Case Management, Presentation, Discussion and Sharing of Information on Non complicated Skin and
Soft Tissue Infection
Robelle Joan A. Peralta, MD
First Year Resident
General
Data
F.E.
4/M
Filipino
San Andres Bukid, Manila
Chief
Complaint: Mass, leg, right
History
Of Present Illness
3
wks PTA – the patient was allegedly bitten by an insect and he scratched it.
2
wks PTA – the area of the insect bite was noted to be erythematous, tender, warm to touch, progressively growing mass,
leg, right. There was no associated complaints. No consult was done and
no medication taken.
4 days PTA - there was persistence of the mass, leg, right with associated undocumented fever and body malaise. The patient self medicated with Amoxicillin and Paracetamol but there was no relief
of symptoms so he decided to consult at OMMC.
Past
Medical History
No Hypertension
No Diabetes Mellitus
No PTB
No Bronchial Asthma
No previous hospitalizations
No allergies to food/drugs
Family History
Denies heredofamilial diseases
Personal
and Social History
Second in the brood of 3
Review
of Systems
General: no
anorexia, no weight loss
Skin: no
pruritus, no rashes, no jaundice, no pallor
HEENT: no
headache, no dizziness, no blurring of vision, no doubling of vision, no earache, no tinnitus
Respiratory: no
cough, no dyspnea, no chest pain, no hemoptysis
Cardiac: no
palpitations, no easy fatigability, no orthopnea, no paroxysmal nocturnal dyspnea
Hematologic: no
easy bruisability
Urinary: no
dysuria, no hematuria, no frequency
Endocrine: no
heat/cold intolerance, no polydipsia, no polyuria, no polyphagia
Nervous: no
loss of consciousness, no seizures
Physical
Examination
General
Survey: Conscious, coherent, ambulatory, not in cardiorespiratory distress
Vital
Signs: BP: 90/60 CR: 94 RR: 24 T: 39.8șC
HEENT: pink palpebral conjunctiva, anicteric sclerae, no naso aural discharge, no cervical
lymphadenopathies
Chest
and Lungs: symmetrical chest expansion, no retractions, clear breath sounds
Heart: Adynamic precordium, normal rate & regular rhythm, no murmur
Abdomen: Flabby, normoactive bowel sounds, soft, nontender
Extremities:
(+) fluctuant, erythematous, tender, warm to touch mass approximately 5 x 6 cm, leg, right
Salient
Features
4/M
Chief complaint:
mass, leg, right
History of insect bite
Febrile episodes
Extremities:
(+) fluctuant, erythematous, tender, warm to touch mass approximately 5 x 6 cm, leg, right
Algorithm
Do I need a para-clinical diagnostic procedure?
No
Para
Clinical Diagnostic Procedure
The decision to do any diagnostic test, including
wound or blood cultures, depends on its clinical utility and the likelihood that the result will change management.
Based on the current available evidence, the management
of uncomplicated abscesses, even those caused by CA-MRSA, is solely incision and drainage, which is associated with a cure
rate of 85% to 90%.
Fredrick M. Abrahamian, DO, FACEP,
et al. Management of Skin and Soft-Tissue Infections in the Emergency Department. Infectious Disease Clinics of North America
- Volume 22, Issue 1 (March 2008)
Treatment Goals
Resolution
of abscess
Prevention
of spread of infection
Patient
send home without complications
Treatment Options
Treatment
Our findings of high clinical cure rates (84 to
90%) and no difference in clinical cure rates for beta-lactam (Cephalexin) compared to placebo indicate that beta-lactam antibiotics
probably do not provide an additional benefit over that afforded by incision and drainage in the treatment of cutaneous abscesses.
Priya M. Rajendran,et al. Randomized,
Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk
for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection . Antimicrob Agents Chemother. 2007 November;
51(11): 4044–4048.
Pre operative Evaluation
Optimize patient’s condition
Secure informed consent
Screen for medical problems
Prepare materials for operation
Operative Management
Patient supine under GETA
Asepsis
and Antisepsis technique done
Sterile
drapes placed
Adequate
incision done over the fluctuant area
Break
down loculations with instrument
Copious
washing with PNSS
Hemostasis
checked
Dry,
sterile dressing
Patient
tolerated the procedure well
Intra-op findings: 30 cc
yellow, purulent, admixed with blood material was evacuated.
Post Operative Management
Placed
on diet as tolerated
Maintain
on IV fluids for adequate hydration
Adequate
IV antibiotic coverage
Adequate
analgesia
Daily
wound flushing
Final
Diagnosis
Abscess, leg, right
s/p incision and drainage
Outcome
Resolution
of the leg mass
Live
patient
No
complications
Satisfied
patient
No
medico-legal suit
Discussion
Skin and soft-tissue infections (SSTIs) are among
the most common infections encountered by emergency physicians.
