Skin and Soft Tissue Infections Bacterial and Fungal

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Skin and Soft Tissue InfectionsBacterial and
Fungal

• Crystal Obering, Pharm.D., MBA
• Clinical Assistant Professor
• Clinical Pharmacist
• Veterans Affairs Medical Center

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Objectives

• Discuss the pathophysiology (including
  responsible organisms) of select skin and soft
  tissue infections (SSTI) and superficial fungal
  infections (SFI)
• Identify clinical features, contributing factors,
  and diagnosing techniques used in patients with
  SSTI and SFI
• Identify goals and treatment options for patients
  with SSTI and SFI
• Understand the resistance patterns of common
  organisms that cause SSTI

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Objectives

• Identify non-pharmacological interventions for
  SSTI and SFI
• Develop a pharmaceutical care plan using your
  knowledge of proper medication selection, dosing,
  duration of therapy, common side effects,
  drug-drug interactions, monitoring parameters,
  and follow up needed for a patient with a SSTI or
  SFI
• Understand possible complications if SSTI and SFI
  are not properly treated

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Future Resources for You!!

• Practice Guidelines from the Infectious Diseases
  Society of America http//www.journals.uchicago.e
  du/IDSA/guidelines/
• The Sanford Guide Guide to Antimicrobial
  Therapy
• Yearly published
• Common causative bacteria
• Empiric antimicrobial therapy
• Dosing adjustments in special populations
• Drug-Drug interactions with antimicrobials

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Skin and Soft Tissue Infections

• Bacterial Infections
• Infected bite wounds
• Erysipelas
• Impetigo
• Folliculitis, etc.
• Cellulitis
• Diabetic foot
• Decubitus Ulcers/Pressure Sores
• Necrotizing
• Bone Infections

• Fungal Infections
• Vaginal candidiasis
• Oral candidiasis
• Mycotic Infections

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Skin and Soft Tissue Infections

• Difficult to develop due to skins physical
  shedding, barrier, low pH, normal flora, good
  blood supply, and dry nature
• Breakdown in host defense can result in infection
• Bacteria exposure, extra moisture, occlusion of
  blood supply, skin damage

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Case Review

• S 43 y/o WM presents to same day care in a WC
  with right shoe removed.
• CC Cat bite to his right foot. States it
  occurred 2 days ago. It has been painful, red,
  and swollen since then. NKDA, No routine
  medications, has not tried anything OTC, denies
  any H/O DM.
• OT 100 F, BP 132/84, HR 73, RR 18.
• PE Small punctate area on dosal base of right
  foot that is weeping serrous/purulent exudate
  with surrounding erythema and warmth that extends
  up the foot to lateral ankle. Painful to lateral
  aspect of right foot with palpation.

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Infected Bite Wounds
Dog, Cat, Human
50 of US population will be bitten during their
lifetime
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Infected Bite Wounds

• Dog bites
• 80 of all bite wounds
• Infection rates 3.2-45.8
• 2 groups
• 8-12 hrs after injury
• Wound care, tear wounds, rabies/tetanus treatment
• gt12 hrs after injury
• Symptoms of infection from puncture wound

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Infected Bite Wounds

• Cat bites
• 5-15 of all bite wounds
• Infection rates 30-50
• Management same as dog bite
• Human bites
• 5-10 of all bite wounds
• Infection rates 10-50

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Animal Bites Clinical

• Features
• Puncture wound
• Infection
• Pain at injury site
• Gray malodorous discharge
• Cellulitis spreading proximal
• Contributing factors
• Time to medical attention
• gt50 years old

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Animal Bites Pathophysiology

• Diagnostic Techniques
• Document cause of injury
• Immunization history of animal
• Patients tetanus immune status
• Wound cultures not helpful
• Causative Bacteria
• Polymicrobial 5 isolates
• Common
• Within 24 hrs Pasteurella
• 24-36 hrs staph, strep
• Other
• Aerobes (74-90) strep, S. aureus, Moraxella,
  Neisseria
• Anaerobes (41-49) Fusobacterium, Bacteroides,
  Porphyromonas, Prevotella

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Animal Bites Treatment

• Goals
• Prevent infection
• Resolve infection and prevent complications
• Non-Pharmaceutical Interventions
• Wound care, elevation, immobilization
• Tetanus-Diphtheria toxoids and tetanus immune
  globulin

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Animal Bites Treatment

• Prophylaxis
• Drug Options x 3-5 days
• Amoxicillin/clavulanate 875/125mg BID
• PCN VK 500mg TID
• Alternative TMP/SMX 160/800mg BID
• Drug Monitoring
• PCN VK rash
• Bactrim GI, rash, photosensitivity, Cr/BUN,
  pregnancy

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Animal Bites Treatment

• Drug Options x 10-14 days
• Within 24 hrs
• Augmentin 875/125mg BID
• Severe PCN 1.2 mUnits q 4-6 hrs
• Alternative clindamycin 300mg BID
• 24-36 hrs
• Dicloxacillin 500mg QID
• Alternative Cefuroxime 500mg BID

