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126-1
SKIN AND SOFT TISSUE
INFECTION (SSTI)
A Pain in the Butt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level II
CASE SUMMARY
A 19-year-old college student presents to the ED with a new-onset
“boil” on his right buttock. This boil is secondary to sports-related
trauma. He was seen at the student health center, where his wound
was cleaned and he was given a prescription for clindamycin
300 mg PO QID (PCN allergy). He was nonadherent to the
clindamycin due to nausea and the QID schedule. About a week
later, he returned to the student health center and was ultimately
sent to the ED for further evaluation and treatment of his continued
skin and soft tissue infection (SSTI). At the ED, he had the abscess
area drained via incision and drainage (I&D) and was sent home
with wound care instructions only.
He returned to the ED 8 days later with a recurrent boil in the
same area. He is afebrile (37.7°C); all vital signs are stable and
a second I&D was performed. The fluid from the second I&D was
sent for culture and sensitivity; he had his nares and groin areas
swabbed for methicillin-resistant Staphylococcus aureus (MRSA)
and blood cultures drawn, all of which are pending. The MRI of the
gluteal area was negative for signs of deep tissue infection, and it
was determined that the patient did not need to be admitted; however, an antibiotic was warranted in this recurrent infection case.
The patient was considered to have a purulent SSTI, with the most
likely organism being S. aureus and methicillin-resistant S. aureus
(MRSA) as the predominant pathogen on the first episode. Since the
patient presented with a mild SSTI I&D alone can be considered an
appropriate treatment regimen (studies and discussion below). On
recurrence, it is assumed that it is again S. aureus and methicillinresistant S. aureus (MRSA) that was reintroduced into the wound,
from either improper hygiene or organism colonization of the skin.
The wound was again drained and all the appropriate cultures were
drawn, and the clinical condition of the patient (afebrile with no
extension of the infection outside of the local area) would now be
considered a moderate infection and would still necessitate only
outpatient treatment; however, an oral antibiotic should be recommended in addition to the I&D for treatment and eradication of
the organism.
The reader(s) should discuss the relative value of minimally
invasive surgical interventions (I&D) and antibiotic therapy at the
time of initial presentation, as well as consider nonpharmacologic
strategies for the treatment of a purulent SSTI. Furthermore, the
same discussion should be repeated after reviewing the Casebook
section “Clinical Course” in this case, but the focus should be more
on the value of antibiotic management, the treatment options, and
follow-up evaluation of the culture data (particularly the fluid).
In addition, the reader(s) should discuss different decolonization
strategies for nares and/or groin positive MRSA swabs (screens) for
this patient case.
Problem Identification
1.a. Classify this patient’s SSTI as purulent or nonpurulent and
either: mild, moderate, or severe.
Classification of SSTI:
• Purulent SSTI:
✓Cutaneous abscesses are collections of pus in the dermal
layer any beyond.1
✓Furuncles are infections surrounding the hair follicle in
which pus can extend to the subcutaneous tissue and
typically result in a relatively small abscess, where a small
abscess forms.1
✓Carbuncles are larger than furuncles in which a collection of
adjacent hair follicles become infected and the fluid collections merge together to form a large abscess.1
• Nonpurulent SSTI:
✓ Infections that do not have any associated pus; (ie, infections
where there is a focal fluid collection and surrounding erythema, often called cellulitis, would be considered purulent).
