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Skin and Soft Tissue Infections

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Nathan Cleveland, MD, MS

Nathan Cleveland, MD, MS

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  • So I’ll start off by lowering the bar a little bit. I’m not super happy with this lecture. In retrospect, it is too broad of a topic to cover in one lecture. It could really be divided into 3 lectures. One on cellulitis, one on abscess and one on necrotizing infections.
  • Let’s start with some history. What was Criton suffering from? Pain out of proportion to exam. Starts as a local process. Quickly causes systemic illness. Swelling. Erythema. Bullae. AMS. Death. Sounds like Hippocrates is describing a rapidly progressive skin and soft tissue infection like necrotizing fasciitis.
  • Skin and Soft Tissue Infections (SSTIs) are some of the earliest and most well-described bacterial infections in the historical medical literature. The function of antibiotic substances was first described by Pasteur in 1877 and despite millennia of trying to treat SSTIs and 135 years of antibiotic research, we still have difficulty diagnosing and managing these infections.
  • This is the problem:
  • First we’re going to review skin anatomy. Second, were going to describe the various types of SSTIs. We’re going to review the current best evidence for diagnosis and management of SSTIs by trying to answer some of the common questions we kick around regarding SSTIs. And we’re going to highlight the current CDC and IDSA recommendations.
  • I should also mention a couple of things that we’re NOT going to focus on.
  • OK, just a brief review of skin anatomy. The most superficial layer is the keratinized epidermis. Next we have the dermis which contains the majority of the glands and functional structures of the skin. Below this is the subcutaneous fat followed by deep structures such as fascia, muscle, cartilage and bone.
  • SSTIs can be cause by bacterial, fungal, viral and parasitic organisms. They are typically classified based on the pathogen as well as the depth of involvement. You will hear them referred to as SSTI, cSSSI, ABSSSI, etc. etc.
  • Just a reminder. Bewware the red herring. All that is red is not cellulitis. It seems like more and more when someone presents with any lower extremity redness, we order an US to r/o DVT, then if the US is negative, our default is to call it cellulitis and treat with antibiotics. This is actually venous stasis dermatitis. This person’s legs always look that way. It might be warm, but is usually not painful. It is common to see this unilaterally especially after vein harvesting for CABG.
  • Necfasc can present with impressive skin findings but the problem is that sometimes it presents with little to no skin changes, like this.
  • Cellulitis and erisypelas are not the same disease process. It is important to make the distinction between these two diseases because it will affect the way that we treat the infection.
  • There are only a handful of studies looking at culturing cellulitis. There are two ways to try to cx – needle aspiration or biopsy – and the studies vary widely in success rates. This is the largest study of needle aspiration I could find and resulted in isolation of potential pathogen in only 10%. Punch biopsy is a little better at 25-40%.
  • There are only a handful of studies looking at culturing cellulitis. There are two ways to try to cx – needle aspiration or biopsy – and the studies vary widely in success rates. This is the largest study of needle aspiration I could find and resulted in isolation of potential pathogen in only 10%. Punch biopsy is a little better at 25-40%.
  • Punch biopsy is a little better at 25-40% but you have to actually punch out a section of skin and get someone in the lab to either culture the specimen or do immunoflourescent staining to determine the pathogen in less than half of the cases.
  • First, let’s agree that in the afebrile and “not sick” category of patients, blood cultures are rarely useful – except to meet quality measures.
  • The largest study included in the meta-analysis was by Perl et al – out of 553 pts, 2% had positive blood cx. 82% of those were gram+. So in only 2/553 pts, was an organism isolated that could have influenced management.
  • They do comment that there is not enough data to know whether it may be more useful in immunocompromisedpts that may be more at risk for bacteremia.
  • Imaging of the diabetic foot or chronic wounds in order to evaluate for osteomyelitis is a different story.
