SSTI s :A Guideline for Effective Treatment of Skin and Soft Tissue Infections

Transcription

1 SSTI s :A Guideline for Effective Treatment of Skin and Soft Tissue Infections Dr. Javan S. Bass, FACFAS Metro Foot & Ankle Centers, PC Georgia Podiatric Association Board of Directors

2 Disclosures Bako Consultant

3 Patient 0 45 Y/O AA male SSTI Osteomyelitis BKA recommendation White Count 30.5

4 WC WC-26.3 WC-18.6 WC-10.1 WC-9.0

5 May 6 th Elevated WC -Disarticulated Talus

6 Guidelines UK Hospital multidisciplinary approach - reduced total amputation 40% - reduced major amputation 62% over 11yr Lost Financial Support = amputation rates rose Regained Support = amputation rates fell Krishnan et al Diabetes Care 2008

7 Antibiotics Resistance???????? -Spectrum -Course -Diagnosis

8 IDSA 10 questions 1. Which Diabetic wounds should I suspect infx 2. How should I assess a Diabetic pt. with infx 3. When and from whom should I consult 4. Which pt.'s to hospitalize, when to discharge 5. How to culture, when to culture Lipsky et al 2012

9 IDSA 10 Questions 6. How to select and modify and abx regimen 7. When to consider imaging studies 8. How to diagnose and treat Osteomyelitis 9. Which patients warrant surgical intervention 10.Which wound care techniques are appropriate Lipsky et al 2012

10 IDSA Recommendations Which Diabetic wounds should I suspect infx -Probe to bone positive -Previous amputation -Ulceration > 30 days -Sensory loss -History of recurrent ulcers -Renal Insufficiency -Traumatic wounds -Hx of barefoot walking -PVD of affected limb Lipsky et al 2012

11 Conservative Fail

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13 IDSA Recommendations Which pt.'s to hospitalize, when to discharge -All patients with severe infection -Moderate infx, with complications PVD or Lack of home support -Psychological vs Social Non-compliance (initially) -Failed Outpatient therapy Lipsky et al 2012

14 Discharge? cont. Which pt.'s to hospitalize, when to discharge -Clinically Stable (no admit for wound care) -Urgent surgery completed -Glycemic control -Discharge plan arranged i.e. abx, home care, wound care, offloading, F/U Lipsky et al 2012

15 IDSA Recommendations How to culture, when to culture -No culture for clinically uninfected -Culture prior to empiric therapy -Culture deep tissue post debridement Lipsky et al 2012

16 Culture? Cont. Avoid swab specimen -less accuracy -often contaminated, -fail to yield deep pathogens -less likely to grow anaerobic/fastidious aerobic Lipsky et al 2012

17 Antibiosis Today Diagnoses -69 pt., poor concordance between wound culture swabs and percutaneous bone biopsies (22.5%) Senneville et al CID 2006

18 How to select and modify and abx regimen -Mild to Moderate Infections -targeting GPC sufficient -oral therapy 1-2 weeks -no evidence supporting abx for wound care Lipsky et al 2012

19 Antibiotic cont. Moderate to Severe infections -Broad spectrum parental therapy pending cx with switch to oral therapy Lipsky et al 2012

20 Antibiotic cont. Pseudomonas aeruginosa -Usually unnecessary unless specific risk factors -Usually a non-pathologic colonizer -Recent studies report < 10% isolated -Pt s improve despite inadequate abx Lipsky et al 2012

21 Antibiotic cont. MRSA -History of MRSA or colonizer within 1 year -Local prevalence is high -Severe infection with elevated risks Lipsky et al 2012

22 IDSA Recommendations How to diagnose and treat Osteomyelitis -Suspect osteo for wounds > 6 weeks old -Negative PTB test does not exclude osteo -2-5 day course of abx with clean proximal margin ->4 week course when margins remain infected Lipsky et al 2012

23 (fast healing) Biologics (neutralize infection) Antibiotic (prevent recurrence) Surgery

24 Patient WC WC-26.3 WC-18.6 WC-10.1 WC-9.0

25 Bead Therapy

26 Local Antibiotic Delivery Systemic side effects Delivery Site Inhibition Antibiotic toxicity Direct Administration Maintain elevated local levels of antibiotic

27 Local Antibiotic Delivery Active against common pathogens (osteo) Local concentration exceed (several times) MIC Should not - enter circulation - provoke adverse side effects - or be unstable at body temp Kanellakopoulou K et al Drugs 2000

28 Bead Therapy Non-Biodegradable -Polymethylmethacrylate (PMMA) Biodegradable -Calcium sulfate (CaSO4) -Hydroxyapatite (HA) -Protein materials -Synthetic polymers

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32 (fast healing) Biologics (neutralize infection) Antibiotic (prevent recurrence) Surgery

33 1st Clinic Visit 42 Y/O Diabetic PVD HTN Staph Infection BKA Recommendation

34 2 Applications 7 Weeks Limited Debridement

35 2 Applications 8.5Weeks Non-Compliance

36 3 Applications 11 Weeks

37 4 Applications 15 Weeks Non-Compliance

38 4 Applications 17 Weeks

39 20 Weeks

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41 Metro Foot and Ankle Centers, P.C Metrofootanklepc.com