✓Cellulitis is a diffuse spreading infection of the dermis and
beyond that is red, warm and tender with no definitive
border.1,2
✓Erysipelas is similar in presentation to cellulitis, and is most
commonly associated with the face only, but has a well
demarcated border.1,2
✓Cellulitis and erysipelas are synonymous in some literature.1
• Mild
✓The absence of systemic signs of infection1
• Moderate1
✓The presence of systemic signs of infection, but not otherwise clinically stable and not meeting the severe critieria.1
• Severe purulent infections1
✓ Failed incision and drainage plus oral antibiotics or the presence systemic signs of infection such as: temperature >38°C,
tachycardia (heart rate >90 bpm), tachypnea (respiratory
rate >24 breaths per minute) or abnormal white blood cell
count (>12,000 cells/mm3 or <4000 cells/mm3 or immunocompromised patients).1
• Severe nonpurulent infections1:
✓Failed oral antibiotic treatment or the presence systemic
signs of infection (defined above), or immunocompromised,
or those with deeper tissue involvement as evidenced by:
bullae, skin sloughing, hypotension, or organ dysfunction.1
The classification of Jimmie’s cellulitis at his initial presentation
to student health would be considered mild and there is insufficient
evidence to know if purulence was present. His return to the student
health center and referral to the ED due to the lack of response to
oral clindamycin is driven by his noncompliance and the development of a purulent infection (which could have been present
initially) would indicate the need for I&D (which is considered a
standard of care), and should not escalate diagnosis. The severity of
Jimmie’s purulent SSTI would be classified as mild (no true systemic
manifestations). Keep in mind his infection has not been adequately
treated until he received the initial I&D in the ED.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Skin and Soft Tissue Infection (SSTI)
Jarrett R. Amsden, PharmD, BCPS
QUESTIONS
CHAPTER 126
126
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SECTION 16
1.b.What subjective and objective clinical data are consistent
with the diagnosis of purulent SSTI?
• Pain, irritation, and swelling in right gluteal area secondary to
a trauma.
• Right gluteal area: red, erythematous, warm, and tender to
touch; localized fluid collection that appears fluctuant, consistent with a carbuncle and surrounding erythema.
• Large 2 × 4 cm red swollen area over the right buttock, a localized fluid collection and surrounding erythema.
Infectious Diseases
• Low-grade temperature (37.5°C [99.5°F]).
• White blood cell (WBC) 11.3 × 103/mm3 (slightly elevated, but
not meeting the definition of systemic sign of infection).
1.c. What are the most common causative organisms of a purulent vs nonpurulent SSTI?
• Purulent SSTI:
✓Methicillin-sensitive S. aureus (MSSA) or methicillin-resistant
S. aureus (MRSA) (in particular, the community-associated
MRSA (CA-MRSA) phenotype: retains susceptibility to
trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline
or minocycline, and sometimes clindamycin).1,2
• Nonpurulent SSTI:
✓Group A (β-hemolytic) streptococci (Streptococcus pyogenes); less common streptococci are groups B, C, and G
(sources unclear, but are typically seen in domestic nonhuman animal species (horses, dogs, etc.).2
✓Methicillin-sensitive S. aureus (MSSA) for moderate and
severe infections.
Desired Outcome
2.a. What are the goals of nonpharmacologic management of
this patient’s SSTI?
• Drainage or incision and drainage (I&D) of the wound is
imperative. (If there is fluid, drain it!)
• Reduce pain, swelling, and erythema in the right buttock to
relieve pain associated with sitting and allow the patient to
attend class.
• Dress the wound to prevent tearing or continual opening of
the wound as well as reinfecting or reinoculating the wound.
• Reduce temperature (while not febrile, the patient does report
febrile episodes).
2.b. What are the goals of pharmacotherapy for the treatment of
this patient’s SSTI?
• With the initial presentation to the ED, I&D alone (no additional antibiotic therapy) is sufficient since the patient would
be categorized as mild.
• Drain the abscess—the Infectious Diseases Society of America
(IDSA) guidelines for the treatment of skin and soft tissue
infections1 and MRSA3 recommend I&D for all purulent
abscesses, if amenable to this intervention.
• Reduce temperature (while not febrile, the patient does report
febrile episodes).
• Restore patient’s activities of daily living and attendance of
classes.
Therapeutic Alternatives
3.a. Create a list of nonpharmacologic treatment or supportive
options for this patient in the treatment of SSTI.
• Purulent SSTIs, that are not drained or nonpurulent SSTIs:
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
✓In mild-to-moderate and even severe cases, the patient may
benefit from cool sterile saline dressings initially to reduce
pain, followed by warm, moist heat to aid in localization and
allow spontaneous drainage.1,2
✓Elevation and immobilization may reduce the edema and
swelling; however, in this case, given the location, elevation
and immobilization are not likely to be feasible. Reduced
pressure (load bearing) on the buttock area would also be
beneficial.
✓Local wound care is typically not necessary unless there is
exudate.