  • The best review article I can find on erysipelas suggests that strep species are responsible for almost all erysipelas. Although this article was published before the age of MRSA, they note that all studies where culture of erysipelas was attempted, found strep as the primary pathogen. In addition, when reviewing all studies on treatment of erysipelas we see that many of these included macrolides (which have relatively poor action against staph) and still resulted in high cure rates. So most current recommendations are that when we see erysipelas, we treat for strep. This study from 1989 found that 96% of cases of erysipelas were strep.
  • Answering the question about the causal organisms for cellulitis is a more difficult question.
  • The few older studies have found strep as the predominant cause when cultures can be obtained. I’ve even told some of you this in the ED.
  • More recently, a systematic review of all studies looking at cellulitis in intact skin found that half of the isolates are staph and only about a quarter are strep. This review included the older studies but also some smaller, newer studies and may suggest that the epidemiology is changing. They were not able to tell us how much of that staph is MRSA.
  • More recently, a systematic review of all studies looking at cellulitis in intact skin found that half of the isolates are staph and only about a quarter are strep. This review included the older studies but also some smaller, newer studies and may suggest that the epidemiology is changing. They were not able to tell us how much of that staph is MRSA.
  • The problem with answering this question is defining cellulitis.
  • There is some thought that MRSA possesses certain virulence factors that increase the likelihood of abscess formation, therefore without abscess, MRSA is a less likely cause of the infection.
  • The best information I found was actually a recent pharmacoeconomic analysis of the question. In their study they present this diagram. What it shows is that initial antibiotics for cellulitis should not necessarily be aimed at MRSA unless the probability of the infection being staph are greater than 60% and the probability of MRSA in staph is greater than 60%. Whichis a nice concept in theory, but how could you possibly know that.
  • Some have argued that MRSA is now so common that the probability of any SSTI being MRSA is greater than 60%. That argument is based on data like this from NEJM. However, again we’re hindered by the ability to culture non-purulent cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • P
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • Well, there are a couple things to know about MRSA. First, it contains the Panton-Valentine Leukocidin. I’m not even going to pretend that I have any idea how this works other than to say that it does seem to allow the bacteria to deystroy cell membranes more easily and therefore create abscesses more easily. This is one of the reasons that MRSA is thought to be less likely in non-purulent cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • Here is the NEJM article from 2006 summarizing a few studies that looked at MRSA prevalence. We see percentages that show a range from a low of 15% to a high of 72%. And it has probably increased since then.
  • Here is the NEJM article from 2006 summarizing a few studies that looked at MRSA prevalence. We see percentages that show a range from a low of 15% to a high of 72%. And it has probably increased since then.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • In 2007 they studied cure rate after I&D with/without cephalexin. They found almost identical cure rates. Which makes sense since we already believe that many abscesses are caused by MRSA which is resistant to keflex. So this study would suggest that Abx are not needed.
  • But studies in the age of MRSA are less clear. We do know that physicians are less and less likely to manage abscesses by I&D alone. One of the best studies of simple I&D without antibiotics for the management of cutaneous abscesses was done in 2004 in children. They found that the factor most predictive of cure by I&D alone was the diameter of the total area of inflammation. Many people have tried to make the claim that we should treat “if there is surrounding cellulitis” but unfortunately there are no good studies looking at this.
  • But studies in the age of MRSA are less clear. We do know that physicians are less and less likely to manage abscesses by I&D alone. One of the best studies of simple I&D without antibiotics for the management of cutaneous abscesses was done in 2004 in children. They found that the factor most predictive of cure by I&D alone was the diameter of the total area of inflammation. Many people have tried to make the claim that we should treat “if there is surrounding cellulitis” but unfortunately there are no good studies looking at this.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • A good review of necfasc in Chest found that even still, mortality is approximately 1/3. That is a staggering number. Antibiotics should be given but their role is really to try to prevent overwhelming sepsis not cure the local disease. These pts must go to the OR and must go fast. Of all of the non-traumatic indications for emergent surgery, this is one of the most time-dependent.
