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Home , Erysipelas, Pimple, Pyoderma, Tetanus

Difficult and Soft tissue OHSUErin Bonura, MD, MCR Oregon Health & Science University Objectives

• Compare and contrast the epidemiology and clinical presentation of common skin and soft tissue diseases • State the management for skin and soft tissue infections OHSU• Differentiate true from infectious disease mimics of the skin Casey

Casey is a 2 year old boy who presents with this . What is the best treatment? A. Soap and Water B. Ibuprofen, it will self OHSUresolve C. Dicloxacillin D. Mupirocin OHSUImpetigo Epidemiology and Treatment OHSU Ellen

Ellen is a 54 year old morbidly obese woman with DM, HTN and venous stasis who presented with a painful left leg and . She has had 3 episodes in the last 6 months. What do you recommend? A. Cefazolin followed by oral amoxicillin prophylaxis B. Vancomycin – this is likely OHSUMRSA C. Amoxicillin – this is likely D. to cover staph and strep Impetigo OHSUErysipelas Erysipelas

Risk: , stasis, obesity, paresis, DM, ETOH OHSURecurrence rate: 30% in 3 yrs Treatment: Impetigo

Erysipelas

OHSUCellulitis Cellulitis

• DEEPER than erysipelas • Microbiology: – 6-48hrs post op: think GAS… too early for staph (days in the making)! – Periorbital – Staph, Strep pneumoniae, GAS OHSU– Post Varicella - GAS – Skin popping – Staph + almost anything! Framework for Skin and Soft Tissue Infections (SSTIs)

NONPurulent Purulent Necrotizing/Cellulitis/Erysipelas Furuncle//

Severe Moderate Mild Severe Moderate Mild

I&D I&D I&D I&D IV Rx Oral Rx C&S C&S C&S C&S Vanc + Pip-tazo

OHSUEmpiric IV Empiric MRSA Oral MRSA TMP/SMX Doxy What Are Your “Go-To” Oral Options For Non-Purulent SSTI?

Amoxicillin OHSUCephalexin Doxycycline Trimethoprim-Sulfamethoxazole OHSU

Miller LG, et al. Clindamycin versus Trimethoprim-Sulfamethoxazole for uncomplicated skin infections. NEJM.2015;372(12):1093-1103 Cure rate: Clinda vs TMP/SMX vs Placebo

Clindamycin TMP-SMX Placebo All - ITT 83.1 81.7 68.9 - Evaluated 92.9 92.7 80.5 Children - ITT 89.1 82.4 68.5 - Evaluated 97.8 92.6 82.4 Adults - ITT 79.4 81.4 69.0 - Evaluated 89.7 92.7 79.5 No S. aureus - ITT 83.8 91.9 83.1 OHSU- Evaluated 90.5 90.8 90.8

Daum RS., et al. A placebo-controlled trial of for smaller skin . NEJM. 2017;376(26):2545-2555 What About Prophylaxis?

Erythromycin x 18 m No prophylaxis Complete Prevention 16 Relapse ------8 (One Relapse) (7) OHSU(Two Relapses) (1)

Kremer M, et al. Long-term antimicrobial therapy in the prevention of recurrent soft-tissue infections. J Infect. 1991;22(1):37-40. More Data on Prophylaxis OHSU

Sjoblom AC et al. prophylaxis in recurrent erysipelas. Infection 1993;21:390–3. When Should We Give Prophylaxis?

• 1st: Identify and treat predisposing conditions • If still 3-4 episodes per year • Penicillin or BID x 4-52 weeks or IM benzathine PCN every 2-4 weeks • Continue as long as predisposing factors OHSUpresent

IDSA Practice Guidelines for SSTI. 2014 Jessie is a 32 yo radio host at NPR who volunteers at the local animal shelter. She was bitten by a cat 2 hours ago and comes in for evaluation. She has 2 puncture marks on her L thenar eminence without spreading . Her last shot was 3 years ago. What should you do? A. Treat with amoxicillin B. Treat with amoxicillin-clavulanate OHSUC. Send her to the ED for IV antibiotics D. Wash the wound, give a tetanus booster, and do not give antibiotics Cats…. OHSU

Messer Biting Things 19 Dogs…. OHSU

Messer Biting Things 20 Microbiology of cat and dog bites

Dog Bites Cat Bites • Pasteurella spp (50%) • Pasteurella spp (75%) • Streptococci (46%) • Streptococci (46%) • Staphylococci (46%) • Staphylococci (35%) • Neisseria spp (32%) • Neisseria spp (35%) • Fusobacterium spp (32%) • Fusobacterium spp (33%) OHSU• Capnocyphaga canimorsus • Bartonella henslae

Clin Microbiol Rev. 2011 Apr; 24(2): 231–246.

