in the name of the most high. skin and soft tissue infections

IN THE NAME IN THE NAME OF THE OF THE

MOST HIGHMOST HIGH

SKIN AND SKIN AND SOFT SOFT

TISSUE TISSUE INFECTIONSINFECTIONS

PHYSICAL CHARACTERISTICS PHYSICAL CHARACTERISTICS OF THE SKINOF THE SKIN

Mechanical barrier of stratum corneumMechanical barrier of stratum corneum

Relatively low PH(~5.5)Relatively low PH(~5.5)

Natural antibacterial substances in the Natural antibacterial substances in the secretions of sebaceous glandssecretions of sebaceous glands

Relative dryness of normal skinRelative dryness of normal skin

Bacterial interferenceBacterial interference

PREDISPOSING FACTORSPREDISPOSING FACTORSDisruption of stratum corneumDisruption of stratum corneum

Burn and bites Burn and bites

abrasion abrasion

Surgery Surgery

Vascular/pressure ulcerVascular/pressure ulcer

Underlying condition (dermatitis ,HSV, varicella)Underlying condition (dermatitis ,HSV, varicella)

injectionsinjections

Foreign body ( IV cath. Suture )Foreign body ( IV cath. Suture )

Hair follicle : normal floraHair follicle : normal flora

extrinsic bacteriaextrinsic bacteria

PREDISPOSING FACTORSPREDISPOSING FACTORS

Reduced vascular supplyReduced vascular supplyDisruption of lymphatic or venous Disruption of lymphatic or venous

drainagedrainageCompromised immune systemCompromised immune system

IMPETIGOIMPETIGO

EtiologyEtiology

gASgAS

Staphylococcus aureus Staphylococcus aureus (MRSA has (MRSA has been reported)been reported)

gCS gCS rarelyrarely

gGSgGS

Gbs Gbs (in newborn)(in newborn)

EpidemiologyEpidemiologygAS: -hot,humid,summer weather gAS: -hot,humid,summer weather (tropical, semitropical)(tropical, semitropical)

-young children (2 – 5 y)-young children (2 – 5 y) -follows -follows skin colonizationskin colonization by 10d by 10d --sporadicsporadic cases in cooler climates may cases in cooler climates may

be due to contagious spread from be due to contagious spread from nasopharynxnasopharynx Highly communicableHighly communicable Related to PSGN but not ARF Related to PSGN but not ARF

S.aereus: -follow nasal colonization S.aereus: -follow nasal colonization

Predisposing factorPredisposing factor

Poor hygienePoor hygieneCrowdingCrowding

Minor trauma (scratch)Minor trauma (scratch)

Insect biteInsect bite

Preexisting skin disease(dermatitis)Preexisting skin disease(dermatitis)

Clinical manifestationClinical manifestation

Red papule Red papule Small vesicle Small vesicle pustulate pustulate rupture rupture

Thick yellow stuck-on crustsThick yellow stuck-on crustsUsual siteUsual site: face(around the nose and mouth): face(around the nose and mouth)

legslegsPainlessPainlessPruriticPruriticMild regional adenopathyMild regional adenopathyMinimal constitutional symptomsMinimal constitutional symptomsRecovery without scarRecovery without scar

Bullous impetigoBullous impetigo

S.aureusS.aureus

Newborn and younger childrenNewborn and younger children

10% of all cases of impetigo10% of all cases of impetigo

Epidermal split caused by Epidermal split caused by exfoliative toxinexfoliative toxin

More extensive lesions More extensive lesions

1-2 cm bullae containing neutrophils and 1-2 cm bullae containing neutrophils and organismorganism

thin paper-like cruststhin paper-like crusts

TREATMENTTREATMENT

Topical mupirocinTopical mupirocin

PRP cloxacillin 250mg qidPRP cloxacillin 250mg qid

11stst g. ceph. cephalexin 250mg qid g. ceph. cephalexin 250mg qid

In the past penicillins (benzathin,oral P.V,In the past penicillins (benzathin,oral P.V,

amoxicillin)amoxicillin) in case of allergy: erythromycinin case of allergy: erythromycin duration : 10dduration : 10d

