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Cellulitis

Cellulitis. Presented by Wendy Gerstein, MD Thursday School 7/24/14. Question 1.

shelley-reese
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Cellulitis

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  1. Cellulitis Presented by Wendy Gerstein, MD Thursday School 7/24/14

  2. Question 1 • 38 yo woman is evaluated in urgent care for redness and pus that developed near a scratch on her right shin. On PE: T=37.3 C, bp 135/75, p 78, rr 14. A 3x2 cm erythematous, warm patch is present over the right shin with associated purulence/pus, but no fluctuance, drainable abscess or lymphadenopathy is present. WBC is 10k with 70% N and 30% L. She has no drug allergies. • Which of the following is the most appropriate outpatient therapy? • A) Cephalexin (Keflex) • B) Dicloxacillin • C) Trimethoprim-sulfamethoxazole (Bactrim) • D) Amoxicillin

  3. Question 2 • A 27 yo male is evaluated for redness that developed over his left forearm at the site of a mosquito bite. He is otherwise healthy and takes no medications. PE: T= 37.2 C, bp 120/70, p 68, rr 14. There is an erythematous 3x3 cm patch on the left forearm. The area is warm to the touch with no evidence of purulence, fluctuance, crepitus, or lymphadenopathy. • Which of the following is the most appropriate empiric outpatient therapy? • A) Doxycycline • B) Cephalexin (Keflex) • C) Fluconazole • D) Trimethoprim-sulfamethoxazole (Bactrim) • E) Metronidazole

  4. answers • Answer for question 1: C, Bactrim • Answer for question 2: B, Cephalexin (Keflex) • What is the one important difference between the two cases?

  5. Cellulitis

  6. Cellulitis • Clinical presentation: local tenderness, pain and erythema that rapidly increases. Borders are not elevated or sharply demarcated (as in erysipelas). May have patchy involvement with skip areas. • Systemic manifestations include mild fever, chills and malaise, can progress to sepsis.

  7. cellulitis • Complications can include bacteremia, abscesses, overlying skin necrosis, muscle/joint/bone involvement. • Risk factors: lymphedema, chronic venous stasis, trauma, skin breakdown (fungal infection), diabetes, immunosuppression, altered anatomy/surgery. • Patient who are showing systemic signs (i.e., meet SIRS criteria) should be admitted for initial treatment with IV antibiotics, then transition to appropriate oral therapy.

  8. organisms • Most common organisms: streptococci (group A β-hemolytic [GABHS] most likely) and Staphylococcus aureus. • Think strep if “peaud’orange” skin changes and lymphangitis are present. • Think S. aureus (and CA-MRSA, MRSA) if purulence or abscess present. • Erysipelas: superficial, well-demarcated, intensely erythematous, indurated borders. GABHS.

  9. Cellulitis • Post-operative infections with Group A strep are uncommon but can spread rapidly and develop into bacteremia/sepsis. Can occur within 6-48 hours after surgery. • Hypotension may be the first signs of infection prior to cellulitis. • Thin serous discharge may be expressed from the surgical site that is gram stain positive for streptococci.

  10. Cellulitis • Diabetics: at risk for polymicrobial infections including: • GPC including S. aureus, Enterococcus, various streptococcal species, peptostreptococcus (anaerobe). • GN aerobes: Enterobacter, Acinetobacter, and Pseudomonas. • GN anaerobes: Bacteroides

  11. Antibiotics in Cellulitis • At minimum, need empiric coverage for strep species and S. aureus. • Include a β-lactam antibiotic with activity against penicillinase-producing S. aureus(MSSA). • If not severe may treat as outpatient. • Cephalexin or dicloxacillin have good strep and MSSA coverage. • Clindamycin may be used for strep and CA-MRSA (know local antibiogram). • If suspect MRSA then consider TMP-SMX or doxycycline (can add clindamycin or amoxillin if need improved strep coverage). May also consider Linezolid.

  12. Antibiotics cont. • Inpatient antibiotic choices: • Strep/MSSA choices: nafcillin, cefazolin, clindamycin • CA-MRSA/MRSA: clindamycin (know antibiogram), vancomycin, daptomycin, linezolid, ceftaroline. • Diabetics: broaden to amp-sulbactam (moderate infection), pip/tazobactam (severe) plus MRSA coverage. Remember ceftriaxone does not have anaerobic coverage. • Septic patient: start broad, then narrow coverage as cultures return.

  13. Ca-mrsa/mrsa

  14. MRSA cellulitis Guidelines • For a cutaneous abscess incision and drainage is the primary treatment. • When is adjunct antibiotic therapy recommend for abscesses? • Severe or extensive (multiple sites) or rapid progression in presence of cellulitis. • Signs of systemic illness. • Associated comorbidities or immunosuppressed. • Extremes of age.

