Study Notes - Rosen 135 Soft Tissue Infections

Front 1

Define cellulitis.

Back 1

- Soft tissue infection of the skin and subcutaneous tissue

Front 2

What are the hallmark characteristics of cellulitis?

Back 2

Pain
- Erythema
- Swelling- Tenderness
- Local warms

Front 3

What are the most common sites for cellulitis?

Back 3

- Lower extremities
- Upper extremities
- Face

Front 4

What are the most common bugs causative of cellulitis?

Back 4

- Staphylococcus aureus
- Streptococcus pyogenes
- Hemophilus influenza (facial cellulites in children)

Front 5

List risk factors for cellulites.

Back 5

- Lymphedema
- Portal of entry
- Venous insufficiency
- Obesity

Front 6

Are diabetes, alcohol misuse and smoking risk factors for cellulites?

Back 6

- No

Front 7

What is Ludwig’s angina?

Back 7

- Cellulitis of the submandibular spaces bilaterally

Front 8

Why is Ludwig’s angina important to recognize?

Back 8

- Potential for airway and respiratory compromise as the swelling of the floor of the mouth can cause elevation of the tongue and airway obstruction

Front 9

What is the most common cause of Ludwig’s angina?

Back 9

- Local spread of odontogenic infection/oral bacteria (i.e. 2nd and 3rd lower molars)

Front 10

What does fever suggest in the patient with cellulitis?

Back 10

- Associated bacteremia

Front 11

List management steps on cellulites.

Back 11

- Immobilization, Elevation, Heat or warm moist packs (no evidence)
- Antibiotics

Front 12

List options for oral therapy for Soft Tissue infections.

Back 12

Group A Streptococcus

Penicillin V (phenoxymethylpenicillin)250–500 mg qid

First-generation cephalosporin250–500 mg qid

Erythromycin250–500 mg qid

Azithromycin500 mg × 1 dose then 250 mg qd × 4

Clarithromycin500 mg bid

Staphylococcus aureus (not MRSA)

Dicloxacillin125–500 mg qid

Cloxacillin250–500 mg qid

First-generation cephalosporin250–500 mg qid

Erythromycin (variable effectiveness)250–500 mg qid

Azithromycin500 mg × 1 dose then 250 mg qd × 4

Clarithromycin500 mg bid

Clindamycin150–450 mg qid

Amoxicillin/clavulanate875/125 mg bid or

500/125 mg tid

Ciprofloxacin500 mg bid

Haemophilus influenzae

Amoxicillin/clavulanate250–500 mg tid

Cefaclor250–500 mg tid

Trimethoprim (TMP)/sulfamethoxazole160 mg TMP/800 mg

(SMX)SMX bid

Azithromycin500 mg × 1 dose then 250 mg qd × 4

Clarithromycin500 mg bid

Front 13

List indications for admission for cellulitis.

Back 13

Systemic toxicity/sepsis
- Deep infections
- Severe infections involving significant portions of the extremity i.e. hands and feet, head and neck and perineum

Failure of out patient therapy
- Immunocompetence (Diabetes, alcoholics, chemotherapy, steroids, asplenic)

Front 14

What is the venous drainage of the orbital and periorbital tissues?

Back 14

- Venous cavernous sinuses (intracranial)

Front 15

List clinical features of periorbital cellulitis.

Back 15

Swelling of the lid
- Discolouration or orbital skin
- Redness
- Warmth
- Conjunctival injection
- +/- Discharge
- Fever
- Leukocytosis
- Normal vision, EOMS, pupillary findings, and optometric exam

Front 16

What is the most common cause of orbital cellulites?

Back 16

- Sinus infection

Front 17

List clinical features that suggest orbital cellulitis.

Back 17

- Proptosis
- Decreased ocular mobility
- Ocular pain
- Tenderness with eye movement
- Altered vision
- Sharp margin of erythema

Front 18

What is the diagnostic procedure of choice if concerned about orbital cellulites?

Back 18

CT orbits

Front 19

What additional test should be considered in someone with orbital cellulites?

Back 19

- Blood cultures
- Lumbar puncture

Front 20

What are the treatments for periorbital and orbital cellulites?

Back 20

- Periorbital cellulites – Oral antibiotic with close follow up
o Cefuroxime x 2 days then switch to po
- Orbital cellulites – IV antibiotics and admit
o Broad spectrum (

Front 21

List indications for operative management of orbital cellulites.

Back 21

- Failure of IV antibiotics
- Foreign body
- Abscess

Front 22

Compare and contrast orbital cellulitis and preseptal cellulitis

Back 22

Front 23

What is erysipelas?

Back 23

Acute superficial cellulites with sharply demarcated border surrounding skin that is raised, deeply erythematous, indurated, painful

Front 24

What layers are involved in erysipelas?

How do patients with erysipelas appear?

Back 24

- Dermis
- Lymphatics
- Superficial subcutaneous tissue

- Toxic

Front 25

List cause of erysipelas.

