Skin and soft tissue

infection
 objectives
• Define and describe the epidemiology of
skin and soft tissues (SSTIs).
• Discuss the approach to establishing a
diagnosis of an SSTIs.
• Review the evidence-based management
of SSTIs.
• Differentiate the microbiologic etiology and
treatment of non-purulent cellulitis and
purulent cellulitis (i.e., cutaneous abscess).
 Principle 1
Skin and soft tissue infections are increasingly common infections in
people of all ages.
 Defining skin and soft tissue infections
• SSTIs can be categorized according to their
clinical presentation, which is usually determined
by the layer of skin or soft tissue that is infected.

Clinical presentations:
• Impetigo
• Erysipelas/cellulitis
• Cutaneous abscess
• Pyomyositis
• Necrotizing fasciitis
Skin and soft tissue infections can be further
characterized as purulent or non-purulent
Ambulatory visits have been increasing for skin and
soft-tissue infections
 Antibiotic prescribing for skin and soft-tissue
infections is inappropriate in more than 60% of cases
Management of SSTIs often deviates from
clinical practice guidelines:

• Selecting inappropriate antibiotics.

• Treating for a longer duration than
required.
• Failing to drain abscesses and/or obtain
cultures.
 Antibiotic prescribing for skin and soft-tissue
infections is inappropriate in more than 60% of
cases
Only 35% of prescriptions were for recommended
first-line antibiotics
 Hospitalized patients receive unnecessarily broad
antibiotic coverage
For hospitalized patients at one academic institution,
antibiotics for uncomplicated non-purulent cellulitis
include the following:
• 61% of patients received unnecessary broad
-spectrum Gram-negative coverage.
• 74% of patients received unnecessary anaerobic
coverage.
• Only 38% of patients receive exclusively Gram
-positive coverage.
Take-home 1
 Principle 2
Appropriate diagnosis of skin and soft-tissue infections is critical to
using antibiotics appropriately.
Skin and soft-tissue infections are diagnosed by
clinical criteria rather than laboratory tests
 Skin and soft-tissue infections are diagnosed by
clinical criteria rather than laboratory tests (cont.)

Very suggestive of cellulitis, if present:

• Proximal lymphadenopathy.
• Lymphangitic streaking.
• Bullae formation.
Many other conditions are frequently misdiagnosed
as cellulitis

Remember: Cellulitis is usually a NEW, UNILATERAL condition.

Common conditions mimicking cellulitis:

• Stasis dermatitis (The image on the right).
• Deep vein thrombosis.
• Contact dermatitis.
• Erythema nodosum.
• Gout.
Warning signs of a serious, necrotizing infection
Risk factors for other pathogens
Treatment of cellulitis is empiric because making a
microbiological diagnosis is difficult
Take-home 2
 Principle 3
Management of skin and soft-tissue infections depends upon whether the infection
is purulent or non-purulent.
Non-purulent cellulitis is usually caused by
streptococcus species
Beta-lactams are the recommended treatment for
non-purulent cellulitis
Five days of antibiotics should be sufficient for most
cases of uncomplicated cellulitis
Staphylococcus aureus is the most common cause of
cutaneous abscesses (Purulent skin and soft tissue
infection)
Incision and drainage is the most important
intervention for cutaneous abscesses
Take-home 3
Overview: take-home principles
Overview: take-home principles (c0nt.)