Dr.Paul's Video of the Day

Dupuytren Contracture: Most Important Points

2011-07-29T09:54:00.000-04:00

Kaposi's Sarcoma

2011-05-27T14:30:00.001-04:00

Hyponatremia: Basic Points

2011-03-13T12:16:00.002-04:00

Herpes Zoster Ophthalmicus

2011-03-11T19:13:00.002-05:00

Plummer Vinson Syndrome

2010-11-02T15:02:00.001-04:00

Endometrial Cancer

2010-10-07T20:23:00.000-04:00

Separation Anxiety Disorder

2010-06-11T23:26:00.000-04:00

Health Care Proxy and Power of Attorney

2010-06-09T23:48:00.002-04:00

Seborrheic Dermatitis

2010-06-09T00:42:00.000-04:00

Malignant Melanoma

2010-06-07T01:25:00.002-04:00

Atopic Dermatitis: Key Points

2010-06-03T18:53:00.003-04:00

Atomic dermatitis is a very important disease to study for USMLE

Scleroderma: Major Manifestations

2010-06-03T04:15:00.003-04:00

MRSA infection

2010-05-29T22:18:00.002-04:00

Hypokalemia

2010-05-24T02:41:00.002-04:00

Hyperkalemia:EKG changes, Emergency Treatment

2010-05-22T02:20:00.002-04:00

Morton Neuroma

2010-05-21T02:32:00.001-04:00

Heparin Induced Thrombocytopenia

2010-05-19T22:57:00.002-04:00

Hypokalemia: Symptoms, EKG changes,Treatment

2010-05-17T23:55:00.002-04:00

Rh isoimmunization & incompatibility in Pregnancy

2010-05-16T22:49:00.002-04:00

Trigeminal Neuralgia: Most Important Things to Know

2010-05-14T23:20:00.002-04:00

Antidepressant-Induced Sexual Dysfunction

2010-05-13T23:54:00.002-04:00

Rheumatoid Arthritis: Diagnostic Tests and Differential Diagnosis

2010-05-12T12:16:00.002-04:00

Third-Trimester Bleeding: Most Important Points

2010-05-12T00:46:00.002-04:00

Rheumatoid Arthritis: Key Clinical Symptoms and Signs

2010-05-10T16:22:00.002-04:00

Syphilis: Most Important Things to Know

2010-05-09T02:18:00.001-04:00

MRSA Infection: Most Important Antibiotics

2010-05-08T00:10:00.001-04:00

Neonatal Abstinence Syndrome: Morphine, Methadone and Drug Rehabilitation

2010-05-04T23:11:00.002-04:00

Hypocalcemia: Most Important Points

2010-05-03T22:07:00.002-04:00

Respiratory Alkalosis: Most Important Points

2010-05-03T01:11:00.002-04:00

MRSA Infection: Notes of Important Points

2010-05-01T00:53:00.001-04:00

The increasing incidence of skin and soft tissue infections requires family physicians to be familiar with the management of these conditions. Evidence of systemic infection, such as fever, tachycardia, and hypotension, is an indication for inpatient management. Urgent surgical referral is imperative for those with life-threatening or rapidly advancing infections. In settings where suspicion of methicillin-resistant Staphylococcus aureus (MRSA) is low, beta-lactam antibiotics are the first-line treatments for uncomplicated skin and soft tissue infections without focal coalescence or trauma. When empiric coverage for MRSA is indicated and the infection is uncomplicated,

oral agents, such a

s tetracyclines,

trimethoprim/sulfamethoxazole,

and clindamycin, are preferred.

Vancomycin is the first-line agent for MRSA in hospitalized patients, and

newer agents, such as

linezolid,

daptomycin, and

tigecycline, should be reserved for patients who do not respond to or cannot tolerate vancomycin therapy. .

