ENDOCARDITIS (Arch Intern Med 2009;169(5):463)
History
• RFs: IVDU, congenital or acquired valvular dz, prosthetic valves, structural heart dz, HD, indwelling venous catheters, cardiac surgery, bacteremia, chronic alcoholism, previous endocarditis
• Difficult to Dx 2/2 nonspecific sx (lethargy, weak, anorexia, low-grade temp), or negative w/u
Findings
• Fever (96%), new murmur (48%), CHF (32%), splenomegaly (11%), petechiae
• Classic physical exam findings
• Roth spots (2%): Exudative, edematous retinal lesions w/ central clearing
• Osler nodes (3%): Violaceous tender nodules on toes & fingers
• Janeway lesions (5%): Nontender, blanching, macular plaques on soles & palms
• Splinter hemorrhages (8%): Nonblanching, linear, reddish-brown under nails
• Septic emboli (mitral valve vegetations)
Diagnosis
Evaluation
• EKG, CBC, Chem, coags; CXR, ↑ ESR/CRP (nonspecific), ≥2 blood cx
• Typically Staph or Strep species; also gram-negative bacilli, Candida (prosthetic)
• Echo for vegetations or valve ring abscesses; TEE more sens than TTE
Treatment
• Hemodynamic stabilization if valve rupture, can present w/ acute pulmonary edema cultures
• Immediate abx in suspected cases, preferably after blood cultures (see table)
Disposition
• Admit w/ continuous telemetry & IV abx, ICU if hemodynamic compromise
Pearls
• Infection of endothelium of heart (including but not limited to valves)
• Consider cardiac surgery consultation for refractory CHF, fungal endocarditis, recurrent septic emboli, conduction disturbance, persistent sepsis, aneurysm rupture of sinus of Valsalva, kissing infection of anterior mitral leaflet w/ aortic valve endocarditis
• Mortality w/ native valve dz: ∼25%; prosthetic valve higher
• Worse prognosis if involves aortic valve, DM, S. aureus (30–40%)
• Left-sided endocarditis (mitral 41%, aortic valve 31%) most common
• IVDU: Tricuspid valve endocarditis; rheumatic valve dz: Mitral, then aortic valve
ABSCESS
Approach
• ↓ activity of infiltrated local anesthetic agents b/c of the low pH of abscess area; consider regional nerve or field blocks + IV procedural sedation/analgesia
• Gram stain & wound cx rarely necessary for skin or perirectal abscesses
• Cx from intra-abdominal, spinal, or epidural abscesses usually sent from OR to guide therapy
• Pharyngeal abscess cx can also help tailor antibiotic therapy
• In diabetic, immunocompromised, w/ systemic sxs, septic, obtain labs & blood cultures, start IVF & abx & admit for IV abx
SOFT TISSUE
Cutaneous Abscess (Clin Infect Dis 2005;41(10):1373)
History
• ↑ pain, tenderness & induration, usually w/o h/o fever or systemic tox
• Disruption of skin from trauma or penetrating injury, often pt cannot recall injury
• H/o IVDA/skin popping, prior MRSA abscesses
Findings
• Exquisitely tender, soft, fluctuant mass surrounded by erythema
• Most commonly Staph species, often polymicrobial
Evaluation
• Blood work rarely needed unless appear systemically ill; US may help w/ localization
• Culture from abscess only if tx w/ abx, severe infection, systemic illnesses, failed initial tx
Treatment
• No abx indicated in healthy hosts unless cellulitis, fever, immunosuppression, failed I&D
• I&D w/ regional nerve or field block ± procedural sedation
• Create elliptical incision to prevent premature wound closure
• Break up loculations in abscess cavity w/ hemostat
• Consider irrigate & pack w/ 1/4-in gauze × 48 h (24 h if cosmetically important)
• If surrounding cellulitis, nafcillin 2 g IV q4h, cefazolin 1 g IV q8h, or cephalexin PO
• If for complicated abscess: Clindamycin, Bactrim, tetracycline, linezolid, vancomycin
Disposition
• D/c w/ wound care instructions, 2-d f/u
• Warm soaks TID × 2–3 d after removal of packing to allow continued wound drainage
Pearl
• Can develop essentially anywhere: Furuncle, acne, skin breakdown, insect bites
• Routine packing of abscesses after I&D is controversial
Paronychia
History
• Pain & swelling lateral to nail edge; superficial infection of epithelium