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Animal Bites Treatment

• Drug Monitoring
• Augmentin AST/ALT, rash
• Clindamycin AST/ALT, Cr/BUN, diarrhea
• Dicloxacillin GI, rash
• Cefuroxime PT, Cr/BUN

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Animal Bites Complications

• Soft tissue infection
• Prophylaxis
• Rabies
• Tetanus
• Osteomyelitis
• Amputation

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Human Bites Clinical

• Features
• Self inflicted
• Hands sucking/biting nails
• Mouth/Lips
• Clenched-fist injuries
• 3rd/4th Metacarbophalangeal joint
• Blows to the mouth
• Pain, throbbing, swollen extremity
• Purulent discharge
• Decreased range of motion

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Human Bites Pathophysiology

• Diagnostic Technique
• Appearance
• Culture/Sensitivity
• Immunization status of biter
• Causative Bacteria
• Normal Flora
• S. aureus, Streptococcus, Eikenella corrodens,
  Bacteroides, Peptostreptococcus

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Human Bites Treatment

• Goals
• Prevent infection
• Resolve infection and prevent complications
• Non-Pharmaceutical Interventions
• Wound care, elevation, immobilization
• Rabies, tetanus, HIV prophylaxis if needed

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Human Bites Treatment

• Prophylaxis x 3-5 days
• Drug Options
• Augmentin 875/125mg BID
• Alternative TCN 500mg QID
• Drug Monitoring
• Augmentin AST/ALT, rash
• TCN Pregnancy, AST/ALT, sun exposure

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Human Bites Treatment

• Drug Options x 7-14 days
• Empiric Augmentin 875/125mg BID
• Severe Ampicillin/sulbactam (Unasyn) 1.5mg q6hrs
• Alternative Clindamycin (FQ or TMP/SMX)
• Drug Monitoring
• Unasyn diarrhea, rash
• Clindamycin AST/ALT, Cr/BUN, diarrhea
• FQ Cr/BUN, rash, tendonitis, cardiac-QT, seizure
• TMP/SMX pregnancy, sun exposure, AST/ALT,
  Cr/BUN

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Human Bites Complications

• Osteomyelitis
• Septic arthritis
• Tenosynovitis
• Loss of digit/hands

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Bites Follow-up/Dz Monitoring

• Resolution of symptoms of infection
• Vitals, WBC, cultures as indicated
• Edema, other signs of cellulitis

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Case Review

• S 43 y/o WM presents to same day care in a WC
  with right shoe removed.
• CC Cat bite to his right foot. States it
  occurred 2 days ago. It has been painful, red,
  and swollen since then. NKDA, No routine
  medications, has not tried anything OTC, denies
  any H/O DM.
• OT 100 F, BP 132/84, HR 73, RR 18.
• PE Small punctate area on dosal base of right
  foot that is weeping serrous/purulent exudate
  with surrounding erythema and warmth that extends
  up the foot to lateral ankle. Painful to lateral
  aspect of right foot with palpation.

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Case Questions

• If you feel that additional information is
  needed, please list the specific facts you need
  below. You may list no more than 2 additional
  facts. Any facts listed beyond this will not be
  graded.
• List and prioritize all of the patient problems
  you have identified in this case.
• State the short-term and long-term, time-specific
  therapeutic goals.
• Identify your recommended treatments. Include
  both nonpharmaceutical and pharmaceutical
  treatments you would initiate, change or continue
  and justify.

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Case Questions

• If necessary, list no more than 4 patient
  education points/issues that you would
  communicate to the patient regarding the therapy
  you have just recommended.
• List the monitoring parameters you feel are
  necessary to follow and the frequency at which
  you would follow them. Discuss key parameters
  which would cause you to intervene and/or change
  your plan.

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Erysipelas
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Erysipelas Clinical

• St. Anthonys Fire
• Features
• Superficial cellulitis with extensive lymphatic
  involvement
• Bright, edematous, indurated, painful
• Sharply circumscribed plaque by elevated border
• Face and legs most common location
• Contributing factors
• Most frequent in infants, young children,
  elderly, nephrotic syndrome
• Environment aiding in inoculation
• Preexisting lymphatic obstruction or edema
• Small break in skin

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Erysipelas Pathophysiology

• Diagnostic Techniques
• Primarily based on appearance
• Can aspirate from edge of advancing lesion
• Causative Bacteria
• Group A streptococci (S. pyogenes)
• Less common S. aureus

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Erysipelas Treatment

• Goals
• Eradication of infection
• Drug Options
• Mild to Moderate Topical mupirocin or PenVK
  250-500mg QID x 7-10 days
• Serious IV Pen G 2-8 million units Qday
• Alternate Erythromycin 500mg Qday
• Drug Monitoring
• PCN WBC, vitals, rash
• Erythro EKG in high risk pts QT prolongation