Community-Acquired MRSA

The recent rapid increase in community-acquired MRSA soft tissue infections has forced physicians to reconsider their approach to routine SSTIs. Recent reports of antimicrobial resistance patterns have found that community-acquired MRSA is responsible for up to 60 percent of SSTIs in U.S. emergency departments.10,11 These rates are higher in certain populations, including ethnic minorities, children, intravenous drug users, patients who have received recent antibiotic treatment, men who have sex with men, residents of long-term care facilities and prisons, and patients receiving hemodialysis.5,12,13 In addition to purulent SSTIs, community-acquired MRSA is associated with other infectious processes, such as necrotizing pneumonia and sepsis.10 Although many patients with community-acquired MRSA infections describe the initial presentation as resembling a spider bite, there are no reliable signs and symptoms to distinguish community-acquired MRSA infections from other purulent SSTIs.13,14

Diagnosis and Assessment of SSTIs

SSTIs in the presence of comorbid infections, such as

diabetes,

neutropenia,

or cirrhosis, are more likely to be severe and caused by uncommon organisms (e.g., Pseudomonas species, Klebsiella species, yeast, fungi).7

Complicated and potentially life-threatening SSTIs are characterized by fever,

widespread or a rapidly spreading area of involvement, firm and hard feel of subcutaneous tissues, pain disproportionate to examination, skin sloughing, cutaneous bleeding with or without bullae, and skin crepitus.15 Additionally, patients with necrotizing infections may be lethargic or disorientated.7 Rapidly progressive and life-threatening infections warrant urgent surgical referral.3,7,16

Hospitalization should be considered in patients with the following laboratory findings:

left shift in complete blood count with differential,

elevated serum creatinine level,

reduced serum bicarbonate level,

elevated creatine kinase level, or

C-reactive protein level greater than 13 mg per L (123.81 nmol per L).7

wound cultures of purulent secretions should be performed in patients with multiple or extensive lesions,

fever or other evidence of systemic illness,

prior treatment failure, immunocompromise, trauma, water contact, or animal or human bites.7 If wound cultures are indicated, fluid or tissue specimens should be collected using aseptic technique via needle aspiration or tissue biopsy.

Antimicrobial Treatment

When indicated, antimicrobial therapy for uncomplicated SSTIs is usually initiated empirically. Familiarity with common pathogens and with local flora and resistance patterns is essential in choosing initial agents.

Oral antibiotics that have been shown to be effective against community-acquired MRSA include

trimethoprim/sulfamethoxazole (Bactrim, Septra),

tetracyclines, and

clindamycin (Cleocin).3,7

Local patterns of sensitivity may vary, however. In one study, patients with uncomplicated cellulitis who received five days of antibiotic treatment had similar outcomes to those who were treated for 10 days.26 In patients with widespread or systemic infection, comorbidities, or an inability to tolerate oral treatment, vancomycin is the first-line parenteral anti-MRSA agent, although clindamycin, quinolones, linezolid (Zyvox), tigecycline (Tygacil), and daptomycin (Cubicin) may also be used.3

If clindamycin therapy is considered,

a D-zone test should be performed to

identify patients with inducible clindamycin resistance.

LINEZOLID

Linezolid is effective against methicillin-sensitive S. aureus (MSSA) and MRSA, and the nearly equal bioavailability of oral and intravenous preparations makes it a convenient alternative to vancomycin. Because of cost (approximately $1,700 for a 10-day oral course) and the potential for the development of additional drug resistance, linezolid should be reserved for patients with MRSA who do not respond to other agents and for patients with complicated SSTIs in whom alternative treatment has been inferior.

1.As a weak monoamine oxidase inhibitor, linezolid may be associated with an increase in blood pressure.

2. Serotonin syndrome has been reported in patients taking selective serotonin reuptake inhibitors with line-zolid.

3.Linezolid also should be used with caution in patients with chronic kidney disease because it is renally excreted.26

TIGECYCLINE

Tigecycline is indicated for the treatment of complicated SSTIs caused by MSSA and MRSA infections.

The drug is metabolized in the liver; therefore, dosing adjustments are

needed in patients with severely impaired liver function (i.e., those with Child-Pugh classification C cirrhosis).

No dosing adjustment is needed in patients with renal impairment,

and tigecycline does not alter the effectiveness of warfarin (Coumadin) therapy.31

Tigecycline is administered intravenously.

The most common adverse effects are nausea and vomiting.

