Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5200_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
30.08.2026
Размер:
52 Мб
Скачать
☆
Batheregularly. Avoidscratching. Avoidirritants,includingtightclothingandocclusivecosmeticsanddeodorants. Avoidreusingorsharingpersonalitemssuchasdisposablerazors,towels,andbedsheets. Disinfectcommonlytouchedsurfacessuchasdoorknobs,counters,andtoiletseats.
Lipsky,B.A.,Berendt,A.R.,Cornia,P.B.,etal.2012InfectiousDiseasesSocietyofAmericaclinicalpracticeguidelineforthediagnosis andtreatmentofdiabeticfootinfections.ClinicalInfectiousDiseases:AnOfficialPublicationoftheInfectiousDiseasesSocietyof America,54(12),e132–e173.
Inmanycases,systemicantibiotictherapy(Table13.4)isprescribedempiricallybasedonknowledge oftheorganismscommonlyresponsibleforspecificskininfections,suchasS.aureusandGAS.Therapy isthennarrowedoncecultureresults,ifcollected.
In the case of puncture or bite wounds that are not initially infected, antibiotics are prescribed as prophylaxis in immunocompromised individuals because of the high risk of infection associated with thesewounds(Box13.1).
Topical medications, suchas mupirocin (Bactroban) ointment, can be occasionally used as primary therapyforminorinfections(e.g.,impetigo)oralternativelyusedincombinationwithsystemicagentsfor moreseriousinfections.InsomepatientsthoughttobechroniccarriersofS.aureus,infectionsmaybe recurrent.
Severalotheradjunctivemeasuresmayalsobeusedincombinationwithdrugtherapy.Bedsidewarm soaksandincisionanddrainageproceduresmayhelpresolvepustularlesions.Patientswithaparonychia may need to have the nail bed decompressed to relieve the pressure, and deeper and more invasive infectionsalmostalwaysrequireincisionanddrainage.
GoalsofDrugTherapy
The goals in treating bacterial skin infections are to cure the infection, prevent worsening, minimize scarring,andpreventrecurrence.Manyminorinfectionsresolvewithin10to14days.Ifresolutiondoes notoccur,alternative agentsmay be prescribed.Theprescriber mustdecidewhenit is appropriateto initiate treatment with an alternative agent or whether a referral to a specialist for more definitive diagnosisandtreatmentisindicated.
TABLE13.4
OverviewofSelectedAntibioticsforSkinInfections
Generic
Dosage
and
-
Broad
Spectrum
(
Trade)Name
Penicillins
Selected
Adverse
Events
Contraindications
Special
Considerations
Amoxicillin—clavulanate
Augmentin
(
Adults
:
Children
basedonthe
Dicloxacillin Adults
:
Children
q
PO
-
First
Generation
Cephalexin
Adults
:
Children
divided
Cefazolin(Ancef
Adults
:
Children
)
500
875
-
weight
:
Dynapen
(
125-250
6.25-12.5
:
6
h
(
Keflex
mg
500
25-50
:
3
in
-
g
q
:
50
IV
8
mg
1
mg
q
12
h
-
PO
4
)
dosing
based
formulation
)
mg
mg
q
PO
/
mg
kg
Cephalosporins
)
q
6
h
/
kg
/
d
doses
h
d
/kg/
divided
IV
into3doses
vomiting
Nausea
Serious
,
,
allergic
rash
infection
:
colitis,seizures
as
Same
6
h
Nausea
Serious
amoxicillin—clavulanate
vomiting
,
,
allergic
rash
infections
:
colitis,seizures
cephalexin
as
Same
,
diarrhea
reactions
,
,
fungal
Pseudomembranous
(
high
,
diarrhea
reactions
doses
,
fungal
,
)
Pseudomembranous
(
high
doses
)
Allergy
to
Use
Penicillin Use
Serious
Use
caution
with
renal
disease,less
allergy
allergy
caution
with
dysfunction
renal
penicillin
allergy
cautioninrenal
with
disease
cephalexin
as
Same
penicillin
severe
in
severe
cephalosporins
to
severe
in
allergy
,
cephalosporins
to
Food
Renal
Comes
.