  • So lets look at some of the recommendations for Abx treatment in cellulitis.
  • But we still have a very difficult time making this diagnosis. So I’m going to propose that you use the Laboratory Risk Indicator for Necrotizing Infections.
  • But we still have a very difficult time making this diagnosis. So I’m going to propose that you use the Laboratory Risk Indicator for Necrotizing Infections.
  • But we still have a very difficult time making this diagnosis. So I’m going to propose that you use the Laboratory Risk Indicator for Necrotizing Infections.
  • Of the 145 incident cases, 2 had a score less than 5, two had a score of five. So using a cutoff of less than 6, the LRINEC had a PPV 92% and a NPV 96%. Three subsequent validation studies have found the PPV to be much lower 40% (which we’re ok with) but the NPV has been right around 95%. In other words, if the score is <6, you are ok to proceed cautiously with antibiotics but without a fascial biopsy or trip to the OR. If it is over 6, you should be calling a surgeon.
  • Although it is not on their recommendations, I would also cover with vanc or linezolid. They’re about due for new recommendations and I suspect that will change.
  • Although it is not on their recommendations, I would also cover with vanc or linezolid. They’re about due for new recommendations and I suspect that will change.
  • Although it is not on their recommendations, I would also cover with vanc or linezolid. They’re about due for new recommendations and I suspect that will change.
  • Although it is not on their recommendations, I would also cover with vanc or linezolid. They’re about due for new recommendations and I suspect that will change.
  • Transcript

    • 1. EVIDENCE-BASED MANAGEMENT NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 22 AUGUST 2012
    • 2. EVIDENCE-BASED MANAGMENT “Criton, in Thasus, while still on foot, and going about, was seized with a violent pain in the great toe; he took to bed the same day, had rigors and nausea, recovered his heat slightly, at night was delirious. On the second, swelling of the whole foot, and about the ankle erythema, with distension and small bullae (phlyctaenae); acute fever; he became furiously deranged; alvine discharges bilious, unmixed, and rather frequent. He died on the second day from the commencement.” HIPPOCRATES, 4th Century B.C. VISUAL I.D. SSTI OVERVIEW GOALS INTRO HISTORY TITLE NOT GOALS ANATOMY
    • 3. EVIDENCE-BASED MANAGMENT “Thou art a boil, a plague-sore, an embossed carbuncle, in my corrupted blood.” -King Lear, Act II, Scene IV VISUAL I.D. SSTI OVERVIEW GOALS INTRO HISTORY TITLE NOT GOALS ANATOMY
    • 4. EVIDENCE-BASED MANAGMENT “Most recommendations for the diagnosis and treatment of skin and soft-tissue infections are based on tradition, consensus, or (too often) medical mythology. The literature on this subject is crippled by a paucity of randomized, controlled trials.” FAQs Slaven EM, DeBlieux PM. Skin and soft tissue infections: The common, the rare and the deadly. EM Practice 2001;3(1):1-22 VISUAL I.D. SSTI OVERVIEW GOALS INTRO HISTORY TITLE NOT GOALS ANATOMY
    • 5. EVIDENCE-BASED MANAGMENT CELLULITIS 1. Review skin anatomy 2. Describe types of SSTIs 3. Current best evidence • Diagnosis • Management 4. Highlight CDC and IDSA recommendations FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO HISTORY NOT GOALS ANATOMY
    • 6. EVIDENCE-BASED MANAGMENT vs ERYSIPELAS 1. 2. 3. 4. CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO NOT GOALS ANATOMY
    • 7. EVIDENCE-BASED MANAGMENT 5. vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO NOT GOALS ANATOMY
    • 8. EVIDENCE-BASED MANAGMENT RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS NOT GOALS ANATOMY
    • 9. EVIDENCE-BASED MANAGMENT 1. Bacterial, fungal, viral, parasitic 2. Focus on bacterial 3. Classified based on depth 4. Many names – SSTI, cSSSI, ABSSSI CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW NOT GOALS ANATOMY