• No inciting injury but can be secondary to contaminated nail care instruments or trauma
Findings
• Purulent collection lateral to nail bed w/ minimal surrounding erythema
• Most commonly Staph or Strep species but can have mixed aerobic & anaerobic flora
Evaluation
• No labs necessary
Treatment
• No abx indicated in healthy hosts
• Digital block w/ 1% lidocaine with or without epinephrine in each web space of affected digit
• #11 blade scalpel to lift cuticle from nail on affected side & express purulent material
Disposition
• D/c w/ wound care instructions, 2-d f/u
• Warm soaks to finger TID × 2–3 d to allow complete drainage
Pearls
• Often h/o manicure/pedicure, nail biting
• If recurrent or chronic paronychia, consider Candida infection
• May spread to pulp space of finger (felon) or deep spaces of hand, tendon if neglected
Pilonidal Cyst
History
• Painful, tender abscess in alar cleft, often in obese or hirsute individuals
• More prevalent in males; fever & systemic tox very rare
Findings
• Painful, localized abscess in natal cleavage/midline sacrococcygeal region, 4–5 cm posterior to anal opening; surrounding erythema & fluctuance
• Mixed flora: Staph or Strep species, anaerobic cocci, mixed aerobic & anaerobic flora
Evaluation
• No labs necessary unless systemically ill
Treatment
• Same as for cutaneous abscess, I&D
• Surgical referral for excision of follicle & sinus tract after acute episode subsides
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
Pearls
• High recurrence rate (40–50%) unless follicle surgically removed
• Thought to be caused by hair penetrating into subcutaneous tissues creating abscess
Bartholin Gland Cyst/Abscess
History
• Severe localized pain in labia caused by obstructed Bartholin duct
• Difficulty walking & sitting secondary to pain
• Fever & signs of systemic tox are rare
Findings
• Painful, tender, cystic mass on inferior lateral margin of vaginal introitus, often w/ purulent drainage from sinus tract
• Typically anaerobes, MRSA, also Staph, Strep, & E. coli species, chlamydia, gonorrhea
Evaluation
• Culture for chlamydia, gonorrhea
Treatment
• I&D through mucosal surface, place Word catheter ×48 h
• Sitz baths TID for the 1st 2–3 d to assist drainage
• Gyn f/u for consideration of marsupialization to prevent recurrence
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
Pearl
• Recurrence rate still 5–15% after marsupialization; consider gyn malignancy
PERIRECTAL Abscesses (Int J Colorectal Dis 2012;27:831)
History
• Pain & swelling in rectal area w/ defecation & often w/ sitting down or walking
• High fever & signs of systemic tox are rare
• Pts often have h/o Crohn dz, obesity, DM, or PID
Findings
• Rectal exam essential to ensure abscess localized outside of anal sphincter & to identify upper extent of abscess
• Typically E. coli species, Enterococcus, Bacteroides species, S. aureus, MRSA
Evaluation
• Lab studies unnecessary unless systemically ill
• DM or immunocompromised should have Chem, CBC
• CT/MRI if concern for intersphincteric or supralevator or postanal abscess or fistula
Treatment
• ED I&D of superficial abscesses outside the anal verge w/ visible indurated area
• Pain control; I&D extremely painful, procedural sedation often needed
• If abscess is only identified on rectal exam & no induration visible, refer to surgery for I&D under general anesthesia
• DM or immunocompromised pts should undergo I&D in OR to ensure full drainage
• Pack w/ Vaseline gauze ×48 h, Sitz baths TID for 1st 2–3 d to assist drainage
• No abx for healthy host w/ superficial abscess
• Consider abx for immunocompromised, prosthetic device/valve, incomplete I&D
• Levofloxacin 500 mg QD (ampicillin 1 g + gentamicin 80 mg q8h) + metronidazole 500 mg q8h, consider vancomycin
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
• Admit diabetic & immunocompromised for IV abx
Pearls
• 35–50% treated w/ I&D or spontaneous drainage will develop chronic anal fistula
• Bilateral tenderness raises possibility of “horseshoe” abscess
