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ID Exam 4 C
Beck SSTI
| Question | Answer |
|---|---|
| What is step 1 for SSTI treatment? | Determine if SSTI is purulent or non-purulent *purulent (pus or no pus) |
| What are the 2 types of Non-Purulent SSTIs? | Erysipelas; Cellulitis |
| Non-Purulent SSTIs: Erysipelas is? | Upper part of the dermis; redness is raised above surrounding skin; Clear line of demarcation b/w tissue involved and no-involved; *More superficial |
| Non-purulent SSTIs: Cellulitis is? | Extends deeper into dermis, sometimes with involvement w. the subcutaneous fat *More dermis and fat |
| A skin abscess is a ________ __ ______within the dermis or subcutaneous space | collection of pus |
| What is Step 2 for SSTI treatment? | Assess the severity of the infection *Step 2 is important b/c if you get the severity wrong, your next step, which is going to be looking at pathogens will DIFFER. So just like CAP, depending on severity, pathogen list changes. |
| Looking at the severity of SSTI: in MILD, systemic signs are ______ | ABSENT; Cellulitis/Erysipelas: Typical presentation WITHOUT focus of purulence |
| Looking at the severity of SSTI: in MODERATE, systemic signs are ______ | PRESENT; Cellulitis/Erysipelas: Typical presentation WITH systemic signs of infection present |
| Looking at the severity of SSTI: in SEVERE, systemic signs are ______ | PRESENT PLUS Any one of the following: Immunocompromised (HIV, Transplant meds, pregnancy, cancer, chronic steroid use), failed oral abx; signs of deeper infection (fluid filled blisters, skin sloughing (peeling off); Hypotension or evidence of organ dysfunction (such as sepsis or septic shock) |
| IN SSTI treatment, when systemic signs are present or absent, what do these signs include? | Temperature > 100.4 F; HR > 90bpm; RR > 24 BPM; WBC > 12 or <4 |
| Diagnostic tools to help diagnose NON-purulent SSTI: Cultures (blood, biopsies, swabs) are NOT routinely recommended in erysipelas or cellulitis EXCEPT in: | 1. Pt with cancer actively going through chemotherapy; 2. Pt with neutropenia (low neutrophils, like less than 1); 3. SSTI obtained from immersion injuries (while in water); 4. SSTI obtained from animal bites |
| What is step 3 for SSTI treatment? | Identify the most likely etiology of the infection *what bug am I concerned about? |
| What are my probable pathogens in a NON-PURULENT SSTI mild case? | Streptococcus species (strong evidence) |
| What are my probable pathogens in a NON-PURULENT SSTI moderate case? | Streptococcus species (strong evidence) PLUS MSSA/MRSA (weak evidence) |
| What are my probable pathogens in a NON-PURULENT SSTI Severe case? | Streptococcus species + MRSA + Gram (-)??? Anaerobes??? *so severe? treat for scary bug; assume its MRSA and go to severe; Gram (-) bugs involved could include (E.coli, Klebsiella, PsA) |
| Remember for NON-PURULENT, we think _______ | STREP (#1 bug to target) |
| What is Step 4 for SSTI treatment? | Start empiric tx based off most likely etiology; Collect any cultures (if necessary) before starting tx |
| What are my empiric drug options for MILD non-purulent SSTI? | Oral meds: PCN VK, Cephalosporin, Dicloxacillin, Clindamycin *Clinda for pt w/ B-lactam allergy but remember the C. Diff diarrhea |
| What are my empiric drug options for MODERATE non-purulent SSTI? | Per guidelines we give IV Beta-lactams: Penicillin, Ceftriaxone, Cefazolin, and Clindamycin; *PCNs, Cephs, and Clinda for Strep coverage *Clinda for pt w/ B-lactam allergy *Ceftriaxone, Cefazolin, and Clindamycin for MSSA coverage |
| What are my empiric drug options for SEVERE non-purulent SSTI? | IV meds: Vancomycin + Pip-tazo; *Vanco is for strep and MRSA Pip-tazo for Strep coverage as well as gram (-) such as PsA; Tazo allows for anaerobic coverage |
