Infectious Diseases - 05

Arthur Yanez sbobinatore and Mirko Vicinanza reviewer
Infectious Diseases – 05
25/10/2021
Skin and Soft Tissue Infections

Classification according to IDSA1 and FDA
IDSA Classification
There is separation between acute and chronic. Acute is divided between complicated and uncomplicated.
● Uncomplicated are usually easy to treat, but there are differences among them. They are divided
into primary and secondary.
● Complicated is divided into non-necrotizing and necrotizing. The importance in this division is
related to the management of the infections. Necrotizing may demand a combination of surgical
treatment and medical approach because these lesions can be lethal.
FDA Classification
It is a different classification from the IDSA, as we can see in the right side of the table. It was put by the
professor so that we know that there is more than one classification. ABSSSI means Acute Bacterial Skin
and Skin Structure Infections.
1
Infectious Diseases Society of America (IDSA)
Lecture 5 Skin and Soft Tissue Infections & Clinical aspects of Bone and Joint Infections 25/10/2021
Cellulitis / Erysipelas
Definition
Cellulitis, abscess, or both are among the most common skin and soft tissue infections. Cellulitis (which
includes erysipelas) manifests as an area of skin erythema, edema, and warmth as a result of bacterial
entry via breaches in the skin barrier. A skin abscess is a collection of pus within the dermis or
subcutaneous space.
Cellulitis vs Erysipelas
Cellulitis Erysipelas
Involves dermis and hypodermis Involves superficial dermis and lymphatics
Confluent poorly demarcated area, (this larger Clearly demarcated area

spread of the disease is related to the fact that it
usually also involves the hypodermis)
Caused by Streptococcus pyogenes and other Typically caused by Streptococcus pyogenes

pathogens
2
I found this on the web to help clarify. The source is:
https://www.uptodate.com/contents/image?imageKey=ID%2F110605.
1
Common factors: Etiology, risk factors , diagnosis and management of Erysipelas and Cellulitis are similar.
Most consider Erysipelas as a form of cellulitis
Etiology: commons causes

Cellulitis in immunocompetent adults is usually thought to be caused by group A streptococci
(Streptococcus pyogenes), with Staphylococcus aureus as a notable but less common cause
In table 1 we can see that:

● #GAS (group A streptococci): 46%
● #S. Aureus (Staphylococcus Aureus): 14%
The other agents reported in the table are not so important for cellulitis and erysipelas according to the
professor. Notice the #positive, that shows the reported cases of positive blood culture during a skin
infection. Notice that only 4.6 percent of patients have a positive blood culture. This is because
microbiology usually isn’t very helpful in management of cases even though we search for a theoretical
cause we usually will not find the actual cause of infection since it's very difficult to isolate pathogens from
blood culture and from skin biopsy.
Etiology: commons causes
Immunocompromised patients: pathogens include some gram-negative bacteria, some mycobacteria, and
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cryptococcus (a fungus) and other uncommon bacteria.
Chronic kidney disease: vibrio vulnificus, vibrio alginolyticus, Neisseria meningitidis, and E. coli.
Aquatic injury: vibrio, mycobacterium, and another very particular kind of infection which is Erysipelothrix
rhusiopathiae, a typical infection after injury with the bone of a fish. At risk are fishers and workers of the
food industry.
Animal and human bite: the most important is Pasteurella which usually is a common opportunistic
infection that is present in the mouth of dogs and cats. Streptococcus, Staphylococcus and Neisseria are
also important.
Differential diagnosis
When we have a patient with a skin infection it's typical that the disease is misdiagnosed into other similar
conditions, so we have to make a differential diagnosis into other both infectious and non-infectious
conditions.
Bilateral vs unilateral: Usually infections are unilateral, because it is very difficult that the patient will
develop in the same exact moment, the same process in two different sides of the body. When we see
something that is bilateral we have to think about a systemic process, probably non-infectious. Sometimes
we can see this in a patient with chronic edema of the lower limbs, for example, in a patient with a chronic
heart failure or with cirrhosis.
Symptoms of dolor, calor, rubor and tumor are also seen in DVT and in gout: in DVT it typically involves
the legs which become dark color and this patient can also be febrile, especially if they have a
complication. One one thing that we need to do is just to check with ultrasound whether we have a
thrombosis in the lower limbs.
Biomarkers (WBC, CRP, PCT): these three can be useful to identify infectious processes versus
non-infectious processes.
Risk factors and comorbidities
Notice that age is an important factor, because it divides the patients into 2 groups with different risk
factors and comorbidities associated.
For patients younger than 65 we have to pay attention to dermatophytosis3, chronic skin ulcer, and
obesity.
For patients older than 65 there are more risks associated. Two are the same as for older patients, they are
3
From wikipedia: Dermatophytosis, also known as ringworm, is a fungal infection of the skin. Typically it
results in a red, itchy, scaly, circular rash. Hair loss may occur in the area affected. Symptoms begin four to
fourteen days after exposure. Multiple areas can be affected at a given time.
3
chronic skin ulcer and dermatophytosis. The other factors are diabetes mellitus, phlebitis /
thrombophlebitis, varicose veins of the legs / lymphedema, and heart failure.
Microbiology
Microbiology is not very useful for uncomplicated skin infections and usually is not recommended. The
reason is because blood culture is positive in only 2-10% of the cases.
When do you consider doing it?