FOLLICULITISFOLLICULITIS

General considerationsGeneral considerations

Etiology:Etiology: Staphylococcus.aureus Staphylococcus.aureusSuperficial infection within Superficial infection within hair follicleshair follicles & & apocrine regionapocrine regionpapulepapulesmall(2-5mm)small(2-5mm)erythematouserythematousOccasionally pruriticOccasionally pruriticTopped by a central pustuleTopped by a central pustule

TreatmentTreatment

Local measuresLocal measures

saline compresssaline compress

topical antibacterialstopical antibacterials

Duration :until resolution of infection Duration :until resolution of infection

(5-7 d)(5-7 d)

Chronic folliculitis: Chronic folliculitis: Uncommon except in acne vulgaris,Uncommon except in acne vulgaris, Constituents of the normal flora Constituents of the normal flora ((ee..gg.., ,

Propionibacterium acnesPropionibacterium acnes)) may play a may play a rolerole

Diffuse folliculitis:Diffuse folliculitis:Hot-tub folliculitisSwimmer’s itch

Hot-tub folliculitisHot-tub folliculitisPseudomona.aeruginosa:Pseudomona.aeruginosa:

-contaminated swimming pools-contaminated swimming pools insufficiently chlorinatedinsufficiently chlorinated , , 37-40°c 37-40°c --IP:IP:48h48h -papulourticarial-papulourticarialpustulepustule -healing within -healing within 55 days days --bacteremiabacteremia has been reported has been reported

swimmer’s itchswimmer’s itch

Exposure of skin to freshwater infested Exposure of skin to freshwater infested with with avian schistosomesavian schistosomesWarmWarm water and water and alkalinealkaline PH: PH:

suitable for molluskssuitable for mollusks(intermediate host)(intermediate host)

Schistosomal cercariae penetrate hair Schistosomal cercariae penetrate hair follicles but quickly diesfollicles but quickly diesAllergic reactionAllergic reaction : intense itching and : intense itching and erythemaerythema

Other less common formsOther less common forms

EnterbacteriaceaeEnterbacteriaceae

-complicate acne-complicate acne

-during prolonged AB therapy-during prolonged AB therapy

CandidaCandida

-surrounding areas of intertriginous-surrounding areas of intertriginous

-pruritic satellite lesion-pruritic satellite lesion

-prolonged AB or C.S -prolonged AB or C.S

FURUNCLE&CARBUNCLEFURUNCLE&CARBUNCLE

FuruncleFuruncle

Deep seated Deep seated (subcut.)(subcut.) necrotic infection necrotic infection

Extend from a hair follicle to a true abscessExtend from a hair follicle to a true abscess

Site:areas that are subject to areas that are subject to frictionfriction and and perspiration perspiration and contain and contain hair follicleshair follicles (buttock,face,neck)(buttock,face,neck)

Painful , firm, red nodulePainful , firm, red nodule

Fever and constitutional symptoms Fever and constitutional symptoms

Subside after spontaneous drainageSubside after spontaneous drainage

CarbuncleCarbuncleDeep infectionDeep infection of a group of contiguous of a group of contiguous folliclesfollicles

Site: back of the neck,shoulders,hip,thigh: back of the neck,shoulders,hip,thigh

More severe,necrotic and painfulMore severe,necrotic and painful

External drainage along hair folliculesExternal drainage along hair follicules

Intense inflammation of surrounding and Intense inflammation of surrounding and underlying connective tissueunderlying connective tissue

Fever ,malaise and leukocytosisFever ,malaise and leukocytosis

Predisposing factorsPredisposing factors

Diabetes mellitusDiabetes mellitus

ObesityObesity

Blood dyscrasiaBlood dyscrasia

Corticosteroid therapyCorticosteroid therapy

Defect in neutrophil functionDefect in neutrophil function

ComplicationComplication

Blood stream invasionBlood stream invasion

Infective endocarditisInfective endocarditis

Metastatic fociMetastatic foci

OsteomyelitisOsteomyelitis

Upper lip,noseUpper lip,nose: : spread to cavernous spread to cavernous sinussinus