• Drainage or incision and drainage [I&D] of furuncles and
carbuncles:
✓ In all types of purulent cellulitis, adequate drainage (I&D) of
the fluid collection is considered the standard of care.1–3 For
smaller fluid collections, application of warm compresses to
induce spontaneous drainage is recommended.1–3 For larger
fluid collections, I&D of the wound should be employed
if these are in areas easily accessed.1–4 This is generally not
necessary or possible in typical uncomplicated cellulitis
cases (no fluid focus to be drained),1 but is more commonly
encountered in MRSA SSTIs.1–4
✓Topical wound care with dry, gauze dressings are typically
adequate and less expensive; occlusive dressings can also
be considered but are usually more expensive and were not
associated with improved healing after surgery.
✓Topical dressings also provide a protective barrier
against reinoculation or reintroduction of the infective
organism(s).1,2
✓The addition of topical antimicrobial therapy (eg, silver sulfadiazine, povidone–iodine) may also be considered, but is
not required.
• MRSA infections are prevalent in patients who are otherwise
healthy.2,4 These infections are usually purulent and should be
drained if possible.1–4 Of note, MRSA lesions may present as
a “boil,” cutaneous abscess, furuncle or carbuncle that can be
progressive and move from site to site. In such cases, surgical
debridement is required for successful outcomes.1–4
3.b.What feasible oral antimicrobial options are available for
the treatment of purulent and nonpurulent SSTIs?
• As highlighted above (see the section “Problem Identification”),
the most common pathogens in cases of purulent SSTIs are
S. aureus, both methicillin-sensitive and methicillin-resistant.1
As severity and patient complexity increases, other less commonly associated pathogens include other gram-positive (+)
cocci, some gram-negative (–) bacilli, and anaerobes. The latter
organisms are often found in specific patient populations (ie,
diabetes mellitus or immunocompromised) or necrotizing and
hospital-acquired cases of SSTIs.1,2
• The treatment of purulent infections with antibiotics (active
against MRSA) is controversial.1–3 Some believe simple surgical
drainage is adequate, while others believe I&D + antimicrobial
therapy is necessary. The IDSA guidelines for the treatment of
skin and soft tissue infections and MRSA1,3 recommend antibiotic therapy in addition to I&D when the following conditions
are present:
✓Severe or extensive disease (multisite) or rapid progression
in the presence of associated SSTI
✓Presence of systemic signs and symptoms
✓
Presence of
medications
immunosuppressive
comorbidities
or
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✓Multiple abscesses or those in a difficult area to drain
✓Associated septic phlebitis
Empiric antibiotic selection:
• Mild purulent SSTIs
✓Trimethoprim–sulfamethoxazole (TMP-SMX) 1–2 double
strength (DS) tablets PO BID
• Due to the limited clinical data with TMP-SMX in the treatment
of streptococci, current guidelines suggest adding a beta-lactam
to TMP-SMX when both streptococci and MRSA are suspected;
however, in nonpurulent infections the beta-lactam alone would
be sufficient.1
• Of note, the use of TMP-SMX 2 DS tablets (high dose) was
largely utilized due to the reduced activity against streptococci.
Stein and colleagues5 demonstrated excellent tissue concentrations and subsequent bactericidal activity against both S. aureus
and Group A (β-hemolytic) streptococci with both 1 and 2 DS
tablet doses.
✓Doxycycline 100 mg PO BID
• Due to the limited clinical data with doxycycline in the treatment
of streptococci, current guidelines suggest adding a beta-lactam
to doxycycline when both streptococci and MRSA are suspected;
however, in nonpurulent infections the beta-lactam alone would
be sufficient.1
✓All the empiric antibiotic choices listed above would be considered appropriate for penicillin allergic patients
• Mild nonpurulent SSTIs
✓In patients with a nonimmediate or nonanaphylactic penicillin allergy, cephalexin may be the first alternative.1,2
✓In cases of true penicillin allergy (immediate or anaphylaxis),
clindamycin is recommended.1,2
✓Clindamycin 300–450 mg PO TID-QID; doses >450 mg TID
are often not tolerated due to N/V.