● Immunocompromised patients
● cSTTIs (pyomyositis or necrotizing fasciitis)
● Unusual predisposing factors (in case we suspect an atypical pathogen caused the disease, as seen
before, in cases of aquatic injury or animal bites)
● Suspected fungal or viral infection
Specimens for culture can be taken in purulent SSTIs (skin and soft tissue infections) or in lesions
undergoing surgical incision and/or debridement or imaging-guided drainage. Different methods are
recommended according to each case, as seen in the table above.
Treatment
Uncomplicated infections (for example: cellulitis as non-necrotizing infection)
● Amoxicillin with clavulanate with or without clindamycin.
When do we add clindamycin to the basic treatment?
This drug has a role in blocking protein synthesis, therefore blocking bacterial toxins. It can be used for
pathogens that cause severe infection, for infections that can evolve to a necrotizing process, or in cases
where the patient may suffer from toxic shock syndrome.
When do we suspect MRSA (medication resistant staphylococcus aureus) infection?
Risk factors are hemodialysis, previous colonization, and healthcare associated infection.
How do we treat MRSA suspected infections?
These pathogens are resistant to the basic treatment of amoxicillin+clavulanate. In these cases treatment
is based on other drugs: linezolid, doxycycline, trimethoprim/sulfamethoxazole.
Necrotizing fasciitis
Definition
Rapidly progressive acute infection of muscular fascia with necrosis of subcutaneous tissue. Surgical
diagnosis characterized by friability of the superficial fascia, dishwater-gray exudate, and a notable absence
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of pus (diagnosis is discussed later). It can occur after major traumatic injuries, as well as after minor
breaches of the skin or mucosa (e.g., tears, abrasions, lacerations, or insect bites), varicella infection,
nonpenetrating soft-tissue injuries.
Classification of Necrotizing Soft Tissue Infection (NSSTI)

Necrotizing fasciitis is a Necrotizing Soft Tissue Infection (NSSTI), which is a group of lesions that include
Necrotizing Cellulitis, Necrotizing Fasciitis, and Necrotizing Subcutaneous Infection. These are typically
caused by a mixture of aerobic and anaerobic organisms that cause necrosis of subcutaneous tissue, usually
including the fascia.4
Necrotizing Soft Tissue Infection (NSSTI) are classified according to several characteristics into different
groups:
● Type 1:
○ Elderly, immunocompromised, diabetic patients.
○ Polymicrobial (involves both gram positive and negative), non-clostridial anaerobes,
Gram-negatives.
● Type 2
○ Any age group, persons without any underlying illness.
○ Monomicrobial, Gram-positives (Group A Streptococcus, Staphylococcus aureus). These 2
(GAS and S. Aureus) are usually involved because they produce toxins, being the reason
that they can affect everyone, unlike the type 1 pathogens.
● Gas gangrene
○ Penetrating trauma, drug injection, neutropenia, colorectal cancer.
○ Clostridium perfringens, Clostridium histolyticum, Clostridium septicum.
● Fournier gangrene
○ Necrotizing fasciitis affecting the external genitalia or perineum.
○ Occurs on elderly, immunocompromised, diabetic patients (like type 1).
○ Gram-negative bacilli, Staphylococcus aureus, Clostridia. Since these infections occur
mostly in the perineum they are usually caused by gram-negative bacilli (the mechanism of
this relationship wasn’t described).
4
This classification part of the lecture missed some context so I added extra info to make more sense. This
was taken from the MSD Manual (professional version).
5
Multidrug resistant organisms that cause necrotizing fasciitis
MRSA: Staphylococcus aureus is the major pathogen.

