Antibiotic Stewardship for Skin and Soft Tissue Infection and Respiratory Tract Infections

Ghinwa Dumyati, MDProfessor of MedicineCenter for Community Health andInfectious Diseases DivisionUniversity of Rochester Medical CenterGhinwa-dumyati@urmc.rochester.eduFeb 28, 2018

Outline

• Review common reasons for a “red leg”

• Discuss when skin lesions need to be cultured

• Differentiate between upper and lower respiratory tract

infections

• Review treatment duration for cellulitis and pneumonia

Stewardship Opportunities in the Nursing Home

41%

35%

14%

10%

Common Indications for Antibiotic Prescriptions among Nursing Home Patients

Urinary Tract Infection

Respiratory (Upper and Lower)Tract Infection

Skin and Soft Tissue Infection(SSTI)

Other

Katz PR et al. Arch Intern Med 1990; 150:1465-8

Stewardship Opportunities in the Rochester Nursing Homes

SSTI28%

UTI25%

PNEUMONIA21%

HEENT INFECTION9%

BONE/JOINT INFECTION8%

C. DIFF5%

DENTAL/SURGICAL PROPHYLAXIS

4%

Proportion of residents treated by indication, example from one of the Rochester nursing homes

Skin and Soft Tissue Infections (SSTI): Many Diagnostic Challenges

• High prevalence of chronic skin changes

• Peripheral vascular disease

• Venous stasis disease

• Pressure ulcers

• Chronic wounds colonized with bacteria

• Difficulty in getting information due to cognitive impairment

Which one of these wounds should be cultured and Treated?

DermNet New Zealand

SSTI Diagnostic and Treatment CriteriaMcGeer Criteria Loeb Minimum Criteria

Pus at SSTI site

OR Any four (4) of the following

Increased warmth Increased redness Increased swelling Increased tenderness Serous drainage Constitutional findings (temp, WBC, etc)

New of increased purulence at SSTI site

OR Any two (2) of the following

Increased warmth Increased redness Increased swelling Increased tenderness Fever (Temp > 100*F, or 2.4*F > baseline)

Stone ND, et al. Infect Control Hosp Epidemiol. 2012;33(10):965-77Loeb M, et al. Infect Control Hosp Epidemiol. 2001;22(2):120-4

A 60 year old male with history of CAD, CHF, chronic lower extremity edema and diabetes mellitus with ESRD in hemodialysis

He had an abrupt onset of lower extremity pain associated with redness and swelling that evolved over a period of several hours

•What is your diagnosis?

•What can mimic cellulitis?

Cellulitis

Non Purulent Purulent

Usually due to Streptococcus Group A, B, G Usually due to Staphylococcus aureus

Stasis Dermatitis

Pictures Visual DX

Stasis Dermatitis

•Extremely common

•Can present with erythema, edema mimicking cellulitis

•Can present with bullae, drainage and crusting

•Severe presentations can mimic bacterial infection

Leg Cellulitis -vs- Stasis Dermatitis

Cellulitis

• Often a history of preceding trauma, bite or injury preceding by days

• Lymphangitic streaking

• Unilateral

• Acute episode

• Fever or chills possible but not mandatory for diagnosis

• Usually no scale or skin breakdown

• Leukocytosis

Stasis Dermatitis

• Varicose veins, lymphedema

• Skin redness often associated with scale

• Unilateral or Bilateral

• Usually chronic or recurring

• Afebrile

• Pruritic lesions, weeping lesions

• Relapsing and Remitting Course

Bilateral Cellulitis

Stasis DermatitisStasis Dermatitis

Stasis DermatitisBut really –stasis, stasis, stasis

Stasis DermatitisBut really –stasis, stasis, stasis

Stasis Dermatitis: Scale Obvious or SubtleBut really –stasis, stasis, stasis

Stasis Dermatitis: Can ulcerateStasis dermatitis- Can ulcerate

Stasis Dermatitis

LymphedemaLymphedema

Other Cellulitis Mimics

Fungal Dermatitis Deep Vein Thrombosis

Eczema or Contact Dermatitis

Healthline.com

Gout

Spider Bite Chemical Dermatitis at Peg

Don’t Miss

Necrotizing Fasciitis

• Group A strep common etiology

• Unexplained and rapidly progressing pain disproportional to the physical findings

