DOCSLIB.ORG

Lyme Disease Update

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Lyme Disease Update Tick-borne Ilnesses Luciano Kapelusznik, MD Infectious Disease Physician Common Tick Vectors http://facstaff.cbu.edu/~seisen/IxodesSpp.htm 2 Western Black-legged Tick Distribution Lyme diseases Cycle Confirmed Lyme disease cases by age and sex--United States, 2001-2010 Confirmed Lyme cases by month of onset--United States, 2001 -2010 Clinical Manifestations of Confirmed Lyme Cases--US, 2001-2010 Lyme in PA by County Natural History of Untreated Lyme Disease Morrison C et al. J Am Board Fam Med 2009;22:219-222 21 Clinical Stages of Lyme Disease EARLY LOCALIZED Days to Month post tick bite EARLY DISSEMINATED Weeks to Months post tick bite LATE LYME DISEASE Months to Years post tick bite Early Localized Lyme Disease Days – One Month ERYTHEMA MIGRANS (EM) May occur in 80% “Cellulitis” in an atypical location May see a necrotic center ASSOCIATED SYMPTOMS Fever Flu symptoms Adenopathy Headache “Classic” Lyme disease rash Expanding rash with central crust Multiple rashes, disseminated infection Red, oval plaque on trunk Expanding rash with central clearing Bluish rash, no central clearing Red-blue lesion with central clearing Early Disseminated Lyme Weeks - Months . CARDITIS . 5% untreated patients . AV blocks/Cardiomyopathy/Myopericarditis . NEUROLOGIC . 15% untreated patients . Lymphocytic meningitis, encephalitis, cranial neuropathy (III, VI, VII), radiculopathy . SKIN . Days to weeks after EM with multiple irregular sized lesions Late Lyme Disease MUSCULOSKELETAL Seen in about 60% of untreated patients Mono-oligoarticular arthritis - mostly knee(s) Expect 20-30K PMN-predominant joint fluid May include chronic synovitis or a Baker’s cyst CUTANEOUS Acrodermatitis chronica atrophicans Morphea-like lesions (Europe) NEUROLOGIC ? incidence because few cases Encephalomyelitis (cognitive), peripheral neuropathy Diagnosis Lyme Serology: Two-Tier Testing First: EIA/IFA Screen (Total AB) Second: Western blots (immunoblots) IgM: Need 2/3 bands: 23,39,41 kDa Caution: Use only for illness < 1 month Positive IgM WB alone = frequent false (+) Lyme diagnosis Cross reactive with other bacterial and non-bacterial antigens MMWR 1995;44:590 34 Lyme Serology Western blot IgG: Need 5 of 10 potential bands 18,23,28,30,39,41,45,58,66 or 93 kDa More reliable test Usually positive by wk 4-6 of infection MMWR 1995;44:590 35 LYME C 6 Testing in a 2 Tier IgG-only Approach Using only C6 test as a second tier test after a positive ELISA screen 100% C6 peptide ELISA IgG proved 90% positive earlier in the progression of 80% stages of LD (Stage 2) in 2 70% independent labs. 60% This approach eliminates the need for, 50% Std. 2 tier and confusion with, IgM testing. 40% C6 2-tier As a “stand alone” test, C6 had a lower 30% IgM WB sensitivity (96%) and specificity (96%) 20% in late LD than 2-tier testing 10% 0% Stage Stage Stage 1 2 3 Caveats of Lyme Serology Early/appropriate antibiotic therapy may often abort a seroconversion. Background rates of seropositivity maybe higher than 5%. Both ELISA and WB (IgM/IgG) positivity may persist for 10- 20 years. Subsequent infection Dx can only be made clinically. 79% had + 2-tier testing when asymptomatic as controls in prospective study. Misuse of Lyme Serology No serologic “test of cure”, repeated testing after treatment useless. There is no marginal change in WB band conversions – ie: declining number of bands to monitor response to treatment. Early Lyme Disease Treatment Recommendations Doxycycline or Amoxicillin for 10 to 14 days Erythema Migrans Disseminated skin lesions Early neurologic - cranial neuropathy Parenteral Ceftriaxone for 28 days . Early neurologic – meningitis/radiculitis Late Lyme Disease Treatment Recommendations Doxycycline or Amoxicillin po for 28 days . Arthritis . Recurrent arthritis (see below) Ceftriaxone 2 gm IV qd . Central or peripheral nervous system disease . Recurrent arthritis . Cardiac disease Single Dose Therapy for Tick Exposure Considered effective therapy to prevent Lyme disease in the following settings: If tick is attached for at least 36 hours – engorged in and endemic area: Doxycycline 200 mg PO x 1 dose Babesiosis - Epidemiology Parasitic tick-borne infection Agent: Babesia spp. (B. microti, B. duncani, B. divergens) Vector: Blacklegged tick (Ixodes scapularis) Endemic foci in U.S. suspected to be similar to Lyme disease Incubation period: varies based on mode of transmission Tick-borne: 1-3 weeks Blood-borne: weeks to months 42 Babesia microti 43 Babesia spp. Life Cycle 44 Babesiosis Incidence Not previously reportable, so data are limited CT, RI, NY and MA have highest known incidence based on CMS claims data In 2008, 43/50 states had CMS claims for babesiosis Limited data on seasonality and age distribution Majority of treatment dates on CMS claims: July- August 45 Transfusion-transmitted Babesiosis (TTB) Babesia spp. can also be transmitted via blood products Over 100 cases of TTB documented since 1980 11 total deaths documented since 1998 (10 from 2006–2008) There is no licensed screening test available for detecting Babesia spp. in blood donors Current strategy is donor deferral-based approach using a screening question 46 Clinical Signs and Symptoms Ranges from asymptomatic to severe infection Seroprevalence surveys indicate asymptomatic infection common Fever, myalgias, sweats, fatigue, jaundice Hemolytic anemia, thrombocytopenia, elevated liver enzymes Several life-threatening complications Several host factors increase disease severity 47 Diagnosis Microscopy (gold standard) Giemsa/Wright stain Molecular Polymerase chain reaction (PCR) Nucleic acid amplification (NAA) Serology Indirect Fluorescent Antibody (IFA) Babesia spp. IgG (or total Ig) 48 Treatment IDSA Guidelines (Published 2006) http://cid.oxfordjournals.org/content/43/9/1089.full 7–10 days of antibiotic treatment for active cases Atovaquone + azithromycin OR Clindamycin + quinine Oral or IV depending on severity Severe cases may require blood transfusion 49 Kapelusznik et al. 18th International Congress on Infectious Diseases, March 2018. Patients (n = 88) with positive blood smears for Babesia by year and hospital Year Lank BMH Paoli Riddle Total Cases 2008 1 1 2009 1 1 2 2010 1 1 2011 2 4 6 2012 3 2 2 7 2013 3 1 4 2 10 2014 1 2 1 4 2015 2 7 11 6 26 2016 1 7 4 12 2017 5 11 3 19 Totals 8 22 36 22 88 Babesia cases by patient Zip Code of residence Kapelusznik et al. 18th International Congress on Infectious Diseases, March 2018. Ehrlichiosis and Anaplasmosis What are they? Rickettsiaceae family Human Monocytic Ehrlichiosis (HME) Lone star tick Human Granulocytic Anaplasmosis (HGA) Ixodes ticks Where is it? Everywhere Human Monocytic Ehrlichiosis E. chaffeensis First described in 1987 Primarily infects mononuclear cells Reservoir: deer, dogs, goats Vector: Lone star tick (Amblyomma americanum) Human Granulocytic Anaplasmosis First described in 1994 Organism recently named Anaplasma phagocytophilum. Reservoir: deer, rodents, elk Vector: Ixodes ticks Ehrlichiosis and Anaplasmosis SIGNS AND SYMPTOMS Incubation period: 5 - 10 days Early symptoms are non-specific (“flu-like”) Fever, headache, myalgias GI symptoms can occur Rash variable Laboratory Leucopenia, thrombocytopenia, abnormal liver enzymes Ehrlichiosis and Anaplasmosis COMPLICATIONS Can be very severe Renal failure ARDS DIC Encephalitis 3% mortality Worse in patients with impaired host defenses Watch out for dual or triple infections with Borrelia burgdorferi and Babesia Ehrlichiosis and Anaplasmosis DIAGNOSIS Peripheral smear looking for morulae Serology PCR (state laboratories) Culture Treat based on epidemiologic and clinical clues. Do not delay while waiting for confirmation. Ehrlichiosis and Anaplasmosis Morulae Ehrlichiosis and Anaplasmosis TREATMENT Treatment should not be delayed until laboratory confirmation is obtained Doxycycline: 100 mg PO/IV Until 3 days after fever abates Expect response in 24 - 72 hours Pregnancy and children ??? Rifampin 600 mg IV/PO has been used How can you protect yourself from ticks? Wear long pants tucked into your socks to keep ticks off you. Wear long-sleeved shirts and, light colored