Messer Biting Things 21 Evaluation and management of animal bites

• Animal – ownership - provocation, History • history • Pt History

• Expose area • Type of Wound • Function Exam OHSU• LAD • No culture if no infection >24hs Further • Xray if suspicion for fracture, osteo, FB • Copious I&D Work up • Possibly closure Who do you treat? OHSU When to give and Tetanus Ig

Previous # Clean and Minor Wounds All other Wounds Toxoid Doses (dirt, feces, soil, saliva, puncture, avulsions, crushing, burns, frostbite) Tetanus toxoid Tetanus Ig Tetanus toxoid Tetanus Ig vaccine

<3 doses YES NO YES YES OHSU>3 doses If >10yrs ago NO If > 5yrs ago NO Jane is a 62 yo female with lupus on prednisone 10 and azathioprine who presents with recurrent MRSA abscesses. She has undergone numerous I&Ds and rounds of antibiotics. What do you suggest?

A. Decolonize with mupirocin and chlorhexidine B. Decrease her immunosuppression OHSUC. Start suppressive antibiotics D. Treat what comes Stringent Decolonization in a German Village (2002-2005)

Personal Items & Linens Body Wash • TID x 5 • Chlorhexidine • Comb • Alcohol days • Skin & Hair • Razor based • Jewlery Mupirocin Gargling • Clothes Tub/Shower OHSU• Sheets

Wiese-Posselt M, et al. Clin Infect Dis. 2007;44(11):e88-95 Stringent Decolonization in a German Village (2002-2005) OHSU

Wiese-Posselt M, et al. Clin Infect Dis. 2007;44(11):e88-95 Eradication of Carriage versus Recurrence of Disease

183 Peds Subjects OHSUCases Decolonization Case Household

Fritz SA, et al. Clin Infect Dis. 2012;54(6):743-51 Eradication versus Recurrence

Recurrence Rate At 12 months • 72% in case OHSU• 52% in household (P=0.02)

Fritz SA, et al. Clin Infect Dis. 2012;54(6):743-51 Management of Recurrent Abscesses

• If occur since childhood, evaluate for defect • If at the same site, evaluate for local cause • Drain and culture • Treat 5-10 days OHSU• *Consider* decolonization

Practice Guidelines SSSI. CID. 2014 Al, is a 65 yo diabetic man with a HbA1c of 10 on insulin. He presents to the ED with a rash over his L buttock that is warm, and extremely tender. He states there was a that popped and over the next few hours this developed. He has a fever to 101 with other vitals stable. On exam, he has a warm, erythematous area of 20x16 cm which is more tender than you would expect on exam and does not have clear demarcations. There is no crepitus. • Pair up with the person next to you. OHSU• What is the working diagnosis? • What is your management? • Look like cellulitis • Spreads along fascia • Pain out of proportion • Rapidly progressive OHSU• Surgical emergency Type I Type II Type III Conventional Name Fournier’s (GU) Streptococcal Gas gangrene Polymicrobial Group A Strep pyogenes S. aureus Host Diabetics Varicella Traumatic injury Immunocompromised Peripheral Vascular Disease OHSURecent Surgery OHSU Empiric Antibiotic Choice

Suspected Option 1 Option 2 Option 3 pathogens Mixed Pip-tazo + vanc Carbapenem Cefotaxime+ metro or clinda Streptococcal Penicillin + Clinda Staph aureus Nafcillin Vancomycin Clindamycin* Clostridial Penicillin + Clinda

*Bacteriostatic; potential cross-resistance and emergence of resistance in OHSUerythromycin resistant strains; inducible resistance in MRSA Clindamycin Data OHSU

Stevens DL., et al. International Journal of Antimicrobial Agents 4 (1994) 297-301 Clindamycin data OHSU

Stevens, DL., et al. Clinical Infectious Diseases, Vol. 20, Supplement 2. Proceedings of the 1994 Meeting of the Anaerobe Society of the Americas (Jun., 1995), pp. S154-S157 OHSU New Case of PG

Sarah is a 32 yo female with a history of IBS who presents to you with this wound. She states it started as a pustule that OHSUprogressed. She has tried multiple course of antibiotics but nothing works. Case of the Non-healing Wound

What is the cause? 1. MRSA 2. Mycobacteria marinum 3. Vascular disease 4. OHSUSweet’s Syndrome 5. gangrenosum OHSU

Instructor Name Session Title and Date Delivered 41 OHSUThank you for your participation!! I would like to acknowledge Dr. Bill Messer & Dr. Melissa Nyendak OHSU When to give toxoid and Tetanus Ig

Previous # Clean and Minor Wounds All other Wounds Toxoid Doses (dirt, feces, soil, saliva, puncture, avulsions, crushing, burns, frostbite) Tetanus toxoid Tetanus Ig Tetanus toxoid Tetanus Ig vaccine vaccine

<3 doses YES NO YES YES OHSU>3 doses If >10yrs ago NO If > 5yrs ago NO Sweet Syndrome OHSU

Instructor Name Session Title and Date Delivered 45 Sweet Syndrome

• Inflammatory • 87% Heme • Many! Bowel Disease • URI, GI • Pregnancy OHSUClassical Malignancy Drug

Instructor Name Session Title and Date Delivered 46 Neutrophilic Infiltration OHSU

Instructor Name Session Title and Date Delivered 47