TreatmentTreatmentSystemic antibiotics esp. if cellulitisSystemic antibiotics esp. if cellulitis

feverfever midfacemidface

SevereSevere infection: nafcillin/cloxacillin infection: nafcillin/cloxacillin 1-2g iv q4h1-2g iv q4h cefazolin 1g iv q8hcefazolin 1g iv q8h

MildMild infection: cloxacillin/cephalexin infection: cloxacillin/cephalexin 250-500mg po qid250-500mg po qid

Duration :Duration : 7-10d 7-10dSurgerySurgery: large and fluctuent: large and fluctuent

FuruncleFuruncle

CarbuncleCarbuncle

ERYSIPELASERYSIPELAS

EtiologyEtiology

gAStrepgAStrep

Uncommonly gC & gGStrepUncommonly gC & gGStrep

In newborns gBStrepIn newborns gBStrep

Clinical manifestationClinical manifestationSiteSite: : formerlyformerly face was most common face was most common

nownow distribution has changed: distribution has changed:

70-80% lower extremity70-80% lower extremity

5-20% face5-20% face

Infants and elderly adults most affectedInfants and elderly adults most affected


Abrupt onsetAbrupt onset

Rapid progressionRapid progression Translocation of strep. laterally via lymphaticsTranslocation of strep. laterally via lymphatics

Flaccid edema of the epidermisFlaccid edema of the epidermis Engorgement or obstruction of lymphaticsEngorgement or obstruction of lymphatics

Clinical manifestationClinical manifestationBright,redBright,red swelling swellingWarm , intense painWarm , intense painRaised,indurated,sharply demarcated Raised,indurated,sharply demarcated marginmarginPeau d ‘ orangePeau d ‘ orange texture texture

involvement of superficial lymphaticinvolvement of superficial lymphaticFlaccid bullae during Flaccid bullae during 22ndnd or 3 or 3rdrd day dayDesquamationDesquamation 5-10 days5-10 days in to the illness in to the illnessFever , leukocytosis is a feature Fever , leukocytosis is a feature Extension to deeper soft tissue is rare Extension to deeper soft tissue is rare

TreatmentTreatmentMild,early: -procaine penicillin 1.2mu bid IMMild,early: -procaine penicillin 1.2mu bid IM

-penicillin.V oral-penicillin.V oral -erythromycin in case of allergy -erythromycin in case of allergy

Severe : -penicillin.G 1-2mu q4h IVSevere : -penicillin.G 1-2mu q4h IV

If cellulitis is a D.Dx: -PRP(nafcillin,oxacillin)If cellulitis is a D.Dx: -PRP(nafcillin,oxacillin) -1-1stst g. ceph. g. ceph.

TreatmentTreatmentSwelling may progress despite appropriate Swelling may progress despite appropriate treatmenttreatment

FeverFever

Pain diminishPain diminish

Intense red colorIntense red color

CELLULITISCELLULITIS

EtiologyEtiology

S.aereus:S.aereus:MRSA is rapidly replacing MSSAMRSA is rapidly replacing MSSA

gA strep.gA strep.gC strep sometimes gC strep sometimes gG strep sometimesgG strep sometimes

Wide variety of exogenous bacteriaWide variety of exogenous bacteria

Predisposing factorPredisposing factorS.aureusS.aureus : : central localized infectioncentral localized infection (e.g. abscess , folliculitis , infected foreign (e.g. abscess , folliculitis , infected foreign body , surgical or traumatic wounds)body , surgical or traumatic wounds)

Strep.Strep. : : minor or inapparent breaks minor or inapparent breaks

disrupted lymphatic drainagedisrupted lymphatic drainage

surgical wound infectionsurgical wound infection (1(1stst 24 h ) 24 h )

Clinical manifestationClinical manifestationPain and local tendernessPain and local tenderness

Hot Hot

swollen swollen

ErythemaErythema

Strep Strep : more rapidly spreading: more rapidly spreading

frequently associated with fever frequently associated with fever

and lymphangitisand lymphangitis


Diffuse spreading infectionDiffuse spreading infection

Involves skin and subcutaneous tissueInvolves skin and subcutaneous tissue

(deeper than erysipelas)(deeper than erysipelas)

Systemic signs (fever,malaise,chills)Systemic signs (fever,malaise,chills)

