Skin and Soft Tissue Non purulent SSTI Recurrent SSTI Infections: - PDF document

4/16/2014 Overview • Purulent SSTI Skin and Soft Tissue • Non ‐ purulent SSTI • Recurrent SSTI Infections: MRSA and Beyond • Animal Bites • Necrotizing soft tissue infections Catherine Liu, M.D. Assistant Professor of Clinical Medicine • Potpourri of cases Division of Infectious Diseases University of California, San Francisco What is the appropriate management of Case 1 this patient? 20 y/o M presents with A. Incision and drainage alone 3 days of an enlarging, painful lesion on his L B. Incision and drainage plus cephalexin arm that he attributes to a spider bite C. Incision and drainage plus TMP ‐ SMX D. Cephalexin T 36.9 BP 118/70 P 82 E. TMP ‐ SMX 1

4/16/2014 What is the appropriate management of Abscesses: Do antibiotics provide this patient? benefit over I&D alone? 100% A. Incision and drainage alone 80% % patients cured B. Incision and drainage plus cephalexin 60% Placebo C. Incision and drainage plus TMP ‐ SMX Antibiotic 40% p=.52 p=.25 p=.12 D. Cephalexin 20% Cephalexin TMP-SMX TMP-SMX 0% E. TMP ‐ SMX Rajendran '07 Duong '09 Schmitz '10 1 Rajendran P AAC 2007; 2 Schmitz G Ann Emerg Med 2010; 3 Duong M Ann Emerg Med 2009 Antibiotic therapy is recommended for Microbiology of Purulent SSTIs: abscesses associated with: ER Patients • Severe, extensive disease, rapidly progressive with associated cellulitis or septic phlebitis • Signs & sx of systemic illness • Associated comorbidities, immunosuppressed • Extremes of age • Difficult to drain area (e.g. face, hand, genitalia) • Failure of prior I&D 2004 2008 Liu C Clin Inf Dis 2011 Moran G NEJM 2006; Talan D Clin Inf Dis 2011 2

4/16/2014 Outpatient purulent cellulitis: Case 2 Empiric Rx for MRSA  ‐ hemolytic MRSA MSSA Comments 28 year old woman with strep erythema of her left foot x 48 hours. No TMP/ SMX + + ‐ /? Low rates of 1 ‐ 2 DS tab BID resistance purulent drainage, Doxycycline, + + ‐ Low rates of exudate or abscess. Minocycline resistance 100 mg BID  C. diff risk Clindamycin +/ ‐ + + 300 ‐ 450 TID T 37.0 BP 132/70 P 78 Eells SJ et al Epidemiology and Infection 2010 Linezolid + + + Most 600 mg BID expensive option What is the appropriate management of What is the appropriate management of this patient? this patient? A. Clindamycin 300 mg PO TID A. Clindamycin 300 mg PO TID B. Cephalexin 500 mg QID B. Cephalexin 500 mg QID C. Cephalexin 500 mg QID and TMP/ SMX 2 C. Cephalexin 500 mg QID and TMP/ SMX 2 DS tab PO bid DS tab PO bid 3

4/16/2014 Nonpurulent Cellulitis Cephalexin vs. Cephalexin + TMP ‐ SMX in patients with Uncomplicated Cellulitis  ‐ hemolytic strep vs. S. aureus ? • Prospective study, hospitalized patients (N=248) N=146 Methods – Acute and convalescent titers (ASO and anti ‐ DNaseB) – Rx with  ‐ lactam antibiotics (cefazolin/oxacillin) Results p=.66 p=1.0 p=.62 – 73% due to  ‐ hemolytic strep; 27% no cause identified – 96% response rate to  ‐ lactam antibiotic Pallin D Clin Inf Dis 2013 Jeng A Medicine 2010 Microbiology of SSTI: Outpatient nonpurulent cellulitis: Empiric Rx for  ‐ hemolytic streptococci, +/ ‐ MRSA Hospitalized Patients  ‐ hemolytic strep MRSA MSSA Penicillin V ‐ K ‐ Rare +/ ‐ ‐ ‐ + 500 mg QID/ Amoxicillin 500 mg TID Dicloxacillin ‐ + + 500 mg QID Cephalexin ‐ + + 500 mg QID Clindamycin +/ ‐ + + 300 ‐ 450 mg TID Linezolid + + + 600 mg BID Jenkins T Clin Inf Dis 2010 4

4/16/2014 Antibiotic Utilization Among Hospitalized Antibiotic Utilization Among Hospitalized Patients with SSTI: Baseline Patients with SSTI: Post ‐ QI Intervention *Recommended empiric vanco *Discouraged gram neg/ anaerobic N=169 *Suggested Rx for 7 days p<.001 Jenkins T Arch Intern Med 2011 Jenkins T Arch Intern Med 2011 FDA Approved Agents for Treatment Other Outcomes of Complicated SSTI •  Median duration of Rx (13 vs. 10d, p<.001) Antibiotic Adult • No differences in clinical outcomes Vancomycin 15 ‐ 20 mg/kg IV Q8 ‐ 12 – Clinical failure (7.7% vs. 7.4%, p=NS) Linezolid 600 mg PO/ IV BID – Recurrent infection Daptomycin 4 mg/kg IV QD Telavancin 10 mg/kg IV QD – Rehospitalization due to SSTI Ceftaroline 600 mg IV Q12 – Length of hospital stay Tigecycline 100 mg IV x 1, then 50 IV Q12 Jenkins T Arch Intern Med 2011 5