INTRACRANIAL ABSCESS
History
• Caused by contiguous spread (sinus, ear, dental), hematogenous seeding from distant infection, (endocarditis) or post-CNS surgery/penetrating trauma
• HA (70–90%), fever (50%), meningismus, photophobia, sz (30%), vomiting (25–50%), AMS
• Subacute time course (vs. meningitis or encephalitis)
Findings
• Focal neuro deficits, low-grade fever, obtundation (mass effect), sz, AMS, nuchal rigidity (25%), papilledema (10–50%)
• Wide variety of organisms depending on method of entry, 1/3 polymicrobial
Evaluation
• Blood cultures, CBC (WBC nonspecific), Chem, coags
• CT scan w/ & w/o IV contrast; MRI more sens for cerebritis, posterior fossa lesions
• CSF findings nonspecific, avoid LP
Treatment
• Emergency neurosurgical consult for drainage in OR; airway management, sz tx
• Early IV abx w/ good CSF penetration, tailored to likely pathogen
• Start broad-spectrum IV abx: Ceftriaxone 2 g + vancomycin 1 g + metronidazole 500 mg
• Corticosteroids ONLY for tx of cerebral edema: Decadron 10 mg IV × 1 then 4 mg q6h
Disposition
• Neurosurgical intervention for operative washout, 6–8 wk IV abx then 4–8 wk PO abx
Pearls
• Mortality 24–27%, unless abscess ruptures into ventricular system (mortality 80%)
• Morbidity from residual neuro deficits, new sz from scar tissue or neuropsych Δ (50%)
SOFT TISSUE INFECTIONS
Approach
• Careful hx, associated sxs (V/D, cough, abd pain, AMS), progression
• Check blood sugar if diabetic
• Assess VS for significant abnormalities that may indicate serious infection (↓ BP, ↑ HR)
• If immunosuppressed (HIV/AIDS, elderly, malnourished, chronic steroids) or neutropenic, more intensive eval & testing: CBC, Chem, UA & cx, CXR; consider blood cx & admission
• If recent foreign travel: Consider travel-related infectious etiologies
DERMATOLOGIC
Cutaneous/Subcutaneous Cellulitis (Clin Infect Dis 2005;41(10):1373)
History
• Often no h/o broken skin; ± local trauma, recent surgery, FB
• May report fever, chills, malaise
Findings
• Warm, blanching erythema & tenderness to palpation, mild to moderate swelling
• ± distal skin disruption (eg, tinea pedis b/w toes w/ cellulitis of anterior shin)
Evaluation
• If elevated BS, check Chem, UA; Rule out abscess clinically or with bedside ultrasound
• Consider blood cultures, CBC w/ differential, chemistries, CRP, CPK in systemically ill pts
• Bacterial cultures of inflamed area not indicated; only 10–50% positive
• Most often caused by Strep or S. aureus (including MRSA); can be from metastatic seeding
Treatment
• If LE cellulitis, recommend rest & elevation × 48 h, crutches if needed
• PO abx: cephalexin 500 mg PO QID, dicloxacillin 500 mg PO QID, or Augmentin 500 mg PO TID
• IV abx: Cefazolin, ceftriaxone, nafcillin
• If PCN allergic: clindamycin 500 mg PO QID, or azithromycin 500 mg PO × 1, then 250 mg PO × 4 d, levofloxacin 500 mg QD × 5 d
• If diabetic or immunocompromised, use broader coverage abx
• Consider MRSA coverage: Vancomycin, gentamicin, tetracyclines, Bactrim, rifampin, Daptomycin, linezolid
• Pain control w/ NSAID/APAP; if severe pain consider necrotizing infection
• Wound débridement if infected, contaminated or devitalized wound
• Surgery consult if aggressive/necrotizing infection/gas in soft tissue
Disposition
• D/c w/ PO abx & 24–48 h f/u, strict return instructions
• Admit if signs of systemic infection, DM, immunocompromise, failure of outpt tx
Pearls
• Due to inflammation of dermal & subcutaneous tissue due to nonsuppurative bacteria, infection does not involve fascia or muscles
• Consider Doppler vascular studies in single limb w/ diffuse swelling, posterior calf or medial thigh to rule out DVT
• Mark border w/ permanent ink, write time & date
Erysipelas
History
• Extremes of age, obesity, DM, CHF, postop, nephrotic syndrome at higher risk
• Acute onset pain, erythema, induration
• Initial fever & chills followed by painful rash 1–2 d later
• May have systemic sxs: Myalgias, arthralgias, nausea, HA
Findings