Organism-specific antimicrobial selection:
• S. pyogenes:1–2
✓Mild:
■■ Penicillin VK 250–500 mg PO QID
■■ Amoxicillin 500 mg PO TID
• Methicillin-sensitive S. aureus (MSSA):1–2
✓Mild
■■ Dicloxacillin 250–500 mg PO QID
■■ Cephalexin 500 mg PO TID–QID
• MRSA:1–4
✓Mild:
■■ Trimethoprim–sulfamethoxazole one to two DS tablets
PO BID
■■ Doxycycline 100 mg PO BID
■■ Minocycline 100 mg PO BID
■■ Linezolid 600 mg PO BID—most expensive option
■■ Clindamycin 300–450 mg PO TID-QID: doses >450 mg
TID are often not tolerated due to N/V
✓Minocycline 100 mg PO BID
✓Linezolid 600 mg PO BID
✓Clindamycin 300–450 mg PO TID-QID; doses >450 mg TID
are often not tolerated due nausea and vomiting (N/V)
• MRSA strains have demonstrated increasing resistance to
clindamycin (geographically variable), particularly in adults
(~50% resistant).
• In all cases, culture and susceptibility results should be followedup on and antibiotic therapy should be tailored to these results.
The process for this follow-up is often sporadic and pharmacists
(particularly those in the ED) can aid in making sure patients get
the most appropriate antibiotic therapy based upon culture and
susceptibility results.
• Mild nonpurulent SSTIs:
or
first-generation
■■ Dicloxacillin 500 mg PO QID
■■ Cephalexin 500 mg PO TID–QID
■■ Cefadroxil 0.5–1 g BID (can be used in place of cephalexin)
• Both dicloxacillin and cephalexin have activity against the
primary gram-positive pathogens (Group A (β-hemolytic)
streptococci (Streptococcus pyogenes) and methicillin-sensitive
S. aureus).1–3
• For mild nonpurulent SSTIs dicloxacillin is considered the
first-line antimicrobial agent due to the robust amount of literature. However, cephalexin regimen may be more conducive
✓MRSA strains have demonstrated increasing resistance to
clindamycin (geographically variable), particularly in adults
(~50% resistant).
✓In all cases, culture and susceptibility results should be
followed-up on and antibiotic therapy should be tailored to
these results. The process for this follow-up is often sporadic
and pharmacists (particularly those in the ED) can aid in
making sure patients get the most appropriate antibiotic
therapy based upon culture and susceptibility results.
• Anaerobes:2
✓ In Jimmie’s case we would not have any suspicion for anaerobic organisms, but these were included to make the potential
discussion complete.
✓In cases where anaerobes are thought to be potential causative pathogens, antibiotic classes listed as follows have good
anaerobic activity without adding additional agents such as
metronidazole or clindamycin.
• β-Lactam + β-lactam inhibitor combinations (ie, amoxicillin/
clavulanate)
✓In cases where anaerobes are thought to be potential causative pathogens, the following agents should have metronidazole or clindamycin added.
• β-Lactams alone
✓Clinical pearl: Above the diaphragm (noncentral nervous
system [CNS])
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Skin and Soft Tissue Infection (SSTI)
• Jimmie’s infection could arguably be considered progressive,
but his continued infection has not been adequately treated
due to noncompliance with clindamycin and he has not had a
surgical intervention until his presentation to the ED. He also
displays some precursor systemic signs and symptoms of infection, but again his infection is just being adequately treated for
the first time in the ED and he is otherwise clinically stable.
penicillin
Penicillin allergy:
• Mild purulent SSTIs
✓Lack of response to I&D alone
✓
Penicillinase-resistant
cephalosporin1–3:
to promoting adherence and has been demonstrated to be
effective.3
CHAPTER 126
✓Extremes of age
126-4
• Clindamycin 300–450 mg PO TID–QID
SECTION 16
✓Clinical pearl: Below the diaphragm or CNS
• Metronidazole 500 mg PO TID–QID
Optimal Plan
4.a.What is the most appropriate treatment course for this
patient (pharmacologic vs nonpharmacologic)?
