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When evaluating cellulitis or bites and choosing antibiotics (abx) consider these factors:
Cellulitis = Redness, pain, swelling and warmth in the skin caused by an introduction of infection. Note: Misdiagnosis is common (Li, JAMA Dermatol 2018).
Think Staphylococcus if purulence is present.
Erysipelas – superficial
Cellulitis – deeper infection into the dermis
Abscess – collection of purulence in the dermis
Kashlak Pearl: Dr Titanji writes a time range (e.g. 5-7 day script) and schedules a re-evaluation during that time period to determine the need to extend the course of therapy (or stop early).
Kashlak Pearl: Dr Titanji may be more aggressive with IV antibiotics based on location of the cellulitis (e.g. face) and immunocompromised status. She may add coverage for anaerobes if infection involves the genitals, axilla, perioral tissues or perineum.
Kashlak Pearl: Bilateral cellulitis is rare so consider an alternate explanation! E.g. pseudocellulitis
Look for underlying predisposing factors like venous stasis, obesity, or lymphedema. Also, ask yourself, “Is this really cellulitis or pseudocellulitis?”. Early consultation with dermatology can help identify pseudocellulitis (Li, JAMA Dermatol 2018). Common mimics include: stasis dermatitis, contact dermatitis, viral rash, trauma, and chronic wounds.
Suppressive (prophylactic) antibiotics work, but they select for resistant organisms. Compressive therapy, in addition to patient education, recently proved effective for the prevention of recurrent cellulitis of the leg (Webb, NEJM 2020).
Bacteria found in fish and water that may contribute to skin infection include Erysipelothrix rhusiopathiae, Aeromonas, and *Vibrio. *Be on high alert for severe infection if the patient has underlying liver disease or hemochromatosis.
Treatment for Erysipelothrix, Aeromonas = Fluoroquinolones
Treatment for Vibrio = Doxycycline
Think Staph aureus.
MRSA risk factors include: HIV, on dialysis, long term resident in a facility, recent hospitalization or surgery (UpToDate accessed 12/5/20), military recruits, and those in gyms.
Dr Titanji notes imaging and blood cultures are more likely beneficial if over a bony prominence (expert opinion), near implanted hardware (expert opinion) or in patients who are immunocompromised, severely ill, or have animal bite wounds (IDSA SSTI Guideline 2014). Note: Imaging and blood cultures are not required or cost-effective for all-comers (Ko, JAMA Int Med 2018).
Culture purulent exudates if present. Even finding MSSA is useful as it allows antibiotics to be narrowed.
Kashlak Pearl: Limb elevation and offloading of the affected limb can improve recovery time.
Kashlak Pearl: Remember to cover for anaerobes (w/either clinda or metronidazole) in areas where anaerobes are likely to be lurking e.g. perianal and perioral tissues, axilla, and groin (expert opinion).
Transition to oral when clinical exam improves and vitals signs have normalized (expert opinion).
Kashlak Pearl: In the hospital we often give vancomycin plus a cephalosporin. The latter agents have better bactericidal action, plus coverage for MSSA and Strep. Step down regimens from vancomycin should be tailored based on suspected organisms, convenience of dosing and tolerability of a regimen (expert opinion).
Dr Titanji’s rule of thumb: *Small abscesses under 2 cm typically don’t need antibiotics after incision & drainage (expert opinion). Be sure to follow up and ensure resolution. Caveats: Dr Titanji may prescribe antibiotics (short course) for patients who have diabetes or are immunocompromised as they might need an extra boost to help “mop up” the infection.
For *large abscesses over 2 cm, Dr Titanji recommends antibiotics (typically doxy, TMP-SMX or clindamycin) plus incision & drainage. Don’t forget to send wound cultures for patients receiving antibiotics to help tailor therapy.
*Note: A recent trial found high cure rates at 7-10 days follow up for abscesses less than 5cm treated with I&D plus adjunctive clindamycin or TMP-SMX for 10 days (Daum, NEJM 2017).
Not a requirement. It can be uncomfortable for the patient. Dr Titanji mentions packing may be considered if the clinician is worried that further drainage is needed (i.e. infection was left behind). It’s not clear that packing works (List, S D Med 2016 )
Huang et al found that a decolonization regimen of chlorhexidine mouthwash, baths or showers with chlorhexidine, and nasal mupirocin for 5 days twice per month for 6 months reduced subsequent MRSA infection vs *education alone (Huang, NEJM 2019). Dr Titanji points out that trial adherence was 66%. She engages in shared decision making for patients who’ve had recurrent infections. She notes that decolonization often works initially, but future recurrence is common.
Decolonization of the whole household may be superior to individuals (Fritz, Clin Inf Dis 2011).
*Hygiene practices to prevent household spread include: frequent handwashing, wiping shared surfaces, covering wounds; avoid sharing clothes and towels; change clothes daily and wash sheets weekly (see supplementary material from Huang, NEJM 2019).
Clenched fist injuries often go unnoticed in the moment and therefore, present later in the course. For those patients with active infections Dr Titanji has a low threshold for hospital admission. Antibiotics need to cover anaerobes, particularly Eikenella (normal human periodontal flora).
Kashlak Pearl: Dr Titanji cautions against moxifloxacin monotherapy as there is limited experience and she’d worry about treatment failure (expert opinion).
Preemptive antibiotic therapy for uninfected human bite wounds: Dr Titanji recommends a short course of prophylactic antibiotics and repeat evaluation of the wound.
Dog bites are less likely to be infected than cat bites. Therefore, some dog bites can be followed clinically. Cats have sharp teeth that tend to puncture deeply and therefore, Dr Titanji recommends prophylactic antibiotics for most cat bites.
For infected dog or cat bites the antibiotic choices are the same noted above for human bites as are the principles for early imaging, surgical consultation and potential need for tetanus booster.
Bite wounds are dirty. We must balance the pressure for a cosmetic outcome (e.g. bite wound on the face) with the increased risk for infectious complications. Therefore, Dr Titanji recommends a discussion with the surgical team about risks/benefits of approximating the wound edges vs primary closure of a wound that may still have deeper infection.
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Listeners will develop a framework to approach skin and soft tissue infections including: abscess, cellulitis and bites.
After listening to this episode listeners will…
Dr Titanji reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Watto MF, Titanji BK, Williams PN, Garbitelli B. “246 Take a Bite out of Cellulitis with Dr Boghuma Titanji.” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date December 14, 2020.
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