As with tetracyclines,

tigecycline is not recommended

for use in children.31

DAPTOMYCIN

Daptomycin exhibits bactericidal activity against most gram-positive organisms, including MRSA and vancomycin-resistant enterococci. This unique medication disrupts the ionic electric potentials of the cell membrane by promoting rapid calcium-dependent efflux of potassium from the cell.32,33 In a prospective, open-label study comparing daptomycin with vancomycin for the treatment of complicated SSTIs with risk of MRSA, both groups had complete clinical resolution, with the daptomycin-treated group demonstrating a significantly reduced duration of intravenous therapy and reduced median number of days to achieve clinical cure.34

Daptomycin is administered intravenously.

Potential adverse effects include myopathy and gastrointestinal effects,

such as nausea, vomiting, and diarrhea.

Daptomycin may elevate the prothrombin time and, therefore,

should be used with caution in patients taking warfarin.33

RETAPAMULIN

Retapamulin (Altabax) is a topical antibiotic that has been investigated for use in the treatment of impetigo.

cally significant improvement in outcomes after seven days of retapamulin therapy, compared with placebo.35 Retapamulin has not been compared with topical mupirocin, however.

Prevention of SSTIs

Standard infection control precautions should be implemented and encouraged for all patients in ambulatory and inpatient settings, including

proper and frequent handwashing,

use of gloves when managing wounds, and

contact precautions (e.g., use of gowns and gloves, grouping patients with similar infections) for patients with known or suspected MRSA infections.12 To prevent SSTIs, current consensus guidelines support proper foot care among patients with diabetes, tinea pedis, or pedal edema from venous insufficiency or lymphedema.

Eosinophilic Esophagitis

2010-04-28T10:04:00.002-04:00

Scleroderma:Major Manifestations

2010-04-27T12:41:00.002-04:00

Respiratory Acidosis: Most Important Points

2010-04-24T22:44:00.002-04:00

Metabolic Acidosis: What Should You Remember?

2010-04-06T04:15:00.002-04:00

Heparin Induced Thrombocytopenia: Most Important Points

2010-04-01T04:01:00.001-04:00

Complications of Sinusitis

2010-03-31T03:32:00.001-04:00

Anal Fissure: Most Important Points

2010-03-29T04:35:00.001-04:00

Pilonidal Cyst: Most Important Points

2010-03-26T03:01:00.000-04:00

Fetal Alcohol Syndrome: Most Important Points

2010-03-23T00:50:00.003-04:00

Trigeminal Neuralgia: Most Important Points

2010-03-19T00:05:00.001-04:00

Hepatic Encephalopathy: Most important points

2010-03-17T23:23:00.002-04:00

Anorexia Nervosa: Most Important Points

2010-03-17T03:50:00.002-04:00

Bulimia Nervosa

2010-03-08T22:50:00.002-05:00

Hypertriglyceridemia: Best Medications

2010-02-19T08:50:00.001-05:00

USMLE Questions Review

2010-02-14T09:20:00.001-05:00

Generalized Anxiety Disorder

2010-02-02T21:43:00.000-05:00

Morton Neuroma and Foot Pain

2010-02-01T23:52:00.001-05:00

Whipple Disease

2010-01-31T14:59:00.002-05:00

Pheochromocytoma

2010-01-30T20:44:00.002-05:00

Diabetic Ketoacidosis

2010-01-28T01:24:00.000-05:00

Necrotizing Fasciitis

2010-01-26T23:09:00.002-05:00

Necrotizing fasciitis is a rare but extremely aggressive, life-threatening soft-tissue infection of the subcutaneous and fascial tissues often encountered in diabetic patients. The muscle tissues are generally spared. Clinical examination of the skin reveals streaking erythema and sometimes small blisters, arising in the region of an incidental puncture wound. Local induration is always found, and occasionally subcutaneous crepitation caused by gas in the soft tissues is encountered. Air in the soft tissues can usually be seen on plain radiographs in gas-producing clostridial infections. Serial exams are necessary to track the leading edge of the infection, which rapidly progresses in the direction of venous drainage. Emergent surgical debridement of devitalized tissues (sometimes necessitating amputation) along with antibiotics and intensive care treatment for hypotension are required to prevent death.