ESBL E. Coli: Extended spectrum beta-lactamases (ESBLs) are defined as enzymes produced by certain
bacteria that are able to hydrolyze extended spectrum cephalosporin. They are therefore effective against
beta-lactam antibiotics such as ceftazidime, ceftriaxone, cefotaxime and oxyiminomonobactam. ESBLs are
found in Gram-negative bacteria, especially in enterobacteriacea and Pseudomonas aeruginosa.5
MDR multidrug-resistant non-fermenters: which are Acinetobacter baumannii and Pseudomonas
aeruginosa.
Clinical features and diagnosis

● Absence of fever in most cases.
● Absence of cutaneous manifestation at initial course of the disease.
● Severe pain in the afflicted area without clear signs of infection.
Prediction score for necrotizing fasciitis

When we have a suspicion of necrotizing facilities there are some predictive scores that help in the
diagnosis.
LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
It was developed to distinguish necrotizing fasciitis (nec fasc) from severe cellulitis or abscess.
It includes six variables: CRP, WBC count, hemoglobin level, sodium level, creatinine level, and glucose level.
Patients are categorized as: low risk (<=5 pts; <50% probability of NSTI), medium risk (6-7 pts; 50-75%
probability of NSTI), high risk (>=8 pts; >75% probability of NSTI).
5
I couldn’t understand the professor's explanation, so I got this definition from
https://www.caister.com/cimb/v/v17/11.pdf
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This is very helpful especially if performed in the emergency room because it can predict the need of
management of the disease. A LRINEC score of 8 or greater or a LRINEC score of 6-7 plus lactate of 4 or
greater, give the indication to start managing the condition.
Clinical case scenario

This is a case that the professor saw a couple of years ago.
Date: August 15th
Time: 11am
A 78 year old woman is admitted to the emergency department for back and right leg pain. No skin lesions
were seen at the admission.
at 4pm at 7pm
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after a while (in the slides says 7pm again but it this was taken already during surgery (in the slides
should be wrong) says 7pm again but it should be wrong)
What we saw in this case was the involvement of the entire leg and also of the hip and unfortunately,
despite surgery and prompt antibiotic administration, that patient died from septic shock and multiple
organ failure.
Management
Timing: as we can see from the study above timing is very important to determine survival.
Surgery: it is mandatory, and it has to be performed ASAP.
Broad Spectrum antimicrobials: polymicrobial infections are possible especially in comorbid patients.
AntiMRSA agents: Daptomycin or linezolid.
AntiGram-negative: Piperacillina-tazobactam, Carbapeneme, Clindamycin.
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Fournier gangrene/Ecthyma
It is a type of necrotizing fasciitis affecting the external genitalia or perineum. It occurs on elderly,
immunocompromised, diabetic patients. Causative agents are gram-negative bacilli, Staphylococcus aureus,
Clostridia.
This picture is from a typical case, the necrosis of the perineum is very
similar to a negotiating cyclist but typically localized and external
genitalia.
Usually involve men with the mean age of 50 to 60, with a predisposing
the condition, like colorectal disease, cutaneous disease or diabetes.
As you can see in the pictures above, this is a life-threatening, impressive disease that involves the
superintendent of space and if we don't go with surgery the affection can be lethal.
Management: Hyperbaric chamber
Definition: Hyperbaric oxygen therapy involves placing the patient in an environment of increased ambient
pressure while breathing 100% oxygen, resulting in enhanced oxygenation of the arterial blood and tissues.
6
Some authors suggest hyperbaric oxygen, but this is not clearly demonstrated in the clinical service so we
usually prefer to not recommend this treatment. The reason is because usually people are unstable with
septic shock and need intensive care treatment, and if the patient goes to the hyperbaric oxygen, which is
usually far from the hospital, they will probably receive less intensive treatment.
6
https://jamanetwork.com/journals/jamasurgery/fullarticle/397749
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IDSA guidelines 2014: “Hyperbaric oxygen (HBO) therapy is not recommended because it has not been
proven as a benefit to the patient and may delay resuscitation and surgical debridement (strong, low)”.
Management: Antibiotics
There are 2 approaches depending on the degree of suspicion of NF, done by assessing risk factors, clinical
features, and sepsis/septic shock.
1) Low suspicion for NF (non life-threatening)
a) Amoxicillin-Clavulanate ev
b) Clindamycin ev
2) Suspected NF (life-threatening)
a) Daptomycin
b) Meropenem
c) Clindamycin
Case: 72-year old woman with leukemia, admitted to ED for sepsis

