Complicated Skin and Soft Tissue Infection diagnosis and severity stratification

Transcription

1 Complicated Skin and Soft Tissue Infection diagnosis and severity stratification Muhammad Hussein Gasem Div Infectious Disease, TropMed, and Immunology Dr. Kariadi Hospital, Diponegoro University Semarang, Indonesia

2 Clinical Diagnosis Involvement in skin and soft-tissue infections Ecthyma RAJAN S Cleveland Clinic Journal of Medicine 2012;79:57-66

3 Types of infection affecting skin and soft tissues structure Anatomical structure Epithelium Keratin layer Epidermis Dermis Hair follicles Sebum glands Deeper dermis, subcutaneous fat Fascia Muscle Infection Varicella, Measles Ringworm Impetigo Erysipelas Folliculitis, boils, carbuncles Acne Cellulitis Necrotizing fasciitis Myositis, Gangrene Dryden MS J Antimicrob Chemother 2010; 65 Suppl 3: iii35 44 (with modification)

4 Clinical diagnosis Celulitis Erysipelas Specific clinical appearance of infected skin & soft tissues might useful in guiding empirical antibiotic treatment. Some clinical pictures are not specific, therefore it can be misdiagnosed and treated by antibiotics irrationally

5 Classification of SSTIs #) UNCOMPLICATED Superficial infections - Simple abscesses - Impetigo - Folliculitis - Ecthyma - Furunculosis/carbunculosis - Cellulitis Can be treated by incision-drainage only COMPLICATED (csstis) / severe SSTI Deep soft tissue infections -Necrotizing fasciitis (NSTI) -Complicated surgical site infection Requires significant surgical intervention - Infected ulcers - Infected burns - Major abscesses Significant underlying disease state, which complicate response to treatment f.i. diabetic foot infection (DFI) #) FDA classification with modification

6 Causative organisms of SSTIs *) 1. Gram-positive aerobes -Staphylococcus aureus (MSSA, HA-MRSA, CA-MRSA) -Coagulase-negative Staphylococci -Streptococcus (group A & B) -Enterococcus etc. 2. Gram-negative aerobes -Enterobacteriaceae -Pseudomonas aeruginosa etc. 3. Anaerobes -Bacteriodes fragilis & group isolates -Fusobacterium -Anaerobic Streptococci etc. *) monomicrobial or polymicrobial infections

7 Most common types of monomicrobial SSTIs Causative organism Staphylococcus aureus Streptococcus spp. Type of infection Impetigo & bullous skin infections Folliculitis, furuncle, carbuncle Suppurative hidradenitis Subcutaneus abscesses Cellulitis Erysipelas Ecthyma Streptococcal gangrene Hau T, European J Clin Microb Infect Dis, 2002 Subcutaneus abscess

8 Complicated skin & soft tissue infections a broad range of causative pathogens including patients with diabetic foot infection Petrostreptococci 8 % E. coli 8 % Staphylococcus aureus 52 % E. faecalis 13 % Pseudomonas sp 6 % Non-group A beta hem Strep 21 % Streptococcus pyogenes 13 % Polymicrobial 48 % Polymicrobial 48% Giordano, et al. Int J Antimicrob Agents Nov;26(5): n = 237 (number of patients with respective pathogen)

9 2 isolates: E. coli & methicillin-susceptible S. aureus were cultured from superficial sample Case: Mrs N, 43 yrs, T2DM with chronic diabetic foot ulcer. Wound specimens were taken on admission day. Alcaligenes faecalis was cultured from deep-site sample Dr. Kariadi Hospital, Smg

10 Risk factor for SSTIs caused by specific pathogens (1) Risk factor Recurrent hospital admissions Contact sports, recurrent boils, abscesses Diabetes mellitus Neutropenia Bite wounds human cat dog rat Animal contact Characteristic pathogens MRSA MRSA or MSSA producing PVL S. aureus (MRSA and MSSA), Group -haemolytic, Gram-negative bacilli Gram-negative bacilli, P. aeruginosa Human oral flora Pasteurella multocida Capnocytophaga canimorsus Streptobacillus moniliformis Campylobacter spp, Bartonella henselae Francisella tularensis, Bacillus anthracis Yersinia pestis Dryden MS. J Antimicrob Chemother 2010; 65 Suppl 3: iii35 44

11 Risk factor for SSTIs caused by specific pathogens (2) Risk factor Water exposure (sea, rivers) Reptile contact Injecting drug use Travel Characteristic pathogens Vibrio spp Aeromonas hydrophilia Mycobaterium marinum P. aeruginosa Salmonella spp MRSA Clostridium botulinum Clostridium tetani Leishmanasis Cutaneous larva migrans Myiasis Dryden MS J Antimicrob Chemother 2010; 65 Suppl 3: iii35 44

12 Classification of SSTI according to the severity of local and systemic signs Category Class 1 Class 2 Class 3 Class 4 Clinical features SSTI but no signs or symptoms of systemic toxicity or comorbidities Either systemically unwell or systemically well but with comorbidity (e.g diabetes) that may complicate or delay resolution Toxic and unwell (fever, tachycardia, tachypnoea and/or hypotension) Sepsis syndrome and life-threatening infection (e.g necrotizing fasciitis) Eron LJ et al. J Antimicrob Chemother 2003; 52 Suppl 1: i3 17.

