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CME EDUCATIONAL OBJECTIVE: Readers will recognize and treat skin and soft-tissue infections effectively
CREDIT
SABITHA RAJAN, MD, MSc, FHM*
Division of Inpatient Medicine, Scott & White Health
System, Temple, TX; Assistant Professor of Medicine,
Texas A&M Health Science Center, College Station,
TX; Editor, Milliman Care Guidelines
Categories and definitions of specific subtypes of infec- The increase in hospital admissions for SSTIs
tions are evolving and have implications for treatment. has been attributed to a rising number of infec-
tions with methicillin-resistant Staphylococcus
Methicillin-resistant Staphylococcus aureus (MRSA) and aureus (MRSA).35
streptococci continue to be the predominant organisms in In addition, strains once seen mostly in the
SSTIs. community and other strains that were associ-
ated with health care are now being seen more
often in both settings. Clinical characteristics
A careful history and examination along with clinical do not differ between community-acquired
attention are needed to elucidate atypical and severe and health-care-associated MRSA, and there-
infections. fore the distinction between the two is becom-
ing less useful in guiding empiric therapy.6,7
Laboratory data can help characterize the severity of dis- After steadily increasing for several years,
ease and determine the probability of necrotizing fasciitis. the incidence of MRSA has recently stabi-
lized. The US Centers for Disease Control and
Prevention maintains a surveillance program
Although cultures are unfortunately not reliably positive, and a Web site on MRSA.8
their yield is higher in severe disease and they should be ob- At the same time, infections with group A,
tained, given the importance of antimicrobial susceptibility. B, C, or G streptococci continue to be com-
mon. The SENTRY Antimicrobial Surveil-
The Infectious Diseases Society of America has recently lance Program for the United States and Can-
released guidelines on MRSA, and additional guidelines ad- ada collected data from medical centers in five
dressing the spectrum of SSTIs are expected within a year. Canadian provinces and 32 US states between
1998 and 2004. The data set represents mostly
*
The author has disclosed serving on advisory committees or review panels for Baxter and Astella. complicated infections (see below). Staphylo-
doi:10.3949/ccjm.79a.11044 coccus was the most commonly retrieved or
CL EVEL AN D CL I NI C J O URNAL O F M E DI CI NE V O L UM E 79 NUM BE R 1 J ANUARY 2012 57
SKIN AND SOFT-TISSUE INFECTIONS
TABLE 3
Risk factors for different bacterial skin and soft-tissue infections
Risk factor Associated pathogen
Erysipelas
Impetigo Epidermis
Folliculitis
Ecthyma
Furunculosis Dermis
Carbunculosis
Cellulitis
Superficial fascia
Deep fascia
early detection and prompt surgical interven- Aspiration, swabs, incision and drainage
tion.15 Since necrotizing fasciitis is very dif- Fluid aspirated from abscesses and swabs of
ficult to diagnose, clinicians must maintain a debrided ulcerated wounds should be sent
high level of suspicion and use the LRINEC for Gram stain and culture. Gram stain and
score to trigger early surgical evaluation. Sur- culture have widely varying yields, from
gical exploration is the onlyway to definitive- less than 5% to 40%, depending on the
ly diagnose necrotizing fasciitis. source and technique.19 Cultures were not
routinely obtained before MRSA emerged,
Blood cultures in some cases but knowing antimicrobial susceptibility is
Blood cultures have a low yield and are usually now important to guide antibiotic therapy.