• Erythema may be diffuse or localized or may be absent. Progress to bullae formation and necrosis

• Patients are sick: Fever, malaise, myalgia, diarrhea, and anorexia may also be present• Hypotension may develop initially or over time

• Elevated WBC, bandemia, elevated creatinine

Opportunities of Antimicrobial Stewardship

•Don’t culture uninfected ulcers or wounds

•Don’t treat stasis dermatitis with antibiotics

• Treat cellulitis for 5 days

• Treat purulent cellulitis for 7 days

Respiratory Tract Infections

Respiratory Tract Infections

Upper respiratory tract infections

Lower respiratory tract infections

Blue dots are syndromes caused by viruses

Green dots are syndromes caused primarily by bacteria

90% due to viruses

~70% due to bacteria

**bacterial causes include Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Bordatella pertussis (causes whooping cough). Antibiotics are only appropriate for bronchitis caused by Bordatella pertussis, diagnosed using special tests on nasopharyngeal samples.

Acute Bronchitis vs. PneumoniaAcute Bronchitis Pneumonia

Definition Self-limited inflammation of bronchi, the large airways of the lung

Inflammation or infection of the lung tissue

Cause Viral (with rare exceptions)* ~75% bacteria, ~25% viral

Symptoms Cough for 5 days to 3 weeksFever less common (unless influenza)50% have sputum production

CoughFever is commonSputum productionChest wall painDecline in oxygenation

DiagnosticStudies

Normal to slightly elevated WBCNo specific chest x-ray findings

Elevated WBCInfiltrate, effusions

Evaluation of Pneumonia

Cough

Sputum production

RR ≥ 25

Decrease O2 saturation (<95%)

New or changed lung exam

Pleuritic chest pain

Constitutional symptoms(fever, mental status changes, acute functional decline)

Signs and Symptoms

CBC

Viral nasopharyngeal swab

Legionella urine antigen and sputum culture if severe pneumonia*

CXR (may be)

Workup

*NYSDOH guidelines for legionella https://www.health.ny.gov/diseases/communicable/legionellosis/docs/2015_nursing_home_guidance.pdf

Opportunities for Antibiotic Stewardship

• Re-assess the need for antibiotics after 2-3 days

• CXR: common interpretation “Cannot rule out infiltrate”

• Need to have positive signs and symptoms and exam findings consistent with pneumonia

• Treatment duration: 5-7 days for most residents (longer if slow to respond)

Updated McGeer Surveillance Criteria for Pneumonia

• Positive CXR

• >1 Respiratory criteria

• Cough, sputum, hypoxia, tachypnea, pleurisy, lung findings

• >1 Constitutional criteria

• Fever, neutrophilia/left shift, delirium, decline in function

Stone D N. et al, Infect Control Hosp Epidemiol. 2012; 33(10): 965–977

Loeb Minimum Criteria for Initiating Antibiotics

1. Temp > 1020F AND RR >25 or productive cough

2. Temp >1000 or > 2.4˚F over baseline AND new cough plus:

• P > 100 OR

• Delirium or rigors OR

• RR > 25

3. COPD AND increased cough with purulent sputum

4. New productive cough AND RR > 25 or delirium

Loeb M, Bentley DW, Bradley S, et al. Infect Control Hosp Epidemiol 2001;22:120e124

SBAR tools for SSTI and Lower RTI

Nursing Home Antimicrobial Stewardship Guide

Determine Whether To Treat https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_

Rochester Nursing Home Collaborative Guidelines for Treatment of Common Infectionshttp://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes

Acknowledgments

• Elizabeth Dodds Ashley, PharmD

• Alexandra Yamshchikov, MD

• Joseph Nicholas, MD

• Dallas Nelson, MD

• Annette Medina Walpole, MD

• Timothy Holahan, MD

• Scott Schabel, MD

• Thomas Pingree, MD

• Mary Aydelotte, MD

• Rena Pine, MD

• Kim Petrone, MD

• Brian Heppard, MD

• Diane Kane, MD

• Alexander Karlic, MD

• Robin Jump, MD

Questions?