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1-10-10 Bacterial skin and soft-tissue infections 1.

List the most common skin infection syndromes and describe their presentation and treatment. The common skin infection syndromes include impetigo, erysipelas, folliculitis, furuncles/carbuncles, skin abscess, and cellulitis. Impetigo: superficial vesiculopustular infection that subsequently ruptures and produces a golden crust An intraepidermal infection most commonly caused by group A strep (GAS), but can also be caused by S. aureus Risk factors include humidity, children, poverty/living in crowded places, poor hygiene, spreading within families Presentation with multiple red and tender lesions on face and extremities, often at sites of minor skin trauma There may be some systemic involvement (fever, elevated wbc), but is very mild; maybe some lymphadenopathy Diagnosis is clinical, should include herpes, varicella and psoriasis as differential Treat with topical or systemic antibiotics against GAS and S. aureus (penicllins or cephalosporins; topical mupirocin or retapamulin) Bullous impetigo is seen in newborns and children, and is caused by a specific form of S aureus that produces exfoliative toxins ETA and ETB Erysipelas: superficial skin infection marked by edema in the skin with sharp demarcation between involved and normal tissue, often with prominent lymphatic involvement Caused by GAS Risk factors include young children, older adults, venous stasis, diabetes, alcohol, nephritic syndrome, local edema/lymphatic obstruction (i.e. after radical mastectomy) Presents as bright red, edematnous, indurated lesion on lower extremities or face Diagnose clinically Treat with systemic penicillin Folliculitis: infection of the hair follicles Caused by S aureus (carried in the nose), P. aeruginosa (carried in whirlpools and hot tubs), and Candida (associated with antibiotic or corticosteroid administration) Presents as multiple small erythematous raised lesions with a central pustule. May have very limited systemic toxicity (fever, high wbc). Lesions may spontaneously drain without scarring or progress to furunculosis, especially in the immunocompromised. Diagnosis is clinical Therapy is via antimicrobials Furunculosis and carbuncles: a furuncle (boil) is a deep inflammatory nodule involving the hair follicle that results from progression of folliculitis. A carbuncle is a collection of abscesses in subcutaneous tisse that drain via hair follicles; it can also be a collection of

furuncles. Both are caused exclusively by S. aureus, especially MRSA! Risk factors include areas of skin containing hair follicles exposed to friction and perspiration (Back of the neck, face axilla, buttocks). Predisposing factors include obesity and corticosteroid therapy. Presents as painful nodules that drain spontaneously. May have limited systemic toxicity (fever being more common in carbuncles) Diagnosis is clinical Therapy: warm compresses, systemic antibiotics for S aureus, drainage of carbuncles. Complications include bacteremia. For recurrent episodes, use chlorhexadine washes and mupirocin nasal ointment to eliminate carriage of S. aureus Skin abscess: localized accumulations of PMNs with tissue necrosis involving the dermis and subcutaneous tissue. They are similar to carbuncles but do not arise from follicles and are deeper than carbuncles. Caused by S aureus. MRSA is now common. Moreover, abscesses can be polymicrobial, especially when the form as a consequence of injection drug use when they will contain human mouth flora (anaerobes) and enteric gram negative bacteria (E coli) Risk factors include skin trauma, injection drug use, bactermic seeding of skin Presents with local pain, edema, erythema, regional lymphadenopathy, spontaneous discharge of pus. Systemic involvement is rare unless the patient also has cellulitis Diagnosis is clinical, though one can culture the purulent drainage to guide antimicrobial therapy. Therapy includes surgical drainage and systemic antibiotic therapy. To address MRSA, TMP-SMX (Bactrim) should be combined with clyndamycin or doxycycline. Patients with systemic signs may require IV antibiotics such as vanco. IV drug users must also take antibiotics for anaerobes and enteric gram negatives. Cellulitis: infection of the skin with extension to subQ tissues Caused by GAS or S. aureus. MRSA is NOT a common cause of cellulitis. Risk factors include local trauma, venous/lymphatic insufficiency, diabetes, and alcoholism Presents with erythema, edema, diffuse tenderness, indistinct borders, regional lymphadenopathy, and systemic toxicity (fever and chills!) Diagnosis is clinical, with differentials of DVT and necrotizing soft tissue infection, which unlike cellulitis would be a surgical emergency Therapy includes elevation of extremity and antibiotic therapy for GAS and S. aureus 2. Describe the severe skin and soft-tissue infections and know their presentations and treatment. This is referring to necrotizing soft-tissue infections as well as myonecrosis.