This is another common clinical picture. This 72-year-old
woman with leukemia was admitted to the emergency
department for sepsis and the skin showed these nodules,
with areas of necrosis.
This is a typical case of Ecthyma Gangrenosum, which
usually is a necrotizing infection that spreads through
hematogenous route.
It is a necrotizing vasculitis with extravasation of blood,
edema, and necrosis around the vessel interrupting the
blood supply to these tissues, resulting in secondary
ischemic necrosis.
These nodular lesions rapidly evolve through stages of
central hemorrhage, ulceration, and necrosis. Lesions are
surrounded by normal skin.
It is typical of immunocompromised patients and P.
aeruginosa is commonly isolated from blood cultures.
Case resolution: the patient was treated with ceftazidime

plus levofloxacin. Blood cultures and skin biopsy yielded P.
aeruginosa.
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Case: Mucormycosis in cirrhotic and diabetic patient
This patient is cirrhotic, has uncompensated diabetes, and hypopituitarism in chronic steroid therapy. This is
a Mucormycosis caused by a common mold named Rhizopus spp. This is a very important and life
threatening infection, typical of immunocompromised patients and diabetic patients.
Case: Fusiliosis in a young neutropenic lady with Acute Myeloid Leukemia (AML)
This is another kind of mold infection. It is typical of patients

with leukemia or of patients with allogeneic skin cell
transplant. It is very difficult to treat, the mortality rate is
around 5%. Usually we can see this kind of spread and we see
a lot of different skin areas involved.
Animal bite infections

Incidence of dog bite injuries treated in emergency departments
We can see the number of admission to emergency

departments in the United States for activity or for social
activities. Dog bites are the 2nd cause of emergency
department after baseball injuries.
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Nonfatal dog bite-related injuries treated in hospital emergency departments-United

States, 2001
Usually, dog and animal bites can happen in any kind of

patient but it typically involves young people and
especially is very important to remember that children and even toddlers can be affected, as shown on the
graph on the left (figure 1).
In this graph on the right (figure 2) you can see that there is a differentiation between a typical area
involved in animal bite according to the age. The first group is very young children, from 0 to 4, and as you
can see the head and neck (black color on the graph) is a typical area involved. In people over >15, the
involvement of head and neck and face is less common and the most common common area injured is the
arm and hand.
The epidemiology of bite and scratch injuries by vertebrate animals in Switzerland
If we see the causes of bite and scratch injuries by animals we can see that dogs are involved in 63% of
cases, cats 25% and other domestic 9%. Wild and zoo animal bites are much more uncommon.
Canine and human factors related to dog bite injuries
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According to the factors related to the dog bites, usually working, and sporting dogs, or having activity with
dogs are risk factors. The dogs that cause bites are usually male and pure breed.
There are important cause of bites to all solar dogs so the owner of the dog can be involved very frequently
but usually in most cases in our neighbor neighborhood
Clinical manifestations of bite-related infections

● Severe infections related to dog and cat bites can occur in about 20% of all cases
● Deep abscesses and osteomyelitis are more common with cat bites
● By contrast with other sites, 30–40% of hand bites become infected
Severe infection can be related to dog and cat bites and in 20% of cases these include deep abscesses and
osteomyelitis. Osteomyelitis and deep abscesses are more common with cat bites, they have very thin and long teeth so
the bite, especially when involved the hands, can go directly to the body.
Microbiology
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Remember that any vertebrate can have Clostridium tetani, which is important for immune prophylaxis.
Any mammal can spread rabies.
The most important pathogens involved in dog bites are Pasteurella multocida.
In cats, Pasteurella multocida is the pathogen involved in the cat scratch disease.
Infection caused by rats which is Streptobacillus moniliformis.
When we have fresh water involvement, we have Aeromonas hydrophila.
When we have the involvement of the saltwater species we have to remember Vibrio vulnificus and
Mycobacterium marinum.
The last is a very rare disease caused by a virus named Herpesvirus simiae (B virus) which is usually
involved in macaque bites. This causes a certain malignant encephalitis that can be very very difficult to
diagnose and to treat and lethal.
Rat bite
Rat bite is atypical, and it can spread certain pathogens. Symptoms usually begin 3 to 10 days after the
bite but can be delayed as long as 3 weeks. By this time, any rodent bite or scratch wound that caused the
infection has usually healed.
Symptoms:
● Fever
● Vomiting
● Headache
● Muscle pain, joint pain or swelling (59%)
● Rash (occurs in about 3 out of 4 people with RBF 2-4
days after fever – hand and feet palm/soles)
When we have a skin rash that involves the palms and soles of
hands and feet we have to remember several diseases but one
of these is the rat bite, that is caused by Streptobacillus
moniliformis.
Streptobacillus moniliformis Infection