  15. MRSA cellulitis Guidelines • Abscess in area difficult to drain (face, hand and genitalia). • Associated with septic phlebitis. • Lack of response to incision and drainage.

  16. MRSA cellulitis Guidelines Treatment of purulent cellulitis: • Empiric treatment for CA-MRSA/MRSA. • Bactrim, clindamycin, doxycycline or minocycline, linezolid. • If need MRSA and streptococcus coverage: clindamycin; or bactrimor doxycycline with amoxicillin; or linezolid alone. • If inpatient treat with IV antibiotics initially: vancomycin, clindamycin, linezolid, daptomycin, ceftaroline.

  17. AJM 2010;123:942-950 • Retrospective cohort study in 2005-2007 comparing bactrim to cephalexin to clindamycin for mild to moderate cellulitis. • 405 patients in study: • Excluded patients with severe cellulitis. • MRSA recovered in 72/117 positive culture specimens. • Successful treatment • TMP-SMX 138/152 (91%) • Cephalexin 134/180 (74%) • Clindamycin 34/40 (85%)

  18. How long to treat?? • IDSA guidelines: five days of treatment is a effective as a 10 day course for uncomplicated cellulitis. • Based on a 2004 study in which 87 patients were treated with levofloxacin 500mg poqd x 5 days compared with 43 patients who received levofloxacin for 10 days. Complete resolution on day 14 was similar and day 28 recurrence rate was similar.

  19. However levofloxacin has a longer ½ life than β-lactam antibiotics that are used more commonly. • IDSA recommends evaluation at day 5 – if resolved can stop antibiotics. If persisting, continue to 10 days. • Arch Intern Med 2004;164:1169-1674.

  20. Prophylaxis for recurrent cellulitis • First identify and treat predisposing conditions (edema, obesity, eczema, venous insufficiency, fungal foot infections). • Oral penicillin 250-500 mg po bid for one year should be considered in patients who have >3 episodes per year despite attempts to treat or control predisposing factors. Can continue past one year (indefinitely) if factors persist and patient tolerating. • IDSA guidelines, 2014. Based on two studies, PATCH 1 and PATCH 2.

  21. Special circumstances for cellulitis • Erysipelothrixrhusiopathiae (erysipeloid) – gram positive facultative anaerobic rod. Causes an indolent cellulitis occurring in persons who handle saltwater fish, shellfish, poultry, meat and hides. Treat with penicillin or cephalosporin. • Aeromonashydrophila – gram negative rod that causes an acute cellulitis after laceration while swimming in fresh water. Also associated with medicinal leeches. Treat with ciprofloxacin +/- doxycycline.

  22. Special circumstances for cellulitis • Vibrio vulnificus(curved gram negative rod) causes cellulitis, bullous lesions or necrotic ulcers after exposure to warm coastal water or exposure to drippings from raw seafood. • Infection can progress to necrosis requiring surgical debridement. • Bacteremia with septicemia can occur after eating raw oysters, can develop associated skin findings. • Alcoholic cirrhosis, hemochromatosis and thalassemia increase the risk of septicemia and development of necrotizing fasciitis (due to iron overload). • Treat with doxycycline plus ceftriaxone.

  23. E. rhusiopathiaeand Vibrio Vibrio species E. rhusiopathiae

  24. Other • Animal or human bite: • Clean wound, check tetanus status of patient, rabies status of animal. • Usually polymicrobial infection due to mouth and skin flora. • Empiric antibiotic coverage with Augmentin or unasyn. • Penicillin allergic : fluoroquinolone or doxycycline (plus clindamycin or metronidazole for anaerobic coverage).

  25. Drugs 2003;63:1459-1480

  26. Immunosuppressed (cancer patients, AIDs, transplant) • Differential for skin lesions much broader in this subset – biopsy is necessary is most cases, get early if possible. • Need to consider infection, drug reaction/eruption, Sweet syndrome, malignancy, leukocytoclastic vasculitis, erythema multiforme.

  27. Question 3 • 40 yo male evaluated in ER for LUE skin infection. He works at the VA, where he sustained a minor laceration 3 days ago when trying to prevent a patient’s fall. He cleaned and bandaged the laceration but developed purulence, surrounding tenderness, and now with fever over last 24 hours. On exam T=38.5, bp 125/75, p 90, rr 18. An area of purulent cellulitis measuring 4x5 cm surrounding a 1.5 cm laceration is present. No fluctuance. Rest of exam wnl. WBC 14k, 90% neutrophils. UA nl. Radiograph of arm only shows soft tissue swelling.

