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Cellulitis and
Soft-Tissue
Infections
Prevention page ITC1-2
Physician Writers The content of In the Clinic is drawn from the clinical information and
Lawrence J. Eron, MD education resources of the American College of Physicians (ACP), including
PIER (Physicians Information and Education Resource) and MKSAP (Medical
Section Editors Knowledge and Self-Assessment Program). Annals of Internal Medicine
Christine Laine, MD, MPH editors develop In the Clinic from these primary sources in collaboration with
David R. Goldmann, MD the ACPs Medical Education and Publishing Division and with the assistance
Harold C. Sox, MD of science writers and physician writers. Editorial consultants from PIER and
MKSAP provide expert review of the content. Readers who are interested in these
primary resources for more detail can consult http://pier.acponline.org and other
resources referenced in each issue of In the Clinic.
C
may fol- low a break in the skin or a surgical wound but may
also occur with- out an obvious inciting event. The
microorganisms most frequently
involved include group A streptococci (Streptococcus pyogenes); groups
B, C, and G -hemolytic streptococci; and Staphylococcus aureus. Over
recent decades, cellulitis has challenged clinicians in several ways. First,
physician visits for cellulitis and soft-tissue infections have increased
from 32 to 48 visits per 1000 population from 1997 to 2005 (1).
Second, necrotizing fasci- itis due to group A streptococci is now
Preventio endemic in the United States. Third, S. aureus, the predominant cause
n of cellulitis accompanied by abscesses or wound drainage, has become
increasingly resistant to methicillin, requiring vancomycin and other,
newer antimicrobial agents. A particular community- acquired
methicillin-resistant S. aureus (CA-MRSA) strain, USA 300, is
replacing nosocomial strains of MRSA in hospitals (2).
2008 American College of Physicians ITC1-2 In the Clinic Annals of Internal Medicine 6
January 2009
Which strategies reduce the so for other bites when there is sterile adhesive strips
risk for cellulitis and soft- extensive injury to soft tissue or closed by delayed
tissue infections in patients or when the bite site is near a primary clo- sure. If
with diabetes? joint or bone. For patients sutures are necessary,
Patients with diabetes should allergic to peni- cillin, use then antimicrobial
receive education about proper moxifloxacin plus clin- prophylaxis and close
foot care and should regularly damycin. Doxycycline may follow-up are
inspect their feet to promptly also be used for prophylaxis of indicated.
recognize problem areas. cat bites.
Treatment of super- ficial
A 2001 review of 8 randomized,
plantar ulcers with aggressive
controlled trials compared
cleansing and off-weighting of
antibiotics with placebo or no
the ulcerated area may prevent treatment to prevent infection fol-
subse- quent infection. Plantar lowing mammalian bites. Overall,
calluses should be shaved down. the use of antibiotics was
Multi- disciplinary foot-care associated with a statis- tically
teams may be helpful (6). significant reduction in infection
following human bites but not cat
Which strategies or dog bites. In addition, in analyses
decrease cellulitis and of any mam- malian bite to the
soft-tissue hand, prophylactic antibiotics
infections after mammalian reduced the rate of infection
bites? Bite wounds should be (odds ratio, 0.20 [95% CI, 0.01 to
thoroughly cleansed. Clinicians 0.86]) (7).
should admin- ister amoxicillin
Avoid suturing bite wounds
and clavulanate for prophylaxis
closed except if the wounds
of closed-fist injuries and cat
are on the face. Wound edges
bites and should consider doing
may be approx- imated with
Which interventions decrease the to 10 weeks later while observ- ing Surgical Techniques
risk for cellulitis and soft-tissue for soft-tissue infections. At baseline, that Reduce the
infections associated with 24 (3%) participants were colonized Postoperative
with CA-MRSA and 229 (28%) with Infection Rate
surgical wounds?
