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skin & soft tissue infection

Differential diagnosis: - cellulitis - infection involves deeper dermis & subcutaneous fat - often on legs - borders less distinct than erysipelas - erysipelas - infection of group A Streptococcus (beta-hemolytic Streptococcus) - very red erythematous skin lesion often on face - very distinct elevated borders - impetigo - infection of group A Streptococcus or Staphylococcus - honey colored, crusted pustules - Vibrio vulnificus - exposure to saltwater fish or shellfish in patients with cirrhosis - cellulitis, hemorrhagic bullae, sepsis - Mycobacterium marinum - exposure to fish tanks or marine environments - chronic nodular infection of distal extremities - Sporotrichosis - exposure to plants, thorns &/or soil - chronic nodular infection of distal extremities - Capnocytophaga canimorsus - dog bite in a patient with asplenia - sepsis - necrotizing fasciitis, myonecrosis - deep tissue infection, surgical emergency - swelling, erythema - pain out of proportion to physical examination - subcutaneous abscess - Staphylococcus aureus - acute, tender, well delineated purulent papular lesion (abscess) - folliculitis - due to Staohylococcus aureus - pustules, follicle-centered in beard, axillae, pubic areas & thighs - due to Pseudomonas aeruginosa - associated with hot tub or whirlpool exposure - erythematous papules & pustules, follicle-centered on trunk, axillae & buttocks Management: - non-purulent cellulitis or erysipelas - no signs of systemic infection - oral penicillin, amoxicillin, cephalexin, dicloxacillin or clindamycin - signs of systemic infection - intravenous penicillin, ceftriaxone, cefazoline, clindamycin - purulent cellulitis - mild-moderate, no signs of systemic infection - oral trimethoprim/sulfamethoxazole or doxycycline - extensive infection or signs of systemic infection - vancomycin (IV) or linezolid (oral/IV), daptomycin, telavancin, ceftaroline - treat risk factors for recurrent cellulitis - lymphedema, Tinea pedis, chronic venous insufficiency - impetigo - limited disease: topical mupirocin - more extensive disease: treat as non-purulent cellulitis - folliculitis - Staphylococcus or Pseudomonas - spontaneous resolution more common than not - topical mupirocin, clindamycin, retapamulin - human bites - clenched fist injury - prophylactic amoxicillin clavulanate - ampicillin sulbactam IV for infected wounds - animal bites (without systemic symptoms) - amoxicillin clavulanate - necrotizing fasciitis, myonecrosis, purple bullae or sloughing of skin - magnetic resonance imaging for necrotizing fasciitis or myonecrosis - surgical debridement - vancomycin + piperacillin tazobactam, imipenem or meropenem + clindamycin - abscess, furuncle, carbuncle - primary treatment is incision & drainage - obtain gram stain prior to administration of antibiotics (if administered) - skin abscess may have higher rate of cure if incision & drainage is accompanied by antibiotic treatment with coverage for MRSA [1]

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skin infection soft tissue infection

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Silverberg B. A Structured Approach to Skin and Soft Tissue Infections (SSTIs) in an Ambulatory Setting. Clin Pract. 2021 Feb 1;11(1):65-74. PMID: 33535501 PMCID: PMC7931029 Free PMC article. Review.