Infectious Diseases
• Surgical debridement I&D is considered the standard of care
for any large focal area of fluid collection on the skin (carbuncles and furuncles, often called “boils”) and is necessary
for this patient.1–4
• The addition of antibiotics to surgical debridement (I&D)
is controversial. In studies, the cure rates of surgery alone
exceeded 85% irrespective of active or any antibiotic therapy. In
this case, the absence of systemic symptoms and lack of extensive cellulitis would make surgical debridement an adequate
single therapy option.6,7
• The treatment of purulent infections with antibiotics (active
against MRSA) is controversial.1–3 Some believe simple surgical
drainage is adequate, while others believe I&D + antimicrobial
therapy is necessary. The IDSA guidelines for the treatment of
skin and soft tissue infections and MRSA1,3 recommend antibiotic therapy in addition to I&D when the following conditions
are present: (refer to Question 3.b).
4.b.What antimicrobial agent (or agents), dosage form, dose,
schedule, and duration of therapy are best for this patient?
• According to the IDSA guidelines for the treatment of skin and
soft tissue infections and MRSA,1,3 Jimmie would be an ideal
patient to undergo I&D alone. However, you could make an
argument for progression of his infection or some precursor
signs of systemic manifestations that could warrant the addition of antibiotics. If antibiotics were added after the I&D:
✓Trimethoprim–sulfamethoxazole one to two DS tablets PO
BID
✓Doxycycline 100 mg PO BID
✓Minocycline 100 mg PO BID
✓Linezolid 600 mg PO BID
✓Clindamycin 300–450 mg PO TID-QID
• This could still be a viable treatment option, but Jimmie has
already reported noncompliance with this regimen due to its
frequency and N/V.1
Treatment duration:
• Mild purulent SSTI (for this patient case):
✓Five day duration is the minimum, but treatment can be
extended if the SSTI has not improved by day 5 (5–10 days
pending clinical response)1–3
4.c. Was drainage or I&D alone an appropriate management
strategy for the initial presentation of this patient case?
• Surgical debridement (I&D) is considered the standard of care
for any large focal area of fluid collection on the skin (carbuncles and furuncles, often called “boils”).1–3 At Jimmie’s first
presentation to the ED, I&D alone was a reasonable treatment
option. Now that Jimmie is returning with a recurrent purulent
SSTI, despite I&D, antibiotics in addition to a repeated I&D are
warranted.1–2
4.d. Based on the above information, the patient has failed oral
clindamycin (arguably) and an initial I&D. Does this patient
need antibiotic therapy in addition to the second I&D and if
so, what antimicrobial regimen would you now recommend
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
for this patient? (Please specify dose, schedule, and duration
of therapy.)
• Antibiotic therapy in addition to a repeat I&D is recommended
after lack of response to an initial I&D alone.1 Other criteria
also warrant the addition of antibiotic therapy after I&D (refer
to Question 3.b).
• Acceptable antibiotics should target MRSA and any of the
following would be acceptable; however, trimethoprim–
sulfamethoxazole (Bactrim) has routinely been the most active
antibiotic to date.1–4
✓Trimethoprim–sulfamethoxazole one to two DS tablets PO
BID
✓Doxycycline 100 mg PO BID
✓Minocycline 100 mg PO BID
✓Clindamycin 300–450 mg PO TID–QID
✓Linezolid 600 mg PO BID
• In all cases, culture and susceptibility results should be followed-up on and antibiotic therapy should be tailored to these
results. The process for this follow-up is often sporadic and
pharmacists (particularly those in the ED) can aid in making
sure patients get the most appropriate antibiotic therapy based
upon culture and susceptibility results.
Treatment duration:
• Mild or possibly moderate purulent (or recurrent) SSTI (for
this patient case):
✓Five to 10 days (pending clinical response)1,2
4.e.What are some nonpharmacologic (focus on hygiene or
environmental) measures (outside of proper local/wound
care) you could recommend for Jimmie to use at home/
school/in the locker room?