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Erysipelas Complications

• Diabetics/Immunocompromised Pts
• May be caused by mixed bacterial infections
• Gram and enterococci
• Treat with IV cephalosporin

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Erysipelas Follow-up/Dz Monitoring

• Reassess 3-5 days
• Response is usually quite dramatic
• May worsen shortly after treatment as dying
  organisms release toxins

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Impetigo
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Impetigo Clinical

• Features
• Superficial cellulitis, small fluid filled
  vesicles
• Rapidly develops into pus-filled blisters
• Ruptures and forms golden yellow crusts
• Face nose, mouth
• Contributing factors
• More common in children, eczema, DM2, dialysis

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Impetigo Clinical

• Environment aiding in inoculation
• Minor trauma/scratches/insect bites
• Hot humid weather
• Pruritis further spreads infection
• Highly communicable

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Impetigo Pathophysiology

• Diagnostic Techniques
• Appearance
• Skin swab if other household members infected
• Causative Bacteria
• Bullous S. aureus
• Non-bullous S. aureus or S. pyogenes

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Impetigo Treatment

• Goals
• Resolution of infection
• Minimize scaring
• Non-Pharmaceutical Interventions
• Soaking in soap and warm water
• Bath in antiseptic reduce normal flora

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Impetigo Treatment

• Drug Options 7-10 days
• Small area Topical ABX (Mupirocin) TID
• Dicloxacillin 125mg q6hrs
• Extensive Dicloxacillin 250 q 6hrs
• Cephalexin 500mg BID
• Drug Monitoring
• Mupirocin local irritation
• Dicloxacillin GI, skin rash
• Cephalexin pruritis

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Impetigo Complications

• Extensive cellulitis
• Scaring from lesions

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Impetigo Follow-up/Dz Monitoring

• May resolve spontaneously
• Re-evaluate in 3-5 days
• Vitals, WBC, cultures as indicated
• If no improvement, may add penicillin or
  ampicillin to cover for strep infection

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Folliculitis
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Folliculitis Clinical

• Features
• Superficial infection of pilosebaceous follicles
• In areas of coarse hair scalp, neck, beard,
  limbs
• Crops of multiple small erythematous papules and
  pustules around hair follicle
• Contributing factors
• Prolonged ABX therapy
• Immunosuppression DM or HIV

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Folliculitis Clinical

• Environment aiding in inoculation
• Hot-tub, swimming pool, whirlpool water poorly
  chlorinated
• Sponges/bathtubs poorly cleaned
• Pruritic papules and pustules over area covered
  by bathing suit
• Non-infective due to physical or chemical
  irritation

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Folliculitis Pathophysiology

• Diagnostic Techniques
• Appearance
• Swab from pustules
• Swabs of carriage sites (nares)
• Causative Bacteria
• Most Common S. aureus
• Gram (-) organisms Klebsiella, E. Coli, P.
  mirabilis

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Folliculitis Treatment

• Goals
• Eradication of infection
• Prevent/minimize spread of infection
• Non-Pharmaceutical Interventions
• Warm saline compresses
• Antiseptic wash
• Shave in direction of hair rather than against
• Surgical incision if doesnt drain spontaneously

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Folliculitis Follow-up/Dz Monitoring

• Usually self-limiting resolves w/o treatment
• Vitals, WBC, cultures as indicated
• Treatment usually only needed for furuncles and
  carbuncles

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Folliculitis Complications

• Progress to furuncles and carbuncles (boils)
• Furuncles areas of friction discrete, firm,
  tender, red, nodule lesion
• Carbuncles lesions coalesce and extend into SQ
  tissue
• Fever, chills, and malaise
• Destruction of follicles and alopecia
• Secondary bacteremia in other tissues
• Generalized cellulitis

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Carbuncle
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Folliculitis Treatment

• Drug Options 7-10 days
• Mild Topical ABX (erythromycin, mupirocin) TID
• Severe Dicloxacillin 250mg q6hrs
• Cephalexin 500mg BID
• Alternative Bactrim DD BID or
  Clindamycin 150-300mg qday-q6hrs
• Drug Monitoring
• Mupirocin local irritation
• Dicloxacillin GI, skin rash
• Cephalexin pruritis
• Bactrim rash, GI
• Clindamycin AST/ALT, Cr/BUN, diarrhea

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Case Review Continued

• S Pt comes hopping on 1 foot (carrying
  crutches) into the ER 5 days following initial
  assessment. Reports that he has been taking the
  previously prescribed ABX, but that his foot
  looks worse. He reports that he has had sweats
  but did not check his temperature. Describes
  pain as 7 and constant, throbbing.
• O RLE is erythematous and shiny/tight to lower
  calf. Has ½ cm open ulcer on right dorsal area
  with pus-like drainage that is fluctuant 3cm.
  X-ray of right foot shows no air in soft tissue.
• T 98.5, BP 135/80, P 73, RR 18
• WBC 13.1, Plt 183, Neut 79.2, Lymp 5.4,
  Mono 14.3, Eos 0.9, Baso 0.2.
• Culture Gram stain 2 WBC, 1 Gram cocci,
  100 S. aureus, MRSA

