the skin and beyond: skin and soft tissue infections

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The Skin and Beyond: Skin and Soft Tissue Infections. Presentation to: Infectious Disease Update for the Primary Care Physician Methodist Healthcare John Sinnott, MD, FACP Associate Dean, International Affairs Director, Signature Program in Allergy, Immunology and Infectious Disease - PowerPoint PPT Presentation

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  • The Skin and Beyond:Skin and Soft Tissue InfectionsPresentation to: Infectious Disease Update for the Primary Care PhysicianMethodist Healthcare

    John Sinnott, MD, FACPAssociate Dean, International AffairsDirector, Signature Program in Allergy, Immunology and Infectious DiseaseDirector, Division of Infectious DiseaseUniversity of South Florida, College of Medicine

  • Pretentious Quote: [T]he skin has diseases, one of those diseases is man.Friedrich Nietzsche

  • In General: Skin Lesions Tumors Rashes

  • Melanoma:A symmetricB order irregularC olor pigment variableD iameter > 0.5 cm

  • Skin Infections:

    LAYERINFECTIONEpidermisImpetigoDermisErysipelasSubQCellulitisFasciaFasciitis- (NSTI)MuscleMyositis- (NSTI)

  • Pathogens:Impetigo contagiosum GASImpetigo bullosum StaphErysipelas GASCellulitis Staph, GASFasciitis GAS, MixedMyositis Clostridia

  • CA-MRSA: NBCA MRSA is increasing and may become more like HA-MRSA

    DM, prisoners, contact sports are old risk groups; now everyone is at risk

  • Variant Cellulitis: Bites or Water !

    Human Bite:GASAnaerobesDog Bite:C. canimorsusP. multocidaCat Bite:P. multocidaSaltwater:V. vulnificusM. marinumFresh water:E. tardaA. hydrophila

  • Edwardsiella: Treatment All edwardsiella naturally sensitive to: Tetracyclis, aminoglycosides, most B-Lactams, quinolones, antifolates, chloramphenicol, nitrofurantoin, and fosfomycinAll edwardsiella naturally resistant to:Macrolides, lincosamides, streptogramins, glycopeptides, rifampin, fusidic acid, and oxacillin

    Stock I, Wiedemann B. Natural Antibiotic Susceptibilities of Edwardsiella tarda, E. ictaluri, and E. hoshinae. Antimicrob Agents Chemother, 2001 August; 45 (8): 2245-2255.Harrison's Principles of Internal Medicine, 16th Edition. Kasper D, Braunwald E, Fauci A, et al, Eds. 134: 6. 2006

  • Necrotizing Soft Tissue Infections: NSTISMeleney's synergistic gangreneClostridial anaerobic cellutisClostridial gas gangreneNecrotizing fasciitisType 1 NF- polymicrobial (Fourniers)Type 2 NF- Grp A Strep (IVIG, HB O2)

  • Gas in Soft Tissue:Non-bacterial CausesTrauma / SurgeryAir InjectionH2O2 IrrigationBacterialGlucose Fermenting

  • Diagnosis NSTIs:Serial exams!Serial exams!Soft tissue X- ray, MRI, CTLow threshold for surgeryFull thickness frozen-section BxDirect visualizationGram stain

  • Management and Therapy:Hemodynamic stabilization, nutrition, lytes, fluid resuscitation, oxygenation Early, aggressive and repetitive debridementEarly, aggressive and repetitive debridementHyperbaric txA-Bs

  • 37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A

  • 37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A

  • 37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A

  • Miscellaneous Dermatologic Manifestations of Disease:Pseudomonas folliculitisHerpetic WhitlowHerpes GladiatorumMolluscum ContagiumSeborrheic DermatitisSecondary Syphilis

  • We know too much and believe too little.T. S. Elliot

  • END

    Suspicious lesionNSTI: change in terminology, necrotizing soft tissue infectionGAS group A strepimpetigoGroup A strepImpetigo bulosa staph, often MRSA is causative agentGram stain staphDiabetic pt presents what is DX?Bacterial toxins treat with fluid support pt recoveringGroup A strepCellulitis after punching someoneGram positive and neg synergistic gangreneSlowly enlarging lesion from dog bitecapnocytophasiapasteurellavibriovulnificusvibrioedwardseillaNSTI: all four layers of tissue are deadCellulitis arysipelas, necrotic muscle myositis, 4 layers dead synergistic gangreneGram stain short and long gram neg rods, cocciBiopsy muscle preading gram and gram neg rodsBronze cellulitis pink lady syndrome

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