Interactions
INR
(
decrease
of
Take
absorption
Interactions
(
Decreases
Food Renal
Same
may
decrease
adjustments
suspension
in
:
)
,
contraceptives
oral
contraceptive
empty
on
:
may
decrease
adjustments
cephalexin
as
Gl
:
warfarin
effectiveness
)
stomach
warfarin
)
INR
Gl
symptoms
for
children
may
(
increase
best
for
symptoms
.
Second-Generation
release
h
release
-
20
40
:
1
(
Cefzil
PO
mg
20
:
mg
mg
15
:
(
mg
(
Rocephin
q
g
24
75
50
:
-
)
250-500
:
500
:
/kg/
mg
g
/
d
)
mg
PO
q
h
24
kg
q
/
24
,
Zinacef
q
PO
12
kg
/
PO
Cephalosporins
)
Vantin
q
PO
h
12
)
g
q
12
h
IMorIV
mg
kg
/
Cefaclor(Ceclor
Adults
:
Immediate
q
PO
8
Extended
q
12
h
Children
exceed
to
Cefprozil
Adults
:
500
250-500
mg
Children
Cefuroxime(Ceftin
Adults
500
:
Children
-
Third
Generation
Cefpodoxime
Adults
Ceftriaxone
Adults
Children
or
or
400
:
0.5-1.0
:
1-2
IV
Cephalosporins
Same
mg
mg
PO
q
d
8
not
h
Same
q
or
12
h
h
)
Same
h
q
h
12
Same
Same
h
IMorIV
q
24
h
IM
pseudolithiasis
cephalexin
as
cephalexin
as
cephalexin
as
cephalexin
as
as
cephalexin
and
also
Same
Same
Same
Same
Same
cephalexin
as
cephalexin
as
cephalexin
as
cephalexin
as
as
cephalexin
cephalexin
as
Same
cephalexin
as
Same
cephalexin
as
Same
whole
becauseofbitter
cephalexin
as
Same
Not
recommended
years
12
<
Dilute
at
renal
with
injection
dose
IM
No
:
pain
;
swallow
taste
children
for
lidocaine
reduce
to
site
adjustments
needed
CPK,creatinephosphokinase;GAS,GroupAstreptococcus:GI,gastrointestinal;IM,Intramuscular;INR,internationalnormalizedratio;IV, intravenous;MAO,monoamineoxidase;MRSA,methicillin-resistantS.aureus;QTc,correctedQ-Tinterval.
Antibiotics
Severalclassesofantibioticsareusefulfortreatingbacterialskininfections.Forinformationonspecific agents,refertoTable 13.4. Incertaincircumstances,a combinationofantibioticsmaybe necessaryto treat an infection because of multiple pathogens (i.e., a polymicrobial infection). Agents may be
Fluoroquinolones
Ciprofloxacin(Cipro
Adults
Levofloxacin
Adults
Moxifloxacin
Adults
Miscellaneous
Clindamycin
Adults
Children
Daptomyein
Adults
Children
:
:
:
:
into
:
500-750
750
400
300
20-40
:
-
3
4
mg
4
not
:
mg
Levaquin
(
mg
/
PO
(
Avelox
mg
/
PO
(
Cleocin
-
mg
450
mg
doses
(
Cubicin
kgIVdaily
/
approved
)
IV
)
IV
P
)
PO
/kg/
)
q
0
)
q
24
q
24
q
d
12
h
h
h
6
h
divided
Nausea,diarrhea,altered
dizziness,drowsiness,head
,
ache,insomnia
confusion
Serious
Nausea
Serious
Pseudomembranous
:
,
Stevens
colitis
syndrome
vomiting
,
allergic
,
rash
infections
Pseudomembranous
:
agitation
hypoglycemia
,
-
Johnson
,
diarrhea
reaction
,
colitis
elevation
CPK
myopathy
or
with
(
reversible
without
)
,
taste
-
,
,
fungal
Allergy Myasthenia
Children
Use
Allergy
Allergytodaptomyein
fluoroquinolone
to
gravis
younger
,
pregnancy
18
cautioninrenal
with
hepatic
nervous
older
(
lincomycin
children
age
disease,central
system
adults
safety
not
clindamycin
younger
18
established
than
disease
,
lactation
or
,
than
age
.
and
,
)
Black
Food
warning
box
adverse
fluoroquinolones
and
neuropathy
system
ruptures
effects
tendon
effects
slows
about
assxiated
Tendinitis
:
rupture
,
central
,
and
or
tears
absorption
serious
,
peripheral
nervous
aortic
.