13 Management of SSTI according to grading of severity Category Clinical features Class 1 Class 2 Drainage (if required) and oral antibiotics as outpatient Oral or outpatient parenteral antibiotic therapy (OPAT); may require short period of observation in hospital Class 3 Class 4 Require inpatient treatment with parenteral antibiotics Admit to hospital/icu, urgent surgical assessment and treatment with parenteral antibiotics Eron LJ et al. J Antimicrob Chemother 2003; 52 Suppl 1: i3 17.

14 Initial assessment and classification Class 1 Class 2 Class 3 Class 4 Consider observation status Send home on oral antimicrobial therapy OPAT Admit to hospital Discharge Consider oral switch therapy Discontinue antimicrobial therapy

15 Evaluation algorithm for severity of SSTIs Suspected SSTI If Yes Any ONE of the following comorbidities : Chronic liver/renal dx, Vascular indufficiency, Asplenia, Immunocompromise Any ONE of the following symptoms : Temperature < 35 0 C or > 40 0 C, Hypotension, HR >100 beats/min, altered status No No Head and/or hand involvement, or Size of lesion > 9% body surface area No Any ONE of the following signs symptoms : Bullae, Rapidly progressive, Hemorrhage, Crepitus, Severe pain MILD No SEVERE Yes

16 Diagnostic tests Plain radiography: gas or periostal inflammation (DFI) USG: detect abscesses MRI and CT: image fascial planes (Necrotizing fasciitis) Laboratory tests: CRP, WBC, Hb, Creatinin, Na, Glucose (LRINEC)

17 Risk stratification for patients with Diabetic Foot Infections Clinical Manifestation of Infection Infection Severity PEDIS Grade Wound lacking purulence or any manifestations of inflammation Presence of 2 manifestations of inflammation Any cellulitis/ erythema extends 2 cm around the ulcer Infection limited to the skin or superficial subcutaneous tissues No other local complications or systemic illness Patient is systemically well and metabolically stable 1 of the following characteristics : Cellulitis extending > 2 sm Lymphangitic streaking Spread beneath the superficial fascia Deep-tissue abscess Gangrene Involvement of muscle, tendon, joint, or bone Infection in a patient with systemic toxicity or metabolic instability Uninfected 1 Mild 2 Moderate 3 Severe 4 Lipsky BA, Barendt AR, Deery HG, et al. Clin Infect Dis 2004;39: Abbreviation : PEDIS: Perfusion, Extent/size, Depth/tissue loss, Infection, and Sensation

18 Diabetic foot infection Case 1: PEDIS grade 3 Case 2: PEDIS grade 4 with systemic signs (sepsis)

19 Necrotizing Soft Tissue Infections Early presentation of NSTI may not be recognized, with few skin signs Diagnosis should be suspected in patients whose pain and toxicity appear to be out of proportion to clinical findings Diagnosis is based on the clinical picture and should not be delayed while waiting for test results Treatment are resuscitation, aggressive surgical debridement, and empiric broad-spectrum intravenous antibiotics Mortality is high, and increase with delayed diagnosis and treatment

20 Risk factors for Necrotizing Soft Tissue Infections Diabetes mellitus Chronic disease Immunosuppressive drugs Malnutrition Age > 60 years Intravenous drug misuse Peripheral vascular disease Underlying malignancy Obesity

21 Clinical features suggestive severe SSTI : Necrotizing Soft Tissue Infections (NSTI) Skin Pain General Erythematic with ill- Pain that extends past Fever with toxic defines margins margin of apparent infection appearance Tense edema with grayish or brown discharge Severe pain that appears disproportionate to physical finding Altered mental state Tachycardia Lack of lymphangitis or lymphadenopathy Vesicles or bullae, hemorrhagic bullae Necrosis, crepitus Decreased pain or anesthesia at apparent site of infection Early recognition of NSTI or Distinguishing NSTI from other severe SSTIs is often difficult clinically need a diagnostic scoring system based on laboratory tests Tachypnea due to acidosis Presentation with DKA or HHNK DKA-diabetic ketoacidosis, HHNK-hyperosmolar hyperglycemic non-ketotic acidosis Puvanendran R et al Can Fam Physician 2009

22 Laboratory risk indicator for Necrotizing Fasciitis (LRINEC score): Investigation Serum C-reactive protein > 150 mg/l White blood cell count / L / L > / L Hemoglobin g/dl < 11 g/dl Serum sodium < 135 meq/dl Serum creatinine > 1.6 mg/dl {141 mmol/l} Serum glucose > 180 mg/dl {10 mmol/l} Score 4 points 1 point 2 points 1 point 2 points 2 points 2 points 1 point 5 points indicated a low risk (< 50% probability) of NF 6-7 points indicate on intermediate risk (50%-70% probability) of NF 8 points indicate a high risk (>75% probability) of NF Puvanendran R et al Can Fam Physician 2009;55:981-7 Napolitano LMInfect Dis Clin N Am 23 (2009)

23 Terimakasih