Causative agent of:
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● Rat-bite fever.
● Haverhill fever, an infection that is acquired through ingestion of the organism.
● Erythema arthriticum epidemicum, a migratory polyarthritis or arthralgia.
Commonly carried in the upper respiratory tract of rodents.

Humans are usually infected through a rat bite, or rat contact with a break in the skin, or ingestion of the
organism.
Bite-related and septic syndromes caused by cats and dogs

Panel: Management and treatment of dog and cat bites
The following are the options we have to approach a patient that was bitten by a dog or a cat, and
their indications.
● Cultures
○ Cultures are indicated if abscess, severe cellulitis, devitalised tissue, or sepsis present
○ Cultures are appropriate in this case because the causative pathogens are atypical.
● Irrigation
○ Normal saline irrigation copiously with high-pressure jet from syringe
● Debridement
○ Debride necrotic tissue and remove any foreign bodies
● Imaging
○ Plain radiographs, MRI, or CT if fracture or bone penetration, to rule out osteomyelitis
● Wound closure
○ Primary wound closure is not usually indicated
● Antimicrobial therapy
○ Prophylactic antibiotics in selected cases. Coverage based on type and kind of bite
● Hospitalisation
○ Indications include sepsis, cellulitis, substantial oedema or crush injury,loss of function,
immunocompromised status,
● Immunisations
○ Consider tetanus and rabies immunization/prophylaxis
Antibiotic prophylaxis for mammalian bites
When do we have to give antibiotics for mammalian bites? This is a meta-analysis from several studies
15
that were performed to assess whether or not to give antibiotics. Usually, the indication is to give
antibiotics in human bites in all cases. In case of any bites that involve hands and face. The face because it
is more risky for infection and because the infection can have an aesthetic outcome.
The hands are at higher risk of infection especially when they are caused by cat bites, probably because the
hands are typically more colonized with the other pathogens and in the hands the bones are very near the
skin and cat bites can go deep to the bone, so in these cases we prefer to treat with antibiotics even as a
prophylaxis.
Treatment options (cat, dog, rat and human)

1) Antibiotics
a) Amoxi/clav 1 gr every 8 hours for 3-5 days
2) Antibiotics, for those with allergy to penicillin:
a) Clindamycin 300 mg/6h + ciprofloxacin 500 mg/12h
b) Doxicycline 100 mg/12h + metronidazole 500 mg/8h
3) Tetanus prophylaxis
4) Rabies prophylaxis
Rabies Prophylaxis
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Clinical Aspects of Bone and Joint infections