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Cellulitis
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Cellulitis Clinical

• Features
• Ill-defined erythema, edema, warmth
• Pain and tenderness
• Blister, exudate, lymphangitis
• Systemic fever, rigors, malaise, confusion
• Frequent in legs

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Cellulitis Clinical

• Contributing factors
• Elderly
• Gain access through broken skin
• Infective Risks pressure ulcers, injection drug
• Non-Infective Risks lymphedema, leg edema,
  venous insufficiency, obesity

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Cellulitis Pathophysiology

• Diagnostic Techniques
• Skin swabs often negative
• Needle aspiration
• Blood cultures complicated/severe cases
• Differential DVT ultrasound
• Causative Bacteria
• Group A streptococci S. pyogenes
• S. aureus

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Cellulitis Treatment

• Goals
• Rapid eradication of infection
• Prevention of complications
• Non-Pharmaceutical Interventions
• Elevation
• Immobilization of involved area to decrease edema
• Moist dressing
• Surgical intervention

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Cellulitis Treatment

• Drug Options x 7-10 days
• Guided by cultures/sensitivities
• Empiric Dicloxacillin 500mg QID or
• Cefazolin 1gm IV QID
• Alternative Macrolide or 1st Gen. cephalosporin
• Severe IV PCN-G 1-2 mUnits Q6hrs
• Alternative Vanco added, macrolides, Linezolid,
  quinupristin/dalfopristin

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Cellulitis - Treatment

• Drug Monitoring
• Dicloxacillin GI, skin rash
• Cefazolin seizures, rash
• Erythromycin EKG in high risk pts QT
  prolongation
• PCN G rash
• Vancomycin levels, ototoxicity, Cr/BUN, rash

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Cellulitis Complications

• Spread through lymphatic tissue and bloodstream
• Bacteremia 30 of cases
• Thrombophlebitis
• Local abscess
• Osteomyelitis
• Septic arthritis
• Gangrene
• Amputation

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Cellulitis Follow-up/Dz Monitoring

• Symptom improvement within 48 hrs
• Vitals, WBC, cultures as indicated
• Identify focus of infection
• Obtain culture if indicated
• Appearance of crepitus
• Prophylaxis questionable
• 30 previous cellulitis

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Case Review Continued

• S Pt comes hopping on 1 foot (carrying
  crutches) into the ER 5 days following initial
  assessment. Reports that he has been taking the
  previously prescribed ABX, but that his foot
  looks worse. He reports that he has had sweats
  but did not check his temperature. Describes
  pain as 7 and constant, throbbing.
• O RLE is erythematous and shiny/tight to lower
  calf. Has ½ cm open ulcer on right dorsal area
  with pus-like drainage that is fluctuant 3cm.
  X-ray of right foot shows no air in soft tissue.
• T 98.5, BP 135/80, P 73, RR 18
• WBC 13.1, Plt 183, Neut 79.2, Lymp 5.4,
  Mono 14.3, Eos 0.9, Baso 0.2.
• Culture Gram stain 2 WBC, 1 Gram cocci,
  100 S. aureus, MRSA
• PATIENT IS ADMITTED.

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Case Questions

• If you feel that additional information is
  needed, please list the specific facts you need
  below. You may list no more than 2 additional
  facts. Any facts listed beyond this will not be
  graded.
• List and prioritize all of the patient problems
  you have identified in this case.
• State the short-term and long-term, time-specific
  therapeutic goals.
• Identify your recommended treatments. Include
  both nonpharmaceutical and pharmaceutical
  treatments you would initiate, change or continue
  and justify.

65
Case Questions

• If necessary, list no more than 4 patient
  education points/issues that you would
  communicate to the patient regarding the therapy
  you have just recommended.
• List the monitoring parameters you feel are
  necessary to follow and the frequency at which
  you would follow them. Discuss key parameters
  which would cause you to intervene and/or change
  your plan.

66
Case Review

• S A 43 y/o AAF with a recent history of a
  diabetic foot infection presents to wound clinic
  for follow-up. She is noted to have had
  draining, macerated tissue with minimal
  devitalization. Currently denies any
  fever/chills/night sweat/nausea/vomitting.
  Extensive debridement is preformed and the
  patient is admitted for IV ABX.
• O She was previously treated with 11 days IV
  ceftriaxone and 10 days PO metronidazole.
• Cultures E. faecalis, S. aureus, Morganella
  sp., S. pneumonia, bacteroides sp.