Interactions:antacids,zinc
theophylline
,
,
sucralfate
warfarin
glucocorticoids
adjustments
Renal
prolongation
QTc
Take
with
glass
full
esophageal
Check
susceptibility
Monitor
especially
HMG-CoAreductase
iron
,
probenecid
,
didanosine
or
without
of
water
irritation
antibiogram
for
CPK
for
rates
elevations
patients
in
,
foscarnet
food
avoid
to
local
for
MRSA
receiving
inhibitors
with
,
,
,
with
,
Doxycycline(Doxy
Adults
Children
Linezolid Adults
Children
Tigecycline(Tygacil
Adults
Children Sulfamethoxazole
Adults
Children
Vancomycin
Adults
Children
100
:
not
:
(
Zyvox
600
:
10
:
100
:
mg
q
50
not
:
(
Bactrim
tablets
component
q
12
:
h
:
1-2
8
:
15
10
:
)
q
mg
100
mg
PO
approved
)
mg
or
IV
mg
kg
/
)
x
mg
1
12
h
approved
trimethoprim
-
-
double
12
h
mg
kg
trimethoprim
/
day
PO
/
(
Vancocin
kg
/
IV
mg
kg
/
q
12
q
dose
strength
q
IV
)
h
q
PO
12
8
h
,
then
divided
)
12
h
q
6
h
Photosensitivity
abdominal
,
diarrhea
pain
,
upper
Pregnancy
Children
8
<
years
No
renal
Unreliable
check
,
marrow
Bone
h
optic
neuropathy
Nausea
headache
marrow
Bone
rash
ing,hyperkalemia
dysfunction
Infusion
man
injury
suppression
neuritis
,
with
vomiting
,
,
hepatic
suppression
,
-
syndrome
,
nausea
related
reactions(red
or
,
diarrhea
and
)
,
rare
peripheral
use
2
>
weeks
,
dysfunction
,
vomit
-
,
renal
phlebitis
,
renal
Allergy
Allergytotigecycline
Allergy
Allergytovancomycin
uncontrolled
tension,and
use
of
use
also
patients
tetracyclines
to
trimethoprim
patients
folate
who
have
severe
prior
from
concurrent
inhibitors
MAO
caution
allergies
with
sulfonamides
,
pregnant
nursing
,
deficiency
developed
thrombocytopenia
therapy
,
-
hyper
Interaction
reuptake
inhibitors
to
Dosage
severe
for
Reserved
coverage
Poor
Requires
;
in
or
mothers,Monitor
or
those
creatinine
Administer
water
adjustments
Renal
.
Monitor
dose
to
Rate
of
man
red
adjustments
dose
streptococcus
antibiogram
local
selective
with
inhibitors
adjustment
hepatic
very
for
renal
potassium
with
and
necessary
is
impairment
resistant
against
adjustments
dose
and
glass
a
full
GAS
levelsorconsult
can
infusion
syndrome
be
occurs
coverage
serotonin
MAO
cases
serum
of
pharmacy
slowed
if
:
administeredtopically,orally,intramuscularly,orintravenously,depending onthespecificinfectionand theconditionofthepatient.
The most common adverse effects occurring with most antibiotics are nausea, vomiting, diarrhea, rashes, allergic reactions, and urticaria. Patients taking antibiotic therapy, especially for a prolonged duration,candevelopfungalinfectionssuchasvaginalcandidiasisorthrush.