not cost-effective, but they should be obtained Unfortunately, in cellulitis, swabs and aspi-
in patients who have lymphedema, immune rates of the leading edge have a low yield
deficiency, fever, pain out of proportion to the of around 10%.25 One prospective study of
findings on examination, tachycardia, or hy- 25 hospitalized patients did report a higher
potension, as blood cultures are more likely to yield of positive cultures in patients with fe-
be positive in more serious infections and can ver or underlying disease,26 so aspirates may
help guide antimicrobial therapy. Blood cul- be used in selected cases. In small studies,
tures are also recommended in patients with the yield of punch biopsies was slightly bet-
infections involving specific anatomic sites, ter than that of needle aspirates and was as
such as the mouth and eyes.19 high as 20% to 30%.27
CL EVEL AN D CL I NI C J O URNAL O F M E DI CI NE V O L UM E 79 NUM BE R 1 J ANUARY 2012 61
SKIN AND SOFT-TISSUE INFECTIONS
TABLE 5
Treatment recommendations for methicillin-resistant Staphylococcus aureus
Diagnosis Treatment Coverage
before starting one of these antibiotics. although not specifically for MRSA. Mino-
The use of rifampin (Rifadin) as a single cycline may be an option even when strains
agent is not recommended because resistance are resistant to doxycycline, since it does not
is likely to develop. Also, rifampin is not use- induce its own resistance as doxycycline does.
ful as adjunctive therapy, as evidence does not Tigecycline is a glycylcycline (a tetra-
support its efficacy.19,27,29 cycline derivative) and is FDA-approved in
adults for complicated SSTIs and intra-ab-
ANTIMICROBIAL TREATMENT FOR SSTIs dominal infections. It has a large volume of
IN HOSPITALIZED PATIENTS distribution and achieves high concentrations
in tissues and low concentrations in serum.
For hospitalized patients with a complicated The FDA recently issued a warning to con-
or severe SSTI, empiric therapy for MRSA sider alternative agents in patients with seri-
should be started pending culture results. ous infections because of higher rates of all-
FDA-approved options are vancomycin, li- cause mortality noted in phase III and phase
nezolid, daptomycin (Cubicin), tigecycline IV clinical trials. Due to this warning and
(Tygacil), and telavancin (Vibativ). Data on the availability of multiple alternatives active
clindamycin are very limited in this popula- against MRSA, tigecycline was not included
tion. A beta-lactam antibiotic such as cefazo- in the Infectious Diseases Society of America
lin (Ancef) may be considered in hospitalized guidelines.31
patients with nonpurulent cellulitis, and the Linezolid is a synthetic oxazolidinone
regimen can be modified to MRSA-active and is FDA-approved for treating SSTIs and
therapy if there is no clinical response. Li- nosocomial pneumonia caused by MRSA. It
nezolid, daptomycin, vancomycin, and tela- has 100% oral bioavailability, so parenteral
vancin have adequate streptococcal coverage therapy should only be given if there are prob-
in addition to MRSA coverage. lems with gastrointestinal absorption or if the
Clindamycin is approved by the FDA for patient is unable to take oral medications.
treating serious infections due to S aureus. It Long-term use of linezolid (> 2 weeks) is
The depth has excellent tissue penetration, particularly limited by hematologic toxicity, especially
of infection in bone and abscesses. thrombocytopenia, which occurs more fre-
Clindamycin resistance in staphylococci quently than anemia and neutropenia. Lactic
is hard to tell can be either constitutive or inducible, and acidosis and peripheral and optic neuropathy
on examination clinicians must be watchful for signs of resis- are also limiting toxicities. Although myelo-
tance. suppression is generally reversible, peripheral
Diarrhea is the most common adverse ef- and optic neuropathy may not be.
fect and occurs in up to 20% of patients. Linezolid should not used in patients tak-
Clostridium difficile colitis may occur more ing selective serotonin reuptake inhibitors if
frequently with clindamycin than with other they cannot stop taking these antidepressant
oral agents, but it has also has been reported drugs during therapy, as the combination can
with fluoroquinolones and can be associated lead to the serotonin syndrome.
with any antibiotic therapy.30 Vancomycin is still the mainstay of paren-
Trimethoprim-sulfamethoxazole is not teral therapy for MRSA infections. However,
FDA-approved for treating any staphylococ- its efficacy has come into question, with con-
cal infection. However, because 95% to 100% cerns over its slow bactericidal activity and
of community-acquired MRSA strains are sus- the emergence of resistant strains. The rate of
ceptible to it in vitro, it has become an im- treatment failure is high in those with infec-
portant option in the outpatient treatment of tion caused by MRSA having minimum in-
SSTIs. Caution is advised when using it in el- hibitory concentrations of 1 g/mL or greater.
