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Infectious Disease [SKIN INFECTIONS]

Cellulitis
Cellulitis is an infection of the subcutaneous tissue of the skin.
It’s most often caused by infection by the skin flora: Group A
Strep and Staph aureus. The presentation of a cellulitis is
usually red, hot, tender skin that’s often well-demarcated (ie
you can draw a pen or marker on the edge and watch it grow or
recede). It usually has a portal of entry (like a scratch, scrape, or
puncture wound). The diagnosis is often clinical – it rarely
requires culture or biopsy. If there’s an abscess (likely to be
Staph) it should be drained; culture the pus. But without purulent
drainage there should be no attempt to culture the cellulitis, as
what you’ll likely receive is the polymicrobial sample of the skin.

The treatment for cellulitis is affected by one of two scenarios.


When the person isn’t toxic and they walk into clinic without
systemic signs of infection, a 1st generation cephalosporin such Scenario Treatment
as cephalexin, or antibiotics that’ll cover community acquired Non-Toxic Outpatient 1st Gen Cephalosporin
MRSA such as TMP-SMX (Bactrim) or Clindamycin can be Non-Toxic CA-MRSA TMP-SMX, Clinda
picked.
Toxic (inpatient) Vanc, Dapto, Linezolid
If a person is toxic – there’s sepsis - it’s time to reach for the
bigger guns such as vancomycin or linezolid. Daptomycin is an
alternative.

You know you’re winning when the ring of cellulitis recedes


towards the portal of entry. A failure to recede may indicate you
have the wrong bug, the wrong drug, or that there’s something
under the skin that can’t be seen. Routine imaging isn’t required
for cellulitis, but can be done when there’s a failure to resolve.

Osteomyelitis Osteomyelitis
Osteomyelitis is infection of the bone. This occurs via Risk Factors Bug
hematogenous seeding or by direct inoculation (trauma, Most Common S. aureus
fracture). If you can probe to bone through a wound, it’s osteo. Penetrating / Sneakers Pseudomonas
The other way to catch osteomyelitis is in a refractory or recurrent Sickle Cell Salmonella
cellulitis. Gardening Sporothrix
DM/PVD Polymicrobial, cover for
Diagnose with X-ray. If there’s osteolytic changes, the diagnosis pseudomonas
is made. It’s often negative, because it takes two weeks to turn Oysters + Cirrhotic V. vulnificus
positive. If suspicion of osteo is high, but the X-ray is negative,
the best radiographic test is MRI. Two tests that are usually the
wrong thing to do are Bone Scan (useful only when there’s no
overlying inflammation) and Tagged WBC scan, which is
always wrong. Once osteo is identified, take a biopsy. It’s the best
way to confirm osteo and is necessary to direct antibiotic therapy.

Treatment is 4-6 weeks of antibiotics, which is why the culture


and sensitivity is wanted. Follow with ESR and CRP weekly to
gauge the response to therapy. DO NOT repeat the MRI. DO NOT
repeat the biopsy.


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Infectious Disease [SKIN INFECTIONS]

Gas Gangrene
Gas Gangrene is caused by Clostridium perfringens. The patient
will present with some sort of wound, often a penetrating wound
that gets contaminated. Crepitus will be able to be felt. The
diagnosis begins with an X-ray, showing gas in the soft tissue.
The treatment is debridement and PCN + Clindamycin. Gas
gangrene is induced by a toxin, so clinda’s ability to interrupt
protein synthesis makes it ideal.

Necrotizing Fasciitis
“Neck Fack” is a life threatening surgical emergency. It’s caused
by the same things that cause cellulitis: Strep and Staph. It
presents as a really bad cellulitis. Look for a cellulitis that is:

1) Rapidly progressive with fast spread


2) Crepitus
3) Pain out of proportion with the physical exam
4) Blue-Grey discoloration of the skin

The diagnosis starts with X-ray, which will show gas in the
tissues. We know from Gas Gangrene that we’ll need to get
surgical debridement right away. If on a limb, often we simply
amputate to prevent the spread of infection through fascial planes.
Broad spectrum antibiotics is required. It’s fatal if untreated.

If this process is occurring in the groin (male genitalia or female


perineum) it’s referred to as Fournier’s Gangrene.

Red, Hot,
Tender, Skin
The Effective Workup
When cellulitis is seen you want to think a little bit more about it.
Alarm Symptoms?
If they’re non-toxic it’s easy – treat empirically. But there are
some things that should be on the radar, such as: draining tracts
Crepitus Ø Draining Tracts
and palpable bone (osteo) or crepitus and pain out of Pain out of proportion Palpable Bone
proportion (gas gangrene or necrotizing fasciitis). Cellulitis
Gas Gangrene Osteomyelitis
The x-ray can reveal osteolytic changes of osteomyelitis, or the or Nec Fac
X-Ray
gas of the gas gangrene / nec fac. But, if nothing’s found and
there’s still suspicion of Osteo, get an MRI of the bone plus a Gas in the tissue Osteolytic Changes
biopsy if possible. MRI
Gas Gangrene Osteomyelitis
or Nec Fac
Only give antibiotics to osteo after the culture or if the patient is
toxic. Debridement Biopsy Abx, One-Time Cx
Broad-Spectrum Abx MRI qWeek
Hyperbaric O 2 Tx based on Culture CRP/ESR qWeek
Always give antibiotics to Gas Gangrene and Nec Fec. and Sensitivity


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