Cellulitits and SSTI (Inpatient)

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Cellulitis is one of the most common outpatient presentations and is pretty straightforward. Yet, inpatient management can be a bit more complicated. Here's an approach from @pointofcaremed along with some high-yield pearls! - Thread - #MedEd #MedTwitter #FOAMed #POCM

Check out some of the @pointofcaremed digital resources! Template: pointofcaremedicine.com/infectious-disease/cellulitis-and-ssti Podcast: anchor.fm/pointofcarepodcast/episodes/Cellulitis-and-SSTI-Inpatient-e1urv9f YouTube: youtu.be/9DeTW7jfgm8

Skin and soft tissue infections (SSTIs) is the umbrella term including all infections of the epidermis, dermis, subQ tissue, and superficial fascia. Cellulitis is an acute spread of infection along the dermis and/or subQ tissue. The diagnosis of cellulitis is clinical.

Some criteria that suggest a patient would benefit from an inpatient admission: - failed outpatient PO treatment - systemic symptoms - purulence - risk factors for MRSA or PsA - need for imaging due to c/f necrotizing infections

Here's a checklist of other things to think about when admitting a patient with cellulitis. Chart Check: - Prior micro data - Recent abx use - IV Drug use - Immunosuppression Can't Miss - gas gangrene - necrotizing fasciitis - septic joint - DVT

Here's a sample HPI intake when you meet the patient. Common MRSA RF's: IVDU, dialysis, recent hospital encounters, athletes Common PsA RF's: neutropenia, penetrating trauma, post-op

On exam, you should note: - erythema - warmth - pain - edema - poorly vs well demarcated - purulence or fluctuance - necrosis or crepitus - lymphadenopathy - strength/sensation of limb

Key diagnoses to keep on your ddx: Most Common - Gout - DVT - Contact and Stasis Dermatitis Can't Miss - septic joint - necrotizing fascitis Rarer - Pyoderma gangrenosum - Sarcoid - Zoster - Calciphylaxis - Erythema Migrans

Here's a sample workup. Key takeaways: - BCx have low yield unless systemic symptoms or RF's - wound cultures are most valuable if there is a concern for resistant organisms - US can evaluate for abscess - CT can evaluate for deeper severe infection

In most situations, treatment will initially be with IV abx, and then narrowed to a PO option. If there was an abscess or purulence, the PO option will usually cover for MRSA unless a susceptible bug is grown. Key exception is nec fasc which is a surgical emergency.

EMERGEncy ID Net Study suggested MRSA was the most common identifiable cause of SSTI in patients presenting to the ED in U.S. Susceptibilities - Clinda - 95% - Bactrim - 100% - Tetracycline - 92% But go based on your local antibiogram! pubmed.ncbi.nlm.nih.gov/16914702/

Some Key Pearls: - if purulence, think staph (specifically MRSA) - If bilateral, you should strongly consider other diagnoses - Erythema may worsen after starting abx, but should improve within 72 hours - ALT-70 Score - points for asymmetry, age >70, WBC >10L, HR >90

Classic Associations - Gas Gangrene - C. Perfringens - Dog/Cat Bites - pasteurella - Human Bites - eikenella, oral anaerobes - Freshwater - aeromonas, plesiomonas - Saltwater - vibrio vulnificus - Neutropenia - pseudomonas - Immunocompromised - nocardia, fungi

If you remember nothing else: - most commonly caused by staph and strep - if purulent, more likely staph, and should cover for MRSA - rarely bilateral - should think of other ddx - can't miss necrotizing fasciitis, DVT, septic joint

Here's a @GlassHealthHQ page with this summarized content. glass.health/pages/b96f7e88-b1ca-43a6-8687-338d256e553a/