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DiabeticFoot Processes
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Diabetic Foot Processes

• Most common complication of diabetes
• Account for 1 in 5 hospitalizations
• Affect 25- of the 12 million diabetics
• Over 50 of all non-traumatic lower extremity
  amputations
• Generally preventable

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Diabetic Foot Clinical

• Features
• Common on pad, heel, and metacarpals
• Chemical vs. mechanical
• Size/Depth of ulcer
• Odor, exudate
• Undermining
• Neuropathic
• Neuroischemic most common
• Ischemic rare

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Diabetic Foot Clinical

• Contributing factors
• Age
• Chronic renal disease
• Blindness
• Duration/Control of DM
• Prior ulcers

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Diabetic Foot Clinical

• Environment aiding in inoculation
• Combination of various pathologies and
  environmental factors
• Neuropathy
• Peripheral vascular disease
• Abnormalities in pressures
• Trauma
• Presence of callus, edema, food deformities

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Diabetic Foot - Clinical

• Diagnostic grading of ulcer
• 0 at-risk foot, no ulcer, callus formation
• 1 superficial ulcer not infected
• 2 deeper ulcer often infected
• 3 deep ulcer, abscess formation, bone
  involvement
• 4 partial gangrene of foot (heel or toe)
• 5 Gangrene of whole foot
• Diagnostic staging of wound
• A clean wound
• B nonischemic infected wound
• C ischemic non-infected wound
• D Ischemic, infected wound

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Diabetic Foot Infection Clinical

• Non-Limb Threatening
• Limb Threatening
• gt 2cm cellulitis, lymphangitis, soft-tissue
  necrosis, fluctuant, odor, gangrene,
  osteomyelitis
• Life Threatening
• Septic situation deferred

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Diabetic Foot Infection Clinical

• Diagnostic Tests
• ESR, WBC, cultures
• X-ray to determine bone involvement
• Renal function, glycemic control
• Fever
• Causative Bacteria
• Polymicrobial
• S. aureus, Group B strep, enterococci,
  Corynebacterium, Bacteroides

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Diabetic Foot Infection Treatment

• Non-Pharmaceutical Interventions
• PREVENTION, PREVENTION, PREVENTION!!
• Podiatric care
• Protective shoes
• Pressure reduction
• Prophylactic surgery
• Preventative Education
• Surgery/Amputation
• Debridement chemical, surgical

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Diabetic Foot Infection Treatment

• Drug Options
• Non-Limb Threatening x 10 days
• PO AMX/CL 875mg BID
• Alt Levofloxacin 500mg Qday Metronidazole
• IV Ampicillin/Sulbactam (Unasyn) 1.5-3g q6h or
  Piperacillin/Tazobactam (Zosyn) 3.375g q6h
• Limb Threatening IV broad spectrum
• Imipenem 0.5g q6h Vanco
• Alt Vancomycin 15mg/kg q12h Levofloxacin 500mg
  Qday Metronidazole 500mg q6h

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Diabetic Foot Infection Treatment

• Drug Monitoring
• Augmentin - AST/ALT, rash
• Levofloxacin Cr/BUN, rash, tendinitis,
  cardiac-QT, seizure
• Unasyn/Zosyn diarrhea, rash
• Primaxin seizure, PCN allergy
• Vancomycin levels, ototoxicity, Cr/BUN, rash
• Metronidazole Cr/BUN, leukopenia, seizure

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Diabetic Foot Infection Complications

• Lymphangitis
• Cellulitis
• Necrosis
• Gangrene
• Osteomyelitis
• Amputations

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Diabetic Foot Infection F/U, Dz Monitoring

• Reassess in 48-72 hrs
• Vitals, WBC, cultures as indicated
• Reduction of pressure elevation of limb
• Frequent foot exams self and clinical
• Appearance of crepitus

80
Case Review

• S A 43 y/o AAF with a recent history of a
  diabetic foot infection presents to wound clinic
  for follow-up. She is noted to have had
  draining, macerated tissue with minimal
  devitalization. Currently denies any
  fever/chills/night sweat/nausea/vomitting.
  Extensive debridement is preformed and the
  patient is admitted.
• O She was previously treated with 11 days IV
  ceftriaxone and 10 days PO metronidazole.
• Cultures E. faecalis, S. aureus, Morganella
  sp., S. pneumonia, bacteroides sp.
• Grade 2, Stage D

81
Case Questions

• If you feel that additional information is
  needed, please list the specific facts you need
  below. You may list no more than 2 additional
  facts. Any facts listed beyond this will not be
  graded.
• List and prioritize all of the patient problems
  you have identified in this case.
• State the short-term and long-term, time-specific
  therapeutic goals.
• Identify your recommended treatments. Include
  both nonpharmaceutical and pharmaceutical
  treatments you would initiate, change or continue
  and justify.

82
Case Questions

• If necessary, list no more than 4 patient
  education points/issues that you would
  communicate to the patient regarding the therapy
  you have just recommended.
• List the monitoring parameters you feel are
  necessary to follow and the frequency at which
  you would follow them. Discuss key parameters
  which would cause you to intervene and/or change
  your plan.