| What are my risk factors for CA-MRSA (Community- Associated Methicillin resistant Staphylococcus Aureus)? | Penetrating trauma to the skin (something pierces like a nail); IV drug abuse; Evidence of MRSA infection in the past; SIRS criteria met (greater than or equal to 2 criteria) |
| Dosing for Beck in SSTI NON-Purulent: remember the frequency: MILD Streptococcus coverage: Drug/Dose/Frequency? | Cephalexin 500 mg PO Q6h--> also meets MSSA coverage Penicillin VK 250-500 mg PO Q6h--> no MSSA coverage |
| Dosing for Beck in SSTI NON-Purulent: remember the frequency: MODERATE Streptococcus coverage + MSSA/MRSA: Drug/Dose/Frequency? | Pen G IV 2-4 million units Q4-6h--> No MSSA/MRSA coverage; Cefazolin 1000 mg IV q8h-->Yes to MSSA coverage but no MRSA coverage; Nafacillin 1000-2000 mg IV q4-6h--> yes MSSA coverage, NO MRSA coverage; Clindamycin 600-900 mg IV q8h--> yes MSSA coverage, Yes (??) for CA-MRSA coverage |
| When determining if a pt "failed tx" for SSTI, we need to think of? | what is the appropriate abx, what is their Strep coverage? *i.e if pt is taking TMP-SMX for my STREP species, its not an appropriate option (YELLOW coverage) |
| Lets assume pt came with temperature of 100.9 F. How does this change your empiric tx? a. Cephalexin + doxy; B. Clindamycin; C. Vancomycin IV; D. Vancomycin + pip/tazo; E. IV Cefazolin; F: No change | For A: we are not targeting MRSA so no need for doxy; For B. we save Clinda for when we can't do the Beta-lactam; For C. Vanco is overkill and should save for MRSA; D. Vanco + pip/tazo (no need for anaerobic coverage and save for severe); Best option is IV Cefazolin |
| What is Step 5 for SSTI treatment? | Follow up on any cultures needed and de-escalate therapy based off cultures and susceptibilities for the appropriate duration of tx |
| What does it mean to "stream-line" therapy"? | means i have culture data and i know exactly what bug i need to target |
| So after we receive cultures, and pathogen turns out to be S. Pyogenes, what is my course of action in stream-lining from severe IV Vanco + Pip-Tazo? | Mono-bacterial: Use PCN + Clindamycin -why is clindamycin being used in combo w/ PCN? S. Pyogenes |
| -why is clindamycin being used in combo w/ PCN when the determined pathogen is S. Pyogenes? | S. Pyogenes is known to produce toxins and that's why for Strep throat, it can lead to those complications (toxins being released into the body thtat eat away at your skin. Clinda is for TOXIN PRODUCTION CONTROL, not meant to kill S. Pyogenes but limit toxins being released |
| After we receive cultures, and pathogen turns out to be Clostridium species, what is my course of action in stream-lining from severe IV Vanco + Pip-Tazo? | Mono-bacterial: Penicillin + Clindamycin (Clinda for extra anaerobe coverage) |
| So after we receive cultures, and pathogen turns out to be Vibrio vulnificus, what is my course of action in stream-lining from severe IV Vanco + Pip-Tazo? | Mono-bacterial: Doxycycline + Ceftazidime (*vibrio could come from oysters or from fresh water injury) |
| So after we receive cultures, and pathogen turns out to be Aeromonas hydrophilia, what is my course of action in stream-lining from severe IV Vanco + Pip-Tazo? | Mono-bacterial: Doxycycline + Ciprofloxacin |
| So after we receive cultures and comes back as POLY-BACTERIAL, what is my course of action? | Continue IV Vancomycin + Pip-Tazo |
| Duration of Non-purulent SSTI is for how many days? | minimum of 5 days (mild); can extend out if infection has not improved in that time period; more likely to extend tx w/ more severe infections (7-14 days) |