Surgical site infections develop in methicillin- sensitive S. aureus (MSSA). Proper skin
Of those with CA-MRSA, 9 (38%) preparation
2% to 5% of all surgical proce- Gentle traction
developed soft-tissue infection
dures. To prevent them, health compared with 8 (3%) with MSSA during surgery
care providers must practice good (relative risk, 10.7 [CI, 4.6 to 25.2]). At Effective
hand hygiene, proper preparation hemostasis
of the patients skin, and good Removal of
devitalized tissues
surgical technique (see Box). Obliteration of dead
space
Proper perioperative Irrigation of
antimicrobial prophylaxis, tissues
administered within 1 hour Fine,
before surgical incision, also nonabsorbable
monofilament
prevents surgical wound infection. suture material
Recommendations are for single- Closed-suction
dose administration or multiple drains
doses to end within 24 hours Wound closure
follow- ing the end of surgery (see without tension
Box) (8).
2008 American College of Physicians ITC1-4 In the Clinic Annals of Internal Medicine 6
January 2009
infection by gas-producing nonlimb-threatening superficial cellulitis, because the former
organisms, such as an anaerobic requires hospitalization whereas outpatient treatment is usually
bacteria or a gram-negative suf- ficient for the latter (17). See Box
bacil- lus. A foul odor may
indicate infec- tion by anaerobic
microorganisms, whereas a
sweet odor may indicate the
presence of Pseudomonas or
clostridial species.
Impetigo is characterized by
blis- ters and sores on the face
or extremities, is due to
streptococci or staphylococci
(S. aureus has become
predominant in recent years),
and usually occurs in chil-
dren. Necrotizing fasciitis
involves deeper tissue planes
(fascia and muscle), whereas
less-severe forms
involve subcutaneous tissue
(celluli- tis) or epidermis and
dermis (erysipelas) (Figure).
2008 American College of Physicians ITC1-6 In the Clinic Annals of Internal Medicine 6
January 2009
Types of Necrotizing Fasciitis
viability of underlying Necrotizing fasciitis type 1:
due to nonnecrotizing infection musculature. Diagnostic Mild- to-moderate fever and
by streptococci are sterile. incisions can be extended to systemic toxicity. Little to no
Streptococcal infection, although perform radical debridement, diffuse pain and mild-to-
highly inflam- matory, is moderate localized pain. Mild-
should necrotizing infection be to-moderate gas in tis- sues.
paucibacterial. In the future, visible. Other signs suggesting Portal of entry usually obvi-
polymerase chain reaction the need for surgical ous. Higher risk with diabetes
technology may permit rapid intervention include drainage,
(S. aureus, group B
iden- tification of pathogens that streptococci, anaerobes, and
thrombosed vessels, and lack of gram-negative bacilli).
are dif- ficult to culture. resistance to finger dissection in Necrotizing fasciitis type 2
normally adherent tissues (18). (flesh-eating strep):
When should clinicians consult Moderate- to-severe fever.
an interventional radiologist or Interventional radiologists can Little to no diffuse pain and
severe localized pain. Severe
surgeon during the evaluation use diagnostic imaging to locate, systemic toxicity. No gas in
of cellulitis and soft-tissue biopsy, and aspirate deep tissues. Portal of entry not
infection? Patients with collections or masses for
obvious in 50% of cases
(commonly strep- tococci).
necrotizing fasciitis require diagnostic purposes as well as Necrotizing fasciitis type 3
early surgical inspection of the for therapeutic drainage but (gas gangrene): Moderate
deep tissues through a small cannot inspect wounds fever. Little to no diffuse pain
incision that allows evaluation macroscopi- cally or debride and severe local- ized pain.
Severe systemic toxicity. Severe
of the condition of the fascia devitalized tissue. gas in tissues. Portal of
and the entry usually obvious
(clostridial species).