4/16/2014 Summary: Empiric Management of SSTIs Recurrent SSTI Purulent Non ‐ purulent ( β‐ hemolytic strep) (MRSA) • Recurrent abscess, furunculosis: • Cephalexin 500 QID • I&D Staphylococcus aureus (MRSA and MSSA) Uncomplicated • Dicloxacillin 500 QID Consider addition of anti ‐ MRSA (5 days) Consider MRSA active agent if no antibiotic in select situations 1 response • Recurrent cellulitis:  ‐ hemolytic streptococci • I&D plus vancomycin (or • Cefazolin, Nafcillin Complicated alternative 2 ) • Gram negative coverage (5 ‐ 10 days) • Gram negative coverage not needed 3 not needed 3 1. Systemic illness, purulent cellulitis/wound infection, comorbidities, extremes of age, abscess difficult to drain or face/hand, septic phlebitis, lack of response of to I&D alone. MRSA active PO antibiotic: TMP ‐ SMX, doxycycline, clindamycin 2. Daptomycin, linezolid, tigecycline, telavancin, ceftaroline 3. Except: critically ill pts with serious SSTI (nec fasc), perirectal/ periorbital infections, decubitus ulcer infections, severe diabetic foot infections, animal bites, water ‐ exposure Recurrent Staphylococcal SSTI Recurrent Staphylococcal SSTI Management Strategies: Hygiene Education • Cover draining wounds • Wash hands after touching infected wound Host • Avoid sharing personal items • Use liquid pump/ pour soaps & lotions (vs. bar soaps) • Launder towels and washcloths after each use, linens once weekly Environment Pathogen • Clean high touch surfaces 6

4/16/2014 Mupirocin vs Mupirocin + Recurrent Staphylococcal SSTI Chlorhexidine vs Mupirocin + Bleach Management Strategies: Decolonization • Mupirocin: 5 days/ mth x 1 year ↓ recurrent SSTI among 34 MSSA nasal carriers N=229 * • Chlorhexidine (CHG) washes alone: Not effective • Mupirocin + CHG: Household >> individual decol • Bleach baths: No benefit vs hygiene education • Oral antibiotics: Mupirocin + hexachlorophene + TMP ‐ SMX or doxy x 10 d ↓ recurrent MRSA SSTI (31 pts); Anecdotal experience with rifampin ‐ based therapy *All groups received hygiene education Raz Arch Intern Med 1996; Whitman ICHE 2010; Fritz ICHE 2012; Kaplan CID 2013; Miller AAC 2012 Fritz S Inf Control Hosp Epi 2011 Household vs. Individual Decolonization Bleach Baths + Hygiene vs. Hygiene w/Mupirocin + CHG x 5 days p=.12 p=.02 p=.008 p=.02 *All groups received hygiene education Bleach Baths: Twice weekly for 15 minutes x 3 months Kaplan S Clin Inf Dis 2013 Fritz S Clin Inf Dis 2012 7

4/16/2014 PCN 250 BID vs. Placebo For Recurrent Streptococcal Cellulitis Prevention of Recurrent Cellulitis Management Strategies • Most patients have predisposing factor: – Obesity, lymphedema, venous insufficiency, prior N=274 trauma/ surgery to area, tinea pedis • Management approach: – Treat underlying conditions whenever possible (e.g. compressive stockings, Rx interdigital maceration/ tinea, emollients to avoid dryness/ cracking, diuretics) – Prophylactic antibiotics if frequent recurrence • Penicillin VK 250 mg PO twice daily • Benzathine PCN 1.2 MU IM every 2 ‐ 4 weeks Stevens D Clin Inf Dis 2005 Thomas K NEJM 2013 In addition to wound care, what is the Case 3 appropriate management of this patient? • 21 yo M is tossing a ball in Golden Gate Park A. No antibiotic prophylaxis needed with a friend. As he goes after the ball, he B. Antibiotic prophylaxis with clindamycin passes close to a dog that was resting in the shade with his owner. The dog jumps up and C. Antibiotic prophylaxis with amoxicillin/ bites him on the leg inflicting several wounds clavulanate on the calf. D. Administer rabies immunoglobulin and rabies vaccine for post ‐ exposure prophylaxis E. C and D 8

4/16/2014 Microbiology of Animal Bites: In addition to wound care, what is the appropriate management of this patient? What’s in their mouth and on your skin A. No antibiotic prophylaxis needed • Average 5 organisms (range 0 ‐ 16) per wound B. Antibiotic prophylaxis with clindamycin Dogs Cats Pasturella sp 50% 75% C. Antibiotic prophylaxis with amoxicillin/ Streptococcus sp. 46% 46% clavulanate Staphylococcus aureus 20% 4% D. Administer rabies immunoglobulin and Anaerobes mixed w/ aerobes 48% 63% rabies vaccine for post ‐ exposure prophylaxis Anaerobes alone 1% 0% E. C and D Talan D NEJM 1999 Antibiotic Coverage for Pasteurella Animal bites • What you want to use but won ’ t work … • Empiric treatment regimens – Amoxicillin/clavulanic acid +/ ‐ anti ‐ MRSA – cephalexin – Pen allergy: cipro + clindamycin or moxifloxacin – dicloxacillin • Prophylaxis? – clindamycin – Moderate ‐ severe bites • What works… – Deep puncture wounds (i.e. cat bites, 50% – Amoxicillin/ penicillin infection risk) – doxycycline – Bites involving face, hands – Immunocompromised (splenectomized) – fluoroquinolones 9