Skin and Soft Tissue Infections

The Bugs

Non-Purulent

Purulent

Necrotizing Strep pyogenes, Staph aureus

Vibrio vulnificus, Aeromonas hydrophila
Infections Clostridium perfringens

Non-Purulent
Cellulitis Vs. Erysipleas

 Erysipleas = superficial; limited to upper dermis + superficial lymphatics

o If erysipleas has facial involvement, treat as MRSA
 Cellulitis = deeper tissue; deeper dermis + subcutaneous fat

Presentation:

 Erythema, warmth, edema, tenderness to palpation

 Non-elevated with poorly defined margins

Classification of Severity:

 Moderate
o ______________________________
 Severe:
o _____________________
o SIRS criteria (temp > 38C, HR > 90 bpm, RR > 24, abnormal WBC)
o Signs of deeper infection (i.e. bullae, skin sloughing, hypotension, organ dysfunction)
o Immunocompromised

Mild
Moderate
Oral Antibiotics:
Severe
- IV Antibiotics:
- - -Emergent Surgical
- - Consult to rule out
necrotizing infection
- -
-Broad spectrum
- empiric antibiotics
Kaitlyn Kastberg, PharmD
PGY-1 Pharmacy Resident
 **Duration: 5 days

Recurrent Cellulitis:

 Defined as _______ episodes per year

 Control pre-disposing factors
o Obesity, Edema, Eczema, Venous Insufficiency, Toe Web Abnormalities
 Can consider prophylactic antibiotics
o Oral penicillin or erthromycin BID x 4-52 weeks
o IM Pencillin Benzathine every 2-4 weeks
 Infections may recur once prophylaxis is discontinued

Conditions that can mimic cellulitis:

 Gout
o Can present with fever or leukocytosis
o Should be considered when erythema is over a joint
 Hematoma
o Common in patients on __________________
 Stasis Dermatitis
o Caused by venous insufficiency
o Distinguishing characteristics: ________________________
o No systemic antibiotic benefit

Purulent
Presentation:

 Erythema, pus-filled bumps

Classification of Severity:

 Moderate:
o Systemic signs of infection
 Severe:
o Failed I&D + oral antibiotics
o SIRS criteria (temp > 38C, HR > 90 bpm, RR > 24, abnormal WBC)
o Immunocompromised
Mild
Incision and Drainage
Moderate
Incision and Drainage +
Severe
Empiric Antibiotics
Incision and Drainage +
- Empiric Antibiotics
- -
- **Duration 5-7 days
-
-
Kaitlyn Kastberg, PharmD -
PGY-1 Pharmacy Resident
Recurrent Purulent SSTI:

 Deconolization in otherwise healthy adults

o Patient should NOT have an active infection
 Culture multiple sites in attempt to identify colonizing bug
o Nose, throat, inguinal area
 Mupirocin in nostrils/under fingernails BID + chlorhexidine 4% shower daily x 5-7 days
 Doxycyline 100 mg BID + Rifampin 300 mg BID x 7d
o Do NOT use rifampin alone due to rapid staph aureus resistance development
o If MSSA carrier, use ________________ in place of doxycycline

Necrotizing Infections
Presentation:

 Systemic toxicity – high temperatures, disorientation, and lethargy

 Underlying tissues are firm – fascial planes and muscle groups cannot be discerned by palpation
 Skin color changes (purple/black)
 Gas on imaging

Factors Differentating Necrotizing Infections from Cellulitis:

 Pain out of proportion to clinical signs

 Hypotension
 Skin Necrosis
 Hemorrhagic bullae
 Recent surgery

Type 1

 Polymicrobial  aerobic + anaerobic

o Predisposing factors: diabetic or decubitus ulcers, hemorrhoids, rectal fissures,
colonic/urologic surgeries, and episiotomies

Type 2

 Monomicrobial
o Associated with _________________

Kaitlyn Kastberg, PharmD

PGY-1 Pharmacy Resident
Why is Clindamycin added to the empiric regimen?