CLINICAL
BOTTOM LINE
Treatment
Which adjuvant measures are When is topical
helpful in the treatment of antimicrobial therapy
patients with cellulitis and appropriate?
soft- tissue infection? Topical mupirocin is an option
Compression dressings in for impetigo with limited
patients with chronic venous lesions, but it is expensive and 22. Stevens DL,
Bryant AE,
insufficiency or pedal edema some staphylococci are Adams K, et al.
Evaluation of
promote resolution of cellulitis. resistant. Oral therapy with ther- apy with
Negative pressure dressings for penicillinase-resistant hyperbaric
oxygen for
large, exudative penicillins or first-generation experi- mental
infection with
wounds reduce proteolytic cephalosporins is preferred (16). Clostridium per-
enzymes and other substances fringens. Clin
Infect Dis.
that retard wound healing. How should clinicians 1993;17:231-7.
[PMID: 8399871]
Remediation of lymphedema or determine whether to 23. Eron LJ, Lipsky
BA, Low DE, et al.
compromised vascular supply prescribe oral or parenteral Expert panel on
may improve deliv- ery of antimicrobials? managing skin
and soft tissue
oxygen and antimicrobials High bioavailability makes par- infections.
Managing skin
to the site of infection. There is enteral administration of and soft tissue
insufficient evidence about the antimicro- bials largely infections: expert
panel
benefits of hyperbaric oxygen for unnecessary for mild, recommenda-
tions on key deci-
infected diabetic foot ulcers and uncomplicated cellulitis. sion points. J
Antimi- crob
gas gangrene (23). Parenteral therapy is usually Chemother.
2003;52 Suppl 1:i3-
reserved for mod- erate-to- 17. [PMID:
severe infections that may 14662806]
require hospitalization.
However,
2008 American College of Physicians ITC1-8 In the Clinic Annals of Internal Medicine 6
January 2009
MRSA is supported only by vancomycin in compara- tive Parenteral Antibiotic
obser- vational studies (34, 35). trials. Some studies reported Therapy
more rapid resolution of Ceftriaxone, cefazolin,
In patients for whom clinical signs of inflammation and cefuroxime (for
streptococci and MSSA
parenteral therapy is in patients receiving infections)
appropriate, how should daptomycin compared with a Ertapenem, cefepime,
clinicians choose a specific matched cohort of patients ceftazidime (for gram-
antimicrobial regimen? negative bacillary
receiving vancomycin (36, 37). infection)
The choices for parenteral
Daptomycin and vancomycin
antibi- otics for cellulitis For outpatient parenteral (for
probably caused by treatment of MRSA, MRSA infections)
streptococci, as well as soft-tis- daptomycin has certain Clindamycin (for
sue infection due to MSSA, advantages when compared streptococci, MSSA,
and MRSA infection,
include semisynthetic penicillins with vancomycin. Daptomycin if sensitive)
(nafcillin and oxacillin), pharma- cokinetics allow once- Aminoglycosides (for
cephalosporins (cefa- zolin, daily adminis- tration in resistant gram-negative
bacillary infection)
cefuroxime, or ceftriaxone), patients with healthy renal
clindamycin (for penicillin- function. Rapid administration
allergic patients and if the does not cause red-man
pathogen is shown to be syndrome as
sensitive). If MRSA is
suspected, vancomycin, dapto-
mycin, tigecycline, and linezolid
are appropriate choices for
moder- ate-to-severe infections. Antimicrobials Commonly
The newer agents have been Used for Outpatient
shown to be non- inferior to
happens with vancomycin, and it antigen tests, or imaging studies Treatment of Human and
is not necessary to monitor are crucial. Empiri- cal therapy Animal Bites
dapto- mycin levels. should be quickly initi- ated and Oral treatment
guided by patient-specific Human bite:
A new antimicrobial agent, clinical parameters and the most amoxicillin/clavu- lanate
dalba- vancin, is awaiting Animal bite:
likely pathogens. For example, amoxicillin/clavulanate
approval by the U.S. Food and the most likely pathogens during
Drug Administra- tion. Its Parenteral treatment
the Human bite: ampicillin/sulbactram
pharmacokinetics allow once-
Animal bite: ampicillin/sulbactam
weekly administration, mak- ing
Penicillin allergy
it attractive for outpatient par-
Human bite: moxifloxacin
enteral treatment. Dalbavancin plus clindamycin,
has been compared with trimethoprim/
linezolid and shows similar sulfamethoxazole plus
metronidazole
efficacy (38) (Table Animal bite: doxycycline or
3). Other parenteral agents active moxi- floxacin or
against MRSA and pending trimethoprim/sul-
famethoxazole with either
release include telavancin, clin- damyciin or
ceftobiprole, cef- taroline, and metronidazole
iclaprim.