A less common but potentially life-threatening adverse effect of antibiotic therapy is pseudomembranouscolitis.Thiscausesseverediarrheaandistheresultofovergrowthofthebacterium Clostridiumdifficile. Anaphylaxis andseizures (especiallywhenhighdosesofbeta-lactamantibiotics are used) mayalso occur. To minimize the riskoftheseevents, a thoroughpatient historyis essential beforeprescribingthesedrugs.Therearealsopotentiallymanyinteractionsbetweenantibioticsandother medications a patient might be taking. Since antibiotics are not without risk, it is important to limit durationtotheshortesteffectivecourse.Antibiotictherapyshouldbenarrowedtocoverthepathogenic organism when possible to limit adverse effects, save costs, and reduce development of resistance organisms.
Broad-SpectrumPenicillins
MostskininfectionsarecausedbyGASandS.aureus.Inthepast,therapywithpenicillinwasusually effective intreatingthese infections.Withthegrowingproblemof antibiotic resistance,however,it is now necessaryto choosea broad-spectrum agent.For example,manystrainsofS.aureus producethe enzyme penicillinase,whichcaninactivatepenicillin.Inthiscase,theprovidershouldchooseanagent that is penicillinase resistant. Useful agents in this class for treating specific skin infections include amoxicillin–clavulanate (Augmentin) or dicloxacillin (Dynapen). Penicillin usually still has good coverageofGAS,butlocalresistancepatternsshouldbecheckedtoshowsusceptibility.
Amoxicillin–clavulanate has bactericidal action against many organisms, including beta-hemolytic streptococci,S.aureus,E.coli,andProteusmirabilis(P.mirabilis).Theclavulanateportionofthedrug is a beta-lactamase inhibitor that allows amoxicillin to remain active inthe presence of certain beta­lactamase enzymes such as the penicillinase produced by S. aureus. Amoxicillin–clavulanate is well absorbedorallyandismoreresistanttoacidinactivationthanotherpenicillins.
Commonside effectsarenausea,vomiting, diarrhea,rash,andurticaria.Patientswhoare allergicto penicillinshouldnotbegiventhisagent,anditneedsdoseadjustmentswhenusedinpatientswithrenal dysfunction.
Dicloxacillin has bactericidal activity against penicillinase-producing strains of S. aureus. It is administered orally,andthe adverse effect profile is similar to that of amoxicillin– clavulanate. It is dosedfourtimesdaily,whichmaybemoredifficulttocomplywiththanamoxicillin–clavulanate,which isdosedtwicedaily(seeTable13.4).
First-GenerationCephalosporins
In this class, commonly used drugs for treating skin infections are cephalexin (Keflex) and cefazolin (Ancef). These agents have bactericidal activity against many organisms, including GAS and penicillinase-producing S. aureus. They also have activity against Klebsiella pneumoniae (K. pneumoniae),P.mirabilis,andE.coli.
Cephalexin is administeredorally andhas excellentbioavailability, while cefazolin isadministered intravenously.Theiradverseeffectprofilesaresimilartothoseofthebroad-spectrumpenicillins.These
drugs should not be used in patients with a severe penicillin or cephalosporin allergy, and dosage adjustmentsarenecessaryinpatientswithrenalinsufficiency(seeTable13.4).
Second-GenerationCephalosporins
Second-generation cephalosporins that are useful for skin infections include cefaclor (Ceclor), cefuroxime (Ceftin, Zinacef), andcefprozil (Cefzil).They are effective against the same organisms as first-generation cephalosporins but have additional activity against certain gram-negative organisms, including Haemophilus influenzae (H. influenzae), E. coli, K. pneumoniae, and Proteus organisms. Theseagentsareallwellabsorbedorallyandtheiradverseeffectprofilesaresimilartothoseofthefirst­generationcephalosporins.Theyshouldnotbegiventopatientswhohaveasevereallergytopenicillinor anallergytoothercephalosporins.Dosageadjustmentsarenecessaryinpatientswithrenalinsufficiency (seeTable13.4).
Third-GenerationCephalosporins
Useful third-generation cephalosporins for treating skin infections include cefpodoxime (Vantin), ceftriaxone (Rocephin), and ceftazidime (Fortaz). These drugs are usually reserved for more serious infectionsandarenottypicallychosenasfirst-lineagents.Inaddition,ceftriaxoneandceftazidimearenot availableasoralagents.Cefpodoximeisavailableonlyasanoralagent.
