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Antibiotic Stewardship for Skin and Soft Tissue Infection and Respiratory Tract Infections
Ghinwa Dumyati, MDProfessor of MedicineCenter for Community Health andInfectious Diseases DivisionUniversity of Rochester Medical [email protected] 28, 2018
Outline
• Review common reasons for a “red leg”
• Discuss when skin lesions need to be cultured
• Differentiate between upper and lower respiratory tract
infections
• Review treatment duration for cellulitis and pneumonia
Stewardship Opportunities in the Nursing Home
41%
35%
14%
10%
Common Indications for Antibiotic Prescriptions among Nursing Home Patients
Urinary Tract Infection
Respiratory (Upper and Lower)Tract Infection
Skin and Soft Tissue Infection(SSTI)
Other
Katz PR et al. Arch Intern Med 1990; 150:1465-8
Stewardship Opportunities in the Rochester Nursing Homes
SSTI28%
UTI25%
PNEUMONIA21%
HEENT INFECTION9%
BONE/JOINT INFECTION8%
C. DIFF5%
DENTAL/SURGICAL PROPHYLAXIS
4%
Proportion of residents treated by indication, example from one of the Rochester nursing homes
Skin and Soft Tissue Infections (SSTI): Many Diagnostic Challenges
• High prevalence of chronic skin changes
• Peripheral vascular disease
• Venous stasis disease
• Pressure ulcers
• Chronic wounds colonized with bacteria
• Difficulty in getting information due to cognitive impairment
Which one of these wounds should be cultured and Treated?
DermNet New Zealand
SSTI Diagnostic and Treatment CriteriaMcGeer Criteria Loeb Minimum Criteria
Pus at SSTI site
OR Any four (4) of the following
Increased warmth Increased redness Increased swelling Increased tenderness Serous drainage Constitutional findings (temp, WBC, etc)
New of increased purulence at SSTI site
OR Any two (2) of the following
Increased warmth Increased redness Increased swelling Increased tenderness Fever (Temp > 100*F, or 2.4*F > baseline)
Stone ND, et al. Infect Control Hosp Epidemiol. 2012;33(10):965-77Loeb M, et al. Infect Control Hosp Epidemiol. 2001;22(2):120-4
A 60 year old male with history of CAD, CHF, chronic lower extremity edema and diabetes mellitus with ESRD in hemodialysis
He had an abrupt onset of lower extremity pain associated with redness and swelling that evolved over a period of several hours
•What is your diagnosis?
•What can mimic cellulitis?
Cellulitis
Non Purulent Purulent
Usually due to Streptococcus Group A, B, G Usually due to Staphylococcus aureus
Stasis Dermatitis
Pictures Visual DX
Stasis Dermatitis
•Extremely common
•Can present with erythema, edema mimicking cellulitis
•Can present with bullae, drainage and crusting
•Severe presentations can mimic bacterial infection
Leg Cellulitis -vs- Stasis Dermatitis
Cellulitis
• Often a history of preceding trauma, bite or injury preceding by days
• Lymphangitic streaking
• Unilateral
• Acute episode
• Fever or chills possible but not mandatory for diagnosis
• Usually no scale or skin breakdown
• Leukocytosis
Stasis Dermatitis
• Varicose veins, lymphedema
• Skin redness often associated with scale
• Unilateral or Bilateral
• Usually chronic or recurring
• Afebrile
• Pruritic lesions, weeping lesions
• Relapsing and Remitting Course
Bilateral Cellulitis
Stasis DermatitisStasis Dermatitis
Stasis DermatitisBut really –stasis, stasis, stasis
Stasis DermatitisBut really –stasis, stasis, stasis
Stasis Dermatitis: Scale Obvious or SubtleBut really –stasis, stasis, stasis
Stasis Dermatitis: Can ulcerateStasis dermatitis- Can ulcerate
Stasis Dermatitis
LymphedemaLymphedema
Other Cellulitis Mimics
Fungal Dermatitis Deep Vein Thrombosis
Eczema or Contact Dermatitis
Healthline.com
Gout
Spider Bite Chemical Dermatitis at Peg
Don’t Miss
Necrotizing Fasciitis
• Group A strep common etiology
• Unexplained and rapidly progressing pain disproportional to the physical findings
• Erythema may be diffuse or localized or may be absent. Progress to bullae formation and necrosis
• Patients are sick: Fever, malaise, myalgia, diarrhea, and anorexia may also be present• Hypotension may develop initially or over time
• Elevated WBC, bandemia, elevated creatinine
Opportunities of Antimicrobial Stewardship
•Don’t culture uninfected ulcers or wounds
•Don’t treat stasis dermatitis with antibiotics
• Treat cellulitis for 5 days
• Treat purulent cellulitis for 7 days
Respiratory Tract Infections
Respiratory Tract Infections
Upper respiratory tract infections
Lower respiratory tract infections
Blue dots are syndromes caused by viruses
Green dots are syndromes caused primarily by bacteria
90% due to viruses
~70% due to bacteria
**bacterial causes include Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Bordatella pertussis (causes whooping cough). Antibiotics are only appropriate for bronchitis caused by Bordatella pertussis, diagnosed using special tests on nasopharyngeal samples.