What is appropriate 29. Madaras-Kelly
KJ, Arbogast R,
antimicrobial therapy for Jue S. Increased
therapeu- tic
infections associated with failure for
human or animal bites? cephalexin
versus
See Box for suggested comparator
antibi- otics in
antimicrobial treatment following the treat- ment
bite wounds. The microorganisms of uncompli-
cated
involved in human bites are most outpatient
cellulitis.
commonly Eikenella corrodens, Pharma-
cotherapy.
anaerobes, and viridans 2000;20:199-
streptococci. Animal bites are 205. [PMID:
10678298]
commonly caused by a mixture of 30. Madaras-Kelly
KJ, Remington
bacteria, including Pasteurella RE, Oliphant CM,
mutocida, Streptococcus et al. Efficacy of
oral beta-
intermedius, anaerobes, and S. lactam versus
non- beta-
aureus. A rare cause of infection lactam treat-
ment of
following dog bites is uncomplicated
Capnocytophaga canimorsus, which cel- lulitis. Am J
Med.
causes severe sepsis syn- drome 2008;121:41
9-25. [PMID:
with disseminated intravas- cular 18456038]
coagulation but is susceptible to 31. Daum RS.
Clinical
penicillins. practice. Skin
and soft-tissue
infections
Are there special considerations caused by
methi- cillin-
for antimicrobial selection in resistant
immunocompromised patients Staphylococcus
aureus. N Engl J
with cellulitis and soft-tissue Med.
2007;357:380-
infection? The clinical signs of 90. [PMID:
17652653]
infection in 32. Markowitz N,
the immunocompromised patient Quinn EL,
Saravolatz LD.
may be subtle or absent due to Trimethoprim-
sul-
decreased inflammatory response. famethoxazole
Because of the extremely broad com- pared with
van- comycin
range of opportunistic pathogens for the treatment
of Staphy-
in this patient population, lococcus aureus
infection. Ann
attempts to definitively identify Intern Med.
pathogens with cultures, biopsies, 1992;117:390-
8. [PMID: 1503330] famethoxazole or aureus.
33. Cenizal MJ, Skiest D, doxycycline for out- Antimicrob
Luber S, et al. patient skin and soft Agents
Prospective random- tissue infections in Chemother.
ized trial of empiric an area of high 2007;51:262
therapy with prevalence of methi- 8-30. [PMID:
trimethoprim-sul- cillin-resistant 17502411]
Staphylococcus
2008 American College of Physicians ITC1-10 In the Clinic Annals of Internal Medicine 6 January 2009
Table 3. Drug Treatment for Cellulitis and Soft-Tissue Infections (continued)
Agent Dosage Side Effects Notes
Tobramycin 2 mg/kg load, then 1.5 mg/kg, Ototoxicity and nephrotoxicity Good spectrum of activity against resistant
q8h; 5.0 mg/kg (if critically gram-negative bacteria. Follow levels to
ill, 7.0 mg/kg), q24h load guide dosing
Amikacin 15 mg/kg per day
Glycopeptides
Vancomycin 15 mg/kg, q12h IV. Follow Can cause nephrotoxicity and the red-man Used primarily against MRSA
serum levels syndrome with rapid infusion.
