"What's new in Infectious skin diseases" Prof. Dr. med. Kathrin Mühlemann Dep. of Infectious Diseases, Inselspital Institute for Infectious Diseases, University of Bern
Disclosure Educational Grant with Pfizer AG: Surveillance of S. pneumoniae Support Novartis: ECCMID conference Milano May 2011
Community-acquired MRSA infections Skin-/soft tissue infections Insect sting Relapsing Clustering (family, etc.) Severe infections necrotising fasciitis necrotising pneumonia Virulence factor PVL (Panton-Valentine leukocidin) in CH MSSA 1-2% MRSA 15-40-?% depends on clonality MRSA = Methicillin-resistant Staphylococcus aureus PVL = Panton-Valentin Leukocidin toxin Recommendations for infection control measures in outpatient practice www.ifik.unibe.ch/infektiologie/spitalhygiene
Community-acquired MRSA an STI?
S. aureus methicillin-resistant (MRSA) USA 1999-2005 MRSA hopitalized Clinical manifestations ICAAC/IDSA 2008; Pallin D Ann Emger Med 2008; Van Loo I et al. Emerg Infect Dis 2008
Susceptibility (%) in community S. aureus from skin infection, Kanton Bern 2009/2010 Oxacillin Erythromycin Clindamycin Trimethoprimsulfamethoxazole Ciprofloxacin Tetracycline Rifampicin Vancomycin 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Susceptible Routine Active surveillance Kronenberg et al. Clin Microb Infect In press
Procalcitonin in autoimmune disease Sensitivity 53% Specificity 97% PCT value <0.5 ng/ml does not exclude invasive bacterial infection n 15 PCT elevated: -M. Wegener - M. Still - Kawasaki disease n 14 Buhaescu I et al Semin Arthr Rheum 2010;40:176-83; Tamaki K et al. J Rheumatol 2008;35:114-9
Erysipela DD infectious phlegmona / necrotising fasciitis DD non-infectious (thrombosis, Stauungsdermatitis, systemic disease, ) MICROBIOLOGY: S. aureus, Group A streptococcus,.. Risik factors for unusual microbes / resistance - long antibiotic treatment last 3 months - Known colonisation - Immunsuppression / aplasia last 3 months - Diabetes with end organ disease ( P. aeruginosa) DIAGNOSTICS: Blood cultures (2x 2-3) Local sample is possible Take biopsy / puncture if possible (swabs lower yield!!!)
Empirical Treatment 1. Choice Amoxicillin / Clavulanic acid tid 2. Choice Clindamycin Duration skin / soft tissue infection: according to clinic (1-2 weeks)
Risk for non-severe infection and immunsuppression Dixon WG et al. ARD 2011
Screening for latent tuberculosis History Tuberkulosis - treated? Haushold contact prophylaxis? Stay 6 Mo in high prevalence region Thorax Rx Specific signs Aktive Tbc? Laboratory IGRA (Mantoux?) * Beglinger C et al. SMW 2007;137:621
Chemoprophylaxis for latent tuberculosis Isoniazid: 300 mg qd 9 Months Hepatoxicity Rifampicin: 10 mg / kg qd 4 Months P450 interaction Hepatoxicity (Rifampicin / Pyrazinamid 3 Months Hepatoxicity!)
Opportunistic infections Infliximab Etanercept p n/10 5 n/10 5 Tuberculosis 54 28 <0.001 Atypical mycobacteria 11 6 Candidiasis 10 5 Aspergillosis 9 6 Listeriosis 8 0.8 Nocardiosis 4 0.8 Pneumocystosis 0.5 1 Legionella 0.5 0 0.06 0.06 <0.001 Tbc Risk: Adalimumab Infliximab Wallis RS Lance Infect Dis 2008
Treatment of Herpes zoster Indication: Effect: >50j, strong pain, sensitive location (eye) Duration, postherpetic neuralgia Start as early as possible Aciclocvir 5x 800mg /d po Valaciclovir 3x 1000mg /d po 7 Tage Famciclovir 3x 500mg /d po Brivudin 1x 125mg /d po (CAVE: 5-FU, 5-Fluoropyrimidine) Severe presentation, immunsuppression Aciclovir 3x 5mg/kg iv per d 7-10 d Pain treatment: Local disinfection: Prevention of postherpetic neuralgia? CAVE: bacterial super infection Kempf W et al. Swiss recommendations. Swiss Med Wkly 2007
Herpes viruses DIAGNOSTICS Viral detection: PCR, direct IF, culture Viral transport medium
Prevention of Herpes zoster: VACCINE Vaccine: Zostavax, attenuated live vaccine Strain Oka/Merck: 19 400 PBE >50 yrs, 1 dose s.c., ~CHF 250.- EKIF/SFOPH: no official recommedation to vaccinate cost-benefit not given Protection from HZ: ~50% (but >70 yrs 38%) Symptoms: 21 versus 24 days (intensity ) Protection from neuralgia: only if >70 yr: 9.8% vs 18.5% Duration? >3 years? BAG Bulletin, 8.2.2010