Regional lymphadenopathyRegional lymphadenopathy

Border Border notnot elevated , elevated ,notnot demarcated demarcated

Diagnosis Diagnosis

IfIf : drainage : drainage

an open wound gram stain an open wound gram stain

an obvious port of entry culturean obvious port of entry culture

In the absence of these findings definite In the absence of these findings definite diagnosis of etiology is difficultdiagnosis of etiology is difficult

Culture of needle aspiration and punch Culture of needle aspiration and punch biopsy biopsy 20%20%

Blood culture Blood culture <5%<5%

Differential diagnosisDifferential diagnosis

Necrotizing fasciitisNecrotizing fasciitis

Insect biteInsect bite

Fixed drug eruptionFixed drug eruption

DVT DVT

FMFFMF

Pyoderma gangrenosaPyoderma gangrenosa

Sweet’s syndromeSweet’s syndrome

TreatmentTreatment

Indications for admission:Indications for admission:

- - rapid progressionrapid progression

- systemic reaction (chills and fever) - systemic reaction (chills and fever)

- underlying condition- underlying condition (immunedefficiency, asplenia, previous (immunedefficiency, asplenia, previous edema, cirrhosis, renal failure, heart edema, cirrhosis, renal failure, heart failure) failure)

Treatment Treatment Hospitalized patients:Hospitalized patients:

-Nafcillin or oxacillin 2g iv q4-6h-Nafcillin or oxacillin 2g iv q4-6h

-Cefazolin 1-2g iv q8h-Cefazolin 1-2g iv q8h

Mild infectionMild infection

-Cloxacillin 500mg po q6h-Cloxacillin 500mg po q6h

-Cephalexin 500mg po q6h-Cephalexin 500mg po q6h

Other agentsOther agents: vancomycin, clindamycin, : vancomycin, clindamycin, erythromycin, TMP/SMX, quinolones erythromycin, TMP/SMX, quinolones (CAMRSA)(CAMRSA)

TreatmentTreatment

Duration :Duration : 10-1410-14 days days

Shift from Shift from IVIV to to POPO after systemic symptoms after systemic symptoms and erythema resolvedand erythema resolved

Recurrent formsRecurrent forms

Saphenous venectomy for CABGSaphenous venectomy for CABG

Edema,erythema,tendernessEdema,erythema,tenderness

Chills,high fever,toxicityChills,high fever,toxicity

Associated lymphangitisAssociated lymphangitis

Spread along the course of venectomySpread along the course of venectomy

Etiology:gA & non gAßHS (gC,gG)Etiology:gA & non gAßHS (gC,gG)

Port of entry:associated area of tinea pedisPort of entry:associated area of tinea pedis

Recurrent formsRecurrent forms

Chronic lower extremity lymphedemaChronic lower extremity lymphedema

Radiation therapyRadiation therapy

Neoplastic involvement of pelvic lymph Neoplastic involvement of pelvic lymph nodenode

Lymph node dissectionLymph node dissection

Chronic venous stasis (prior DVT)Chronic venous stasis (prior DVT)

Recurrent formsRecurrent formsStapylococcus :Stapylococcus :

Job ‘s syndrome Job ‘s syndrome (eosinophilia and, IgE)(eosinophilia and, IgE) Nasal carriers of staph Nasal carriers of staph

Other microorganismsOther microorganismsS.agalactiae(gBS)S.agalactiae(gBS)

Elderly, diabetes, neurologic impairment, Elderly, diabetes, neurologic impairment, Peripheral vascular disease, HIV Peripheral vascular disease, HIV

Haemophilus.influenzaHaemophilus.influenzaChildrenChildrenViolaceous, facial cellulitis(periorbital,cheek)Violaceous, facial cellulitis(periorbital,cheek) In association with sinusitis,otitis,epiglotitisIn association with sinusitis,otitis,epiglotitis

Other microorganismsOther microorganisms

P.aeruginosaP.aeruginosa 3 types3 types of soft tissue infections: of soft tissue infections: Ecthyma gangrenosumEcthyma gangrenosum in neutropenic patients in neutropenic patients Hot tub folliculitisHot tub folliculitis Cellulitis :Cellulitis : penetrating injuries (step on a nail) penetrating injuries (step on a nail)

hospitalized immunocompromised hosthospitalized immunocompromised host

Treatment :surgical drainage and inspectionTreatment :surgical drainage and inspection

+ antimicrobial (+ antimicrobial (AG , 3AG , 3rdrd generation ceph. generation ceph.

