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7/30/2019 0 Comments

Skin and Soft Tissue Infections


Skin and Soft Tissue Infections
 

Epidemiology 
  • Cellulitis 2.3 million visits in the ED annually
  • 15% get admitted
  • Up to 30% of diagnosed cellulitis is really a “cellulitis mimic”
 
Important Aspects of your History
  • Travel? Water exposure?
  • Recent trauma or bug bite?
  • Recent antibiotics?
  • Immunocompromised? Diabetes w/ complications (neuropathy, sugar uncontrolled, etc)?
 
The Mimics
  • Venous stasis
  • PAD
  • DVT or superficial thrombophlebitis
  • Dermatosclerosis
  • Diabetic myonecrosis
  • Lymphedema
  • Contact dermatitis
  • Necrotizing fasciitis 
 
Workup
  • Good history and physical exam
  • Always ultrasound to look for purulence or abscess
  • Labs largely unhelpful
 
Treatment
  • Simple cellulitis w/out purulence = Keflex (consult local antibiogram)
  • Cellulitis w/ purulence = Keflex plus Staph Aureus coverage
  • Abscess – Drain and only give antibiotics in special circumstances
 
“Special” cellulitis
  • Perichondritis
    • Needs coverage for pseudomonas
  • Bites – think Pasteurella
    • Augmentin
  • Water exposure
    • Vibrio– doxycycline
    • Aeromonas– Rocephin, Bactrim, or a fluoroquinolone. 
  • Orbital cellulitis
    • IV abx, CT scan
  • Unvaccinated children
    • H. influenzacellulitis associated with 90% bacteremia
  • Abscess
    • Needs drainage
    • Bactrim if abscess > 5cm, patient immunocompromised, in axilla or groin
 
 
Necrotizing fasciitis +/- Toxic Shock Syndrome 
  • When patient presents in extremis, the diagnosis is easy
  • Helpful physical exam findings
    • Pain out of proportion
    • Pain outside the margin of the rash
    • Bullae, skin necrosis, pallor, hypoesthesia, crepitus are late findings
  • Labs are unhelpful and cannot be relied upon until it is too late
  • Resuscitate and give Vancomycin, Zosyn, and Clindamycin
    • Clindamycin needed for decreased toxin release in setting of toxic shock syndrome. Always give with first wave of antibiotics if you are treating necrotizing fasciitis
  • Imaging is not universally helpful
  • Very tough diagnosis, you need a high index of suspicion
  • Consult surgery quickly if suspicious, you will need source control 
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