Bone
Bone is a less vascularized tissue than, for example, the lungs or skin. The composition of bone is different
from that of other tissues, and it is difficult to predict whether agents showing good penetration into other
tissues will also achieve high concentrations in bone. That is one of the reasons why the treatment of skin
for bone infection is more complicated than other kinds of infections.
Biofilm
OUR WORST ENEMY
The Biofilm: a Secret Refuge of the Microbial World
A bacterial biofilm is defined as a structured community of
sessile bacterial cells enclosed in a self-produced polymeric
matrix, adherent to an inert or living surface, within which
the bacteria metabolically cooperate to protect themselves in
a hostile environment.
Sessile (or stationary) forms are characterized by slower
cellular division.
The concentration of antibiotic required to inhibit the growth
of bacteria in biofilms can be up to 1000-fold higher with the
planktonic phenotype (form characterized by rapid cellular division).
When we use antibiotics to treat biofilm related infection, we need to know, that the extracellular matrix
protects the microbes and the metabolism of bacteria is slower, and when we have drugs that in somehow
alter the metabolism of bacteria, if the metabolism is slower, the ability to kill is lower.
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Formation of biofilms
Biofilm formation is not very fast, it usually takes some days to develop, and some in certain cases
also several weeks.
Guidelines
When we think about skin or bone and joint infection, we must face the fact that there are no
common guidelines. This is the only guideline that was produced in the last years, so it's very
difficult for the clinician to have a guide to manageme these processes.
Psychological problems
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Typically, patients with bone and joint infections are patient with the with history of a higher number of
failure of treatments. For example, in Bologna, we have a specialized team for bone and joint infection and
we collect cases from all over Italy. In these cases, usually people face a very high number of failure before
uh to go to a specialized center.
Therapy
The treatment of this condition usually involves surgery (if specialized on treating bone infection is even
better) and antibiotic treatment.
But despite advances in surgical medical management, osteomyelitis, and general bone infections, are still
considered one of the most difficult to treat infectious diseases.
Usually, bone infections are not life-threatening because these infections are caused by slow growing
pathogens, very localized. And if we have a very poor vascularized tissue it is very difficult to treat but at
the same time it is very difficult for the infection to spread to other organs, and that is why we don’t have
cases of septic shock, multiple organ failure or death.
Pathogenesis
The pathogenesis is due to 2 typical mechanisms:
1. Direct inoculation of microorganisms into the bone because of trauma and surgery. For example,
if we have a patient that receives a hip prosthesis, during surgery there can be direct inoculation of
slow growing pathogens and after weeks or months we can develop an infection.
2. Hematogenous. In this case, we have a trauma or inoculation of pathogens on the other side of the
body but with a hematogenous route it will localize in the bone.
Classification
There are two major osteomyelitis classification schemes:
1) Cierny and Mader classified osteomyelitis based on the affected portion of the bone, the
physiologic status of the host and the local environment.
2) Lew and Waldvogel classified osteomyelitis based on the duration of illness (acute vs chronic), the
mechanism of infection (hematogenous vs contiguous), and the presence of vascular insufficiency:
is an etiologic classification and does not implicate a specific therapeutic strategy
Cierny and Mader Classification
19
In this stage, the medullary part of the bone is typically involved as we can see on the CT scan.
Stage II, or superficial osteomyelitis, usually happens after a trauma.
Stage III, which is a localized osteomyelitis, involve both medullary and superficial part of the bone.
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Stage IV, or diffuse osteomyelitis, in which the structure of the bone is completely changed.
Multidisciplinary team
In 1944, with the introduction of penicillin, John Albert Key, wrote: “continuous drug over a long period
time will lessen the amount of discharge, but it will not cure the disease because it cannot sterilize dead
bone or cavities with necrotic content and rigid walls”.
Even after the introduction of penicillin it was clear that only drugs cannot sterilize all the bone cavities
and necrotic content, so it became clear that the management of this infection should include both
surgeon and infectious disease specialists.
Essential is the strong collaboration between all involved medical and surgical specialists (eg, orthopedic
surgeons, radiologists, neurosurgeons, infectious disease specialists, pain specialists, microbiologists,
pharmacologists…).
Chronic osteomyelitis
It manifests in 3 forms:
1) Spondylodiscitis: it is osteomyelitis on the spine and it usually involves the lumbar part of the spine
but it can involve any kind of vertebrae. It can be both pyogenic (means that usually involve
staphylococci, streptococci, etc) or granulomatous (these are usually caused by tuberculosis, and in
this case it can be called pot disease, or can be caused by Brucella).
2) Osteomyelitis after septic arthritis: an infection that occurs after the penetration of pathogen into
the joint cavity and prosthesis infection. It occurs only in 0.2-0.5 percent of cases but when it
happens morbidity is very high.
3) Osteomyelitis and delayed JPI (joint prosthesis infection)
Management
21
When we have a vertebral osteomyelitis, the initial management of patients should include:
1) MRI with contrast
2) Sometimes vertebral biopsy, especially if blood cultures are negative. This is important if you want
to exclude non-common diseases such as tuberculosis and Brucella.
3) Blood tests
4) Orthopedic visit for indication for surgery.
5) Pain therapist.
Treatment of vertebral osteomyelitis

In most of these cases (90%), we can treat only with antibiotics. This is an exception, since in most cases of
bone and joint infection the management is both surgical and medical.
Surgical débridement should be considered in patients with a large paravertebral abscess, when an epidural
abscess is compressing the spinal cord, when medical management fails, or when the spine is mechanically
unstable
● Recommend a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial

therapy for most patients with bacterial NVO.
● Single published randomized clinical trial that showed that 6 weeks of antibiotic treatment in
noninferior to 12 weeks in patients with NVO.
Bernard L, Dinh A, Ghout I, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic
vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015;
385:875–82.
● Recommend a total duration of 3 months of antimicrobial therapy for most patients with NVO due
to Brucella species (strong, moderate).
Classification of prosthetic infections