clothes to make it easier to Use bug spray spot ticks. What if you find a tick on you? Carefully remove ticks with a pair of fine point tweezers. Wash the bite with soap and water. Do not use gasoline or a match. Do not use Vaseline. Protect yourself from ticks. When you have been outside… Check for ticks on your body every day. Prevent Lyme Disease Make your yard Before safer—create a dry path between woods and your yard. After Pets can get Lyme Disease, too. Check your pet for ticks after it has been outside. There are collars, sprays, powders, and other treatments to stop ticks from biting your pet. Ask your veterinarian for advice on protecting your pet from tick bites. .
Load more

Recommended publications
  • Cellulitis (You Say, Sell-You-Ly-Tis)
    Cellulitis (you say, sell-you-ly-tis) Any area of skin can become infected with cellulitis if the skin is broken, for example from a sore, insect bite, boil, rash, cut, burn or graze. Cellulitis can also infect the flesh under the skin if it is damaged or bruised or if there is poor circulation. Signs your child has cellulitis: The skin will look red, and feel warm and painful to touch. There may be pus or fluid leaking from the skin. The skin may start swelling. The red area keeps growing. Gently mark the edge of the infected red area How is with a pen to see if the red area grows bigger. cellulitis spread? Red lines may appear in the skin spreading out from the centre of the infection. Bad bacteria (germs) gets into broken skin such as a cut or insect bite. What to do Wash your hands before and Cellulitis is a serious infection that needs to after touching the infected area. be treated with antibiotics. Keep your child’s nails short and Go to the doctor if the infected area is clean. painful or bigger than a 10 cent piece. Don’t let your child share Go to the doctor immediately if cellulitis is bath water, towels, sheets and near an eye as this can be very serious. clothes. Make sure your child takes the antibiotics Make sure your child rests every day until they are finished, even if and eats plenty of fruit and the infection seems to have cleared up. The vegetables and drinks plenty of antibiotics need to keep killing the infection water.
    [Show full text]
  • Skin Disease and Disorders
    Sports Dermatology Robert Kiningham, MD, FACSM Department of Family Medicine University of Michigan Health System Disclosures/Conflicts of Interest ◼ None Goals and Objectives ◼ Review skin infections common in athletes ◼ Establish a logical treatment approach to skin infections ◼ Discuss ways to decrease the risk of athlete’s acquiring and spreading skin infections ◼ Discuss disqualification and return-to-play criteria for athletes with skin infections ◼ Recognize and treat non-infectious skin conditions in athletes Skin Infections in Athletes ◼ Bacterial ◼ Herpetic ◼ Fungal Skin Infections in Athletes ◼ Very common – most common cause of practice-loss time in wrestlers ◼ Athletes are susceptible because: – Prone to skin breakdown (abrasions, cuts) – Warm, moist environment – Close contacts Cases 1 -3 ◼ 21 year old male football player with 4 day h/o left axillary pain and tenderness. Two days ago he noticed a tender “bump” that is getting bigger and more tender. ◼ 16 year old football player with 3 day h/o mildly tender lesions on chin. Started as a single lesion, but now has “spread”. Over the past day the lesions have developed a dark yellowish crust. ◼ 19 year old wrestler with a 3 day h/o lesions on right side of face. Noticed “tingling” 4 days ago, small fluid filled lesions then appeared that have now started to crust over. Skin Infections Bacterial Skin Infections ◼ Cellulitis ◼ Erysipelas ◼ Impetigo ◼ Furunculosis ◼ Folliculitis ◼ Paronychea Cellulitis Cellulitis ◼ Diffuse infection of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin – Triad of erythema, edema, and warmth in the absence of underlying foci ◼ S. aureus or S. pyogenes Erysipelas Erysipelas ◼ Superficial infection of the dermis ◼ Distinguished from cellulitis by the intracutaneous edema that produces palpable margins of the skin.