Subarachnoid Hemorrhage

2010-01-25T22:17:00.003-05:00

Intussusception

2010-01-24T00:17:00.003-05:00

Digoxin: What should know about it?

2010-01-23T00:26:00.002-05:00

AIDS: Most Common Diseases

2010-01-22T00:44:00.001-05:00

Aspirin: The Wonder Drug

2010-01-21T01:20:00.002-05:00

Molluscum contagiosum

2010-01-18T22:51:00.002-05:00

Cholesterol: Prevention of Heart Disease

2010-01-18T00:00:00.000-05:00

Deep Venous Thrombosis: Treatment Strategies

2010-01-16T22:37:00.000-05:00

Visit our new website www.doctorpaul.org

2010-01-16T14:05:00.001-05:00

Wegener Granulomatosis

2010-01-15T13:41:00.001-05:00

Pilonidal Cyst

2010-01-14T23:44:00.001-05:00

Irritable Bowel Syndrome

2010-01-13T23:42:00.001-05:00

Rocky Mountain Spotted Fever

2010-01-07T21:09:00.000-05:00

Psittacosis

2009-12-30T11:01:00.000-05:00

HELLP SYNDROME

2009-12-24T03:14:00.001-05:00

Brain Metastases

2009-12-22T09:46:00.001-05:00

Fitz-Hugh-Curtis Syndrome

2009-12-20T09:12:00.001-05:00

Gonorrhea in Pregnancy for USMLE

2009-12-18T13:20:00.001-05:00

Vibrio Vulnificus: Oysters, Shrimp, and Hurricane Katrina

2009-12-16T21:14:00.001-05:00

Norwalk Virus: Cruise Ship Connection

2009-12-13T12:07:00.000-05:00

Urinary Tract Infection: Causative Pathogens, Diagnosis

2009-12-11T11:23:00.001-05:00

Syphilis

2009-12-09T09:59:00.001-05:00

Pulmonary Embolism

2009-12-08T06:50:00.001-05:00

Nocardia

2009-12-04T11:14:00.001-05:00

Treatment of Depression: A Slide Show

2009-11-10T22:57:00.001-05:00

Granuloma Annulare

2009-09-26T17:46:00.001-04:00

Malignant Melanoma

2009-09-12T22:57:00.001-04:00

Genital Warts: Medications and Treatment

2009-04-27T18:10:00.001-04:00

DVT: Treatment Strategies

2009-04-14T04:03:00.001-04:00

Hyperkalemia: Management

2009-04-13T00:03:00.000-04:00

Infectious Mononucleosis

2009-04-10T04:03:00.001-04:00

ACE Inhibitors

2009-04-09T02:24:00.000-04:00

Hyperkalemia: EKG changes and Emergency Treatment

2009-04-07T03:43:00.001-04:00

Fever Case in Step-2 CS: What Questions Should You Ask?

2009-04-05T00:12:00.000-04:00

COPD: Basic Health Care

2009-04-03T02:48:00.001-04:00

Tumor Markers in Cancer

2009-03-31T02:37:00.001-04:00

Rocky Mountain Spotted Fever

2009-03-27T02:27:00.001-04:00

Tarsal Tunnel Syndrome

2009-03-24T22:12:00.001-04:00

Obstructive Sleep Apnea: Management

2009-03-24T00:39:00.001-04:00

Bulimia Nervosa

2009-03-09T01:59:00.001-04:00

Alzheimer Disease

2009-02-12T03:15:00.001-05:00

Heriditary Spherocytosis

2009-01-26T14:10:00.001-05:00

Metformin: Most Important Points

2009-01-19T13:50:00.001-05:00

Diabetic Ketoacidosis: Treatment

2009-01-16T13:26:00.001-05:00

Diabetic ketoacidocis, part 1

2009-01-15T13:50:00.000-05:00

Slipped Capital Femoral Epiphysis

2008-12-17T23:37:00.001-05:00

Post-Traumatic Stress Disorder

2008-12-10T22:35:00.001-05:00

Irritable Bowel Syndrome

2008-12-08T09:39:00.001-05:00

AIDS: Most Common Diseases

2008-12-05T03:01:00.000-05:00