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
Disclosures Bako Consultant
Patient 0 45 Y/O AA male SSTI Osteomyelitis BKA recommendation White Count 30.5
8-8-14 WC- 30.5 8-12 8-15 8-27 8-29 WC-26.3 WC-18.6 WC-10.1 WC-9.0
May 6 th 2015 - Elevated WC -Disarticulated Talus
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
Antibiotics Resistance???????? -Spectrum -Course -Diagnosis
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
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
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
Conservative Fail
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
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
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
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
Antibiosis Today Diagnoses -69 pt., poor concordance between wound culture swabs and percutaneous bone biopsies (22.5%) Senneville et al CID 2006
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
Antibiotic cont. Moderate to Severe infections -Broad spectrum parental therapy pending cx with switch to oral therapy Lipsky et al 2012
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
Antibiotic cont. MRSA -History of MRSA or colonizer within 1 year -Local prevalence is high -Severe infection with elevated risks Lipsky et al 2012
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
(fast healing) Biologics (neutralize infection) Antibiotic (prevent recurrence) Surgery
Patient 0 8-8-14 WC- 30.5 8-12 8-15 8-27 8-29 WC-26.3 WC-18.6 WC-10.1 WC-9.0
Bead Therapy
Local Antibiotic Delivery Systemic side effects Delivery Site Inhibition Antibiotic toxicity Direct Administration Maintain elevated local levels of antibiotic
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
Bead Therapy Non-Biodegradable -Polymethylmethacrylate (PMMA) Biodegradable -Calcium sulfate (CaSO4) -Hydroxyapatite (HA) -Protein materials -Synthetic polymers
(fast healing) Biologics (neutralize infection) Antibiotic (prevent recurrence) Surgery
1st Clinic Visit 42 Y/O Diabetic PVD HTN Staph Infection BKA Recommendation
2 Applications 7 Weeks Limited Debridement
2 Applications 8.5Weeks Non-Compliance
3 Applications 11 Weeks
4 Applications 15 Weeks Non-Compliance
4 Applications 17 Weeks
20 Weeks
Metro Foot and Ankle Centers, P.C Metrofootanklepc.com Info@metrofootanklepc.com Javanbass@yahoo.com I.G. @drjavanbass 770-484-9599