The spectrum of antibacterial activity for these agents is similar to that of the second-generation cephalosporins. However, theyare less effective against S. aureus andmore effective against certain gram-negative organisms, includingEnterobacter,H. influenzae, E.coli,K. pneumoniae,andProteus species.CeftazidimeistheonlyagentinthisgroupthatcanberecommendedforinfectionscausedbyP. aeruginosa. Ceftriaxone is absorbed intramuscularly, but this route of administration may be painful. Cefpodoximeiswellabsorbedorallywhentakenwithfood,althoughabsorptionislessthanthatoforal first-generationcephalosporins.
Theadverseeffectprofile fortheseagentsissimilar to thatoftheother cephalosporins andbroad­spectrumpenicillins.
Theseantibioticsneedtoberenallyadjustedinpatientswithrenaldysfunction,withtheexceptionfor ceftriaxone. Caution should be used before administering these medications to patients with severe penicillin or cephalosporin allergies and generally should be avoided. Rarely, ceftriaxone may cause pseudolithiasis(seeTable13.4).
Clindamycin
Clindamycin(Cleocin)isanalternativeagentthatcanbeconsideredfortreatingbacterialskininfections duetoS.aureusandGASwhenpatientsareallergictopenicillinsandcephalosporins.Susceptibilityto S.aureusincludingMRSAmaybelow,andtheclinicianshouldcheckthiswiththelocalantibiogram,if available.Inaddition,clindamycinmaybeconsideredwhengram-positiveanaerobicbacterialcoverage isnecessaryforpolymicrobialinfections.
Clindamycinisavailablefororalor IV administrationandisgenerallywelltolerated.Commonside effects include diarrhea, nausea, and abdominal pain. Also, this agent has been more commonly associatedwithC.difficile–associatedpseudomembranouscolitis.
Fluoroquinolones
Levofloxacin (Levaquin), moxifloxacin (Avelox), and ciprofloxacin (Cipro) are the fluoroquinolone antibioticsusedinthetreatmentofskinandskinstructureinfections.Theyareusefulforseriousinfections in patients with penicillin allergies that have infections caused by gram-negative organisms. Their spectrumofactivityincludesmanygram-negativebacteria,suchasE.coli,Klebsiella,andEnterobacter species. In addition, levofloxacin and ciprofloxacin are active against P. aeruginosa. Each fluoroquinoloneagentisavailableIVandorallyandeachhasexcellentbioavailability.
Commonadverse effectsare diarrhea,nausea, abdominalpain,dizziness,drowsiness,headache,and insomnia. Uncommon but severe events include Stevens-Johnson syndrome, seizures, Achilles tendon rupture,andpseudomembranouscolitis.Inaddition,therehavebeenseveralblackboxwarningsissued bytheFoodandDrugAdministration(FDA)regardingseriousadverseeffectssuchastendinitis,tendon rupture,peripheralneuropathy,centralnervoussystem(CNS)effects,andaorticrupturesortears.These agentsshouldbeusedaslast-linetherapy.Fluroquinolonesalsohaveseveraldruginteractions(seeTable
13.4).
Fluoroquinoloneantibioticsarenotrecommendedinchildrenyoungerthanage18orduringpregnancy and lactation. They are also contraindicated in patients allergic to other fluoroquinolones. These medicationsshouldbeusedcautiouslyinolderadultsandpatientswithCNSdiseases,seizuredisorders, orrenalimpairment.
AdditionalAntimicrobialAgents
Vancomycin,daptomycin,telavancin,dalbavancin,oritavancin,linezolid,tedizolid,andtigecyclinehave antibacterial activity against drug-resistant, gram-positive pathogens including MRSA. Vancomycin remains the drug of choice for bacterial skin infections due to MRSA when parenteral therapy is necessary; however, daptomycin, telavancin, dalbavancin, oritavancin, linezolid, tedizolid, and tigecyclinearealsoeffectivebutaremoreexpensiveoptions.Dalbavancinandoritavancinareuniquedue totheir verylong half-lives. As a result, treatment withdalbavancinrequires onlytwo dosesgiven1 weekapart,while oritavancinisindicatedtotreatbacterialskininfectionsusingonlyasingleIVdose. Linezolid and tedizolid are the only agents in this group thatare available orally,which provides an option for clinicianstoswitchfrom IVto oral therapy when patientsare clinicallystable but require additional treatment. Linezolid should not be continued for more than 14 days due to the increased incidenceofdevelopingseriousadverseeffects.Tedizolidisoftenusedfor6daysmaximumfora skin andsofttissueinfection,butitisveryexpensiveandoftenreservedforspecialcasesneedinginfectious diseasesconsultation.