• The spread of MRSA is common to athletes, other individuals
who share common environments (jails and military quarters),
household contacts, intravenous drug users (IVDU), and
men who have sex with men (MSM).1,4,8 The most common
method by which MRSA causes infection is via the skin; thus,
breaks in the skin barrier (athlete’s foot, in Jimmie’s case) are
often the entry point for infection. The spread of MRSA is
attributed to its colonization of the nares, but also its prevalence in non-nasal sites such as the axilla, groin, and rectal
areas.8 To further aid its spread from person to person, MRSA
is known to contaminate solid surfaces, towels, razors, and
other commonly touched site/objects (collectively referred to
as fomites).8 Taken together, these risk factors and exposures
have made it relatively easy for MRSA to become an epidemic.8
• To educate the public on the risk factors for MRSA, the five
“Cs” were created: (1) contact (direct skin–skin contact);
(2) cleanliness; (3) compromised skin integrity; (4) contaminated objects, surfaces, and items; and (5) crowded living conditions.9 Thus, measures to control each aspect of these risk
factors are recommended for the prevention and spread of
MRSA. For athletes in particular, the following recommendations were made9:
1. First aid training.
2. Encourage good hygiene.
a. Hand washing after communal surface contact and
person-to-person contact
b. Showering after activities
3. Clean and cover all skin wounds, scrapes, and other injuries
where the skin is not intact.
126-5
b. Encourage athletes to report such injuries.
c. Consider treating any cases of athlete’s foot to reduce
potential portals of entry.
4. Do not share towels or personal items; routinely clean mats,
equipment, communal showers/baths/whirlpools, etc.
• Jimmie, specifically, should be encouraged to:
1. Take the full course of his antibiotic.
2. Practice good hand washing before and after his wound
care.
3. Use antimicrobial soaps/detergents and good hand washing
in all instances.
4. Wash towels, sheets, and clothing in hot water cycles.
5. Not share or use anyone else’s personal hygiene items or
communal hygiene items.
6. Wipe down all communal surfaces with antibacterial products or diluted bleach products (counters, phones, doorknobs, remote controls, and gaming consoles).
7. Bring attention of his wound to his coach for proper environmental decontamination and limit contact with other
players as necessary.
4.f. What decolonization measures could be considered for Jimmie, if his nares and/or groin culture(s) is/are positive for
MRSA? (Please discuss the relative options for both, if you
would treat them differently.)
• Decolonization of everyone is impractical and not recommended. However, decolonization of selected patients with
recurrent MRSA infections or a closely defined group of
patients (household contacts, athletic teams, etc.) may be of
value.1,2 Strategies to decolonize patients have ranged from
topical methods to the use of systemic antibiotics. Each
modality has its pros and cons, but all have been associated
with reducing the recurrence of MRSA infections in some
manner.10 The most commonly employed method consists of
two therapies: (1) topical mupirocin (Bactroban) locally to the
nares; (2) chlorhexidine 4% scrub to the entire body. While
only mupirocin is FDA indicated for MRSA decolonization,
the use of both modalities has been the most successful at
reducing MRSA recurrences or infections.10 Other methods
have been utilized successfully, but the use of mupirocin to
the nares and chlorhexidine scrub to the entire body is the
consensus recommendation from an expert panel for recurrent infections or close contact outbreaks.1,8 Mupirocin ointment to the nares would be the best agent for decolonizing a
person with a positive nasal swab; however, this alone has been
associated with failure because MRSA does not solely colonize
the nares.10 Likewise, the use of only the chlorhexidine scrub
for any non-nares swab culture (groin in this case) would not
be considered optimal given that up to 30% of patients may
have MRSA colonization of their nares. Given the propensity
for MRSA to colonize many distinct body sites, a multifaceted
approach to decolonization makes the most sense for patients
with recurrent infections or close contact outbreaks, even if
only one swab culture is positive.1,3,10
Case readers may refer to McConeghy et al.10 for a complete
list of potential decolonizing agents.
5.What clinical and laboratory parameters are necessary to evaluate the therapy for its effectiveness in treating this patient’s
SSTI?
• Monitor for decreased pain, inflammation, and redness in
right gluteal area as well as ability to perform ADLs, such as
attending class.
• Monitoring patient-reported symptoms would be appropriate. Provide the patient with a thermometer to aid in truly
discerning a febrile episode. (Keeping a detailed diary of any
recurrent episodes could be considered, although not likely in
this patient case.)
