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Infecciones de piel y partes blandas: ¿Cómo mejorar su manejo?

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Análisis de la problemática relacionada con el manejo de las infecciones de piel y partes blandas

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Infecciones de piel y partes blandas: ¿Cómo mejorar su manejo?

  1. 1. ¿Cómo mejorar el manejo de las infecciones de piel y partes blandas en el Hospital? José Ramón Paño Pardo Medicina Interna UMCEI-HULP Joaquín Llorente García R4 Medicina Interna Complejo Asistencial Universitario de León Sesión de Enfermedades Infecciosas Hospital Universitario La Paz 25 de Febrero de 2015
  2. 2. Contexto/Relevan cia
  3. 3. Guía de tratamiento de las infecciones de piel y tejidos blandos Rev Esp Quimioterap, Diciembre 2006; Vol. 19 (Nº 4): 378-394 CLASIFICACÍÓN / DIAGNÓSTICO ABORDAJE MÉDICO-QUIRURGUICO Contexto/Relevancia
  4. 4. National Trends in Ambulatory Visits and Antibiotic Prescribing for Skin and Soft-Tissue Infections Adam L. Hersh. Arch Intern Med. 2008;168(14):1585-1591 AUMENTO DE INCIDENCIA Contexto/Relevancia
  5. 5. Guión/Metodolog ía
  6. 6. Metodología Identificación de problemas en el manejo de IPPB* JLLG & JRP (a propósito de 2 casos clínicos) Revisión de la literatura JLLG ¿Soluciones? (JLLG & JRP) + ¡¡Audiencia!! Ámbito: IPPB, excluyendo ILQ** y Pie diabético * IPPB: Infección de piel y partes blandas ** ILQ: infección de localización quirúrgica
  7. 7. Problemas en el manejo de IPPB
  8. 8. 1. Identificación de la gravedad 2. Identificación/anticipación de la etiología 3. Monitorización de la evolución Identificación de problemas Problemas Diagnósticos
  9. 9. 1. Gravedad 2. Etiología 6. Evolución Identificación de problemas Problemas Terapéuticos 3. ¿Antibiótico inicial? 4. ¿Ámbito sanitario? (AP/ingreso/UCI) 5. ¿Indicación quirúrgica? (paciente/momento) 7. ¿Ajuste antibiótico? (fármaco/duración) Problemas Diagnósticos
  10. 10. Problemas en el manejo de IPPB 1. Identificación de la gravedad
  11. 11. 1.1. Gravedad sistémica 1. Identificación de la gravedad • No SIRS/ Sepsis*/ Sepsis Grave / Shock Séptico • Score de Pitt • APACHE, SOFA, etc ¡Común al resto de infecciones!
  12. 12. 1.1. Gravedad local 1. Identificación de la gravedad Extensión Profundidad ¡Necrosis! Localización
  13. 13. 1.1. Gravedad local 1. Identificación de la gravedad ¿Se puede identificar clínicamente la gravedad local? ¿Bien? ¿Mal? ¿Regular?
  14. 14. ¿Clasificaciones clínicas para el manejo clínico de las infecciones de piel y partes blandas?
  15. 15. CLASIFICACIÓN CLÁSICA Enfermedades de piel y partes blandas. Porras Leal L. et al Protocolos de Enfermedades Infecciosas. SEMI
  16. 16. ERISIPELA • Tipo específico de celulitis superficial de la piel con una intensa afectación linfática (SGA) • Dolorosa, rojo brillante, con piel edematosa e indurada («piel de naranja») y un borde elevado de avance bien delimitado Celulitis, Infecciones necrotizantes e infecciones del tejido subcutáneo. Enfermedades Infecciosas. Principios y práctica., 7th ed, Mandell GL, Bennett JE, Dolin R (Eds), Elsevier, Philadelphia 2010.
