Rapid update on common skin infections

NICE/PHE guidance into practice

Pulse Live Birmingham 11.11.2021

T L Lewis, GP

Tessa Lewis DOI

• No financial interests in the pharmaceutical or healthcare industries.

• GP

• Chair NICE Managing Common Infections Committee

(travel & accommodation expenses, honorarium)

• Other roles include independent medical advisor, NICE committee work including Quality Standards & Indicators,

• Adviser to TARGET (UK HSA primary care unit , formerly PHE)

Topics

1. Impetigo

2. Cellulitis- inflammation,

- insufficiency

- or infection?

Rapid update on skin infections Incorporating NICE/PHE common infections guidelines into daily general practice

Challenge in Practice:Antimicrobial stewardship vs Sepsis

4

Spectrum of illness & risk

LOW RISK

• Young adult • Fit and well • Symptoms - recent mild• Signs - none

HIGH RISK • Age extremes• Comorbidities• Polypharmacy• Recent admission• Recurrent illness • Social circumstances • Condition-specific

considerations

SIGNS Home readings

✓ Temp, pulse, BP, blood glucose, PFR

Impetigo NICE/PHE NG 153

Non-bullous impetigo

most common age 2-5yrs

James Heilman, MD

Bullous impetigo

more common in <2yrs

Mainly Staphylococcus aureus,

also Streptococcus pyogenes

Tip – Cold sore?

Impetigo NICE/PHE NG 153

Video call with mum: Daughter S 5yrs developed a spot on her cheek 3 days ago which has now spread with several yellow crusty lesions over a 50p sized area and a couple of spots under her chin. She is otherwise well, no allergies. You diagnose impetigo (non-bullous)

What treatment do you recommend?

1. Clarithromycin

2. Antiseptic or hydrogen peroxide cream

3. Flucloxacillin

4. Fucidin 2% cream

Quiz question

Impetigo NICE/PHE NG 153

Quiz answerVideo call with mum: Daughter S 5yrs developed a spot on her cheek 3 days ago which has now spread with several yellow crusty lesions over a 50p sized area and a couple of spots under her chin. She is otherwise well, no allergies. You diagnose impetigo (non-bullous)

What treatment do you recommend?

1. Clarithromycin – No

2. Antiseptic or hydrogen peroxide cream

3. Flucloxacillin - No

4. Fucidin 2% cream

TIP : if antiseptic/ hydrogen peroxide not used this time,

can suggest at onset if future lesions

Impetigo NICE/PHE NG 153

Hydrogen peroxide?

Evidence

Topical fusidic acid 2% vs. Hydrogen peroxide cream1%

(both bd-tds for up to 21 days)

not significantly different for cure or improvement

Children with impetigo SR(Koning et al. 2012)

1 RCT, n=256, 82.0% vs 72%,

RR 1.14, 95% CI 1.00 - 1.31;

moderate quality evidence

Does not lead to antimicrobial resistance so useful alternative

Other topical antiseptics - no studies found

Advice• Available OTC [Crystacide]• “should be prescribed on NHS ..due to high

retail price”• Dry film will appear on the skin after

application, can be washed off with water• Avoid contact with the eyes.• Do not use on large or deep wounds.• Do not apply to healthy skin.• Can bleach fabric

https://www.prescqipp.info/our-resources/webkits/hot-topics/

Impetigo NICE/PHE NG 153

Treatment

Impetigo NICE/PHE NG 153

Antibiotics: topical = oral

AMR can develop rapidly with extended or repeated topical antibiotic

=EvidenceTopical vs oral antibiotics

Systematic review and meta-analysis (Koning et al. 2012)Number of analyses e.g. no statistically significant difference effectiveness topical mupirocin vs oral erythromycin 10RCTs N=581 mod quality evidence

Impetigo

Frequent recurrenceSend a skin swab Consider nasal swab & treatment

for suppression.