83
Case Review

• 80 y/o bed bound, WM who presents today for
  routine 6 mo follow up. Continues Foley
  catheter, last changed 2 weeks ago. No current
  complaints of burning, hematuria, or pain around
  Foley
• SH Married, lives with wife who cares for him,
  has VN that helps with bowel/bladder needs and
  bathing.
• PE T 96.5, BP 142/73, P 58, RR 18. Derm
  small stage 2 decubiti, noted in the sacral
  region axilla are involved, R gt L. Poor skin
  turgor, skin dry, cracked, thin. Bony prominences
  protruding. Obvious eating deficits.

84
Case Review, cont

• PMH DM2 Neuropathy HTN CAD-CVAx3 w/ residual
  L side weakness Prostate CA GERD neurogenic
  bladder urethral stricture.
• Labs WNL. Wound Swab Neg
• Meds NPH Insulin 18 Units Qam 8 Qpm Gabapentin
  300mg TID Atenolol 50mg Qday Furosemide 40mg
  Qday Lisinopril 40mg Qday ASA 81mg Qday
  Simvastatin 10mg PHs Omeprazole 20mg Qday MVI.

85
Pressure Ulcers
86
Pressure Ulcers Clinical

• AKA pressure sores, bed sores, decubitus ulcers
• Prevalence
• 2.5-24 in LTC facilities
• 70 of affected are 70 years
• 50 increase in nursing time
• Contributing factors
• Alterations in sensation or response to
  discomfort
• Alterations in mobility
• Significant changes in weight
• Incontinence

87
Pressure Ulcers Clinical

• Environment
• Pressure bony prominences
• Shear forces elevated HOB
• Friction skin against bed, chair, clothing
• Moisture incontinence
• Affected areas
• Girdle area (ischium, sacrum, coccyx,
  trochanters)
• Heels

88
Pressure Ulcer Classifications

• Stage 1Non-blanchable erythema of intact skin,
  or discoloration, edema, induration, and warmth
  over a bony prominence among patients with darker
  skin the heralding lesion of skin ulceration.

89
Pressure Ulcer Classifications

• Stage 2Partial thickness skin loss involving
  epidermis, dermis, or both. The ulcer is
  superficial and presents clinically as an
  abrasion, blister, or shallow crater.

90
Pressure Ulcer Classifications

• Stage 3Full thickness skin loss involving
  damage to, or necrosis of, subcutaneous tissue
  that may extend down to, but not through, fascia.
  The ulcer presents clinically as a deep crater
  with or without undermining of adjacent tissue.

91
Pressure Ulcer Classifications

• Stage 4Full thickness skin loss with extensive
  destruction, tissue necrosis or damage to muscle,
  bone, or supporting structures (e.g., tendon,
  joint capsule). Undermining and sinus tracts also
  may be associated with Stage 4 pressure ulcers

92
Pressure Ulcers Treatment

• Goals
• PREVENTION, PREVENTION, PREVENTION!
• Promote wound healing
• Minimize effect on pts overall condition

93
Pressure Ulcers Non- Pharm Treatment

• Prevention
• Maintain personal hygiene
• Adequate nutrition and hydration
• Evaluate and manage incontinence
• Relief of 5 min q 2 hrs can prevent sore
  formation
• Approximately 29-79 min of nursing time per day
• Pressure-relieving devices foam pads, inflating
  mattresses, sheep skins, not donut shaped devised
• Body placement in bed and handling

94
Pressure Ulcers Non- Pharm Treatment

• Debridement surgical, chemical
• Cleansing
• Proper wound care
• Hyperbaric Oxygenation

95
Pressure Ulcers Pathophysiology

• Infection Diagnostic Criteria
• Appearance suggestive of infection
• All wounds are colonized to some degree
• Redness, heat, pain
• Odor, purulent drainage, advancing inflammation
  gt1cm
• Culture from biopsy or needle aspiration

96
Managing Ulcer Colonization and Local and
Systemic Infection
97
Pressure Ulcers Pathophysiology

• Causative Bacteria
• Become infected as they worsen
• Polymicrobotic
• S. pyogenes, enterococci, anaerobic strep.,
  Enterobacteria, Pseudomonas, Bacteroides, S.
  aureus

98
Pressure Ulcer Treatment

• Drug Options x 3-4 weeks
• Initial Topical Antibiotic (silver sulfadiazine
  or Triple ABX)
• Severe Imipenem/Cilastatin 0.5g q 8hr
• If MRSA add Vancomycin
• Drug Monitoring
• Topical irritation
• Primaxin seizure, PCN allergy
• Vancomycin levels, ototoxicity, Cr/BUN, rash

99
Pressure Ulcer Complications

• Cellulitis
• Osteomyelitis
• Necrotizing Fasciitis
• Myositis
• Amputation
• Bacteremia
• Sepsis
• Death

100
Pressure Ulcer F/U, Dz Monitoring

• Preventative measures
• Universal precautions
• Cover wound except during treatment
• Pain control
• WBC, X-ray, ESR
• Treat most contaminated ulcer last

101
Case Review

• 80 y/o bed bound, WM who presents today for
  routine 6 mo follow up. Continues Foley
  catheter, last changed 2 weeks ago. No current
  complaints of burning, hematuria, or pain around
  Foley
• SH Married, lives with wife who cares for him,
  has VN that helps with bowel/bladder needs and
  bathing.
• PE T 96.5, BP 142/73, P 58, RR 18. Derm
  small stage 2 decubiti, noted in the sacral
  region axilla are involved, R gt L. Poor skin
  turgor, skin dry, cracked, thin. Bony prominences
  protruding. Obvious eating deficits.