Back 25

S pyogenses
- S agalactae
- S dysgalactae-

S aureus
- Psuedomonas
- Enterobactereciae

Front 26

List antibiotics for erysipelas.

Back 26

IV Pen G
Amoxicillin
Macrolides

Cephalosporins
Fluroquinolones

Front 27

Compare and contrast erisypelas and cellulitis

Back 27

CellulitisErysipelas

Tissue Layers involvedExtends into subQ tissueSuperficial, cutaneous

Physical exam features

-Erythema, blanching, flat, poorly demarcated

-Indurated, clearly demarcated, raised

Most likely organism Staph aureus GAS

Specific TxPRP (i.e. ancef/keflex)PCN G

Front 28

What is Staphylococcal Scalded Skin Sydrome (Staphylococcal Epidermal Necrolysis)?

Back 28

Toxin producing staphylococcus aureus
- Toxin acts on zona granulose to produce superficial separation of the skin
- Widespread erythema and blistering
- Bullae and vesicles
- Loss of large sheets of superficial epidermis

Front 29

What are is most affected by staphylococcal scalded skin?

Back 29

- Children 6 month – 6 years

Front 30

Is there mucus membrane involvement in staph scalded skin?

Back 30

- No

Front 31

What is Nikolsky’s sign?

Back 31

Easy separation of the outer portion of the epidermis from the basil layer when pressure is applied
- Staphylococcal scalded skin – positive over areas of lesions and seemingly unaffected skin as well

Front 32

What is the differential for Staphylococcal scalded skin syndrome?

Back 32

Toxic epidermal necrolysis
o Mucus membrane involvement
o History of drug ingestion
o Positive Nikolsky only over lesions
o Unresponsive to antibiotics

Front 33

List criteria for the diagnosis of staphylococcal scalded skin syndrome?

Back 33

1. Clinical pattern of tenderness, erythema, desquamation, or bullae formation
2. Histopathologic evidence of intraepithelial cleavage through the stratum granulosum
3. Isolation of an exforliative exotoxin producing staph aureus
4. The absence of pemphigus foliaceus by immnofluorescens

Front 34

What is the treatment of Staphylococcal scalded skin?

Back 34

- Antistaphylococcal penicillinase resistant peniciilin
- Volume and electrolyte resuscitation

Front 35

How haemophilus influenzae cellulites present?

Back 35

- Child < 5 years
- Cellulitis face > extremities
- Acutely ill
- High fever
- Leukocytosis

Front 36

What are drugs for the treatment of Haemophilus cellulites?

Back 36

- 2nd or 3rd generation cephalosporin
- Amoxicillin-clavulanic acid
- Treatment for 10 – 14days

Front 37

List the criteria for Toxic shock syndrome – this criteria is for staph or strep etiology

Back 37

Fever of 38.9° C (102° F) or higher

Rash (diffuse macular erythema) that resembles the rash of scarlet fever

Desquamation of skin 1 to 2 weeks after onset of disease

Hypotension (systolic blood pressure less than 90 mm Hg, orthostatic drop of 15 mm Hg or more, or orthostatic dizziness of syncope)

Clinical or laboratory abnormalities in at least three organ systems:

Gastrointestinal: nausea and vomiting, diarrhea

Muscular: myalgia or creatine phosphokinase at least two times normal level

Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia

Renal: blood urea nitrogen or creatinine level at least twice normal or pyuria greater than five cells per high-power field

Hepatic: bilirubin, serum transaminases at least twice normal level

Hematologic: thrombocytopenia, <100,000/mm3

Neurologic: disorientation or altered consciousness with-out focal findings

Reasonable evidence for the absence of other cause of illness

Front 38

List criteria for Streptococcal Toxic Shock Syndrome.

Back 38

Must meet criteria from both 1 and 2 below:
1. Isolation of group A Streptococcus from:

a. A normally sterile site such as blood or cerebrospinal fluid is a definite case.

b. A normally nonsterile site such as sputum or skin lesion is a probable case.

2. Hypotension and at least two of the following:

a. Renal impairment

b. Coagulopathy

c. Liver involvement

d. Adult respiratory distress syndrome

e. Generalized erythematous macular rash that may desquamate

f. Soft tissue necrosis such as nec fasc, gangrene, myositis

Front 39

Staph TSS VS strep TSS

Back 39

both are caused by an exotoxin
· Staph TSS – in previously healthy individuals, usually starts with a sunburn-type rash, not very painful, rapidly progresses to shock, MOD, and possible death. Staph found in 90%.
· Strep TSS – usually preceded by a skin infection, have a lot of pain, rapid progression to TSS… essentially like nec fasciitis

Front 40

What common childhood illness may precede streptococcal toxic shock syndrome?

Back 40

- Chicken pox

Front 41

What is the treatment of Streptococcal toxic shock syndrome.

Back 41

- Penicillin and clindamycin
- Erythromycin and clindamycin
- Ceftriaxone and clindamycin
- IVIG
- Supportive care

Front 42

What are the effects of clindamycin in streptococcal toxic shock syndrome.