5 days

Impetigo advice What self care & exclusion (school/work) advice do you give ?

HygieneWash affected areas with soap and water,

• Wash hands regularly particular after touching a patch of impetigo

• Avoid scratching affected areas.• Avoids sharing towels, clean potentially

contaminated toys and play equipment. [CKS]

Exclusion Criteria• Children should be excluded from school until

the lesions are crusted and healed or 48 hours after commencing antibiotic treatment [PHE]

• Food handlers are required by law to inform employers immediately if they have impetigo [CKS]

UTI V1.12 June 2020 rcgp.org.uk/TARGETantibiotics13

Impetigo NICE/PHE NG 153

Summary

James Heilman, MD

Impetigo

✓ Consider topical antiseptic / hydrogen peroxide

✓ Antibiotic effectiveness: topical = oral

✓ Avoid extended or repeated use of topical

antibiotics – risk resistance

! Bullous impetigo – offer oral antibiotic

Rx Treatment course 5 days for most

Will you change your practice?

Topics

1. Impetigo

2. Cellulitis- inflammation,

- insufficiency

- or infection?

Rapid update on skin infections Incorporating NICE/PHE common infections guidelines into daily general practice

‘Red Legs’ – What would you do?

Carer rings, Ms Hughes, 77yrs, has inflamed, painful, swollen lower

legs. She is out of sorts and not eating much. Carer says she had

tablets 3 months ago for the same thing.

PMH Hypertension, osteoarthritis, penicillin allergy

No thermometer but doesn’t feel feverish, no shivers, aches or sweats

Has a BP monitor & agrees to check obs: Pulse 98/min , BP 146/73

What do you do at this

point?

1. Prescribe

clarithromycin

2. Prescribe co-

amoxiclav

3. Prescribe

doxycycline

4. None of the above

People with darker skin tones may present with painful swollen legs with change in colour and altered texture

Q - 77yr-old, red painful swollen lower legs, malaise, obs normal

A – None of the above, no antibiotics at this point, uncertain diagnosis

(amlodipine, felodipine)

Venous eczema and lipodermatosclerosis [CKS]

UTI V1.12 June 2020 rcgp.org.uk/TARGETantibiotics18

Risks: Immobility, obesity, VVs, previous DVT

Examination Varying severity: • Hyperpigmentation (haemosiderin)• Venous eczema red, itchy, scaly, or flaky skin, may have blisters

and crusts, +/- Pain and swelling• Lipodermatosclerosis from chronic inflammation and fibrosis

- Acute lipodermatosclerosis (sclerosing panniculitis) painful inflammation above ankles, may be mistaken for cellulitis or phlebitis.- Chronic lipodermatosclerosis painful, hardened, tight,

red or brown skin, which if circumferentially affecting the ankle area may eventually result in the leg having an 'inverted champagne bottle' appearance.

venous insufficiency

Venous skin changes caused by: Venous insufficiency (due to venous valve incompetence or impaired calf muscle pump) causes venous hypertension

Symptoms: heaviness, aching, swelling, and itching, typically worse at end of day, relieved by leg elevation.

Regular emollientFlares – topical corticosteroidCompression stockings ( after ABPI)

Keep active, weight, leg elevation,

Cellulitis [CKS]

Diagnosis and risk factors - Usually unilateral. Bilateral leg cellulitis is rare.

- Acute onset : red, painful, hot, swollen, and tender skin,

that spreads rapidly.

- Fever & malaise

- Check for skin break/organism entry site e.g.

wound/trauma, macerated skin, fungal skin infection,

concomitant skin disorder

Other risk factors & comorbidities which may

complicate or delay resolution of infection

• Oedema, venous insufficiency, obesity.

• Diabetes,

• Peripheral vascular disease,

• Immunosuppression

See CKS for further information

Insect bites & stings - Inflammation of

infection ?