    • 10. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 11. EVIDENCE-BASED MANAGMENT Infectious epidermal eruptions of flaccid pustules, which rupture to form a thick honey-colored to brown crust. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 12. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 13. EVIDENCE-BASED MANAGMENT Inflammation of the hair follicle that appears clinically as an eruption of pustules and/or papules centered upon hair follicles. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 14. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 15. EVIDENCE-BASED MANAGMENT An ulcerative pyoderma of the skin often referred to as a deeper form of impetigo. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 16. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 17. EVIDENCE-BASED MANAGMENT Acute beta-hemolytic group A streptococcal infection of the skin involving the superficial dermal lymphatics that causes marked swelling. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 18. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 19. EVIDENCE-BASED MANAGMENT Deep subcutaneous infection of the skin that results in a localized area of erythema and inflammation. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 20. EVIDENCE-BASED MANAGMENT All that is red is not cellulitis! CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 21. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 22. EVIDENCE-BASED MANAGMENT Localized infection with accumulation of PMN leukocytes with tissue necrosis involving the dermis and subcutaneous tissue. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 23. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 24. EVIDENCE-BASED MANAGMENT An infection of the deeper layers of skin and subcutaneous tissues which spreads along fascial planes. Type I = polymicrobial infection, Type II = monomicrobial infection. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
    • 25. EVIDENCE-BASED MANAGMENT CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW
    • 26. EVIDENCE-BASED MANAGMENT BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D.
    • 27. EVIDENCE-BASED MANAGMENT • Dermal and subdermal • Ill-defined • Indolent • Less systemic symptoms CELLULITIS: Q3 • Dermal lymphatics • Well-demarcated • Acute onset • More systemic symptoms BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs
    • 28. EVIDENCE-BASED MANAGMENT IMAGING IMMUNOCOMPROMISE LYMPHEDEMA VASCULAR INSUFFICIENCY OBESITY TINEA / INTERTRIGO CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS
    • 29. EVIDENCE-BASED MANAGMENT CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS
    • 30. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success ORGANISMS CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
    • 31. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success ORGANISMS CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
    • 32. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success 3. Not cost effective, rarely changes management ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
    • 33. EVIDENCE-BASED MANAGMENT CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1
    • 34. EVIDENCE-BASED MANAGMENT MRSA • Meta-analysis: 5 studies, 844 pts • Mostly inpatients CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE
    • 35. EVIDENCE-BASED MANAGMENT • Largest study: Perl B, et al. Cost- effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999;29: 1483-1488 • 2% positive Cx, 82% gram+ MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE
    • 36. EVIDENCE-BASED MANAGMENT MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE
    • 37. EVIDENCE-BASED MANAGMENT CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2
    • 38. EVIDENCE-BASED MANAGMENT • Often “soft” findings on XR, US, CT • No studies on imaging cellulitis • XR reasonable for foreign body ANTIBIOTICS Struk DW. Munk PL. Lee MJ. Ho SG. Worsley DF. Imaging of soft tissue infections. Radiologic Clinics of North America. 2001;39(2):277-303 CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx
    • 39. EVIDENCE-BASED MANAGMENT CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3
    • 40. EVIDENCE-BASED MANAGMENT IDSA RECS Erysipelas = strep CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
    • 41. EVIDENCE-BASED MANAGMENT • Short answer: • We can’t culture • No one biopsies • We don’t really know IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
    • 42. EVIDENCE-BASED MANAGMENT • 66% isolates = strep IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
    • 43. EVIDENCE-BASED MANAGMENT • 50% isolates = staph • 27% isolates = strep • 27% isolates = “other” Chira S, Miller LG. Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review. Epidemiol Infect. 2010;138(3):313-7. IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
    • 44. EVIDENCE-BASED MANAGMENT • Diabetes changes microbiology • 56% gram+ cocci • 22% gram- aerobes • 22% gram- anaerobes IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
    • 45. EVIDENCE-BASED MANAGMENT ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a