    [Show full text]
  • Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA)
    Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA) INTRODUCTION AND PURPOSE In November 2006, the Connecticut Attorney General (CAG), Richard Blumenthal, initiated an antitrust investigation to determine whether the Infectious Diseases Society of America (IDSA) violated antitrust laws in the promulgation of the IDSA’s 2006 Lyme disease guidelines, entitled “The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America” (the 2006 Lyme Guidelines). IDSA maintained that it had developed the 2006 Lyme disease guidelines based on a proper review of the medical/scientifi c studies and evidence by a panel of experts in the prevention, diagnosis, and treatment of Lyme disease. In April 2008, the CAG and the IDSA reached an agreement to end the investigation. Under the Agreement and its attached Action Plan, the 2006 Lyme Guidelines remain in effect, and the Society agreed to convene a Review Panel whose task would be to determine whether or not the 2006 Lyme Guidelines were based on sound medical/scientifi c evidence and whether or not these guidelines required change or revision. The Review Panel was not charged with updating or rewriting the 2006 Lyme Guidelines. Any recommendation for update or revision to the 2006 Lyme Guidelines would be conducted by a separate IDSA group. This document is the Final Report of the Review Panel. REVIEW PANEL MEMBERS Carol J. Baker, MD, Review Panel Chair Baylor College of Medicine Houston, TX William A. Charini, MD Lawrence General Hospital, Lawrence, MA Paul H.
    [Show full text]
  • Sepsis and Septic Shock: Endothelial Molecular Pathogenesis Associated with Vascular Microthrombotic Disease Jae C
    Chang Thrombosis Journal (2019) 17:10 https://doi.org/10.1186/s12959-019-0198-4 REVIEW Open Access Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease Jae C. Chang Abstract In addition to protective “immune response”, sepsis is characterized by destructive “endothelial response” of the host, leading to endotheliopathy and its molecular dysfunction. Complement activation generates membrane attack complex (MAC). MAC causes channel formation to the cell membrane of pathogen, leading to death of microorganisms. In the host, MAC also may induce channel formation to innocent bystander endothelial cells (ECs) and ECs cannot be protected. This provokes endotheliopathy, which activates two independent molecular pathways: inflammatory and microthrombotic. Activated inflammatory pathway promotes the release of inflammatory cytokines and triggers inflammation. Activated microthrombotic pathway mediates platelet activation and exocytosis of unusually large von Willebrand factor multimers (ULVWF) from ECs and initiates microthrombogenesis. Excessively released ULVWF become anchored to ECs as long elongated strings and recruit activated platelets to assemble platelet-ULVWF complexes and form “microthrombi”. These microthrombi strings trigger disseminated intravascular microthrombosis (DIT), which is the underlying pathology of endotheliopathy- associated vascular microthrombotic disease (EA-VMTD). Sepsis-induced endotheliopathy promotes inflammation and DIT. Inflammation produces inflammatory response
    [Show full text]
  • Perianal Streptococcal Infection Kumara V
    CASE REPORT Perianal Streptococcal Infection Kumara V. Nibhanipudi, MD A 3-year-old boy is brought to the ED for evaluation of perianal desquamation. Case The mother of a 3-year-old boy presented her son to the ED for evaluation after she noticed peeling of the skin in his perianal region. She stated that the peeling had started 1 day prior to presentation. Two days earlier, the mother had brought the same patient to the ED for evaluation of a fever, sore throat, and a slight rash over his face. The boy’s vital signs at the initial presentation were: temperature, 101.8°F; heart rate, 102 beats/minute; and respira- tory rate, 28 breaths/minute. Oxygen satu- ration was 98% on room air. During this first visit, the mother denied the child having had any fever, chills, headache, sore throat, facial rash, joint pain, or pain on defecation. He had no significant medical history and no known drug allergies. After examination, a throat culture was taken, and the patient was giv- en acetaminophen and discharged home with a diagnosis of viral syndrome. At the second presentation, physical examination revealed a well-developed child in no distress. The examination was negative except for a 4 x 2 cm area of des- quamation present over the perianal region (Figure). The area of desquamation was dry, mild- Figure. Photograph of the patient’s perianal region showing the area of desquamation. ly erythematous without discharge, and Dr Nibhanipudi is a professor of clinical emergency medicine at New York Medical College - Metropolitan Hospital Center, New York.