  17. 17. • Se extiende + en profundidad que erisipela (tejidos subcutáneos) • Area afectada extensa y muy enrojecida, caliente e inflamada Celulitis, Infecciones necrotizantes e infecciones del tejido subcutáneo. Enfermedades Infecciosas. Principios y práctica., 7th ed, Mandell GL, Bennett JE, Dolin R (Eds), Elsevier, Philadelphia 2010. CELULITIS • Etiología más frecuente: Estreptococos del grupo A/B o S. • Bordes NO elevados ni bien definidos: afectación parcheada posible • Se pueden formar abscesos* locales y después puede haber necrosis de áreas parcheadas de la piel suprayacente. *Celulitis supurativa: S. aureus
  18. 18. “ In principle, cellulitis is simply defined as an acute infection with inflammation of the skin involving the dermis and subcutaneous tissues. In practice, because of the overlapping signs and symptoms of skin infections, the terminology has become burdened with terms such as erysipelas, purulent cellulitis, nonpurulent cellulitis, nonsuppurative cellulitis, cellulitis with drainage, cellulitis with ulcer, cellulitis with abscess, abscess with surrounding cellulitis, and necrotizing cellulitis” “which lumps cellulitis and abscess together, even though these 2 entities would appear to be easily differentiated clinically and microbiologically. Clearly, an abscess is a collection of pus often in association with pain, swelling, and in-flammation. Whatever cellulitis is, it is not an abscess, as there is no collection of pus, which, if there were, the lesion would be an abscess and not cellulitis.” http://cid.oxfordjournals.org/content/56/12/1763.long
  19. 19. Celulitis, Infecciones necrotizantes e infecciones del tejido subcutáneo. Enfermedades Infecciosas. Principios y práctica., 7th ed, Mandell GL, Bennett JE, Dolin R (Eds), Elsevier, Philadelphia 2010. Infección grave infrecuente que afecta a los tejidos blandos subcutáneos, sobre todo a la fascia superficial 2 entidades bacteriológicas diferentes: Tipo I : Polimicrobiana Tipo II: Estreptocócica Tipo especial: Gangrena de Fournier Según localización: craneal, cervical, periorbitaria. Inicialmente similar a una celulitis Diagnóstico diferencial de las infecciones necrotizantes Necrotizing fasciitis: Contribution and limitations of diagnostic imaging J. Malghem et al. Joint Bone Spine 2013 FASCITIS NECROSANTE
  20. 20. DATOS CLÍNICOS SUGESTIVOS DE GRAVEDAD EXPLORACIÓN Improved results from a standardized approach in treating patients with necrotizing fasciitis. Sudarsky LA et al. Ann Surg. 1987;206(5):661. Guía de tratamiento de las infecciones de piel y tejidos blandos Rev Esp Quimioterap, Diciembre 2006; Vol. 19 (Nº 4): 378-394 Infecciones de piel y partes blandas. Consenso SAEI F. Salgado Ordoñez et al . Medicina Clínica 2009
  21. 21. OTROS DATOS SUGESTIVOS DE GRAVEDAD
  22. 22. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America Dennis L. Stevens et al Clinical Infectious Diseases 2014;59(2):147–59 ¿Cuál os parece mejor?
  23. 23. Problemas en el manejo de IPPB 2. Identificación/anticipación de la etiología 1. Identificación dela gravedad
  24. 24. Erisipelas y celulitis. Estudio retrospectivo de 122 casos J. Concheiro et al. Actas Dermosifiliogr. 2009;100:888-94 2. Identificación/anticipación de la etiología
  25. 25. • “By far the most common cause of skin abscesses (barring unusual exposures or injury such as brack- ish water or bites) is Staphylococcus aureus, and pus and abscess formation are its mo- dus operandi” • “With respect to cellulitis, lack of clarity about the microbiology is a problem” 1. If blood culture is the gold standard (-ve in 90%), then β-hemolytic streptococci cause the majority of cases of cellulitis (57%–75%) and S. aureus causes only 14% 2. In blood culture–negative cases, serologi- cal testing with anti-streptolysin O and anti-DNase-B indicates that β-hemolytic streptococci account for 70% 3. If culture of the skin by various means (biopsy/aspirate/swab), is deemed the gold standard, then these proportions are reversed: (Staphylococcus aureus 50%–82%
  26. 26. DIAGNÓSTICO MICROBIOLÓGICO IDSA Practice Guidelines for SSTIs • CID 2014:59
  27. 27. DIAGNÓSTICO MICROBIOLÓGICO IDSA Practice Guidelines for SSTIs • CID 2014:59 ¿ Alguno (no) extraeríais hemocultivos ?