| Purulent SSTI: Same 5 steps as non-purulent: | Step 1: determine if purulent or non-purulent; step 2: assess the severity of the infection; Step: 3: Identify the most likely etiology of the infection; Step 4: start empiric tx based off most likely etiology; collect any cultures (if necessary) b4 starting tx; Step 5: follow up on cultures and de-escalate tx based off cultures and susceptibilities for appropriate DOT |
| What are the 2 types of Purulent SSTIs? | Abscess and Furuncle/Carbuncle |
| What are abscesses in purulent SSTIs? | collection of pus w/ surrounding granulation; painful swelling w/ induration and central fluctuance |
| What are Furuncle/Carbuncles? | they are examples of purulent SSTIs; walled-off collection of pus; painful, firm, swelling; Carbuncles are LARGER/DEEPER that drain through multiple pores |
| Severity of Purulent SSIT is very similar to that of Non-Purulent SSTI, what is the main difference as seen in SEVERE severity: | seen in the addition section Failed oral ABX--> "PLUS I&D (Incision + drainage)" *so we cut and drain out the pus but didn't improve) |
| Diagnostic tool to help diagnose Purulent SSTI: we can use? | gram stain and culture of Pus (recommended for abscess, furuncles, and carbuncles) (use a swab); *If mild severity--> no need to culture since no systemic signs, may just have pus) |
| What are my probable pathogens in a PURULENT SSTI mild case? | Stapylococcus species (including S. aureus) |
| What are my probable pathogens in a PURULENT SSTI moderate case? | S. Aureus (MSSA or MRSA) |
| What are my probable pathogens in a PURULENT SSTI severe case? | MRSA, if failed initial abx tx or immunocompromised or SIRS w/ hypotension |
| Staph ______ pus; Strep DOES NOT produce pus | produces |
| What are my empiric drug options for MILD Purulent SSTI? | Incision and Drainage (I&D); Guidelines state no abx BUT evidence points to using first line I&D and add on abx (TMP-SMX OR Clindamycin) *Both cover the main bug Staph |
| What are my empiric drug options for MODERATE Purulent SSTI? | (I&D) is first line for any purulence; add on IV or PO abx (Doxycycline or TMP-SMX) Both cover MSSA and MRSA empirically |
| What are my empiric drug options for SEVERE Purulent SSTI? | (I&D) is first line for any purulence; add on an IV MRSA agent: (Vanco, Dapto, Linezolid, Televancin, Ceftaroline, Dalbavancin, Omadacycline, Tedizold) |
| Incision and Drainage (I&D) aids in attaining __________ of the pus as it comes out | cultures |
| Study done in 2014 about "uncomplicated abscesses" stated: for mild purulent SSTI---> ________ and no abx; Newer data shows that I&D + TMP-SMX OR CLINDA for 7 days reduced ______ ______ and recurrent abscesses | I&D; treatment failure |
| Newer data showed that I&D+ 1st or 2nd gen cephalosporin was ___ any better than I&D alone for tx failure | NOT |
| Talk to your pt about the risk v benefits of taking ______ or ______ for 7 days after I&D for MILD purulent SSTI | TMP-SMX; Clindamycin |
| Strem-lining Purulent SSTI therapy: If cultures come back with MSSA, what is my course of drugs to use? | Dicloxacillin or Cephalexin (*Dicloxacillin is your ONLY PO Anti-staph PCN we have, all others are IV) |
| trem-lining Purulent SSTI therapy: If cultures come back with MRSA, what is my course of drugs to use? | IV--> look at empiric treatment for SEVERE infection |
| trem-lining Purulent SSTI therapy: If cultures come back with "others," what is my course of drugs to use? | Go based on susceptibilities of pathogens *Beck note--> "needs us to recognize if its NOT MRSA, de-escalate off MRSA therapy to MSSA (so if we keep Doxycycline, its overkill) |
| Duration of therapy for Purulent SSTI is for how many days? | 5 ot 7 days; can extend out if infection has not improved in that time period; more likely to extend tx with more severe infections (7-14 days) |
Created by:
Xander635
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