derly patients, particularly those with chronic Vancomycin kills staphylococci more slowly
renal insufficiency, because of an increased than do beta-lactams in vitro and is clearly in-
risk of hyperkalemia. ferior to beta-lactams for methicillin-sensitive
Tetracyclines. Doxycycline is FDA-ap- S aureus bacteremia.
proved for treating SSTIs due to S aureus, Daptomycin is a lipopeptide antibiotic
64 CLEV ELA N D C LI N I C JO URNAL OF MEDICINE VOL UME 79 NUM BE R 1 J ANUARY 2012
RAJAN
that is FDA-approved for adults with MRSA tal status, an immunocompromised state, or
bacteremia, right-sided infective endocarditis, organ failure (respiratory, renal, or hepatic)
and complicated SSTI. Elevations in creati- must be hospitalized.
nine phosphokinase, which are rarely treat- Although therapy for MRSA is the main-
ment-limiting, have occurred in patients re- stay of empiric therapy, polymicrobial infec-
ceiving 6 mg/kg/day but not in those receiving tions are not uncommon, and gram-negative
4 mg/kg/day. Patients should be observed for and anaerobic coverage should be added as ap-
development of muscle pain or weakness and propriate. One study revealed a longer length
should have their creatine phosphokinase lev- of stay for hospitalized patients who had inad-
els checked weekly, with more frequent moni- equate initial empiric coverage.33
toring in those with renal insufficiency or who Vigilance should be maintained for overly-
are receiving concomitant statin therapy. ing cellulitis which can mask necrotizing fas-
Telavancin is a parenteral lipoglycopep- ciitis, septic joints, or osteomyelitis.
tide that is bactericidal against MRSA. It Perianal abscesses and infections, infected
is FDA-approved for complicated SSTIs in decubitus ulcers, and moderate to severe dia-
adults. Creatinine levels should be monitored, betic foot infections are often polymicrobial
and the dosage should be adjusted on the basis and warrant coverage for streptococci, MRSA,
of creatinine clearance, because nephrotoxic- aerobic gram-negative bacilli, and anaerobes
ity was more commonly reported among in- until culture results can guide therapy.
dividuals treated with telavancin than among
those treated with vancomycin. INDICATIONS FOR SURGICAL REFERRAL
Ceftaroline (Teflaro), a fifth-generation
cephalosporin, was approved for SSTIs by Extensive perianal or multiple abscesses
the FDA in October 2010. It is active against may require surgical drainage and debride-
MRSA and gram-negative pathogens. ment.
Surgical site infections should be referred
Cost is a consideration for consideration of opening the incision for
Cost is a consideration, as it may limit the drainage.
availability of and access to treatment. In Necrotizing infections warrant prompt
2008, the expense for 10 days of treatment aggressive surgical debridement. Strongly sug-
with generic vancomycin was $183, compared gestive clinical signs include bullae, crepitus,
with $1,661 for daptomycin, $1,362 for tige- gas on radiography, hypotension with systolic
cycline, and $1,560 for linezolid. For outpa- blood pressure less than 90 mm Hg, or skin
tient therapy, the contrast was even starker, as necrosis. However, these are late findings, and
generic trimethoprim-sulfamethoxazole cost fewer than 50% of these patients have one of
$9.40 and generic clindamycin cost $95.10.32 these. Most cases of necrotizing fasciitis origi-
nally have an admitting diagnosis of celluli-
INDICATIONS FOR HOSPITALIZATION tis and cases of fasciitis are relatively rare, so
the diagnosis is easy to miss.15,16 Patients with
Patients who have evidence of tissue necrosis, an LRINEC score of six or more should have
fever, hypotension, severe pain, altered men- prompt surgical evaluation.20,24,34,35
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41:13731406. Scott & White Health System, 2401 South 31st Street, Temple, TX 78608;
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