Necrotizing soft-tissue infections: rare but often fatal (mortality rate of 30%) infection involving deep soft tissues and superficial layers of fascia, resulting in progressive destruction of the fascia and fat. all types of necrotizing infections are characterized by progressive necrosis of the deep subQ tissue, with late involvement of the superficial skin GAS is the most common cause, though it depends on disease type Risk factors generally include diabetes and immunocompromising illnesses Presents as severe pain and rapid progression. There is swelling in the area with/ without erythemia. Systemic signs of fever and elevated wbc are common Diagnosis requires a high index of suspicion and must be prompt. Clinical differentiation from cellulitis is difficult, so looking for clues such as edema/ induration greater than the area of erythema, presence of bullae, presence of subcutaneous gas, and lack of lymphangitis or lympadenopathy helps tremendously. CT or MRI may show induration (swelling) of deep soft tissues. Findings at surgery/pathology are the only way to confirm diagnosis, but by then its too late. Therapy includes surgical debridement. Empiric therapy must cover GAS (penicillin as drug of choice, often given alongside clindamycin). If gram negative bacilli is present, one must also use a broad spectrum piperacillin_tazobactam or a carapenem. High risk MRSA cases require vanco. There are specific types of necrotizing soft-tissue infections with special considerations: Clostridial cellulitis: due to C. perfringens acquired from local trauma such as crush injuries or surgery Necrotizing fasciitis type I: polymicrobial infection with anaerobes, enertobacteria, and streptococci other than GAS Necrotizing fasciitis type II: monomicrobial infection of GAS (called hemolytic streptococcal gangrene) Fourniers gangrene: must involve the scrotal sac of the male and the perianal area; aka idiopathic scrotal gangrene; caused by anaerobes Monomicrobial necrotizing cellulitis: caused by MRSA Monomicrobial necrotizing cellulitis: caused by Vibrio vulnificans from eating raw oysters. Progresses to systemic infection in patients with cirrhosis. Synergistic necrotizing cellulitis: mix of anaerobic bacteria and enteric gram negative bacilli Myonecrosis: infection of muscle following a deep penetrating injury. Aka gas gangrene caused by C. perfringens, though C. septicum may also cause spontaneous nontraumatic diseasevia a GI portal of entry, such as adenocarcinoma. Clostridial toxins cause myonecrosis Risk factors include trauma with penetrating injury. Presents with severe pain, crepitus, bronze colores skin, bullae; systemic toxicity causes tachycardia and hypotension Diagnosis involves history of injury and clinical findings of air in the soft tissue

(i.e. crepitus identified via X-ray, since itll hurt to identify by physical exam

Treat with emergency surgical debridement. Penicillin + clindamycin

3. Know the microbiology of human and animal bite skin infections and the appropriate therapy. Animal bite wounds Most bites are polymicrobial and include Streptococcus, S. aureus, Pasteurella species (both dogs and cats), Pasteurella multocida (cats), and Pasteurella canis (dog). Dog bites are often open wounds Cat bites are puncture wounds and are more likely to develop infection A wound thats presented within the first 8 hours is contaminated, while a wound thats presented after 8 hours is infected. Diagnosis is based on physical findings; must exclude fractures or penetrating joint injuries. For treatment, wounds must be cleaned and left open. Most patients should be treated with antibiotics for 3-5 days for contaminated wounds, longer for established infection. Rabies is not a threat in the US, but is in other countries. Human bite wounds Actually have a higher complication and infection rate than animal bites Usually polymicrobial consisitin of Staph, S. aureus and anaerobes. Eikenella corrodens is seen in 25% of cases Occlusional human bites most often involve the hand. 10-20% of bites are love nips of the breasts and genital areas. Clenched fist injuries are traumatic lacerations that occur when punching. Frequently deep structures like joints and bones are involved. As with animal bites, human bites presenting within the first 8 hours are contaminated, after 8 hours are infected. Diagnose based on history and physical findings; exclusion of fractures and penetrating joint injuries Wounds should be cleaned and left open, treated w/ antibiotics for 3-5 days for contaminated wounds, longer for established infection.