DespitetheiractivityagainstMRSA,eachagenthassignificantsideeffects,andthepotentialfordrug– druginteractionsshouldbeconsideredpriortoinitiatingtherapy.
Sulfamethoxazole–Trimethoprim
Sulfamethoxazole–trimethoprim (SMX–TMP) is another useful agent for the treatment of MRSA infectionsthatcanbe managedwithoraltherapy.Itis important,however,to rememberthatthisagent doesnothavereliableactivityforinfectionscausedbyGAS.Therefore,thediagnosisofMRSAshould bemadepriortotreatment.
Adverse effects associated withSMX–TMPincludegastrointestinal (GI) intolerance,rash, pruritus,
andhyperkale–mia.Inaddition,thisagentmaycausephotosensitivity,andpatientsshouldbecounseledto wearsunprotectionduringtherapy.
TopicalAgents
Topicalagentsmaybeusedasfirst-linetreatmentoradjunctivelyinbacterialskininfections.Mupirocin ointmentiseffectiveagainstS.aureusandsomestreptococcalinfections.
Mupirocinointmentisminimallyabsorbedsystemically.Itismetabolizedbytheskinandusuallywell tolerated. Adverse effectsarefew butincludeheadache,cough,rhinitis, pharyngitis, upper respiratory tractcongestion,andtaste perversion withnasal use. Burning, stinging, rash, erythema, or itching can occurwhenappliedtopically.Mupirocinshouldnotbeusedinpatientswithanallergytothedrugand shouldnotbeusedwithothernasalproducts.
Thetopicalpreparationofgentamicinisavailableinacreamoranointment.Itisapowerfultopical agent and is effective againstmany organisms, including GAS, S. aureus, and Pseudomonas species. Topicalgentamicincanbeusedforavarietyofprimaryandsecondaryskininfections.Itisusuallywell tolerated,althoughirritationmayoccur.Occasionally,fungalinfectionorovergrowthofnon-susceptible bacteriamayoccuratthesiteofuse.
SelectingtheMostAppropriateAgent
Practice guidelinesareavailable toassistcliniciansinthemanagementofskininfectionsincludingthe selectionofappropriateantimicrobialtherapy(Stevensetal.,2014).Mostbacterialskinconditionsare treated empirically based on the prescriber’s knowledge of the organisms most likely to cause a particularinfection(Table13.5).Whentheorganismisnotknown,thepotentialforseriousinfectionis present, or if the patient is already extremely ill, the prescriber needs to confirm the diagnosis and organismeitherbyskinbiopsyorbywoundculture.Insuchcases,empirictreatmentbeginswithabroad­spectrumagentuntilorganismsusceptibilityisavailableandadiagnosisismade.
Otherimportantfactorsinchoosinganantibioticagentincludepatientallergies,pregnancystatus,renal andhepaticfunction,andage.Practicalconcernsthataffectcomplianceincludethetasteofthemedication (especiallyintreatingchildren),itsadverseeffectprofile,howfrequentlyitmustbetaken,andhowmuch itcosts.Anantibiotic agentmaybe changediftheconditiondoes notimproveorifintolerable effects impedecomplianceorposeadangertothepatient.Figure13.1givesanoverviewofthedrugselection process.