    [Show full text]
  • Cellulitis: a Review of 62
    Clinical Review & Education Review Cellulitis A Review Adam B. Raff, MD, PhD; Daniela Kroshinsky, MD, MPH CME Quiz at IMPORTANCE Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting jamanetworkcme.com with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650 000 admissions per year in the United States alone. OBSERVATIONS In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S aureus, with expansion for methicillin-resistant S aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence. CONCLUSIONS AND RELEVANCE The diagnosis of cellulitis is based primarily on history and Author Affiliations: Harvard Medical physical examination. Treatment of uncomplicated cellulitis should be directed against School, Massachusetts General Streptococcus and methicillin-sensitive S aureus. Failure to improve with appropriate first-line Hospital, Boston. antibiotics should prompt consideration for resistant organisms, secondary conditions that Corresponding Author: Daniela mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic Kroshinsky, MD, MPH, liver disease, or chronic kidney disease.
    [Show full text]
  • Facial Impetigo and Preseptal Cellulitis Associated with Job's Syndrome, A
    Facial impetigo and preseptal cellulitis associated with Job’s Syndrome, a rare hyperimmunoglobinemia E syndrome (HIES) C Tong, OD; R Frick, OD, FAAO; D Hitchmoth, OD, FAAO This case discusses the diagnosis and management of severe preseptal cellulitis caused by Job’s Syndrome. This disease compromises several body systems, especially the immune system, and causes recurrent infections. I. Case History -67 year-old white male presents from the emergency department with marked erythema, edema and crusted lesions of both eyelids OD and face for 2 days -Medical history: Job’s Syndrome, hyperlipidemia and Neurofibromatosis Type 1 -Medications: Enoxaparin, Ibuprofen, and Simvastatin. II. Pertinent findings -Best corrected vision: R 20/25 and L 20/30 -Marked honey-colored, encrusted, exudative lesions on upper and lower lids OD, left forehead, and extremities with OD swollen shut -Flat and raised, coffee colored lesions along extremities and trunk -No fever, lymphadenopathy or other systemic complaints -Pupils normal with no afferent defect -No proptosis -Extraocular muscles intact with no diplopia and no pain/paresthesia along cranial nerve V -Anterior and posterior segment unremarkable except iris lisch nodules OU -Computed tomography (CT) with contrast of the orbits found preseptal soft tissue changes [cellulitis] and normal post-septal space without other orbital abnormalities. III. Differential Diagnoses - Preseptal Cellulitis, Herpes Zoster Ophthalmicus, orbital cellulitis, insect bite, hordeola, infectious dermatitis, allergic dermatitis, orbital lymphoma, orbital neurofibroma, Pott’s puffy tumor and other sinus infection IV. Diagnosis and Discussion - Job’s Syndrome, or HIES, is a rare, inherited disease marked by high levels of immunoglobulin E (IgE), an antibody that triggers immune responses against parasites, infections and noninfectious allergens -Patients with HIES often have multi-system ailments involving skin, bones, or lungs and present with recurrent, dramatic skin infections -The exudative skin lesions were classic for impetigo ecthyma.
