Erysipeloid is a cutaneous infection caused by Erysipelothrix rhusiopathiae a thin, pleomorphic, non-spore-forming gram-positive rod. They are based on published clinical trials, descriptive studies, or reports of expert committees, and the clinical experience and opinions of respected authorities. Some trauma centers associated with HBO units may have greater expertise in managing these aggressive infections, but proximity and speed of transfer should be carefully considered before transporting the patient to HBO units, which may delay potentially life-saving surgical intervention. These are typically larger and deeper than furuncles. We thank Irene Collie and Dr Amy E. Bryant for technical assistance in developing the algorithm in Figure 1. Among the many choices is vancomycin, linezolid, or daptomycin combined with one of the following options: (1) piperacillin-tazobactam, (2) a carbapenem (imipenem-cilastatin, meropenem, and ertapenem), (3) ceftriaxone plus metronidazole, or (4) a fluoroquinolone plus metronidazole (Table 4). Treatment of necrotizing fasciitis involves early recognition and surgical consultation for debridement of necrotic tissue combined with empiric high-dose intravenous broad-spectrum antibiotics.5 The antibiotic spectrum can be narrowed once the infecting microbes are identified and susceptibility testing results are available. Remove the clear cap. These recommendations take on new importance because of a dramatic increase in the frequency and severity of infections and the emergence of resistance to many of the antimicrobial agents commonly used to treat SSTIs in the past. Single or multiple painless skin lesions involving the face and scalp develop in 5%10% of clinically infected patients, and in some patients, these lesions may precede documented cryptococcal meningitis by several weeks. Local signs of pain, swelling, erythema, and purulent drainage provide the most reliable information in diagnosing an SSI. Biopsy often reveals a mixture of true hyphae, pseudohyphae, budding yeast, and arthroconidia that may be easily mistaken for Candida species. Large gram-positive cocci in clusters suggest S. aureus. Clindamycin suppresses streptococcal toxin and cytokine production. Unless cultures yield streptococci alone, antimicrobial therapy should be active against both S. aureus and streptococci [12]. Aspergillus, Rhizopus, and Mucor species cause painful erythematous skin nodules that become necrotic and can resemble ecthyma gangrenosum because of their tendency for angioinvasion [222]. Superficial cutaneous candidiasis presents as intertrigo, vaginitis, balanitis, perleche, and paronychia [215] and rarely causes dissemination. Spontaneous gangrene, in contrast to trauma-associated gangrene, is principally associated with the more aerotolerant C. septicum and occurs predominantly in patients with neutropenia or gastrointestinal malignancy. Pyomyositis is the presence of pus within individual muscle groups, caused mainly by S. aureus. The single published trial of antibiotic administration for SSI specifically found no clinical benefit [99]. Accordingly, fever or systemic signs during the first several postoperative days should be followed by direct examination of the wound to rule out signs suggestive of streptococcal or clostridial infection (see section on necrotizing soft tissue infections and clostridial myonecrosis), but should not otherwise cause further manipulation of the wound. Interestingly, in the United States, no resistance to clindamycin was found from invasive strains of group A streptococci in Chicago [117]. Clindamycin was found to be superior to penicillin in animal models, and 2 observational studies show greater efficacy for clindamycin than -lactam antibiotics [112, 113]. Amoxicillin-clavulanate administered in one study for a variety of full-skin thickness animal bites in patients presenting >9 hours after the bite resulted in a lower infection rate [144]. Examples would include postoperative peritonitis, empyema, or joint space infection. Other predisposing conditions include obesity, tobacco use, a history of cancer, and homelessness [66, 67, 71]. Systemic manifestations are usually mild, but fever, tachycardia, confusion, hypotension, and leukocytosis are sometimes present and may occur hours before the skin abnormalities appear. As a result, obtaining a careful history that includes information about the patient's immune status, geographic locale, travel history, recent trauma or surgery, previous antimicrobial therapy, lifestyle, hobbies, and animal exposure or bites is essential when developing an adequate differential diagnosis and an appropriate index of suspicion for specific etiological agents. . Suggested antimicrobials and dosages derive from 3 publications [167169]. XIII. Skin and soft tissue infections result from microbial invasion of the skin and its supporting structures. The efficacy of intravenous immunoglobulin (IVIG) in treating streptococcal toxic shock syndrome has not been definitively established. The cause is unknown but may relate to tape sensitivity or other local tissue insult not involving bacteria. Based on this bacteriology, amoxicillin-clavulanate is appropriate oral therapy that covers the most likely aerobes and anaerobes found in bite wounds. The initial lesion can be trivial, such as a minor abrasion, insect bite, injection site (as in drug addicts), or boil, and a small minority of patients have no visible skin lesion. HIV-infected patients may require lifelong treatment [171]. Computed tomography (CT) or magnetic resonance imaging (MRI) may show edema extending