S.aureus
  • Treatment options: PO
    Cephalexin
    Cloxacillin
    Clindamycin
51
Q

Name the organisms to be covered in moderate DFI and what is the treatment for patient with no MRSA risk factors?

A

Organisms:

  • Streps
  • S.aureus
  • Gram negs (P. aeruginosa if indicated)
  • Anaerobes

Treatment: IV

  • Amox/clav
  • Ceftriaxone + Metronidazole/clindamycin
52
Q

Name the organisms to be covered in severe DFI and what is the treatment for patient with no MRSA risk factors?

A

Organisms:

  • Streps
  • S.aureus
  • Gram-negs (incl. P.aeruginosa)
  • Anaerobes

Treatment: IV

  • Pip/tazo
  • Cefepime + Metronidazole/Clindamycin
53
Q

What is the recommended duration of antibiotic therapy for DFI where the patient has undergone amputation?

A

2-5 days

54
Q

In DFIs, if bone is not involved, what is the recommended duration of antibiotic therapy in mild, moderate and severe cases respectively?

A
  • Mild: 1-2 wks
  • Moderate: 1-3 wks
  • Severe: 2-4 wks
55
Q

A patient who had a severe episode of DFI, but with no bone involved, has been taking antibiotics for 4 weeks. However, his ulcer has not completely healed. even after therapy. Should the antibiotics therapy continue for this patient?

A

No. Ulcer may not heal fast, but antibiotics should not be continued

56
Q

What are the criteria to determine whether a pressure ulcer is infected?

A 
Same criteria for DFI
- Purulent discharge 
OR
- 2 signs and sx of inflammation 
(e.g. erythema, warmth, tenderness, pain, induration)
57
Q

Are infected pressure ulcers usually monomicrobial or polymicrobial?

A

Polymicrobial

Therapeutics (15 decks)

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