    [Show full text]
  • ABX-2 Newslet: Cystitis & Skin
    Antibiotics & Common Infections ABX-2: Uncomplicated Cystitis & Skin Stewardship, Effectiveness, Safety & Clinical Pearls- April 2017 ABX-2 RELATED LINKS RxFILES ACADEMIC DETAILING ON ABX CANADIAN GUIDELINES/REFERENCES We are excited to bring out the ABX-2 topic on the treatment of uncomplicated cystitis Bugs & Drugs: and skin & soft tissue (SSTI) infections. The new charts in this newsletter will support http://www.bugsanddrugs.ca/ our spring academic detailing discussions with providers in Saskatchewan. Our MUMS Guidelines: discussions on ABX-1 were very well received and we know many of you made use of the http://www.mumshealth.com extra support tools such as the “Gone Viral?” office/clinic posters and the patient friendly “Viral Prescription Pad”. These are all available at www.RxFiles.ca/abx. CYSTITIS / UTI U.S. IDSA 2010: ABX-2: A FEW PEARLS FROM INSIDE THAT CAUGHT OUR EYE... Acute Uncomplicated Cystitis and Pylonephritis (UTI) UNCOMPLICATED CYSTISIS - Page 2 - 3 > 60 YEARS https://academic.oup.com/cid/article- lookup/52/5/e103 1) Staying Power: > 60 years & still 96% or better! Susceptibility of E. coli, the most common urinary pathogen, to nitrofurantoin SK MOH 2013: (MACROBID) remains at 96% or better in Saskatchewan (per recent antibiograms). UTI in Continuing Care Settings “I used to be https://saskpic.ipac-canada.org/ so strong...” STAYING POWER photos/custom/UTI%20Guidelines%20 2) 60% - Are you kidding?! 19April2013.pdf In some institutional settings, like long-term care, E. coli resistance to ciprofloxacin can be as high as ~60%. No wonder antimicrobial SOGC 2010: stewardship messaging suggests “Reserve to Preserve” for when we really Recurrent UTI C IPROFLOXAC I N need it! http://www.jogc.com/article/S1701- 2163(16)34717-X/pdf 3) Urine cultures are not required - for most Skip the Urine Req.
    [Show full text]
  • Bacterial Skin Infections
    What is Impetigo? • When treated appropriately, impetigo heals over a • Avoid touching the infected areas and prevent others • Impetigo is a superficial bacterial infection of the few days without leaving scars, although there may from touching them too. skin. be temporary redness and darker pigmentation that • Wash hands after touching affected area. • The most common bacteria causing impetigo is may take weeks or months to resolve. • Wash hands before and after applying creams or Staphylococcus aureus, or “Staph aureus”. Less ointments to the affected area. commonly, it can be caused by another bacteria, How is impetigo diagnosed? • Do not share towels or personal items until the Streptococcus. • Impetigo is diagnosed by the typical appearance and infected area is completely healed. Bacterial Skin • Impetigo is common in young children but can symptoms. • Do not let your child return to school or childcare also affect people of other ages, especially those • A skin swab from the affected area may be taken to facilities until the lesions are dried and healed. Infections with skin that is damaged by cuts, insect bites, or identify the bacteria. eczema. • If the infection recurs, a swab from your child’s nose What is erysipelas/cellulitis? • The bacteria can spread by skin-to-skin contact or by to test for the presence of “Staph aureus” may be • Erysipelas and cellulitis are bacterial infections touching contaminated surfaces such as towels and indicated. affecting deeper layers of skin. clothes. • The most common bacteria causing erysipelas or How is impetigo treated? cellulitis is Streptococcus, but other bacteria may be Treatment depends on the severity and extent of the involved, including Staphylococcus aureus.