along the fascial plane, although the sensitivity and specificity of these imaging studies are ill defined. Acutely ill adults or children should receive an aminoglycoside, preferably streptomycin or possibly gentamicin. What is appropriate for the evaluation and treatment of erysipelas and cellulitis? VII. In addition, MRSA should also be considered if patients are not receiving antimicrobial agents with activity against MRSA (eg, vancomycin, linezolid, daptomycin, or ceftaroline) [209]. A blue ring with a peripheral red halo may appear, giving the lesion a target appearance. Mechanism of Action Clindamycin prevents peptide bond formation, thereby inhibiting protein synthesis by reversibly binding to 50S ribosomal subunits. No single empiric regimen is superior, but all recommended regimens should meet the following criteria: broad-spectrum antimicrobial activity including P. aeruginosa, bactericidal in the absence of circulating neutrophils, and low antibiotic-associated toxicity (Table 7). to maintaining your privacy and will not share your personal information without Bite wounds to the face that are copiously irrigated and treated with preemptive antimicrobial therapy may be closed [166]. Pasteurella species are commonly isolated from both nonpurulent wounds with or without lymphangitis and from abscesses. Cotrimoxazole is a good anti-Gram-positive agent with preserved activity against methicillin-susceptible and methicillin-resistant S. aureus (MRSA) and streptococci. For patients with recurrences despite such efforts, antimicrobial prophylaxis may reduce the frequency of future episodes. A recent study in children found employing preventive measures for the patient and the household contacts resulted in significantly fewer recurrences in the patient than employing the measures in the patient only [34]. The vesicles frequently coalesce, form bullae, and scab before healing. Most large furuncles and all carbuncles should be treated with incision and drainage. The fascia at the time of direct visual examination is swollen and dull gray in appearance with stringy areas of necrosis; a thin, brownish exudate may be present. In nonpurulent cellulitis, the clinical isolation rate of a pathogen is <20%. Clostridial gas gangrene or myonecrosis is most commonly caused by Clostridium perfringens, Clostridium novyi, Clostridium histolyticum, or Clostridium septicum. What is the preferred treatment for erysipeloid? Empiric treatment of polymicrobial necrotizing fasciitis should include agents effective against both aerobes, including MRSA, and anaerobes (Table 4). Increasingly severe pain beginning within 24 hours at the injury site is the first reliable clinical symptom. Skin lesions can present as papules, nodules, or ulcers, or with the dermatological appearance of ecthyma gangrenosum. To apply this medicine: Do not dispense clindamycin topical foam directly onto your hands because the foam will begin to melt on contact with warm skin. Glanders is mainly a disease mainly of solipeds (eg, horses and mules). Treatment of NTM infections of the skin and soft tissues requires prolonged combination therapy . Disseminated or complex SSTIs are more likely to occur among high-risk patients. Was 21.99. It is a zoonosis acquired by handling fish, marine animals, swine, or poultry. At a later stage, 2 moist swabs should be rotated in the ulcer base or beneath the eschar's edge. Due to geographical distribution, this condition is often called tropical pyomyositis, but cases can occur in temperate climates, especially in patients with human immunodeficiency virus (HIV) infection or diabetes mellitus [123]. 4 UNI | 4.95 per 1UNI. Therefore, treatment with amoxicillin-clavulanate, ampicillin-sulbactam, or ertapenem is recommended; if there is history of hypersensitivity to -lactams, a fluoroquinolone, such as ciprofloxacin or levofloxacin plus metronidazole, or moxifloxacin as a single agent is recommended. The development of acyclovir-resistant HSV isolates is well described and occurs more frequently among immunocompromised patients [241]. Human bites may occur from accidental injuries, purposeful biting, or closed-fist injuries. Because the intensity and type of immune defect diminishes or alters dermatological findings, cutaneous lesions that appear localized or innocuous may actually be a manifestation of a systemic or potentially life-threatening infection. Staphylococcus aureus is known to cause this infection as the sole pathogen. XXII. Necrotizing Fasciitis 10. Management is determined by the severity and location of the infection and by patient comorbidities. Patients with complicated infections, including suspected necrotizing fasciitis and gangrene, require empiric polymicrobial antibiotic coverage, inpatient treatment, and surgical consultation for debridement. Two to 3 weeks of therapy is recommended, Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed (severe nonpurulent; Figure 1), In the absence of a definitive etiologic diagnosis, broad-spectrum treatment with vancomycin plus either piperacillin/tazobactam, ampicillin/sulbactam, or a carbapenem antimicrobial is recommended, Hyperbaric oxygen (HBO) therapy is not recommended because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement, Preemptive early antimicrobial therapy for 35 days is recommended for patients who (a) are immunocompromised; (b) are asplenic; (c) have advanced liver disease; (d) have preexisting or resultant edema of the affected area; (e) have moderate to severe injuries, especially to the hand or face; or (f) have injuries that may have penetrated the periosteum or joint capsule, Postexposure prophylaxis for rabies may be indicated; consultation with local health officials is recommended to determine if vaccination should be initiated, An antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate (Table 5) should be used, Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years. The incidence of invasive candidiasis prior to the routine use of azole antifungal prophylaxis was 12% in patients with profound and prolonged neutropenia [214]. Pustules filled with pus that appear like pimples. Furuncles (or boils) are infections of the hair follicle, usually caused by S. aureus, in which suppuration extends through the dermis into the subcutaneous tissue, where a small abscess forms. Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir (800 mg bid) or valacyclovir (500 mg bid) during the first year following transplant for the prevention of VZV and HSV reactivation [240]. These deep infections involve the fascial and/or muscle compartments and are potentially devastating due to major tissue destruction and death. What Is the Appropriate Approach to Assess SSTIs in Immunocompromised Patients? Scrubbing the body thrice weekly with chlorhexidine-impregnated cloths after showering was also deemed ineffective [32]. Regional lymphadenopathy is common, but pus in the lesion is absent unless a secondary infection occurs. The need for rabies prophylaxis and/or therapy should be addressed. In one prospective study, beta-hemolytic streptococcus was found to cause nearly three-fourths of cases of diffuse cellulitis.16 S. aureus, P. aeruginosa, enterococcus, and Escherichia coli are the predominant organisms isolated from hospitalized patients with SSTIs.17 MRSA infections are characterized by liquefaction of infected tissue and abscess formation; the resulting increase in tissue tension causes ischemia and overlying skin necrosis. Tdap is preferred over Td if the former has not been previously given. Diagnosis can be made by blood cultures and by aspirating lymph nodes for staining and culture. Based on in vitro susceptibilities and murine models, fluoroquinolones are another option. Patients with illnesses that result in profound and prolonged immune suppression should receive long-term suppressive therapy with itraconazole after the initial treatment course is complete. Options for treatment of MRSA in those circumstances (Table 2) include intravenous drugs (vancomycin, daptomycin, linezolid, or telavancin) or oral therapy with doxycycline, clindamycin, or SMX-TMP. The panel reviewed all recommendations, their strength, and quality of evidence. Additional studies of the efficacy of IVIG are necessary before a recommendation can be made supporting its use in this setting. For more severe infections, the dose is usually 16 to 25 mg per kg of body weight per day, divided into . The recommendations in this guideline have been developed following a review of studies published in English, although foreign-language articles were included in some of the Cochrane reviews summarized in this guideline. Painful myositis can develop as a consequence of hematogenous infection and is most common with Candida tropicalis [218, 219]. Gram-positive cocci in chains suggest Streptococcus (either group A or anaerobic). Last, surgical exploration or debridement is an important diagnostic, as well as therapeutic, procedure in patients with necrotizing infections or myonecrosis and may be important for selected immunocompromised hosts. In classic cat scratch disease, a papule or pustule develops from 330 days following a scratch or a bite. Lesions begin as vesicles that rupture, resulting in circular, erythematous ulcers with adherent crusts, often with surrounding erythematous edema. Some cases are associated with child delivery and involve the uterus or episiotomy site. IV ciprofoxacin 10mg/kg/dose (to a maximum of 400mg) 8 hourly. VZV in compromised hosts may present with the traditional unilateral dermatome distribution, but may also appear as discrete or multiple skin lesions in random distribution. Bartonella henselae causes most cases of cat scratch disease in immunocompetent hosts. What is the appropriate antimicrobial therapy for patients with SSTIs during persistent or recurrent episodes of fever and neutropenia? Rapidly progressive necrotizing SSTIs may initially be clinically subtle in compromised patients, but MRI scans of the involved area may be helpful in defining the depth of infections. Most textbooks of surgery, infectious diseases, or even surgical infectious diseases extensively discuss the epidemiology, prevention, and surveillance of SSIs, but not their treatment [9197]. Although many specific variations of necrotizing soft tissue infections have been described based on etiology, microbiology, and specific anatomic location of the infection, the initial approach to diagnosis, antimicrobial treatment, and surgical intervention is similar for all forms and is more important than determining the specific variant. A positive Warthin-Starry silver stain of infected lymph node tissue is useful to confirm the diagnosis, although it cannot differentiate species of Bartonella. Wolters Kluwer Health Treatment of cat scratch disease with antimicrobial agents has had variable, but rarely dramatic, results. XXV. What is the appropriate approach for the evaluation and treatment of bacillary angiomatosis and cat scratch disease? Accordingly, this form of treatment is not recommended. Painful myositis may also occur with S. aureus infections as a component of hematogenous dissemination. 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