Back 42

1. More effective killing of strep pyogenes
2. Decrease production of toxin

Front 43

What is impetigo?

Back 43

Superficial infection of the skin caused by GAS > staphylococcus aureus
- Most common cutaneous infection of childhood

Front 44

What are the 2 types of impetigo?

Back 44

· Impetigo contagiosa
o Papules -> vesicles -> rupture -> amber crust
· Bullous Impetigo
o Usually seen in neonates
o 2-5cm bullae, rupture -> varnish like crust remains
o No Nikolsky

Front 45

Can post streptococcal glomerulonephritis follow impetigo?


Does impetigo cause rheumatic fever?

Back 45

- Yes

- No

Front 46

What is a partial DDx for Impetigo?

Back 46

· Infection
o Bullous Impetigo
o Ecthyma
o Herpes Gestationis
· AutoImmune:
o Pemphigus Vulgaris
o Bullous Pemphigoid
o Dermatitis Herpetiformis
o Paraneoplastic Pemphigus
o Cicatricial Pemphigoid (Scarring Pemphigoid)
o Dermatitis Herpetiformis
o Linear IgA Dermatosis (LAD)
o Chronic Bullous Disease of Childhood (CBDC)
o Epidermolysis Bullosa Acquisita (rare)
o Systemic Lupus Erythematosus
· Other Bullous Conditions
o Bullae in Diabetes Mellitus

Front 47

List treatments for impetigo?

Back 47

- Mupirocin ointment 2%
- Erythromyicn
- 1st generation cephalosporins
- Clindamycin

Front 48

Define abscess.

Back 48

- Localized collection of pus resulting in a painful fluctuant soft tissue mass surrounded by firm granulation tissue and erythema

Front 49

List anatomic location common for abscesses.

Back 49

Head and neck
- Axillae
- Extremities

- Perirectal area
- Inguinal area

Front 50

When is the loose packing removed?

Back 50

- 48 hours (24 hours incosmetically important areas)

Front 51

What is the management of a Bartholin Cyst Abscess?

Back 51

I and D and placement of a Word catheter
- Left in place for 4 – 6 weeks
- Sitz baths
- Marsupialization if failure of Word catheter

Front 52

Back 52

a- Levator ani
b- Ischial tuberosity
c- Abal crypts
1- Perirectal abscess (and fistula)
2- Isciorecal abscess
3- Supralevator abscess
4- Intersphincteric abscess

Provide and table of perirectal abscess and where I and D should occur in an otherwise health stable patient.

PerianalI and D in Emergency department

IsciorectalAttempted I and D in ED

SuprealevatorOR I and D

InterspinctericOR I and D

Front 53

Where do pilonidal abscesses occur?

Back 53

- Gluteal fold over coccyx

Front 54

What is a Furuncle?

Back 54

· “boil” – superficial folliculitis that leads to an abcess. Below are multiple furuncles. Tx – I&D

Front 55

What is a carbuncle?

Back 55

· Large boil – result of multiple furuncles coalescing

Front 56

What is hiradenitis suppurativa?

Back 56

· Chronic suppurative abscesses in the apocrine sweat glands
· Usually young adults, females > males, african Americans
· Axilla, groin, perianal area
· Tx: I&D, surgical excision and graft if extensive

Front 57

NECROTIZING FASCIITIS

Back 57

· Pain is out of proportion to physical findings; may have numbness
· Predisposing factors: DM, PVD, cirrhosis, chronic steroids, other immunocompromised states

Front 58

List layers of tissue involved in fasciitis.

Back 58

- Fascia
- Subcutaneous tissue
- Skin

Front 59

List risk factors for fasciitis.

Back 59

- Diabetes
- PVD
- Trauma
- Recent surgery

Front 60

List treatments for fasciitis?

Back 60

- Fluid resuscitation
- Parenteral antibiotics
- Surgical I and D

Front 61

What are the two type of necrotizing fasciitis?

Back 61

- Type 1 – Polymicrobial – Nongroup A strep and anaerobes
- Type 2 – Group A B Hemolytic streptococcus

Front 62

List specific fasciitis syndrome.

Back 62

- Meleney’s synergistic gangrene (Progressive synergistic gangrene)
o Superficial and deep fascial planes
o Thrombosis of subcutaneous vessels and gangrene of tissues

- Clostridial gangrene (anaerobic cellulites, local gas gangrene)
o Gas forming infection of skin and subcutaneous tissue spreads through intrafascial planes

- Nonclostridial crepitant cellulites
o Polymicrobial (e coli, Klebsiella, Enterobacter, Peptostreptococcus, B fragilis)

- Fournier’s syndrome
o Insidious necrotizing subcutaneous infection of the perineum, penis and scrotum
o Men 20 – 50 years old

Front 63

List myonecrosis syndromes.

Back 63

- Clostridial myonecrosis (gas gangrene)
- Nonclostridial myonecrosis
- Synergistic necrotizing cellulites