, semisynthetic penicillin , quinolone), semisynthetic penicillin , quinolone)

Other microorganismsOther microorganismsPasteurella multocidaPasteurella multocida, Staphylococcus , Staphylococcus intermedius and Capnocytophaga intermedius and Capnocytophaga canimorsuscanimorsus

cat or dog bitecat or dog bite

Eikenella corrodensEikenella corrodens human bitehuman bite

AmoxicillinAmoxicillin//clavulanateclavulanate, , ampicillinampicillin//sulbactamsulbactam, , and and cefoxitincefoxitin are good choices for the treatment are good choices for the treatment of of animal animal or or humanhuman bite infections bite infections

Other microorganismsOther microorganismsErysipelothrix.rhusiopathiae Erysipelothrix.rhusiopathiae

Fish and domestic swine: butcher, fisherman, veterinarianFish and domestic swine: butcher, fisherman, veterinarian

Aeromonas hydrophiliaAeromonas hydrophilia Fresh water (lakes,rivers,streams)Fresh water (lakes,rivers,streams)

Vibrio vulnificus Vibrio vulnificus Seawater or seafoodsSeawater or seafoods

M. marinumM. marinum water in aquariums or swimming pools water in aquariums or swimming pools

NECROTIZING SOFT NECROTIZING SOFT TISSUE TISSUE

INFECTIONSINFECTIONS


Destruction of Destruction of subcutaneous tissuesubcutaneous tissue and and fasciafascia

Physical findings ,Physical findings ,particularly earlyparticularly early in in the illness, may the illness, may notnot be striking when be striking when pain or unexplained feverpain or unexplained fever is the only is the only manifestation with no or minimal manifestation with no or minimal erythemaerythema

Infectious disease emergencyInfectious disease emergency

In In the initial phase distinguishing between the initial phase distinguishing between cellulitiscellulitis and and fasciitisfasciitis is difficultis difficult

Necrotizing fasciitisNecrotizing fasciitis Involvement of deeper tissue is suggested:Involvement of deeper tissue is suggested: Failure to respond to therapyFailure to respond to therapy Hard , wooden feel of subcutaneous tissueHard , wooden feel of subcutaneous tissue Systemic toxicitySystemic toxicity Bullous lesionBullous lesion Skin necrosis and ecchymosisSkin necrosis and ecchymosis Rapid spreadRapid spread Gas in soft tissueGas in soft tissue Edema that extends beyond the margin of erythemaEdema that extends beyond the margin of erythema Skin anesthesiaSkin anesthesia


Clinical manifestationClinical manifestation : : severe local painsevere local painanesthesiaanesthesia cellulitis with progressive edema,erythemacellulitis with progressive edema,erythema dark red induration of epidermisdark red induration of epidermis bullae filled with blue or purple fluidbullae filled with blue or purple fluid friable skin with bluish ,maroon or black colorfriable skin with bluish ,maroon or black color thrombose of blood vessels in dermal papilla thrombose of blood vessels in dermal papilla crepitationcrepitation fever , systemic toxicity fever , systemic toxicity shock and multiorgan shock and multiorgan failure failure


TYPE 1TYPE 1 :polymicrobial (anaerobe,g+ ,g- ):polymicrobial (anaerobe,g+ ,g- )

PredisposingPredisposing :- a breach in the integrity of mucous :- a breach in the integrity of mucous membrane (GI or GU) : malignancy , diverticulum …, urethral membrane (GI or GU) : malignancy , diverticulum …, urethral teartear

- surgery- surgery

- diabetes- diabetes

- peripheral vascular disease- peripheral vascular disease

- injection drug use- injection drug use

Necrotizing fasciitisNecrotizing fasciitisTYPE 2TYPE 2 : :gAstrep (streptococcal gangrene)gAstrep (streptococcal gangrene)