  28. Question 3 continued • Which of the following beta-lactam antibiotics is most appropriate for treatment of this infection? • A) Meropenem • B) Oxacillin • C) Zosyn (pip/tazobactam) • D) Ceftaroline • E) Ceftriaxone

  29. Question 3 continued • Correct answer is D, ceftaroline – need MRSA coverage due to purulence, health-care associated. Vancomycin would have been correct if offered as a choice.

  30. Necrotizing Fasciitis • Deep tissue infection that spreads rapidly along fascialplanes. • Clinical features that suggest a necrotizing infection include: • Severe constant pain, pain out of proportion to exam. • Bullae: related to occlusion of deep blood vessels that traverse the fascia or muscles. • Skin necrosis or ecchymosis that precedes the skin necrosis. • Gas in the soft tissues. • Edema that extends beyond the margin of the erythema. • Cutaneous anesthesia. • Systemic toxicity (fever, leukocytosis, delirium, renal failure). • Rapid spread, especially concerning if on antibiotic therapy. • Subcutaneous tissues feels wooden-hard.

  31. Necrotizing Fasciitis

  32. Necrotizing fasciitis

  33. Necrotizing Fasciitis • Type I- Polymicrobial • Includes at least one anaerobic species, commonly Bacteroides or Peptostreptococcus; • Plus one or more facultative anaerobic species such as streptococci; • Plus members of Enterobacteriaceae (E. coli, Enterobacter, Klebsiella, Proteus. • Associated with: • Surgical procedures involving the bowel or penetrating abdominal trauma. • Decubitus ulcer or a perianal abscess. • Site of injection in IVDA. • Spread from a Bartholin abscess or minor vulvovaginalinfection.

  34. Necrotizing Fasciitis • Type II (aka hemolytic streptococcal gangrene): Group A streptococci are isolated either alone or with S. aureus • Usually involves the limbs with 2/3 in the lower extremities. • Associated with underlying disease: • DM • Arteriosclerotic vascular disease • Venous insufficiency with edema • Chronic vascular ulcer • Post varicella infection – commonly due to S. pyogenes • Mortality is high- 50-70% in patients with hypotension and organ failure. Lancet 1994;344:1111-5

  35. Necrotizing Fasciitis • Type III- Gram negative monomicrobial • Vibrio spp • V. damselae and V. vulnificus • Mortality of 30-40% despite prompt diagnosis and aggressive therapy. (J of HosInfec 2010;75:249-257) • Type IV- Fungal • Cases of candida NF very rare, mostly in immunocompromised. • Zygomycotic NF (Mucor and Rhizopusspp) affect immunocompetent patients after severe trauma. • Burns or trauma wounds with aspergillus or zygomycetes should be consider infected (not just colonized). (J of HosInfec 2010;75:249-257

  36. Necrotizing Fasciitis • Determinants of mortality • Retrospective study in 2005 in Taiwan. • Studied both type I and type II necrotizing fasciitis. • 87 pts. Found increased mortality with: • Age >60 • 2 comorbidities, especially DM and liver disease • Thrombocytopenia • Abnormal liver function tests • Increased BUN and Cr • Low serum albumin level • Patients who underwent emergent debridement in <24 hours had a lower mortality than patients whose surgery was delayed (26% vs 45.9%). • Total of 30/87 patients died in this study (34.4%). • J Micro Imm Infect 2005;38:430-435

  37. Necrotizing Fasciitis • Studies • CT scan or MRI may show edema and/or gas extending along the fascial plane. • In practice, clinical judgment is the most important element of diagnosis. • Cultures obtained from deep tissue during surgery are helpful. • Skin cultures usually contaminated with skin flora.

  38. Necrotizing Fasciitis • Treatment: • Surgical intervention: • No response to antibiotic therapy. • Profound toxicity with fever, hypotension, or advancement of skin and soft-tissue infection during antibiotic therapy. • Local wound shows any necrosis with easy dissection along fascia by blunt instrument. • Any soft tissue infection accompanied by gas. • Most patients with necrotizing fasciitis should return to the OR within 24-36 hours after first debridement and daily thereafter until surgical team finds no further need for debridement.

  39. Necrotizing Fasciitis • Empiric coverage: very broad • Piperacillin-tazobactam, plus vancomycinOR • Meropenem/imipenem plus vancomycin. • PCN allergy: Cefotaxime, plus metronidazole or clindamycin, plus vancomycin. • Severe PCN allergy: clindamycin or metronidazole, plus aminoglycoside or fluoroquinolone, plus vancomycin.

  40. Necrotizing Fasciitis • Streptococci infections • PCN: most streptococci are susceptible in the US. • Clindamycin: in vitro studies demonstrate both toxin suppression and modulation of cytokine TNF production. • Give both initially.

  41. Necrotizing fasciitis • IVIG – not enough evidence to recommend therapy. • HBO – hyperbaric oxygen – not enough evidence to recommend therapy.

  42. Questions…

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