• Check culture and sensitivity results so that empiric antibiotics can be tailored to the organism(s) causing the infection,
if necessary. It is likely that any of the four primary agents
(trimethoprim–sulfamethoxazole, doxycycline, minocycline,
or linezolid) should be active in the majority of MRSA cases.
Clindamycin would not be wise given the patient’s report of
intolerance (nausea and vomiting).
• Initiate proper wound care and dressing changes as needed,
and take adequate measures to keep the wound area covered
and protected until the skin is fully healed and intact.
• Some sort of medical follow-up should be considered. This
could be done through the student health center, a primary
care appointment, or a team physician.
Patient Education
6.What information should be provided to the patient to ensure
successful therapy?
Mr Chipwood, since you have had multiple infections and they
required surgical care, you are going to need to know how to care
for these wounds so that they heal properly.
• The wounds need to remain dry and sterile using local wound
care as prescribed.
• You are going to have to change the bandages twice daily. Please
be sure to wash your hands prior to caring for the wound in any
way and also afterwards to prevent the spread of the organism.
• The physician has prescribed trimethoprim–sulfamethoxazole,
one DS tablets twice daily. The key to this therapy is that you
must take it twice daily at the same time each day, and it is
extremely important that you do not miss any doses.
• If you experience changes in your urination habits (going more
frequently, hard to start, or changes in color), this can be a sign
of an adverse reaction in the kidney and you should contact
your physician or go to the emergency room if this occurs. This
is a rare but serious effect. You should drink plenty of water
with each dose of this medication and throughout the day.
• Also, since you are an athlete and will be outside for sporting
events, you should wear protective sunscreen with at least a
sun protection factor (SPF) of 30 or higher. This medication
can make you more susceptible to sunburns, so sunscreen is
recommended.
• You are going to need a follow-up appointment near the end
of completion of your antibiotic course to ensure you are
making good progress and so we may determine whether antibiotics can be safely stopped. This appointment will be made
through the student health center, and here is the appointment
reminder card.
• It is also very important to take the proper steps to reduce
your skin colonization and nose colonization with MRSA.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Skin and Soft Tissue Infection (SSTI)
5. Communal living conditions are an environment for spread.
While these cannot be eliminated, better focused attention
to the hygiene of the individuals and environment can minimize risk for acquisition and/or spread of infection.
Outcome Evaluation
CHAPTER 126
a. Exclude athletes from activities while infectious wounds
are open.
126-6
SECTION 16
Infectious Diseases
This is typically not detrimental and will go away with time,
but since you have had a second bout with this same problem
we are going to ensure we “decolonize” you appropriately. You
have a prescription for nasal Bactroban. You will need to apply
this ointment with a Q-tip (cotton swab) into each nostril of
your nose twice daily for 5 days. You will need to make sure
to get the ointment as far up into your nose as possible. It will
possibly hurt and make your eyes water, but this is normal and
can be a good sign you are getting deeper into the nostril. Do
not force the Q-tip too far to cause excessive pain or bleeding,
as this is not optimal. A second measure we recommend you
take is to bath in a chlorhexidine scrub (Hibiclens) at least
three times per week, preferably daily until the scrub is gone.
This scrub could cause a burning sensation in your wound
area, but this should be only minimal and limited. Ideally, you
should keep your wound covered during bathing to promote
adequate healing. These two methods will help ensure that
your skin is free of the germ and that your wound will not
become reinfected.
• A final measure will be to employ some enhanced hygiene
measures while your wound is open. These include washing all
sheets, bed linens, towels, and any other linens in a hot cycle
(>120°F) before using again. This should be done each time the
item is washed. Second, you should disinfect all your surfaces
of your room, bathroom, and other living and showering quarters with a diluted bleach solution (one teaspoon per gallon of
water) or an antibacterial cleanser. This cleansing should also
include doorknobs, razors, phone receivers, remote controls,
gaming consoles, and other items or areas that are commonly
touched. These steps will ensure your living conditions are also
decolonized.
• All of these measures may seem cumbersome, but these are
the necessary steps needed to prevent your infection from
recurring. It would also be advisable to discuss procedures for
the cleaning of your facilities with your coach to prevent any
further infections to you or your teammates.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
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