Transcript Soft Tissue Infection Case Study 1

Soft Tissue Infection Case
Study 1
By: Linda Iskandar
The Case
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A 52 year old female BIBA
Presents with cellulitis of left lower leg
Painful, swollen and erythematous left lower leg
Febrile (38.5 C), Tachycardic (HR 118/min),
with mild hypotension ( BP 105/65)
Patient was hyperglycaemic BGL (23 mmol/L)
Allergic to penicillin
Patient weighs 110 Kg
Patient/social history
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NIDDM
Hypertension
GORD
Past ulceration of lower leg
Hypothyroidism
Hypercholesterolemia
Depression
osteoarthritis
Social history:
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Ex smoker
Non alcohol
Lives at home by herself
Medication chart
Medications
Metformin
Gliclazide
Ramipril
Esomeprazole
Thyroxine
Atorvastatin
Sertraline
Diazepam
Paracetamol
Dose
1000mg 1 tds
80mg 1 bd
10mg 1 d
40mg 1 d
50 mcg 1 d
40 mg 1 d
50mg 1 d
1 d prn
665mg 2 tds
Indications
NIDDM
NIDDM
Blood pressure
GORD
Hypothyroidism
Hypercholesterolemia
Depression
Anxiety
Osteoarthritis
Blood results
Test
16/03/09
15/03/09
12/03/09
Reference Range
WCC
25.3 x 109/L
22.2 x109/L
19.7 x 109/L
5-15 x 109/L
Neutrophils
14.3 x 109/L
12.3 x109/L
10.1 x 109/L
2.1-7 x 109/L
Creatinine
93 umol/L
89 umol/L
90 umol/L
60-140 umol/L
Hb
127g/L
130g/L
129 g/L
120-155 g/L
CRP
389 mg/L
343mg/L
290 mg/L
< 10mg/L
No major drug interactions where found and physical examination and systemic
symptoms were suggestive of cellulitis
Cellulitis
Cellulitis is a bacterial infection of the skin affecting the dermis and
subcutaneous tissue. The main bacteria responsible for cellulitis are
Streptococcus and Staphylococcus.
Cellulitis may occur anywhere on the body, but the lower leg is the
most common site of infection. It usually begins as a small area of
tenderness, swelling, and redness that spreads to adjacent skin. This
area then begins to enlarge, and following symptoms maybe
experienced;
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Redness of the skin
Warmth
Swelling
Tenderness or pain in an area of skin
Discharge, such as leaking yellow clear fluid or pus.
http://www.cancer.umn.edu/cancerinfo/NCI/Media/CDR0000579036.jpg
Cellulitis
Risk factors:
 Immunosuppression
 Diabetics
 Obesity
 Wounds (surgical and non-surgical)
 History of peripheral vascular disease
Treatment:
First line – di/flucloxacillin 2g IV Q6H
Patients allergic to penicillin;
Cephazoline 2g IV Q8H
Clindamycin 450mg IV or orally Q8H
Course of events
11/03: Patient started on IV Ceftriaxone for cellulitis,
Actrapid for hyperglycaemia and IV fluids.
Ceftriaxone
Ceftriaxone belongs to the antibacterial group
Cephalosporins and it is one of the broad spectrum
antibiotics. This group of antibiotics contain a betalactam ring that interferes with the bacterial
peptidoglycan synthesis.
It is therefore bactericidal and effective against gramnegative and gram positive organisms.
Course of events
13/03: Patient is intermittently febrile with no
improvement, blood cultures negative.
16/03: Still no improvement and increased
oedema of subcutaneous tissue.
17-18/03: Pustules developed and spread to
dorsum of foot and upper leg with signs of fat
necrosis.
Necrotising fasciitis
Necrotising fasciitis (NF) more commonly known as “flesheating disease” is a rare infection of the subcutaneous tissues,
and it is more commonly seen in immune compromised patients.
There are many types of bacteria that might be the cause for NF
these include;
 Group A streptococcus (Streptococcus pyogenes),
 Staphylococcus aureus (MRSA),
 Vibrio vulnificus,
 Clostridium perfringens,
 Bacteroides fragilis.
But the organism that is most commonly found to cause NF is
group A beta-hemolytic streptococci, and normally develops
from a previous complicated wound.
Pathophysiology
The bacteria spreads form the subcutaneous tissue along the superficial
and deep fascial planes. This facilitation happens by bacterial enzymes
and toxins, which leads to vascular occlusion, ischemia, tissue necrosis
and superficial nerves damage.
The following two factors are needed to promote bacterial growth in
NF.
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Surface protein expression:
M1 and M3 surface proteins increase the adherence of streptococci to
the tissue, they also work by protecting the bacteria from phagocytosis.
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Toxin production:
Streptococcal pyrogenic exotoxins (SPEs) A,B and C these release
exotoxins that activate the T-cells and leads to the overproductions of
cytokines.
Signs and symptoms
NF symptoms begins with fever and chills. After 2-3 days,
erythema is noted, with redness, swelling and blister formation.
NF may develop after chronic venous leg ulcers and skin blister.
NF may also occur in the setting of diabetes mellitus, surgery,
trauma, or infectious processes.
Course of events cont...
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19/03: Blood cultures still negative, IV Clindamycin
added.
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20/03: Debridement of skin, subcutaneous tissue
and deep fascia of all affected areas. Slowly the
erythema and oedema reduced and there were no
signs of necrosis.
Clindamycin
Clindamycin belongs to the antibacterial group
lincosamides. It works by reversibly binding to the 50S
sub-unit of bacterial ribosome inhibiting its protein
synthesis and preventing peptide bond formation.