Dalbavancin 1 g, IV followed 1 week later Active against MRSA, VRE (Van B and Van C
by 500 mg, IV strains only). Use for outpatient therapy
once weekly
Lincosamides
Clindamycin 0.150.45 g, q6h PO; 1.2 g, Pseudomembranous colitis Useful for severe group A streptococcal
IV q12h infections and gas gangrene caused by
Clostridium species; inhibits bacterial toxin
production; use for oral or dental infections
Tetracyclines
Doxycycline 100 mg, bid Liver toxicity; photosensitivity; tooth Option for penicillin-allergic patients
discoloration in children
Minocycline 100 mg, qd or bid Dizziness
Tigecycline 100 mg, IV load, 50 mg, q12h Nausea and vomiting Active against MRSA, streptococci, anaerobic
IV thereafter organisms, and gram-negative bacilli except
Pseudomonas species
Penems
Imipenemcilastatin 0.51.0 g, q6h IV Superinfection; allergic reactions; phlebitis; Broadly active against aerobes, anaerobes,
hepatotoxicity; seizures; renal failure gram-positives, and gram-negatives
Meropenem 12 g, q6h IV Diarrhea (5%); nausea, headache
Doripenem 500 mg, q8h IV Headaches 2- to 4-fold lower MIC for Pseudomonas
aeruginosa
Ertapenem 1 g, q24h Nausea, diarrhea, rash Use for outpatient therapy once daily
Oxazolidinone
Linezolid 600 mg, q12h IV or PO Nausea, diarrhea, thrombocytopenia with Active against MRSA and VRE, but also
prolonged treatment (>2 wk), peripheral against other gram-positive bacteria; should
neuropathy, optic neuritis not be used when alternatives are available
Lipopeptides
Daptomycin 46 mg/kg per day CPK elevation; rhabdomyolysis at high dosage Use for outpatient therapy once daily, use
for bacteremia due to MRSA, as it is rapidly
bactericidal
Telavancin 7.5 mg/kg, q24h IV Taste disturbance, headache Rapidly bactericidal with a long postantibi-
otic effect. Active against MRSA, GISA,
VRSA, VRE (including Van A strains), may
have a reduced potential for development of
resistance
bid = twice daily; CNS = central nervous system; DNA = deoxyribonucleic acid; GI = gastrointestinal; GISA = glycopeptide intermediate-resistant
Staphylococcus aureus; IM = intramuscular; IV = intravenous; PO = oral; qd = once daily; MIC = minimal inhibitory concentration; MRSA =
methicillin- resistant Staphylococcus aureus; VISA = vancomycin intermediate-resistant Staphylococcus aureus; VRE = vancomycin-resistant
enterococci;
VRSA = vancomycin-resistant Staphylococcus aureus.
Practice
Improvement What factors do U.S. stakeholders
surgical incision and discontinued
within 24 hours of the end of
use to evaluate the quality of care surgery).
for soft-tissue infection and
cellulitis? What do professional
The Center for Medicare & Med- organizations recommend
icaid Services (CMS) has devel-
45. Weigelt J, Itani K,
Stevens D, et.al. oped measures of quality of care to regarding the care of patients
Line- zolid versus
van- comycin in use in the Physician Quality with cellulitis and soft-tissue
treat- ment of
Reporting Initiative. None of these infection?
complicated skin
and soft tissue infec- measures relates to the treatment of In 2005, the Infectious Disease
tions. Antimicrob
Agents Chemother. cellulitis and soft-tissue infection. Society of America (IDSA)
2005;49:2260-6.