    • 46. EVIDENCE-BASED MANAGMENT • CA-MRSA is most common cause of “purulent” cellulitis in the ED ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS
    • 47. EVIDENCE-BASED MANAGMENT • Assume CA-MRSA causes “non- purulent” cellulitis sometimes • But... Probably not as common ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS
    • 48. EVIDENCE-BASED MANAGMENT ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b
    • 49. EVIDENCE-BASED MANAGMENT ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
    • 50. EVIDENCE-BASED MANAGMENT Moran GJ, Krishnadasan A, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-74 ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
    • 51. EVIDENCE-BASED MANAGMENT Frazee BW, Lynn J, et al. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med. 2005;45(3):311-20 1. MRSA should be covered (first line) only in certain high-risk populations Homeless Jail IVDU Recent hospitalization / Abx ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
    • 52. EVIDENCE-BASED MANAGMENT Phillips S, et al. Analysis of empiric antimicrobial strategies for cellulitis in the era of methicillin-resistant Staphylococcus aureus. Ann Pharmacother. 2007 Jan;41(1):13-20 2. The safest, most cost-effective strategy depends on local prevalence ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
    • 53. EVIDENCE-BASED MANAGMENT PACKING http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_algorithm.html ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5
    • 54. EVIDENCE-BASED MANAGMENT ABSCESS: Q3 Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS
    • 55. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Outpt 1st Line (A-I): • Semisynthetic PCNs - dicloxacillin • 1st / 2nd gen cephalosporin - cephalexin Outpt 2nd Line (or PCN allergy) (A-I): • Macrolide – erythro/azithromycin • Clindamycin • Fouroquinolones – levofloxacin MRSA coverage only if suspected ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS
    • 56. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Outpt 1st Line (A-I): • Semisynthetic PCNs - dicloxacillin • 1st / 2nd gen cephalosporin - cephalexin Outpt 2nd Line (or PCN allergy) (A-I): • Macrolide – erythro/azithromycin • Clindamycin • Fouroquinolones – levofloxacin MRSA coverage only if suspected ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS
    • 57. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Inpt 1st Line (A-I): • Pen G, nafcillin, oxacillin, cefazolin Inpt (PCN allergy) (A-I): • Clindamycin, vancomycin, tigecycline, linezolid ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS
    • 58. EVIDENCE-BASED MANAGMENT IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS
    • 59. EVIDENCE-BASED MANAGMENT ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS
    • 60. EVIDENCE-BASED MANAGMENT ANESTHESIA Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6. Tonkin DM, Murphy E, et al. Perianal abscess: a pilot study comparing packing with nonpacking of the abscess cavity. Dis Colon Rectum. 2004 Sep;47(9):1510-4. Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9. • I&D alone is effective in most cases ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS
    • 61. EVIDENCE-BASED MANAGMENT Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6. • I&D alone is effective in most cases • 1⁰ closure increases recurrence ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS
    • 62. EVIDENCE-BASED MANAGMENT Abraham N, Doudle M, Carson P. Open versus closed surgical treatment of abscesses: a controlled clinical trial. Aust N Z J Surg. 1997 Apr;67(4):173-6. • Some studies of closure after I&D • These do not apply to us!! ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS
    • 63. EVIDENCE-BASED MANAGMENT ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1
    • 64. EVIDENCE-BASED MANAGMENT MRSA Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9. • Probably not • Wick or soak instead ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D
    • 65. EVIDENCE-BASED MANAGMENT ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2
    • 66. EVIDENCE-BASED MANAGMENT ANTIBIOTICS Ultrasound is probably useful in SSTI: • Squire et al (2005) – Bedside US 86% sensitive and 70% specific for abscess • Tayal et al (2006) – Bedside US changed management in about half ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING
    • 67. EVIDENCE-BASED MANAGMENT Plain film should be ordered for FB CT if concern that cavity tracks deep Struk DW. Munk PL. Lee MJ. Ho SG. Worsley DF. Imaging of soft tissue infections. Radiologic Clinics of North America. 2001;39(2):277-303. ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING
    • 68. EVIDENCE-BASED MANAGMENT CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3
    • 69. EVIDENCE-BASED MANAGMENT IDSA Local anesthesia rarely sufficient • Incision → loculations → express → pack Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department--Part I. J Emerg Med. 1985;3(3):227-32 CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING
    • 70. EVIDENCE-BASED MANAGMENT Local anesthesia rarely sufficient • Incision → loculations → express → pack Combo anesthesia works best • Ring block outside erythema, then inject roof • Regional blocks when available • Systemic analgesia • Sometimes conscious sedation Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department--Part I. J Emerg Med. 1985;3(3):227-32 IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING
    • 71. EVIDENCE-BASED MANAGMENT NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4
    • 72. EVIDENCE-BASED MANAGMENT NEC FASC: Q1 MRSA carries additional virulence genes (Panton-Valentine leukocidin) Davis SL, Perri MB, et al. Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus aureus infection. J Clin Microbiol. 2007;45(6):1705 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 73. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals Kazakova SV, Hageman JC, et al. A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players. N Engl J Med 2005;352:468. NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 74. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals • Inducible clindamycin resistance Deresinski S. Methicillin-Resistant Staphylococcus aureus: An Evolutionary, Epidemiologic, and Therapeutic Odyssey. Clinical Infectious Diseases 2005;40:562–573 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 75. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals • Inducible clindamycin resistance • Recurrent in 10-23% Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin- resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-90 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 76. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals • Inducible clindamycin resistance • Recurrent in 10-23% • More easily spread Zafar U, Johnson LB, et al. Prevalence of nasal colonization among patients with community-associated methicillin-resistant Staphylococcus aureus infection and their household contacts. Infect Control Hosp Epidemiol. 2007;28(8):966-9 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 77. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals • Inducible clindamycin resistance • Recurrent in 10-23% • More easily spread • Necrotizing more often than MSSA Wang JL, et al. Comparison of both clinical features and mortality risk associated with bacteremia due to community-acquired methicillin-resistant Staphylococcus aureus and methicillin-susceptible S. aureus. Clin Infect Dis. 2008;46(6):799-806 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 78. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence genes (Panton-Valentine leukocidin) • USA 300 – not from hospitals • Inducible clindamycin resistance • Recurrent in 10-23% • More easily spread • Necrotizing more often than MSSA • Outcomes are worse Davis SL, Perri MB, et al. Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus aureus infection. J Clin Microbiol. 2007;45(6):1705 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 79. EVIDENCE-BASED MANAGMENT SSTI incidence increasing since MRSA emergence Pallin DJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008 Mar;51(3):291-8 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 80. EVIDENCE-BASED MANAGMENT Many studies looking at prevalence Moran GJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-74 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 81. EVIDENCE-BASED MANAGMENT Risk factors for MRSA include: Frazee BW, et al. High prevalence of MRSA in emergency department skin and soft tissue infections. Ann Emerg Med. 2005;45(3):311-20 NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA
    • 82. EVIDENCE-BASED MANAGMENT NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5
    • 83. EVIDENCE-BASED MANAGMENT LRINEC Burn et al 1957: PCN effective after I&D despite very high rates of resistance NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