102
Case Review, cont

• PMH DM2 Neuropathy HTN CAD-CVAx3 w/ residual
  L side weakness Prostate CA GERD neurogenic
  bladder urethral stricture.
• Labs WNL. Wound Swab Neg
• Meds NPH Insulin 18 Units Qam 8 Qpm Gabapentin
  300mg TID Atenolol 50mg Qday Furosemide 40mg
  Qday Lisinopril 40mg Qday ASA 81mg Qday
  Simvastatin 10mg Qhs Omeprazole 20mg Qday MVI.

103
Case Questions

• If you feel that additional information is
  needed, please list the specific facts you need
  below. You may list no more than 2 additional
  facts. Any facts listed beyond this will not be
  graded.
• List and prioritize all of the patient problems
  you have identified in this case.
• State the short-term and long-term, time-specific
  therapeutic goals.
• Identify your recommended treatments. Include
  both nonpharmaceutical and pharmaceutical
  treatments you would initiate, change or continue
  and justify.

104
Case Questions

• If necessary, list no more than 4 patient
  education points/issues that you would
  communicate to the patient regarding the therapy
  you have just recommended.
• List the monitoring parameters you feel are
  necessary to follow and the frequency at which
  you would follow them. Discuss key parameters
  which would cause you to intervene and/or change
  your plan.

105
Necrotizing Infections
106
Necrotizing Infections Clinical

• Features
• Pain
• Skin appearance hot, swollen, erythematous, w/o
  sharp margins
• Etiologic agent
• Gas production
• Muscle involvement
• Systemic toxicity
• Frequent in the abdomen, perineum, and lower
  extremities
• Very rare

107
Necrotizing Infections Treatment

• Goals
• Identification, immediate aggressive surgical
  debridement and resolution of infection
• Diagnostic Tests
• Presentation/Appearance
• X-ray to see if gaseous production
• Causative Bacteria
• Faciitis anaerobes, strep, enterobacteria
• Post surgery/trauma (Gas Gangrene) Clostridium
  perfingens

108
Necrotizing Infections Treatment

• Non-Pharmaceutical
• Surgery
• Drug Options
• Clindamycin IV 900mg q8h
• Primaxin IV 0.5g q6hrs
• Drug Monitoring
• As before

109
Necrotizing Infections Complications, F/U, Dz
Monitoring

• Advances rapidly ICU monitoring

110
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111
Bone Infections

• Osteomyelitis
• Hematogenous vs. Continguous
• Acute vs. Chronic
• Staging anatomic location and physiologic status
  of patient
• Infectious Arthritis

112
Osteomyelitis Clinical

• Direct entry from source outside of the body
• Penetrating wound, fractures, surgical
• Secondary to SSTI fingers and toes
• Abscessed teeth
• Most common in gt50 yo
• Contributing Factors
• Hip fracture
• Diabetes Mellitus
• Severe atherosclerosis
• Age 50-70

113
Osteomyelitis Pathophysiology

• Diagnostic Tests
• Vitals, CBC, blood culture
• X-ray/bone scan of area
• Bone aspiration and culture
• Causative Micro-organism
• Varies based on source
• Most common S. aureus, poly-microbial

114
Ostseomyelitis Treatment

• Goals
• Prevent!!!
• Resolution of infection and prevention of chronic
  infection
• Acute best outcome
• Chronic surgical debridement and prolonged ABX

115
Osteomyelitis Treatment

• High dose
• Usually 4-6 weeks
• Guided by cultures and sensitivities
• Use for oral, outpatient ABX
• Confirmed osteomyelitis
• Organism identified
• ABX sensitivity determined
• Suitable agent available
• Assured compliance
• Not diabetic or have PVD

116
Osteomyelitis Treatment

• Drug Options x 4-6weeks
• Oral AM/CL 875mg BID
• Ciprofloxacin 750mg BID
• Nafcillin 2g IV q4hrs Ceftazidime 2g IV q8hrs
• Alternative Zosyn
• Guided by cultures and sensitivities

117
Osteomyelitis Complications, F/U, Dz Monitoring

• Complications
• Vascular surgery
• Surgical debridement
• Amputation
• Disease Monitoring/Follow-up
• CBC 1-2 q week until normal
• ESR weekly
• Clinical signs daily
• Adherence