  28. 28. FASCITIS NECROTIZANTE IDSA Practice Guidelines for SSTIs • CID 2014:59
  29. 29. ETIOLOGÍA DE FASCITIS NECROTIZANTE Datos Aportados por el Servicio de Cirugía Plástica HULP 32 pacientes con diagnóstico de Fascitis Necrotizante Se tomaron muestras intraoperatorias para Gram y Cultivo 27 positivos (84,3%) 5 estériles (15,7%) Tipo I: 66% de los casos (G- y anaerobios) Tipo II: 33% (G+) Aislamiento más frecuente de microorganismos: E. coli (30,7%) Bacteroides (15,3%) S. pyogenes (15,3%) S. aureus (15,3%)
  30. 30. National Trends in Ambulatory Visits and Antibiotic Prescribing for Skin and Soft-Tissue Infections Adam L. Hersh. Arch Intern Med. 2008;168(14):1585-1591 SARM COMUNITARIO: USA SARM-CA
  31. 31. Prevalencia del 11,2% (37 de 329 SARM) 36 casos de Infección de piel y partes blandas 17 abscesos cutáneos 7 celulitis 4 úlceras maleolares 1 pie diabético 1 infección de herida quirúrgica 3 infecciones de herida traumáticas 3 folicultiis o vesículas sobreinfectadas Metástasis más frecuente que en SAMS Elevada tasa de recidiva Sensibles a antibióticos orales con actividad SARM (80 % de La cepas con CMI vanco >1,5) Epidemiología y forma de presentación clínica de las infecciones originadas por Staphylococcus aureus resistente a meticilina productor de leucocidina de Panton-Valentine Cobos-Trigueros et al. Revista Española de Quimioterapia 2010
  32. 32. Prevalencia de infecciones de piel y tejidos blandos producidas por Staphylococcus aureus resistente a Meticilina Comunitario en Madrid Beatriz Casado-Verrier et al. Enferm Infecc Microbiol Clin. 2012 SARM COMUNITARIO PREVALENCIA BAJA PROBLEMA RELATIVO
  33. 33. Problemas en el manejo de IPPB 3. Antibioterapia inicial 1. Identificación de la gravedad 2. Anticipación/Identificación de la etiología
  34. 34. 3. Antibioterapia inicial VS
  35. 35. CELULITIS/ERISIPELA NO PURULENTA
  36. 36. ¿Es necesario espectro para G-?
  37. 37. Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting Hermione J. Hurley et al. Am J Med. 2013
  38. 38. Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting Hermione J. Hurley et al. Am J Med. 2013 ?
  39. 39. Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting Hermione J. Hurley et al. Am J Med. 2013
  40. 40. Jenkins T. et al. Clinical Infectious Diseases 2010; 51(8):895–903
  41. 41. Jenkins T. et al. Clinical Infectious Diseases 2010; 51(8):895–903
  42. 42. Pallin DJ et al. Clinical Infectious Diseases 2013;56(12):1754–62
  43. 43. Pallin DJ et al. Clinical Infectious Diseases 2013;56(12):1754–62
  44. 44. Problemas en el manejo de IPPB 4. Ámbito sanitario 1. Identificación de la gravedad 2. Anticipación/Identificación de la etiología 3. Tratamiento antibiótico inicial
  45. 45. 4. Ámbito sanitario
  46. 46. Gokulan Phoenix et al. BMJ 2012
  47. 47. Marwick C. et al. J Antimicrob Chemother 2011; 66: 387–397
  48. 48. Mayo Clin Proc. October 2014;89(10):1436-1451
  49. 49. Problemas en el manejo de IPPB 5. Indicación quirúrgica: paciente/momento 1. Identificación de la gravedad 2. Anticipación/Identificación de la etiología 3. Tratamiento antibiótico inicial 4. Ámbito sanitario
  50. 50. 5. Indicación quirúrguica
  51. 51. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections Chin-Ho Wong et al. Crit Care Med 2004
  52. 52. J. Malghem et al. Joint Bone Spine 2013 Radiografía simple: poca utilidad Alteraciones compatibles en el 80% de los casos
  53. 53. Erik Castleberg et al. Western Journal of Emergency Medicine 2014 J. Malghem et al. Joint Bone Spine 2013
  54. 54. CIRUGÍA GOLD STANDARD DIAGNÓSTICO DE FASCITIS NECROTIZANTE SIEMPRE REQUIERE CIRUGÍA ¿Cuándo esta indicado realizar un TC?¿ECO?
  55. 55. Problemas en el manejo de IPPB 6. Monitorización de la evolución 1. Identificación de la gravedad 2. Anticipación/Identificación de la etiología 3. Tratamiento antibiótico inicial 4. Ámbito sanitario 5. Indicación quirúrgica: paciente/momento
  56. 56. 6. Evolución ¿Favorable o desfavorable? Datos sistémicos 24-48 h Datos locales 72 h ¿ENFERMEDAD MÁS PROFUNDA / FACTORES HUESPED / DOSIS / RESISTENCIA?
  57. 57. Problemas en el manejo de IPPB 7. Ajuste antibiótico: tiempo/duración 1. Identificación de la gravedad 2. Anticipación/Identificación de la etiología 3. Tratamiento antibiótico inicial 4. Ámbito sanitario 5. Indicación quirúrgica: paciente/momento 6. Monitorización de la evolución
  58. 58. 7. Ajuste antibiótico INTENTAR DESESCALAR
  59. 59. ¿Cuándo y Cuánto escalar ? MULTIRRESISTENCIA / ENFERMEDAD MÁS PROFUNDA / FACTORES HUESPED
  60. 60. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America Dennis L. Stevens et al Clinical Infectious Diseases 2014;59(2):147–59 7. Duración del antibiótico
  61. 61. Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting Hermione J. Hurley et al. Am J Med. 2013
  62. 62. GRACIAS

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