    • 84. EVIDENCE-BASED MANAGMENT Burn et al 1957: PCN effective after I&D despite very high rates of resistance Many studies: I&D alone is effective Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6 Stewart MP, Laing MR, Krukowski ZH. Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial. Br J Surg. 1985 Jan;72(1):66-7 Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
    • 85. EVIDENCE-BASED MANAGMENT I&D vs I&D + cephalexin equivalent (10% failure) LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
    • 86. EVIDENCE-BASED MANAGMENT “Incision and drainage without adjunctive antibiotic therapy was effective management of CA-MRSA skin and soft tissue abscesses with a diameter of <5 cm in immunocompetent children.” LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
    • 87. EVIDENCE-BASED MANAGMENT • Retrospective: 492 pts, 531 MRSA+ abscesses • I&D alone – 13% failure rate • I&D + anti-MRSA Abx – 5% failure rate Clinical Infectious Diseases. 2007;44:777-84 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
    • 88. EVIDENCE-BASED MANAGMENT NEC FASC: Q2 http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_algorithm.html LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6
    • 89. EVIDENCE-BASED MANAGMENT SUMMARY Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 • I&D (A-I) packing not necessary • Culture not warranted (E-III) • Antibiotics not warranted in simple abscess (E-III) • Eradication should be attempted in outbreaks (B-III) NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS
    • 90. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Outpt 1st line (A-I): • Tetracyclines, TMP-SMX, linezolid, + other Outpt 2nd line (kids, sulfa allergy) (A-I): • Clindamycin SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS
    • 91. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Inpt 1st line (A-I): • vancomycin, daptomycin, linezolid Inpt 2nd line: • TMP-SMX, rifampin SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS
    • 92. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC
    • 93. EVIDENCE-BASED MANAGMENT Type I: Polymicrobial Type II: Monomicrobial GAS accounts for 25-50% MRSA is a cause THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC
    • 94. EVIDENCE-BASED MANAGMENT Mortality – 34% Antibiotics: • Prevent overwhelming sepsis • No role in cure Green RJ, Dafoe DC, Raffin TA: Necrotizing fasciitis. Chest 1996; 110:219–229 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC
    • 95. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA
    • 96. EVIDENCE-BASED MANAGMENT Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Inf Dis. 2007; 44:705-10 • Pain out of proportion • Violaceous bullae • Cutaneous hemorrhage • Skin sloughing • Skin anesthesia • Rapid progression • Gas in the tissue • Skip lesions THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC
    • 97. EVIDENCE-BASED MANAGMENT Retrospective, observational • Derivation cohort (89/314) • Validation cohort (56/140) Wong CH, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-41 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1
    • 98. EVIDENCE-BASED MANAGMENT Wong CH, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-41 ≤2.5 >2.5 ≤180 >180 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1
    • 99. EVIDENCE-BASED MANAGMENT Wong CH, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-41 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1
    • 100. EVIDENCE-BASED MANAGMENT 145 cases of NF • 2 had score < 5 • 2 had score = 5 Using cutoff of < 6 • PPV = 92% • NPV = 96% Wong CH, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-41 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1
    • 101. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC
    • 102. EVIDENCE-BASED MANAGMENT Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406 Surgery is the definitive tx (A-III) Necrotizing fasciitis from GAS: • clindamycin and penicillin (A-II) Community-acquired mixed infections: • ampicillin-sulbactam plus clindamycin plus ciprofloxacin (A-III) THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC
    • 103. EVIDENCE-BASED MANAGMENT 1. No cultures in uncomplicated cellulitis 2. Don’t automatically cover MRSA THE END SUMMARY NEC FASC: Q2 LRINEC
    • 104. EVIDENCE-BASED MANAGMENT 1. I&D all abscesses 2. Wick, don’t pack 3. Assume MRSA 4. Antibiotics if >5cm TMP-SMX or doxycycline + THE END SUMMARY NEC FASC: Q2 LRINEC
    • 105. EVIDENCE-BASED MANAGMENT 1. Surgery is the treatment 2. Use the LRINEC (for now) THE END SUMMARY NEC FASC: Q2 LRINEC
    • 106. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2