The most commonly used classification system for
SSTIs is based on the presence or absence of complicating factors (ie, uncomplicated versus complicated infections).
S. aureus and streptococci are by far
the most common causes of both uncomplicated and complicated SSTIs, with exceptions to animal and human bite-wound infections.
Polymicrobial infections with gram-negative and
anaerobic organisms are typically seen in complicated infections
The most important new development in the era of
SSTI is the emergence of CA-MRSA.
Most infections are noninvasive , involve
skin and soft-tissue structures, and present as purulent skin infections.
In an observational study of 69 children with culture-proven
CA-MRSA abscesses, a patient with an abscess greater than or equal to 5 cm in diameter was more likely to require subsequent
hospitalization with incision and drainage alone.
Based
on this study, The Sanford Guide recommends instituting antibiotics for patients with abscesses greater than or equal to 5
cm in diameter.
In conjunction with surgical drainage, the
IDSA SSTI guidelines recommend the addition of systemic antimicrobial agents in patients with cutaneous abscesses in the following
situations:
multiple lesions
cutaneous gangrene
immunocompromised state
extensive surrounding cellulitis
those
with evidence of systemic toxicity (eg, high fever)
patients requiring hospitalization
recurrent infections
failed initial surgical therapy
The majority of patients with SSTI can be treated
as outpatients.
Hospitalization is indicated for patients with:
hemodynamic instability
altered mental status
severe infection
intractable nausea and vomiting
presence of immunocompromising infection,
failure of outpatient therapy
poor social support
In an expert panel recommendation on the management
of SSTIs, the panel classified patients with SSTIs into four classes:
Class I was afebrile and healthy, other than
cellulitis
Class 2 was febrile and ill-appearing, but with
no unstable comorbidies
Class III was toxic appearing, or with at least
one unstable comorbidity or a limb-threatening infection;
Class IV was with a sepsis syndrome or life-threatening
infection (eg, necrotizing fasciitis).
For Class I patients, outpatient care on oral
antimicrobials was recommended.
For the Class IV patients, hospital admission
was recommended.
For both the Class II and Class III patients,
a period of observation, and depending on the outcome, either outpatient care on oral or intravenous (home or infusion center
delivered) antimicrobials or hospital admission was recommended.
The misclassification of a deep abscess as cellulitis
is a common pitfall.
The presence of an underlying deep abscess should
be considered in patients with cellulitis who fail initial antimicrobial therapy.
Treatment failure may be caused by an undrained
abscess that was missed on the initial presentation, rather than inadequate antimicrobial therapy.
References
Fredrick M. Abrahamian, DO, FACEP,
David A. Talan, MD, FACEP, FAAEM, FIDSA, Gregory J. Moran, MD, FACEP, FAAEM. Management of
Skin and Soft-Tissue Infections in the Emergency Department. Infectious Disease Clinics of North America - Volume 22, Issue
1 (March 2008) - Copyright © 2008 W. B. Saunders Company
Priya M. Rajendran, David Young, Toby Maurer,
Henry Chambers, Francoise Perdreau-Remington, Peter Ro, and Hobart Harris. Randomized, Double-Blind,
Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired
Methicillin-Resistant Staphylococcus aureus Infection. Antimicrob Agents
Chemother. 2007 November; 51(11): 4044–4048
Questions
1.
What are the most common pathogens in Non complicated and complicated SSTI?
Escherichia
coli and Mycobacterium
Staphylococcus
aureus and Streptococcus
Staphylococcus
epidermidis and Bacteroides fragilis
Group A β-hemolytic strep and Peptococcus
2. According
to the Sanger Guide, a 5 cm and greater abscess would ideally be manage by:
A. Incision
and Drainage alone
B. Incision
and Drainage with antibiotics
C. Antibiotics
alone
D. Observation
Write a if 1,2,3 are correct
Write b if 1 and 3 are correct
Write c if 2 and 4 are correct
Write d if only 4 is correct
Write e if 1,2,3,4 are all correct
3. The
following require hospitalization except:
1. altered
mental status
2. poor
social support
3. failure
of outpatient therapy
4. hemodynamically
stable
4. Incision
and Drainage with antibiotics are required in which of the following settings:
1. multiple
lesions
2. immunocompromised
state
3. recurrent
infections
4. failed
initial surgical therapy
5. In which of the following class of SSTI is
hospitalization warranted?
1. Class
1
2. Class
2
3. Class
3
4. Class
4
Thank you!