• Skin painful superficial, indurated, raised; erythema w/ sharply demarcated border
• Irregular erythema w/ lymphangitis, may see desquamation, dimpling, vesicles, LAD
• 70–90% found on lower extremities, 5–20% on face, 5–6% on upper extremity
Evaluation
• None indicated unless toxic appearing
Treatment
• PCN G, amoxicillin, cefazolin 1 g IV q8h or azithromycin 500 mg PO
• PCN allergic: Azithromycin, clindamycin, levofloxacin
Disposition
• D/c w/ PO abx & analgesics, elevate affected area, 24–48 h f/u, strict return instructions
Pearls
• Typically caused by group A β-hemolytic streptococcus; involves dermis, hypodermis, & lymphatics
• More superficial than cellulitis
• Recurrence rate 10–40%
Staphylococcal Scalded Skin Syndrome (SSSS) (Am J Clin Dermatol 2003;4(3):165)
History
• Young children <5 yr, rare in adults, fairly rapid progression of prodromal sore throat, conjunctivitis, fever, malaise to painful red skin w/ sloughing
Findings
• No mucous membrane involvement (vs. TEN)
• Erythematous cellulitis followed by acute exfoliation: Bullae, vesicles → large sheets of skin loss resulting in scalded-appearing skin
• General malaise, fever, irritability, tenderness to palpation, does not appear severely ill
Evaluation
• None indicated unless systemically ill
• Positive Nikolsky sign (epidermis separates when pressure applied)
Treatment
• Similar to burns (IVF, topical wound care, burn consult)
• Most recover w/o abx but still recommended: Nafcillin, vancomycin, clindamycin
Disposition
• Admit for burn care, IVF; consider ICU
Pearls
• Caused by exfoliative exotoxins of S. aureus, reports of MRSA
• Separation of epidermal layers vs. more severe TEN (necrosis at level of basement membrane)
• Prognosis: Children (4% mortality) often w/o significant scarring; adults (60% mortality)
Toxic Shock Syndrome (TSS)
History
• Multiple sxs: Prodrome, pain at site of infection (out of proportion to findings), fever, chills, N/V, abd pain, watery diarrhea, myalgias, arthralgias, pharyngitis, HA, AMS
• Recent surgery, infrequently changed packing (tampons, nasal packing)
Findings
• Clinical Dx w/ findings from all organ systems:
• Temp >38.9°C, ↓ BP (shock/hypovolemia), rash
• “Sandpaper” diffuse, macular rash initially on trunk → spread to arms, legs, palms, soles → flaking full-thickness desquamation, 5–12 d after onset
• Involvement of 3 organ systems (see table)
Evaluation
• CBC w/ differential, Chem, UA, LFTs, coags, cultures (blood, urine, throat)
Treatment
• Remove tampon or packing if still in place, drain abscesses if present; burn care
• Aggressive resuscitation, pressors if needed, Foley catheter to monitor urine output
• Abx, may not have impact (toxin-mediated process); tx any identified source
• Nafcillin, vancomycin, clindamycin to suppress bacterial toxin synthesis; linezolid
• High-dosed steroids reported to improve TSS in case reports
• IVIG 400 mg/kg IV (has antibodies to TSS-1 & other exotoxins) for very ill pts w/ pulmonary edema or who require mechanical ventilation may reduce mortality
• Surgical consult if debridable sources of infection
Disposition
• ICU admission
Pearls
• Rate ↓ w/ ↓ in use of superabsorbent tampons
• Caused by inflammatory response to TSST-1 enterotoxin from Strep & Staph species
• Strep: Usually after surgery or trauma; scarlet fever-like rash; 30–70% mortality, fulminant
• Staph: More indolent, 5% mortality
• Poor prognosis, mortality as high as 70%, 30–50% recurrence, most w/i 2 mo
Necrotizing Fasciitis
History
• H/o mild trauma, often diabetic, PVD, EtOH abuse or nutritionally compromised
• Sudden onset of pain & swelling which progresses to anesthesia
Findings
• Fever, tenderness, erythema, toxic appearing
• Pain out of proportion to exam &/or numbness, crepitus
• Rapidly spreading, progressive erythema/infection of deep fascia w/ secondary necrosis of subcutaneous tissues, subcutaneous air (due gas-forming organisms)
• Can progress to involvement of deeper layers, causing myositis or myonecrosis