Predisposing Predisposing ::

- non penetrating minor trauma(a bruise, muscle - non penetrating minor trauma(a bruise, muscle strain) via transient bactremiastrain) via transient bactremia

- cutaneous infection , penetrating trauma- cutaneous infection , penetrating trauma

Toxicity is severeToxicity is severe

20-40% myositis occur concomitantly20-40% myositis occur concomitantly

Markedly elevated CPKMarkedly elevated CPK

Gas is not usually presentGas is not usually present

Fournier’s gangreneFournier’s gangrene

A type of necrotizing fasciitisA type of necrotizing fasciitis

Leakage to the Leakage to the perinealperineal area area

Mixed aerobe-anaerobe infectionMixed aerobe-anaerobe infection

Massive swelling of scrotum and penisMassive swelling of scrotum and penis

Extension to the Extension to the prineumprineum , , abdominal wallabdominal wall andand legs legs

Necrotizing fasciitisNecrotizing fasciitis Diagnosis :Diagnosis :

Vigilant and serial clinical examinationVigilant and serial clinical examination

Soft tissue radiographs and CTscans:Soft tissue radiographs and CTscans:

Local abscess or gasLocal abscess or gas

only soft tissue swelling in some casesonly soft tissue swelling in some cases

Aspiration of the leading edge or punch biopsy:Aspiration of the leading edge or punch biopsy:

false negative in nearly 80%false negative in nearly 80%

Open surgical inspection with debridementOpen surgical inspection with debridement


RxRx : : surgical drainage and debridement:surgical drainage and debridement:

1) visualize the deep structure1) visualize the deep structure

2)remove necrotic tissue2)remove necrotic tissue

3)reduce compartment pressure3)reduce compartment pressure

4)obtain material for smear & culture4)obtain material for smear & culture

Hyperbaric oxygenHyperbaric oxygen

Necrotizing fasciitisNecrotizing fasciitisRx : Rx : type 1type 1 Ampicillin or ampicillin/sulbactam+ Ampicillin or ampicillin/sulbactam+

Gentamicin+Gentamicin+ metronidazole/clindamycinmetronidazole/clindamycin

ampicillin +ampicillin + ciprofluxacin+ciprofluxacin+ metronidazole/clindamycinmetronidazole/clindamycin

type 2type 2 penicillin G + penicillin G + clindamycinclindamycin

Clostridial gas gangreneClostridial gas gangrene(clostridial myonecrosis)(clostridial myonecrosis)

EtiologyEtiology

Clostridial spp.Clostridial spp.C.perfringesC.perfringes 80 % of cases 80 % of cases

-trauma -trauma

need not to be severeneed not to be severe

but must be deep&necroticbut must be deep&necrotic

-surgery-surgery

-intramuscular injection-intramuscular injection

EtiologyEtiology

C.septicumC.septicumspontanous,nontraumaticspontanous,nontraumatic

GI abn (GI abn (cancercancer,surgery,diverticulitis),surgery,diverticulitis)

leukemia,lymphomaleukemia,lymphoma

neutropenianeutropenia

HIV infectionHIV infection


Short IP almost always<3d frequently<24hShort IP almost always<3d frequently<24hSudden onset of exquisite increasing painSudden onset of exquisite increasing painLocal swelling and edemaLocal swelling and edemaThin hemorrhagic exudateThin hemorrhagic exudateFrothiness of wound exudateFrothiness of wound exudateTachycardia ,minor elevation in temperatureTachycardia ,minor elevation in temperatureGas may be Gas may be absentabsent at early stages at early stages

Clinical manifestationClinical manifestationSkin is tense , white marbled with blue and Skin is tense , white marbled with blue and cooler than normalcooler than normal

Rapid progression of edema & toxemiaRapid progression of edema & toxemia

Profuse serosanginous discharge with Profuse serosanginous discharge with sweetishsweetish smell smell

Bullae ,patches of cutaneous gangrene, Bullae ,patches of cutaneous gangrene, bronze discolorationbronze discoloration

