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What are the uncomplicated skin and soft tissue infections (SSTIs)?
- impetigo
- furuncles
- carbuncles
- erysipelas
- simple cellulitis
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What are the complicated SSTIs?
- necrotizing fasciitis
- severe cellulitis
- severe animal/human bites
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What are the SSTIs of the epidermis?
- impetigo
- folliculitis
- furunculosis
- carbunculosis
- erysipelas
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What are the SSTIs of the dermis?
cellulitis
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What are the SSTIs of subcutaneous tissue?
necrotizing fasciitis
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What pathogens are common in animal bites?
- Pasturella multocida
- S. aureus
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What pathogens are common in human bites?
- Eikenella corrodens
- S. aureus
- oral anaerobes
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What is the most common pathogen found in animal bites?
Pasteurella multocida
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What is the most common skin infection in children?
impetigo
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What pathogens cause impetigo?
- S. pyogenes
- S. aureus including MRSA
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What are the clinical manifestations of impetigo?
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What is the treatment for impetigo?
- cleansing with soap and water
- removal of crusts
- warm water soaks
- Mupirocin
- Retapamulin
- Dicloxacillin (penicillinase-resistant pen)
- Cephalexin (1st gen ceph)
- Bactrim
- Doxycycline (suspected MRSA)
- Minocycline (suspected MRSA)
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When is topical treatment for impetigo appropriate?
when lesions are limited in number
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What antibiotics are used in topical treatment of impetigo?
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What antibiotics are used in oral treatment of impetigo?
- Penicillinase-resistant pens (Dicloxacillin)
- 1st gen cephs (Cephalexin)
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What antibiotics are used to treat impetigo when MRSA is suspected?
- Bactrim
- Doxycycline
- Minocycline
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What is the duration of oral treatment for impetigo even with MRSA?
5-10d
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What are the clinical manifestations of furuncles?
- a "boil" is an acute inflammation of subcutaneous layers of skin and hair follicles
- occurs in skin areas containing hair follicles subject to friction and sweat
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What are the clinical manifestations of carbuncles?
- more extensive than furuncles, extending into subcutaneous fat and developing into multiple abscesses
- larger, deeper, indurated lesion typcially at the nape of the neck, on back, or on thighs
- can be associated with fever and malaise
- commonly repeated attacks (nasal carriage)
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What pathogens cause furuncles and carbuncles?
S aureus (inclucing CA-MRSA)
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What is the treatment for furuncles and carbuncles with lesions < 5cm?
incision and drainage alone MAY be effective
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What is the treatment for furuncles and carbuncles with lesions > 5cm?
- incision and drainage
- antibiotics
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What antibiotics are used for oral treatment of furuncles and carbuncles?
- Bactrim
- TCAs
- Clindamycin (if D test negative)
- Rifampin (not monotherapy)
- Linezolid
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What antibiotics are used for parenteral treatment of furuncles and carbuncles?
- Vancomycin DOC
- Clindamycin (if D test negative)
- Daptomycin
- Llinezolid
- Tigecycline (probably not for much longer)
- Quinupristin/Dalfopristin
- Telavancin
- Ceftaroline (reserved for complicated infections)
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What is erysipelas?
- distinct type of superficial cellulitis of the skin with prominent lymphatic involvement
- usually lower extremities, but can be on the face
- usually occurs in 60s and 70s
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What are the clinical manifestations of erysipelas?
- pain
- swelling
- bright red indurated lesion
- advanced raised border sharply demarcated shiny erythematous plaque
- bulla formation - considered relatively severe
- fever
- leukocytosis
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What pathogens cause erysipelas?
- S. pyogenes
- S. aureus (rare)
- S. agalactiae (newborns)
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What is the treatment for erysipelas?
- Mild-moderate:
- Pen VK
- Suspected CA-MRSA:
- Bactrim
- Doxycycline or Minocycline
- Severe:
- Pen G potassium
- Severe with suspected MSSA:
- penicillinase-resistant pen (dicloxacillin)
- 1st gen ceph (Cephalexin)
- Severe with suspected MRSA or pen allergy:
- Clindamycin (if D test negative)
- Vancomycin
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What is cellulitis?
- acute inflammation of the epidermis and dermis and may spead within the superficial fascia, extending deeper than erysipelas
- previous trauma or underlying condition predisposes development of cellulitis
- may progress to a serious condition since bacteria can spread via blood stream or lymphatics
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What are the symptoms of cellulitis?