    [Show full text]
  • Skin and Soft Tissue Infections in the ED Cellulitis Cellulitis
    Skin and Soft Tissue Skin and Soft Infections in the ED Tissue Infections • Recognize the most common skin and soft in the ED tissue infections and the FEW infections which are TRUE EMERGENCIES • Discuss the diagnosis and treatment of Daniel R. Martin, MD, MBA, FACEP, FAAEM common cases of cellulitis and abscesses Clinical Professor Department of Emergency Medicine • Discuss indications for surgical consult, Vice Chair of Education Dept. of Emergency Medicine admission and systemic antibiotics The Ohio State University Wexner Medical Center • Evaluate the treatment of “Special Cases” in skin and soft tissue infections! Cellulitis • Involves skin and sub-cutaneous tissues • Etiology: Group A Strep, S. aureus Cellulitis • Usually inciting trauma, skin break or tinea • Differential Diagnosis ‒ DVT ‒ Erythema Nodosum ‒ Venous Stasis ‒ Dermatitis 1 Cellulitis Cellulitis Treatment • What you should expect to see… • Penicillinase-resistant penicillin warmth, erythema and swelling • Cephalosporin • Clindamycin • If MRSA suspected clindamycin or Bactrim/cephalexin, doxycyclene Lymphangitis Pearls and Pitfalls • Etiology: usually Group A Strep with spread into the • Consider X-rays or CT to check for gas subcutaneous lymphatics and enlarged tender • Mark the borders of the cellulitis regional LNs • Cultures of the ”leading edge” • Clinically: red streaks with ‒ Yield = 10% distal site of infection and proximal adenopathy • Know your local susceptibilities • Treatment: rest, elevation, • BEWARE of toxic presentations! Penicillinase resistant pcn
    [Show full text]
  • Ed/Uc Abscess/Cellulitis Algorithm
    CLINICAL PATHWAY ED/UC ABSCESS/CELLULITIS ALGORITHM Suspected Abscess/Cellulitis Inclusion Criteria Suspected Abscess/Cellulitis Exclusion Criteria Age <60days *High Consider Immuno-compromised Yes Risk? Specialty Consult Medically Complex (CF, hardware, etc.) Critically Ill *High Risk Concern for necrotizing fasciitis (pain out (Consider Specialty Consult) of proportion, crepitus, etc.) • Concern for joint involvement Major trauma • Facial, eye ! Secondary wound infection • Dental Sample (puncture, dog bite, etc.) • Neck of pus in a syringe is No • Labial • preferred Recurrent peri-rectal (see details below) (swab can be sent if • Recurrent pilonidal cysts there is minimal pus) • Hidradenitis Culture & Antibiotics: • Clindamycin Discharge I&D OR or Drainable? • Sulfamethoxazole & Consider Admission and + Pain Control **High Risk *Consider ultrasound if Yes Yes Trimethoprim (Bactrim) (see text for Characteristics? Surgical Consult for: equivocal more OR Any red flags, toxic appearing, • information) For peri-rectal or pilonidal: high risk sites, failed outpatient Amoxicillin-clavulanic acid treatment ! (Augmentin) No No Packing! Routine Wound Care No Wound stent (wick) or loop procedure No antibiotics/culture should be performed if needed, see text for details **High Risk Characteristics (Consider Antibiotics) Cellulitis: • Cellulitis extending significantly beyond • Outline cellulitis and add picture the boundaries of fluctuance to chart if possible • <2yrs old (with fever and/or fussiness) • Treat pain • Inadequate I&D • F/U in 24-72hrs
    [Show full text]
  • Identify Signs and Symptoms That May Indicate a SSTI List
    SKIN AND SOFT TISSUE INFECTIONS (SSTIs) Learning Objectives: ● Identify signs and symptoms that may indicate a SSTI ● List common causative organisms and risk factors for SSTIs ● Distinguish between antibacterial treatments for SSTIs in the organisms they cover ● Describe supportive therapies that may be indicated in treatment of SSTIs Patient Case: Chief Complaint: “I have a boil on my butt, and I cannot sit down for class.” HPI: Jimmie Chipwood is a 19-year-old college student who presents to the ED with a new-onset “boil” on his right buttock. He noticed some pain and irritation in the right buttock area over the past week, but thought it was due to having slid into second base during a baseball game. The pain gradually increased over the next few days, and he went to the student health center, where they cleaned the wound and gave him a prescription for clindamycin 300 mg QID for 7 days. They recommended he try to keep the area covered until the antibiotic began to work. Today, Jimmie returned to the student health center for further evaluation and was referred to the ED for further care for his continued SSTI. At the ED, Jimmie says the area on his buttock is worse, and he cannot sit down for class. He reports only partial adherence to the clindamycin regimen, because he often forgets to take it and says it makes him nauseous. PMH: Right gluteal skin and soft tissue infection, diagnosed approximately 1 week ago (Rx for clindamycin was given, but the patient reports nonadherence); 2010--appendectomy; 2012--repair of left ACL Meds: Prescription ● Clindamycin 300 mg PO QID × 7 days (prescribed at student health center visit 1 week ago; patient did not complete full course).
    [Show full text]