Gas in affected tissueGas in affected tissue


High LOC until just before deathHigh LOC until just before death

Hypotension ,renal failureHypotension ,renal failure

At surgery -muscle may appear paleAt surgery -muscle may appear pale

-does not contract-does not contract

-beefy red and nonviable when-beefy red and nonviable when

dissecteddissected

Diagnosis & TreatmentDiagnosis & Treatment

Gram stainGram stain :gram positive bacilli (box car) :gram positive bacilli (box car)

paucity of PMNpaucity of PMN

Surgery: Surgery: muscles are pale ,nonviablemuscles are pale ,nonviable

frozen sectionfrozen section

RxRx:: surgicalsurgical removal of devitalized tissue removal of devitalized tissue

antibiotic antibiotic : clindamycin + penicillin: clindamycin + penicillin

metronidazolemetronidazole

chloramphenicolchloramphenicol

hyperbaric oxygenhyperbaric oxygen

DIABETIC FOOT ULCERSDIABETIC FOOT ULCERS

Chronic foot infections in patients with D.M Chronic foot infections in patients with D.M are common and difficult problemsare common and difficult problems

Minor trauma in presence of Minor trauma in presence of peripheral neuropathy , neuropathic peripheral neuropathy , neuropathic ulcers , vascular insufficiencyulcers , vascular insufficiency

Different forms : cellulitis , tissue Different forms : cellulitis , tissue necrosis , osteomyelitisnecrosis , osteomyelitis

Clinical manifestationClinical manifestationNon limb threateningNon limb threatening

SuperficialSuperficial

Lack of systemic toxicityLack of systemic toxicity

Minimal cellulitis < 2 cm from port of Minimal cellulitis < 2 cm from port of entryentry

Ulceration (if present) not fully extending Ulceration (if present) not fully extending through the skinthrough the skin

Lack of significant ischemiaLack of significant ischemia


Limb threatening :Limb threatening :

More extensive cellulitisMore extensive cellulitis

LymphangitisLymphangitis

Ulcer penetrating through skin in to Ulcer penetrating through skin in to subcutaneous tissuesubcutaneous tissue

Prominent ischemiaProminent ischemia

Etiology Etiology

Non limb threatening :Non limb threatening :

S.aureus is major pathogenS.aureus is major pathogen

Facultative streptococci in one thirdFacultative streptococci in one third

Facultative gram negative and anaerobe Facultative gram negative and anaerobe are uncommonare uncommon


Polymicrobial Polymicrobial (S.aureus ,Gbstrep. ,facultative gram (S.aureus ,Gbstrep. ,facultative gram negative ,anaerobe)negative ,anaerobe)

Medical TreatmentMedical Treatment

Non limb threatening :Non limb threatening :

Mild : oral cephalexin , cloxacillin , Mild : oral cephalexin , cloxacillin ,

clindamycinclindamycin

Complicated by cellulitis :parentral cephazolinComplicated by cellulitis :parentral cephazolin


Broad spectrum : eg clindamycin+3Broad spectrum : eg clindamycin+3rdrd g ceph. g ceph.

clindamycin+ciprofluxacinclindamycin+ciprofluxacin

Ampicillin-sulbactamAmpicillin-sulbactam

Surgical managementSurgical management

UnroofingUnroofing

ProbingProbing

Debridement and drainage promptly if :Debridement and drainage promptly if :

-deep ulcers extending to subcutan.-deep ulcers extending to subcutan.

-deep tissue necrosis-deep tissue necrosis

-suppuration-suppuration

Amputation Amputation

Other measuresOther measures

Bed restBed rest

ElevationElevation

Control of diabetesControl of diabetes

Prevention Prevention

Tight glycemic controlTight glycemic controlExamination of the footExamination of the footAvoid extreme bath water temperatureAvoid extreme bath water temperatureAvoid foot soaksAvoid foot soaksDry the foot thoroughly after bathDry the foot thoroughly after bathTrim the nails correctlyTrim the nails correctlyTreat tinea pedis promptlyTreat tinea pedis promptlySelection of appropriate footwearSelection of appropriate footwear

in the name of the most high. skin and soft tissue infections

Documents

folliculitis slide

d slide

impetigo slide

newborn slide

scar slide

high slide

central pustule slide

nasal colonization slide