Acute Bronchitis vs. PneumoniaAcute Bronchitis Pneumonia
Definition Self-limited inflammation of bronchi, the large airways of the lung
Inflammation or infection of the lung tissue
Cause Viral (with rare exceptions)* ~75% bacteria, ~25% viral
Symptoms Cough for 5 days to 3 weeksFever less common (unless influenza)50% have sputum production
CoughFever is commonSputum productionChest wall painDecline in oxygenation
DiagnosticStudies
Normal to slightly elevated WBCNo specific chest x-ray findings
Elevated WBCInfiltrate, effusions
Evaluation of Pneumonia
Cough
Sputum production
RR ≥ 25
Decrease O2 saturation (<95%)
New or changed lung exam
Pleuritic chest pain
Constitutional symptoms(fever, mental status changes, acute functional decline)
Signs and Symptoms
CBC
Viral nasopharyngeal swab
Legionella urine antigen and sputum culture if severe pneumonia*
CXR (may be)
Workup
*NYSDOH guidelines for legionella https://www.health.ny.gov/diseases/communicable/legionellosis/docs/2015_nursing_home_guidance.pdf
Opportunities for Antibiotic Stewardship
• Re-assess the need for antibiotics after 2-3 days
• CXR: common interpretation “Cannot rule out infiltrate”
• Need to have positive signs and symptoms and exam findings consistent with pneumonia
• Treatment duration: 5-7 days for most residents (longer if slow to respond)
Updated McGeer Surveillance Criteria for Pneumonia
• Positive CXR
• >1 Respiratory criteria
• Cough, sputum, hypoxia, tachypnea, pleurisy, lung findings
• >1 Constitutional criteria
• Fever, neutrophilia/left shift, delirium, decline in function
Stone D N. et al, Infect Control Hosp Epidemiol. 2012; 33(10): 965–977
Loeb Minimum Criteria for Initiating Antibiotics
1. Temp > 1020F AND RR >25 or productive cough
2. Temp >1000 or > 2.4˚F over baseline AND new cough plus:
• P > 100 OR
• Delirium or rigors OR
• RR > 25
3. COPD AND increased cough with purulent sputum
4. New productive cough AND RR > 25 or delirium
Loeb M, Bentley DW, Bradley S, et al. Infect Control Hosp Epidemiol 2001;22:120e124
SBAR tools for SSTI and Lower RTI
Nursing Home Antimicrobial Stewardship Guide
Determine Whether To Treat https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_
Rochester Nursing Home Collaborative Guidelines for Treatment of Common Infectionshttp://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes
Acknowledgments
• Elizabeth Dodds Ashley, PharmD
• Alexandra Yamshchikov, MD
• Joseph Nicholas, MD
• Dallas Nelson, MD
• Annette Medina Walpole, MD
• Timothy Holahan, MD
• Scott Schabel, MD
• Thomas Pingree, MD
• Mary Aydelotte, MD
• Rena Pine, MD
• Kim Petrone, MD
• Brian Heppard, MD
• Diane Kane, MD
• Alexander Karlic, MD
• Robin Jump, MD
Questions?