- local tenderness/pain
- erythema
- hot
- swollen
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What pathogens cause cellulitis?
- S. aureus (including MRSA)
- S. pyogenes
- Pseudomonas
- Candida
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What is the oral treatment for cellulitis?
- penicillinase-resistant pen (Dicloxacillin)
- 1st gen ceph (Cephalexin)
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What is the parenteral treatment for cellulitis?
- penicillinase-resistant pen (Nafcillin)
- 1st gen ceph (Cefazolin)
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What is the treatment for cellulitis in pts with pen allergy?
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What is the treatment for cellulitis if MRSA is suspected?
- Vancomycin IV - DOC
- Linezolid IV/PO
- Daptomycin
- Tigecycline
- Telavancin
- Ceftaroline
- Doxycycline (less severe cases only)
- Bactrim (less severe cases only)
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What is the empiric treatment for cellulitis with purulent discharge or abscess?
Clindamycin + Vancomycin
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What is the treatment for mixed infection cellulitis?
- Parenteral tx:
- penicillinase-resistant pen + AG
- AG + Clindamycin
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What are the symptoms of an animal bite infection?
- pain
- erythema
- purulent discharge (often gray and malodorous)
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What is the treatment for animal bites?
- tear and puncture wounds require copious irrigation, immobilization/elevation, and surgical debridement if indicated
- tetanus toxoid
- rabies vaccine/immune globulin
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What is the treatment for human bites?
- aggressive irrigation, surgical debridement, immobilization
- tetanus toxoid
- prophylaxis of non-infected wound is recommended
- IV antibiotics required for severe infections and clenched-fist injury
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What is the duration of antibiotics for treatment of bites?
- treatment: 5-10d
- prophylaxis: 3-5d
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What oral antibiotics are used for treatment of bites?
- Amoxicillin clavulanate
- Clindamycin + Bactrim or Doxycycline
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What are the parenteral antibiotics used for treatment of bites?
- Ampicillin sulbactam
- Ampicillin + Clindamycin
- Clindamycin + Bacrim or Doxycycline
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What is necrotizing fasciitis?
- uncommon, highly lethal, soft tissue infection characterized by:
- rapid spreading inflammation
- necrosis of the muscle, fascia,a nd overlying skin
- extensive inflammation of subcutaneous tissue
- progressively destroys fascia and fat
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What are the symptoms of necrotizing fasciitis?
- Early signs (much like cellulitis):
- hot, severe pain, swollen, shiny, tender, and erythematous
- Suggestive of necrotizing infection:
- diffuse swelling followed by bullae
- severe, constant pain
- skin necrosis
- gas in the soft tissue
- edema extending beyond the margin of erythema
- Systemic symptoms:
- fever, chills, leukocytosis
- shock and organ failure
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What are the types of necrotizing fasciitis?
- Type I:
- skin may be spared and speed of spread is somewhat slower
- polymicrobial, mixed anaerobic/aerobic (Bacteroides, Peptostreptococcus, facultative bacteria, MSSA/MRSA)
- Type II:
- true "flesh-eating" disease
- rapidly extending necrosis of subcutaneous tissues and skin, gangrene, severe local pain, and systemic toxicity
- mortality rate 20-50%, virtually 100% without surgical interventions
- death may occur within hours of diagnosis
- S. pyogenes
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What is the treatment for necrotizing fasciitis?
- immediate and aggressive surgical debridement (multiple surgical procedures over several weeks if the patient survives)
- Critical care unit support (rapid fluid replacement, mechanical ventilation)
- Empiric broad spectrum parenteral antibiotics
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What antibiotics are used to treat necrotizing fasciitis empirically?
- Ampicillin sulbactam or Piperacillin tazobactam
- + Ciprofloxacin or Gentamicin
- + Clindamycin
- + Vancomycin
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What antibiotics are used to treat necrotizing fasciitis when S. pyogenes is identified?
- Pen G potassium + Clindamycin
- both at high doses
- Clindamycin suppresses toxin synthesis (antitoxin activity)
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What is the adjunctive therapy used in necrotizing fasciitis?
- Vacuum-assisted wound closure therapy (VAC dressing)
- Hyperbaric oxygen (HBO)
- Intravenous immunoglobulin
- Recombinant activated protein C (Drotrecogin Alpha)
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