118
Fungal Infections

• Vaginal candidiasis
• Oral candidiasis
• Mycotic Infections

119
Vaginal Candidiasis Clinical

• Features
• Symptoms vulvar itching, soreness, irritation,
  burning
• Signs erythema, discharge, lesions, edema
• Contributing Factors
• Sexually active, vaginal contraceptive agents,
  ABX use
• Environment aiding in inoculation
• Douching, tight fitting clothing

120
Vaginal Candidiasis Pathophysiology

• Diagnostic Criteria
• Clinical presentation
• Vaginal pH normal
• Microscopy blastospores
• Culture usually not required
• Causative
• Candida albicans
• C. glabrata

121
Vaginal Candidiasis Treatment

• Goals
• Treat symptoms
• Non-Pharmacological Intervention
• Diet
• Avoid harsh soaps, douching
• Cool baths
• Loose fitting clothing

122
Vaginal Candidiasis Treatment

• Drug Options
• Topical Clotrimazole 1 1 app x 7 days
• 2 1 app x 3 days
• 10 1 app x 1 day
• Oral Fluconazole 150mg x 1 day
• Drug Monitoring
• For 1 day treatment, allow 72 hr for symptom
  resolution
• Local irritation of topical

123
Vaginal Candidiasis Complications

• Complicated by DM or other immunosuppressed pts
• Treatment continued x 10-14 days
• Pregnancy
• Oral agents contraindicated
• Topical preferred x 10-14 days

124
Vaginal Candidiasis F/U, Dz monitoring

• Recurrent infections
• 4 episodes w/in 12-mo period
• Regular induction Tx x 14 days
• Negative cultures
• Maintenance Tx
• Fluconazole 100mg q week x 6 mo

125
Oral Candidiasis Clinical

• Features
• Diverse presentation
• Symptoms Painful mouth, burning tongue, metallic
  taste, speech difficulty, dysphasia
• Signs lesions on buccal mucosa, throat, tongue,
  gums
• Contributing Factors
• Broad-spectrum ABX use, steroid inhalers, smoker,
  denture wearer, immunocompromised

126
Oral Candidiasis Pathophysiology

• Diagnostic Criteria
• Clinical appearance
• Cytology, culture, biopsy
• Candida in normal flora
• Causative
• Candida albicans
• Other Candida glabrata, tropicalis, krusei,
  parapsilosis

127
Oral Candidiasis Treatment

• Goals
• Eliminate clinical signs/symptoms
• Minimize future relapses
• Non-Pharmacological Intervention
• Proper oral hygiene
• Minimize contributing factors (CS, ABX, Chemo)

128
Oral Candidiasis Treatment

• Drug options
• Local/Regional treatment
• Nystatin 500,000 units sw/sw QID x 14 days
• Clotrimazole 10mg troche QID x 7-14 days
• Systemic
• Fluconazole 200mg x 1 day

129
Oral Candidiasis Treatment

• Drug Monitoring
• For 1 day treatment, allow 72 hr for symptom
  resolution
• Local Tx Complete course even though symptoms
  resolve
• Local irritation of topical

130
Oral Candidiasis Complications, F/U, Dz
monitoring

• Refractory infections
• Higher rate in immunocompromised pts
• Reduction/resolution of symptoms
• Negative culture

131
Mycotic Infections
132
Mycotic Infections Clinical

• Features
• Skin Central clearing surrounded by advancing
  red, scaly, elevated boarder
• Nail chalky, dull, yellow/white, brittle,
  crumbly
• Diagnosis
• Microscopic exam
• Causative
• Dermatophytes Trichophyton, Epidermophyton,
  Microsporum

133
Onychomycosis Treatment

• Goal
• Resolution of infection
• Drug Options
• Topical Ciclopirox lacquer Qhs x 48 wks
• Oral Terbinafine 250mg Qday x 6wks (finger)
  x 12wks (toe)
• Monitoring
• Adherence
• GI, rash, headache, AST/ALT
• CYP2D6 interactions

134
Onychomycosis Complications, F/U, Dz Monitoring

• Infect other nails
• Adherence to regimen
• May take 3-12 months for new nail to grow out

135
Objectives

• Discuss the pathophysiology (including
  responsible organisms) of select skin and soft
  tissue infections (SSTI) and superficial fungal
  infections (SFI)
• Identify clinical features, contributing factors,
  and diagnosing techniques used in patients with
  SSTI and SFI
• Identify goals and treatment options for patients
  with SSTI and SFI
• Understand the resistance patterns of common
  organisms that cause SSTI

136
Objectives

• Identify non-pharmacological interventions for
  SSTI and SFI
• Develop a pharmaceutical care plan using your
  knowledge of proper medication selection, dosing,
  duration of therapy, common side effects,
  drug-drug interactions, monitoring parameters,
  and follow up needed for a patient with a SSTI or
  SFI
• Understand possible complications if SSTI and SFI
  are not properly treated