It is bacteriostatic against a variety of gram +ve aerobic
and anaerobic organisms.
Clindamycin
Gram positive aerobes
Staphylococcus aureus
Streptococcus pneumoniae
Strep pyogenes
Anaerobes
Clostridium perfringens
Fusobacterium necrophorum
Peptostreptococcus anaerobius
Protozoa
Plasmodium falciparum.
Also used in the treatment of Chlamydia trachomatis and Gardnerella vaginalis
NF treatments
The most effective treatment is to perform surgical
debridement or in severe cases amputation as to
prevent further spreading, along with IV antibiotics
(vancomycin or clindamycin) and hyperbaric oxygen
therapy (HBOT).
The inclusion of clindamycin in the initial antibiotic
regimen has been associated with a better outcome in
streptococcal toxic shock, this could possibly be due to
its inhibition of bacterial protein synthesis and thereby
reduces toxin production.
Surgical Debridement
Surgical debridement is a fast and selective
procedure that effectively results in the removal
of the patient's dead, damaged, or infected tissue
in order to promote healing of the surrounding
healthy tissue.
Courses of events cont….
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22/03: Patient was transferred to Prince of
Wales hospital for hyperbaric oxygen treatment
Hyperbaric oxygen therapy (HBOT)
HBOT is sometimes used in treatment of NF depending on the
severity of the infection. It works by providing 100% oxygen at a
higher than atmospheric pressure. The oxygen is used to inhibit
anaerobic bacterial growth and promote tissue recovery. HBOT
has been shown to further reduce morbidity and mortality by
about 10%-20% in some patients when used in conjunction with
antibiotics and surgery.
Take Home Message
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Control the infection before the patient is discharged.
Necrotising fasciitis can commonly be mistaken for
cellulitis.
Provide the patient with preventive measured to
inhibit the infection from coming back (e.g. refer to
community wound care clinic)
Educate on the different signs and symptoms that the
patient needs to look out for especially because she is
a diabetic.
Educate the patient on the importance of QUM and
consider Webster pack to help with compliance.
Promote healthy eating habits and moderate exercise
References
1.
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8.
9.
Australian Medicines Handbook, 2010. Australian Medicines Handbook Pty Ltd.
Adelaide, Australia.
Walker R, Edwards C. (2003). Clinical Pharmacy and Therapeutics. Churchill Livingstone
4th edition; (chapter 37).
Groote De M.A. And Johnson P. (2004). Skin, bone and soft tissue infections. World health
organisation; (chapter 8).
McNamara, D.R., I.M. Tleyjeh, E.F. Berbari, B.D. Lahr, J.W. Martinez, S.A.
Mirzoyev, and L.M. Baddour. "Incidence of Lower-Extremity Cellulitis: A Population-Based
Study in Olmsted County, Minnesota." Mayo Clin Proc. 82.7 July 2007: 817-821.
Cellulitis. Last accessed 25th February; available at:
http://www.merckmanuals.com/home/sec18/ch211/ch211b.html
Bisno AL, Stevens DL. (1996). Streptococcal infections of skin and soft tissues. N Engl J Med
334: 240-245.
Treatment of soft tissue infections. Last accessed 25th February , available at:
http://www.who.int/water_sanitation_health/emerging/en/patmycrobact8.pdf.
Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits
and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. Jul
28 2008;168(14):1585-91.
skin image. Last accessed 28th February 2011, available at:
http://www.cancer.umn.edu/cancerinfo/NCI/Media/CDR0000579036.jpg
8.
9.
10.
11.
12.
Ellis Simonsen SM, van Orman ER, Hatch BE, et al. Cellulitis incidence in a
defined population. Epidemiol Infect. Apr 2006;134(2):293-9.
Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal
infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N
Engl J Med. Aug 22 1996;335(8):547-54.
Cephalosporin. Last accessed 28th February 2011, available at:
http://www.emedexpert.com/compare/cephalosporins.shtml
Cellulitis image. Last accessed 28th February 2011, available at:
http://www.google.com.au/imgres?imgurl=http://findmeacure.com/wp-content
/uploads/2008/03/cellulitis_left_leg.jpg&imgrefurl=http://findmeacure.com/200
8/03/04/cellulitis/&usg=__3Suw8XSrbscuH0f5a-_XFQfhdTc=&h=482&w= 640
&sz=80&hl=en&start=2&zoom=1&um=1&itbs=1&tbnid=1jtZEaU3zf_m4M:&t
bnh=103&tbnw=137&prev=/images%3Fq%3Dcellulitis%26um%3D1%26hl%3D
en%26sa%3DN%26tbs%3Disch:1&ei=QbKGTdrpJI-lcfO3kJUD.
Cellulitis image. Last accessed 28th February 2011, available at:
http://www.google.com.au/imgres?imgurl=http://rpmedia.ask.com/ts%3Fu%3D
/wikipedia/commons/thumb/6/60/Cellulitis3.jpg/190px-Cellulitis3.jpg&imgrefurl
=http://www.ask.com/wiki/Anaerobic_cellulitis&usg= __5YFjswgembbFYmdiky
7Sbr6CeW8=&h=1632&w=1224&sz=271&hl=en&start=25&zoom=1&um=1&it
bs=1&tbnid=-Hsyhm_7Ffmx_M:&tbnh=150&tbnw=113&prev=/images%3Fq%3
Dcellulitis%26start%3D20%26um%3D1%26hl%3Den%26sa%3DN%26ndsp%3D
20%26tbs%3Disch:1&ei=MbOGTaSIPIzQcdHlqbQF