non-purulent infections
Which pathogen typically causes non-purulent cellulitis?
S. pyogenes
Which pathogen typically causes purulent SSTIs?
S. aureus
True or false: all patients with necrotizing fasciitis will show signs of gangrene?
False - while this is a possibility in necrotizing fasciitis, not all patients will have this on presentation and could present with something that looks like cellulitis/erysipelas.
A patient presents complaining of an itchy rash on their face that appears yellow in color. What is at the top of your differential and how would you choose to treat it empirically?
- small area, few lesions: topical mupirocin or retapamulin
- numerous lesions or outbreak: cephalexin or dicloxacillin x7 days (MSSA) OR doxycycline, clindamycin, or Bactrim x7 days
What differentiates between mild and moderate infections?
Systemic signs and symptoms
True or False: empiric therapy for moderate and severe cellulitis should include MRSA coverage
false - empiric MRSA coverage is only required in severe non-purulent infections
What is the first step in mild, moderate, AND severe purulent infections?
Incision and Drainage
What are some of the signs and symptoms patients with necrotizing fasciitis can present with?
A patient presents to the ED with a swollen arm that is red and warm to the touch. She has no fever or signs of systemic symptoms and the physician wants to treat her for cellulitis. What therapy would you recommend?
Penicillin VK
Cephalosporin
Dicloxacillin
Clindamycin
True or false: blood cultures are always useful in de-escalating therapy.
False
What patients would be considered to have a severe cellulitis infection?
- Patients who failed oral antibiotics
OR
- Patients with systemic symptoms that include
OR
- Immunocompromised patients
How long should we treat a purulent SSTI?
5-10 days, depending on clinical response
What is the primary treatment modality for necrotizing fasciitis?
Surgical intervention - debridement
A patient is on your service with a severe case of cellulitis being treated with Vancomycin PLUS Zosyn. Her cultures just resulted showing that she is growing S. pyogenes. How would you like to proceed with her therapy?
Switch her over to penicillin PLUS clindamycin
Which SSTI can be treated with topical pharmacotherapy?
Impetigo - can be treated with topical mupirocin or retapamulin
What could be considered as empiric treatment for a moderate case of cellulitis?
IV PCN
Ceftriaxone
Cefazolin
IV Clindamycin
What could be considered empiric therapy for a purulent skin infection?
Bactrim
Doxycycline
What could be considered as empiric therapy for necrotizing fasciitis?
Vancomycin
Linezolid PLUS Zosyn
Linezolid PLUS carbapenem
Linezolid PLUS ceftriaxone PLUS metronidazole
You are working on the internal medicine floor and are the pharmacist on rounds. The team has diagnosed a patient with a non-purulent cellulitis and wants to start IV antibiotics right away and looks to you for a recommendation. You look at the guidelines and remember that the patient told you they had an anaphylactic reaction to cefdinir last year. Which microbe is most-likely responsible and what is your empiric antibiotic choice?
Streptococcus; Clindamycin
How long should we treat a SSTI caused by S. pyogenes or S. aureus?
about 7 days
What could be considered empiric therapy for a severe case of cellulitis?
Vancomycin PLUS Zosyn
Emergent surgical inspection/debridement to r/o necrotizing process
What could be considered empiric therapy for a purulent SSTI?
Vancomycin
Daptomycin
Linezolid
Telavancin
Ceftaroline
What can a patient be de-escalated to if cultures only show strep species in a patient with necrotizing fasciitis?
Penicillin PLUS clindamycin
A patient presents to the ED for evaluation of a large boil on his back. He reports that the boil has steadily grown larger over the past 3–4 days. His vital signs at the clinic are as follows: temperature 98.8°F (37.1°C), heart rate 71 beats/minute, blood pressure 118/68 mm Hg, and respiratory rate 20 breaths/minute. He reports recently having a rash to amoxicillin. What would be the most appropriate recommendation for the patient at this time?
I&D only
What are risk factors for MRSA infection that would make you want to empirically cover that organism?
Prior MRSA infection
Recent hospitalization
Recent antibiotics
Contact with another person with known MRSA infection