[PMID: 15917519] However, several measures focus on released guidelines on the manage-
46. Hepburn MJ. Dooley
DP, Skidmore PJ, et.
the antibiotic prophylaxis to pre- ment of cellulitis and soft-tissue
Al Comparison of vent surgical wound infections. infection (16). This review largely
short course (5
days) and standard These measures focus on the reflects the IDSA recommenda-
c
(10 days) treatment
for uncomplicated appropriate timing and selection of tions. See the Toolkit for other
cel- lulitis. Arch
Intern Med. 2004;
antibiotic prophylaxis (started guidelines related to the prevention
164:1669-74. [PMID: within 1 hour [2 hours for fluoro- and treatment of soft-tissue
15302637]).
quinolone or vancomycin] before infections.
PIER Modules
in the clinic www.pier.acponline.org
Access the following PIER module: Cellulitis and Soft Tissue Infections. PIER
Tool Kit
modules provide evidence-based, updated information on prevention, diagnosis,
and treatment in an electronic format designed for rapid access at the point of care.
lin
ec i
www.annals.org/intheclinic/toolkit-cellulitis.html
Cellulitis and Access the Patient Information material that appears on the following page for
duplication and distribution to patients.
Soft-Tissue www.nlm.nih.gov/medlineplus/cellulitis.html
Medline Plus
Infections www3.niaid.nih.gov/topics/streptococcal/
National Institute of Allergy and Infectious Diseases
www.healthsystem.virginia.edu/uvahealth/adult_derm/cell.cfm
Patient information developed at University of Virginia (available in English
and Spanish).
Guidelines
in
www.journals.uchicago.edu/doi/pdf/10.1086/497143
ht
Infectious Diseases Society of America: Practice Guidelines for the Diagnosis and
Management of Skin and Soft Tissue Infections
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Centers for Disease Control and Prevention: Guidelines for the Management of
Multi-drug Resistant Organisms in Healthcare Settings
www.shea-online.org/Assets/files/position_papers/SHEA_hand.pdf Healthcare
Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force: Guideline for
Hand Hygiene in Healthcare Settings
www.shea-online.org/Assets/files/position_papers/SHEA_MRSA_VRE.pdf
Society for Healthcare Epidemiology of America
2008 American College of Physicians ITC1-14 In the Clinic Annals of Internal Medicine 6 January 2009
Information
you notice:
intravenous antibiotics may be necessary.
Sometimes surgery is needed to clean and a very large area of red, inflamed skin
drain the infected area. fever
affected area of skin is numb, tingling, or in
Can you prevent cellulitis?
severe pain
Look out for early signs of infection. skin seems black, purple, or has blisters
Clean any skin injuries very well. redness or swelling around the eye(s) or
See a doctor if you have an animal bite. behind the ear(s).
University of Virginia
(information in English and Spanish)
www.healthsystem.virginia.edu/uvahealth/adult_derm/cell.cfm
CME Questions
1. A 20-year-old college wrestler has a 3. An 83-year-old woman is brought to the emergency department physician pre-
painful lesion on his upper back. He first emergency department with redness and scribed warm packs to the area and a
noted a small painful area 7 days ago, swelling of her right lower leg of several course of dicloxacillin. The patient
and the lesion has since enlarged and days duration and a 12-hour history of returns to the emergency department 2
became more red. Other members of his nausea, vomiting, and diarrhea. The days later. The patch is larger and more
wrestling team have developed similar patient has type 2 diabetes mellitus and tender but is still not fluctuant. He is
lesions. His history is otherwise coronary artery disease. Medications slightly ill but does not seem toxic. The
uneventful. Examination of the upper include glyburide, an angiotensin-con- emergency department physician
back reveals a 1 1 cm2 red, raised pus- verting enzyme inhibitor; a -blocker; a changes the antibiotic to cephalexin,
tule that is tender to palpation, with a 4 statin; and low-dose aspirin. but the patient continues to become
2
4 cm area of surrounding erythema. somewhat worse over the next 2 days.