22
In most cases we have delayed infection.

It is very important to differentiate early versus delayed versus late infection because of management.
When we have an early infection, the management can be combined surgical and medical but surgery can
consist only of debridement.
When we have a delayed infection we cannot just do debridement, we need to remove the prosthesis. So
the patient will undergo two different surgical operations one is debridement and removal of the
prosthesis, and the other one will be redoing the prosthesis.
Delayed PJI
23
When we have a delayed infection the probability of biofuel formation is lower so we can try to just do
debridement, doing just one surgical intervention and then the probability of saving the prosthesis is
higher.
When a joint has become distended with pus, if it is freely opened and copiously irrigated, it may forthwith
undergo a startling improvement and, if the patient survives, may completely recover and retain absolutely
free movement.
Penetration of antibacterials into the bone

Penetration of antimicrobials into the bone is very challenging because the blood vessels and the blood
perfusion to the bones is lower than in other tissues. This usually is caused by biofilm formatting
pathogens, and the penetration of biofilm is very challenging for antimicrobials.
We need to treat patients for a long period, from a minimum of 6 weeks to usually 2-3 months, but it can
be even longer, and this means that we can have problems with safety, with side effects, drug resistance,
etc.
The ideal the drug would have the following characteristics:
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1. Activity against MRSA with High MIC for glicopetides

2. Intracellular killing
3. Activity against sessile (biofilm embedded) bacteria
4. Bone penetration
5. Oral bio-availability
6. Long term safety
7. Low level of collateral damage
This is the theoretical penetration of antibiotics into the bones of several drugs. Usually, most of these
drugs have an activity against MRSA.
Notice that Vancomycin, which was one of the main drugs in the past, has a very poor penetration of the
bone, only 14%.
Linezolid has a much higher penetration, but prolonged administration can cause problems because of the
side effects that include bio suppression, peripheral neuropathy, and others.
Levofloxacin is a very good agent; it has 77% of penetration to the bone and it has a good bio availability.
Rifampin is another good treatment; it is an antibiotic that can be used for treatment of tuberculosis but in
combination with some other drugs it can be very useful since it has very good biofilm penetration.
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Infectious Diseases - 05

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Infectious Diseases - 05

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Arthur Yanez sbobinatore and Mirko Vicinanza reviewer

Skin and Soft Tissue Infections

Involves dermis and hypodermis Involves superficial dermis and lymphatics

Confluent poorly demarcated area, (this larger Clearly demarcated area

Caused by Streptococcus pyogenes and other Typically caused by Streptococcus pyogenes

Etiology: commons causes

In table 1 we can see that:

Etiology: commons causes

Risk factors and comorbidities

When do you consider doing it?

Classification of Necrotizing Soft Tissue Infection (NSSTI)

Multidrug resistant organisms that cause necrotizing fasciitis

MRSA: Staphylococcus aureus is the major pathogen.

Clinical features and diagnosis

Prediction score for necrotizing fasciitis

Clinical case scenario

Case: 72-year old woman with leukemia, admitted to ED for sepsis

Case resolution: the patient was treated with ceftazidime

Case: Mucormycosis in cirrhotic and diabetic patient

This is another kind of mold infection. It is typical of patients

Animal bite infections

We can see the number of admission to emergency

Nonfatal dog bite-related injuries treated in hospital emergency departments-United

Usually, dog and animal bites can happen in any kind of

The epidemiology of bite and scratch injuries by vertebrate animals in Switzerland

Canine and human factors related to dog bite injuries

Clinical manifestations of bite-related infections

Streptobacillus moniliformis Infection

Commonly carried in the upper respiratory tract of rodents.

Bite-related and septic syndromes caused by cats and dogs

Antibiotic prophylaxis for mammalian bites

Treatment options (cat, dog, rat and human)

Clinical Aspects of Bone and Joint infections

Cierny and Mader Classification

Stage II, or superficial osteomyelitis, usually happens after a trauma.

Treatment of vertebral osteomyelitis

● Recommend a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial

Classification of prosthetic infections

In most cases we have delayed infection.

Penetration of antibacterials into the bone

1. Activity against MRSA with High MIC for glicopetides

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