• Rapid onset with redness & itching

– likely to be inflammatory or allergic

• unlikely that the skin will become

infected

• Assess symptoms & signs of infection

Cellulitis NICE/PHE NG 141

Most common causative pathogens

Usually streptococcus pyogenes and Staphylococcus aureus therefore flucloxacillin first line .

• penetrating injury, • exposure to water-borne organisms• infection acquired outside UK

Consider marking extent with single-use surgical marker pen

Consider swab if skin broken,+ risk uncommon pathogen e.g.

Manage underlying conditions E.g. diabetes, venous insufficiency eczema and oedema (calcium channel blockers)

Cellulitis NICE/PHE NG 141

Quiz questionMr Jones 83yrs, has a warm red swollen and painful left lower leg, and now covers a 15cm area. You notice a small abrasion on the side of his foot (he remembers he had knocked it in the garden) O/E Temp 37.7

PMH IHD, AF, and hypertension,

What antibiotic course length

would you give?

1. 5 days

2. 7 days

3. 10 days

4. 14 days

Cellulitis NICE/PHE NG 141

Course length - Quiz answer

1. 5 days

2. 7 days

3. 10 days

4. 14 days

5-7 days recommended

A longer course (up to 14 days in total) may be needed based on clinical assessment.

Skin takes time to return to normal,

full resolution at 5 - 7 days is not expected.

Evidence 1RCT fluoroquinolone 5 vs 10days n=87 1RCT tedizolid 6vs10days [SR Kilburn]

NICE NG 141

Course length – skin infections NICE/PHE

Course length days Footnote Impetigo 5 5-day course is appropriate for most

can be increased to 7 days based on clinical judgement, depending on the severity and number of lesions

Human & animal bites

3- prophylaxis

5- treatment

A 5-day course is appropriate for most

can be increased to 7 days (with review) based on clinical assessment of the wound, E.g. Significant tissue destruction or it penetrated bone, joint, tendon or vascular structures.

Secondary skin infection

5-7

Cellulitis 5-7 A longer course (up to 14 days in total) may be needed based on clinical assessment.

However, skin does take time to return to normal, and full resolution at 5 to 7 days is not expected.

Leg Ulcer 7Diabetic foot 7 A longer course (up to a further 7 days) may be needed based on

clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 7 days is not expected

Cellulitis NICE/PHE NG141

Safety nettingAdvice &reassessment:

• skin will take time to return to normal after finishing the antibiotics

• seek medical help/reassess if

- symptoms worsen rapidly or significantly at any time,

- or do not start to improve in 2 to 3 days

- the person is very unwell, has severe pain, or redness or swelling beyond the initial presentation

Admit if they have any symptoms or signs suggesting a more serious illness or condition, such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis.

Necrotising Fasciitis

Early symptoms – intense pain out of proportion to skin damage

Severe infection sprfcl & deep fascia

Most common cause is group A streptococcus.

Rapid progression, skin discolouration , crepitus, bulla, gangrene

Refer – IV antibiotics & surgical

Vanderlei Bailo

Cellulitis NICE/PHE NG 141, CKS

Summary

Diagnosis

• Exclude other causes of skin redness & oedema

• Look for site of entry e.g. skin break

• Usually affects one limb, bilateral cellulitis is rare

Management

• Manage underlying condition e.g. diabetes, venous insufficiency, eczema or oedema (review medcn *felodipine, amlodipine)

Antibiotics

• Is there risk of uncommon pathogens?

• Co-amoxiclav (clarithromycin +metronidazole) if near eyes or

nose or severely unwell

• Course length usually 5-7 days, (up to 14 days)

Advice

• Skin takes some time to return to normal after antibiotics finished

• Prevention advice SAFETY NET

Thank you for listening!

Tessa Lewis, GP tessa.lewis1@btinternet.com

Thanks to colleagues who • Responded to the NICE consultations• Worked with NICE, PHE/RCGP TARGET to

identify key learning points