On physical examination, temperature is
The remainder of the physical examina-
38.9C (102F), pulse rate is 102/min, Which of the following is the most
tion is normal. The lesion is incised,
respiration rate is 20/min, and blood likely cause of this patients
drained, and cultured.
pressure is 92/64 mm Hg. Profuse crack- clinical deterioration?
Which of the following is the most les are heard at both lung bases. A. Lyme disease
appropriate empiric treatment? Cardiac examination discloses a regular B. An abscess
A. Levofloxacin rhythm and no audible murmurs; there C. Fasciitis
B. Doxycycline is a prominent 3
S . The right leg is more D. A -lactamresistant organism
C. Dicloxacillin swollen than the left and is erythema-
D. Cephalexin tous with tenderness to the knee. There 5. A 53-year-old man underwent open
are no open lesions, and no inguinal reduction and internal fixation of a
2. A 32-year-old man has a 1-week history lymphadenopathy is noted. Hemoglobin fractured tibia. The patient has diabetes
of worsening erythema and pruritus level is 11.4 g/dL (114 g/L); hematocrit mellitus and end-stage renal disease
of both axillae. He is otherwise is and requires hemodialysis by means of
asymptomatic. 34%; leukocyte count is 19.8 109/L an arteriovenous graft in the left-upper
On physical examination, temperature is with 80% neutrophils, 15% lympho- extremity. Three weeks postoperatively,
37.1C (98.8F), pulse rate is 72/min, cytes, and 5% monocytes; platelet count his surgical incision became inflamed,
9
respiration rate is 16/min, and blood is 281 10 /L; blood urea nitrogen is 34 with an open section and drainage of
pressure level is 128/62 mm Hg. Both mg/dL (12.14 mmol/L); serum creatinine cloudy yellow fluid. Culture of the dis-
axillae show marked erythema, minimal level is 2.2 mg/dL (194.52 mol/L); and charge grew methicillin-resistant
tenderness, and several small nonpustu- serum electrolytes and liver chemisty Staphylococcus aureus (MRSA) that was
lar vesicles. There is no erythema adja- studies are normal. resistant to erythromycin, clindamycin,
cent to the axillae and no palpable The patient is hospitalized. Blood cul- and tetracycline but was sensitive to
lym- phadenopathy. Hemoglobin level is tures obtained on admission show no vancomycin and trimethoprim
15 g/dL (150 g/L); hematocrit is 47%; growth at 2 days. sulfamethoxazole. The patient was
leukocyte count is 5.3 109/L with Which of the following organisms is
treated intermittently with vancomycin,
72% neutrophils, 18% lymphocytes, 2% 500 mg intravenously. Two months later,
most likely causing this patients current
monocytes, 8% eosinophils; and platelet the surgical incision is unchanged. Cul-
findings?
9
count is 310 10 /L. Cultures of the ture of the discharge now grows
axillae grow several coagulase-negative A. Escherichia coli Entero- coccus faecalis in addition to
staphylococci, Propionibacterium acnes, B. Clostridium tetani MRSA.
and rare Escherichia coli. C. Staphylococcus aureus Both pathogens are resistant to van-
D. Bacillus cereus comycin. Polymerase chain reaction
Which diagnosis is most likely? 4.
shows that the MRSA is vanA ligase
A. Streptococcal cellulitis An 18-year-old male basketball player positive.
B. Staphylococcal cellulitis came to the emergency department in
February because of a red patch on his Which of the following is the most
C. Pasteurella multocida cellulitis
left forearm. He had been well the day appropriate antibiotic agent?
D. Contact dermatitis
E. Hidradenitis suppurativa before, but woke up with a painful area A. Linezolid
measuring about 6 9 cm2 on the B. Trimethoprimsulfamethoxazole
volar surface of the forearm. The area C. Clindamycin
was tender to touch, erythematous, D. Imipenem
and raised but was not fluctuant. The E. Quinupristindalfopristin
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/
to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.
2008 American College of Physicians ITC1-16 In the Clinic Annals of Internal Medicine 6 January 2009