First-LineTherapy:ImpetigoandEcthyma
Forminorcasesofbullousandnon-bullousimpetigo,topicalmupirocinointmentappliedtwicedailyfor 5 days is recommended. For other cases of impetigo and ecthyma, an oral antibiotic with S. aureus coverage is prescribed for 7 days. A broad-spectrum penicillin (e.g., amoxicillin–clavulanate or dicloxacillin)orafirst-generationcephalosporin(e.g.,cephalexin)isagoodfirstchoice.Incaseswhere culturesaretakenandgrowGASonly,penicillinisrecommended.IfMRSAissuspectedorconfirmedor in those with a penicillin allergy, doxycycline, clindamycin, or SMX–TMP may be used. In many communities,S.aureus hasbecomeresistantto clindamycin. Clinicians needto checkwiththeir local antibiogramifavailable.Becauseofthedepthofulcerationandchronicnatureofecthyma,healingtakes weekstomonths,andscarringislikely. Debridementis painfulandnotrecommendedandunnecessary.
When there are outbreaks of streptococcal glomerulonephritis, IV penicillin should be used to help controlandeliminatenephritogenicGAS.
First-LineTherapy:CellulitisandErysipelas
Treatment for mild non-purulent cellulitis and erysipelas should begin promptly and usually on an outpatientbasiswithoralantibiotictherapy.AntibioticsshouldcoverGAS.PenicillinVK,amoxicillin– clavulanate, a cephalosporin such as cephalexin, clindamycin, or dicloxacillin would be acceptable options. Clindamycin should be reserved for those with a penicillin allergy. For those with mild infections caused by MRSA, oral options include SMX–TMP, a tetracycline such as doxycycline or minocycline,orlinezolid(Sartellietal.,2018).Treatmentdurationistypicallyfor5days,whichmaybe extendedifthereisnoimprovement.
Those with moderate cellulitis require parenteral therapy with penicillin, cefazolin, ceftriaxone, or clindamycin. For infections caused by MRSA, IV vancomycin, daptomycin, linezolid, ceftaroline, or dalbavancin can be used. Most commonly, IV vancomycin is used and these other agents are often reservedforinfectiousdiseasesspecialistsforspecialandcomplicatedcases.Severeinfectionsrequire emergency surgical inspection to rule out necrotizing infection. Broad-spectrum empiric antibiotic treatmentshouldbeinitiatedwithvancomycinandpiperacillin–tazobactam.Improvementusuallyoccurs rapidlywithinthefirst48hours.
Second-LineTherapy:CellulitisandErysipelas
Iftheinfectiondoesnotrespondtotheinitialcourseoftreatment,patientsshouldbepromptlyreferredor admittedforIVtherapy.Woundsthatbecomesecondarilyinfectedmayrequiredebridement,withfrequent cleansinganddressingchanges.Surgicaldebridementmaybenecessary.
First-LineTherapy:PurulentSkinInfections
Inallcasesofpurulentskininfectionssuchasabscesses,furuncles,andcarbuncles,incisionanddrainage areindicated.Inmildcases,antibioticsareusuallynotneededsincesourcecontrolhasbeenobtainedand no systemic signs of infection are present. In moderate cases, systemic signs are present andempiric therapywithSMX–TMPordoxycyclineshouldbestarted.Iftreatmentfails,itisthenconsideredasevere infection. Additionally, patients who present with fever, tachycardia, tachypnea, leukopenia, or leukocytosis or are immunocompromised should be treated as patients with severe infection. IV antibiotics withMRSA coveragesuchas vancomycin,daptomycin,linezolid,telavancin,orceftaroline shouldbe started. Pus obtainedfromincisionanddrainageinmoderate tosevere infectionsshouldbe cultured.Oncetheculturespeciatesandsensitivitiesareavailable,antibiotictherapyshouldbenarrowed as appropriate. In moderate infections, oral therapy with SMX–TMP for MRSA, or cephalexin or dicloxacillin for methicillin-susceptible Staphylococcus aureus (MSSA), may be used. In severe infections,de-escalationtocefazolin,nafcillin,oroxacillinmaybedoneifMSSAiscultured.Antibiotics shouldbegivenfor7to14daysforsevereinfections.