_____________________________________________________

Defined regimens if pathogen identified:

 Group A Strep
Early markers for group A strep:
o _____________________
 Clostridial sp. -CRP > 200 mg/L
o _____________________
-Modestly increased WBC w/ left shift
 Vibrio vulnificus
o Doxycyline + Ceftazidime -Elevated SCr w/o hypotension
 Aeromonas hydrophilia
o Doxycyline + Ciprofloxacin

Wounds typically discharge large amounts of tissue fluid  ensure patient is receiving aggressive fluids

Considerations in Cancer Patients with Neutropenia

 Differential diagnosis should include: bacterial, fungal, viral, & parasitic agents
 Careful history should be obtained paying special attention to exposure to raw seafood, pets,
and travel
 Cancer patients with SSTIs during initial episode of fever and neutropenia:
o ______________________________________
o Preferred oral antibiotics in low risk* patients Low Risk*
 Ciprofloxacin + Augmentin
-Anticipated brief (<7
 Cancer patients with SSTIs during persistent or recurrent episodes
days) neutropenia
of fever and neutropenia
o Increased concern for yeasts and molds -Few comorbidities
o Add __________________________
-MASCC score ≥ 21

Uncommon Causes of Cellulitis

Cause Bug
Aquatic Soft Tissue Injury Vibrio
Aeromonas
Erysipelothrix rhusiopathiae
Dog and Cat Bites Pasturella
Fusobacterium
Prevotella
Human Bites Eikenella corrodens
Immunosuppression Cryptococcus
H. influenzae

Kaitlyn Kastberg, PharmD

PGY-1 Pharmacy Resident
 Mycobacterium tuberculosis

New Agents Not in Guidelines

Tedizolid

 Approved for acute bacterial skin and skin structure infections

 Available IV and PO
 Not recommeded in patients with neutropenia
 Lower risk of serotonin syndrome compared to linezolid  less drug interactions

Dalbavancin

 Approved for skin and soft tissue infections

 Available IV
 Given as a one or two dose regimen
o 1.5 g once or 1 g x 1 followed by 500 mg a week later
 Rapid IV infusion may cause reactions similar to Red Man Syndrome

Oritavancin

 Approved for skin and soft tissue infections

 Available IV
 Single dose regimen
 Falsely elevates aPTT for 5 days after administration (avoid UFH)

Delafloxacin

 Approved for skin and soft tissue infections and community-acquired pneumonia
 Available IV and PO
 IV formulation contains cyclodextrin which can accumulate in renal dysfunction

Omadacycline

 Approved for skin and soft tissue infections and community-acquired pneumonia
 Available IV and PO
 Avoid in pregnant patients and children < 8

Kaitlyn Kastberg, PharmD

PGY-1 Pharmacy Resident
References:

1. Chambers HF. Furunculosis, Recurrent. Sanford Guide Online. Antimicrobial Therapy, Inc.
Update May 5, 2021. Accessed August 4, 2022. http://webeditionsanfordguide.com
2. Chambers HF. Skin Abscess, Boils, Furuncles. Sanford Guide Online. Antimicrobial Therapy, Inc.
Update April 7, 2022. Accessed August 4, 2022. http://webeditionsanfordguide.com
3. Dalbavancin. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Health, Inc. Updated July 7, 2022.
Accessed August 8, 2022. http://online.lexi.com
4. Delafloxacin. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Health, Inc. Updated July 27, 2022.
Accessed August 8, 2022. http://online.lexi.com
5. Omadacycline. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Health, Inc. Updated July 29, 2022.
Accessed August 8, 2022. http://online.lexi.com
6. Oritavancin. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Health, Inc. Updated June 29, 2022.
Accessed August 8, 2022. http://online.lexi.com
7. Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-337.
doi:10.1001/jama.2016.8825
8. Stevens DL, Bisno AL, Chambers HF et al. Practice Guidelines for the Diagnosis and Management
of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America.
Clinical Infectious Diseases. 2014;59(2):e10-e52. Doi:10.1093/cid/ciu296
9. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017;377:2253-2265.
Doi:10.1056/NEJMra1600673
10. Tedizolid. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Health, Inc. Updated July 25, 2022.
Accessed August 8, 2022. http://online.lexi.com

Kaitlyn Kastberg, PharmD

PGY-1 Pharmacy Resident