SKIN AND SOFT TISSUE

SIGNS & SYMPTOMS • , warmth, tenderness, , , purulence Epidermis Necrotizing • Systemic signs: Temp. >38°C, HR >90, RR >24 or WBC soft <12,000 or <300 cells/uL tissue Sweat infection gland Hair (NSTI) HISTORY Dermis follicle

• Onset of signs/symptoms? Progression? • Association with trauma? Subcutaneous • Burn(s), frostbite, pressure ulcer, post-surgical? tissue • Environmental risks? Vaccination history? Fascia Muscle • Severity of pain? Radiation? Furuncle • Loss of function? Joint involvement? Carbuncle Non-Purulent SSTI

Erysipelas Associated with fever, well demarcated erythema Group A (GAS)

Non-bullous: painless, erythematous base w/ honey-crusted exudate S. aureus, GAS on face/limbs Impetigo Bullous: clusters of bullae/solidary lesions of exudate + Toxin producing S. aureus desquamation

Edema, pain, poorly demarcated erythema. Orbital cellulitis is a Cellulitis GAS, S. aureus medical emergency!

Generally, rapidly evolving, pain out of proportion, erythematous rash Polymicrobial Necrotizing Monomicrobial w/ fever, toxic appearance, & thrombocytopenia. Hemodynamically GAS, MRSA, Soft Tissue S. aureus most VRE, (NSTI) unstable. common Purulent SSTI (Drainable Collection)

Cutaneous / Deep Soft S. aureus (community-acquired Collection of Tissue Abscess MRSA), GAS

Furuncles, Carbuncles Furuncles () are skin that involve a hair S. aureus (including MRSA), GAS + Cellulitis follicle. Carbuncles are clusters of furuncles. Mild: cellulitis, erysipelas, + purulence Cellulitis, Erysipelas, Moderate: above w/ systemic signs Furuncle, Necrotizing infection Severe: failed oral antibiotics, systemic symptoms, Carbuncle, Abscess immunocompromised, signs of deeper infection (bullae, skin sloughing, hypotension, organ dysfunction)

MILD MODERATE SEVERE MILD MODERATE SEVERE

Oral Intravenous Emergent surgical Incision and I&D PLUS I&D PLUS Debridement Cephalexin Cefazolin OR inspection, debridement Cephalexin PO Vancomycin IV (I&D) Cloxacillin OR R/o necrotizing process OR Cloxacillin Cefazolin IV Ceftriaxone OR Empiric Rx: 1) Vancomycin 2) PLUS Piperacillin- C&S for definitive Tazobactam C&S of purulent fluid for management 3) PLUS Clindamycin* definitive management

NSTIs IN PEDIATRICS EAGLE EFFECT 1) No skin manifestations in up to 50% of cases. The Eagle Effect is the paradoxical effect of 2) A prolonged prodrome or perceived slow onset reduced penicillin efficacy at higher antibiotic should NOT rule out an NSTI. doses. Clindamycin also inhibits bacterial 3) May present with multifocal sites. Always check for toxin production. additional sites during the physical exam.

Published December 2020 Alexander Perry (Medical Student 2021, University of Alberta), Courtney Wilkes (Plastics PGY-5, University of Alberta) & Dr. Jaret Olson (Pediatric Plastic Surgeon, University of Alberta) for www.pedscases.com