TABLE13.5
RecommendedOrderofTreatmentforBacterialSkinInfections
Infection First-LineTherapy Second-LineTherapy
Minorbullousand nonbullousimpetigo
TopicalmupirocinBID×5days Oralantibiotic×7daysorrefertoan
Infectiousdiseasesspecialist Impetigoandecthyma Oralantibiotic×7days AdmitforIVantibiotictreatmentorrefer Cellulitisanderysipelas Oralantibiotic×5days AdmitforIVantibiotictreatmentorrefer Furunclesand
carbuncles
Incisionanddrainage.Oralantibiotic×7days ifinfectioussymptomsnoted
Alternateoralantibioticorrefer
IV,Intravenous.
FIGURE 13–1 Treatment algorithm for impetigo, cellulitis, erysipelas, and other bacterial skin
infections.
Note:Ifthepatienthasnecrotizingfasciitis,admittohospitalandrefertospecialist.
Systemictherapy is notneeded for folliculitis, and it oftenheals withouttreatment in7 to10 days.
Topicalmupirocinorclindamycinmaybeusedincasesofwidespreaddisease.Moistheatapplications
canhelpdrainthepusinfolliculitisandmildfurunculosis.
Forpatientswithparonychia,soakingthefingerortoeinwarmwaterhelpswithspontaneousdrainage. For paronychias withabscesses or felons, incision and drainage is recommended. Antibiotics are not recommendedifnosystemsignsofinfectionarepresent.
Second-LineTherapy:PurulentSkinTissueInfections
Forskininfectionsthatfailoraltherapy,IVtherapyshouldbeconsidered.Additionally,recurrenceofa pustular infection in the samelocation should prompt a workup for a differential diagnosis suchas a pilonidalcystorotherdermatologicdisease.
First-LineTherapy:DiabeticFootInfections
Forulcersthatarenotinfected,antibioticsarenotrecommended.FormildtomoderateDFIs,patientscan betreatedintheoutpatientsettingwithoralantibioticscoveringS.aureusandStreptococcusiftheyhave notrecentlyreceivedantibiotics,inthepastmonth.Suchantibioticsincludecephalexinandamoxicillin– clavulanate.PatientswithsevereDFIswillrequireinpatientadmissionandinitiationofbroad-spectrum parenteralantibiotics.SomepatientswithmoderateinfectionsbutwithcertainriskfactorslikePADmay beinitiallytreatedasthosewithsevereinfections.Additionally,patientswhofailoutpatienttherapymay needtobeadmittedtoahospitalforparenteralantibioticsandfurtherworkup.
Empiric antibiotic coverage for pseudomonas is often unnecessary unless there are risk factors for pseudomonasinfection,suchas warmclimate,highlocalprevalence,or walkingbarefootinbodiesof water (Lipsky et al., 2012). Empiric coverage for MRSAshould be initiated in patients withsevere­appearing infection or prior history of MRSA infection or in areas where prevalence of MRSA colonizationorinfectionishigh.Patientswhohavereceivedantibioticsinthepastmonthshouldreceive antibioticcoverageagainstgram-negativebacilli.Coverageofanaerobicbacteriamaybeneededincases ofsevereDFIs.
Antibiotictherapyshouldbenarrowedonceculturesresultandsusceptibilitiesareavailable.Formild andmoderateDFIs,1to2weeksoftherapyistypicallysufficientandcanbestoppedonceclinicalsigns ofinfectionareresolved.Forpatientswhohaveboneinvolvement,a4-to-6-weekcourseofantibioticsis recommended(Boultonetal.,2018).Antibiotic therapywithoutappropriatewoundcare isinsufficient. Woundcarespecialistsshouldbe consultedifneededandavailable. For anyDFIwithnecrotictissue, debridementshouldbeperformed.
First-LineTherapy:NecrotizingFasciitis
Surgical debridement is needed emergently for the treatment of necrotizing fasciitis. Additional debridement isusuallyrequired tofully removeall necrotic tissue. Broad-spectrum empiric antibiotic therapyshouldbestarted.Anexampleofanempiricantibioticregimenfornecrotizingfasciitisincludes piperacillin–tazobactam, clindamycin, or vancomycin. Clindamycin is primarily used for its toxin and cytokinesuppressing properties. Once culture results are available, antibiotic therapy can be tailored appropriately. Antibioticsarecontinued for 48 to72 hoursafterclinical stability andwhennofurther proceduresareneeded.
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности