The Skin and Beyond: Skin and Soft Tissue Infections John Sinnott, MD, FACP Associate Dean, International Affairs Director, Signature Program in Allergy, Immunology and Infectious Disease Director, Division of Infectious Disease University of South Florida, College of Medicine

Pretentious Quote: … [T]he skin has diseases, one of those diseases is man. Friedrich Nietzsche

In General: Skin Lesions   Tumors Rashes

Melanoma: A symmetric B order — irregular C olor — pigment variable D iameter > 0.5 cm

Skin Infections: LAYERINFECTION EpidermisImpetigo DermisErysipelas SubQCellulitis FasciaFasciitis-(NSTI) MuscleMyositis- (NSTI)

Pathogens: Impetigo contagiosum – GAS Impetigo bullosum – Staph Erysipelas – GAS Cellulitis – Staph, GAS Fasciitis – GAS, Mixed Myositis – Clostridia

CA-MRSA: NB CA – MRSA is increasing and may become more like HA- MRSA DM, prisoners, contact sports are old risk groups; now everyone is at risk

Variant Cellulitis: Bites or Water ! Human Bite:GAS anaerobes Dog Bite:C. canimorsus P. multocida Cat Bite:P. multocida Saltwater:V. vulnificus M. marinum Fresh water:E. tarda A. hydrophila

Edwardsiella: Treatment All Edwardsiella sensitive to: –Tetracyclines, aminoglycosides, most B-Lactams, cephalosporins, quinolones, antifolates All Edwardsiella resistant to: –Macrolides, streptogramins, glycopeptides, rifampin, PRSP’s Stock I, Wiedemann B. Natural Antibiotic Susceptibilities of Edwardsiella tarda, E. ictaluri, and E. hoshinae. Antimicrob Agents Chemother, 2001 August; 45 (8): Harrison's Principles of Internal Medicine, 16th Edition. Kasper D, Braunwald E, Fauci A, et al, Eds. 134:

Necrotizing Soft Tissue Infections: “NSTI’S” Fournier’s gangrene Clostridial anaerobic cellulitis Clostridial gas gangrene Necrotizing fasciitis –Type 1 NF- polymicrobial (Fournier’s) –Type 2 NF- Grp A Strep (IVIG, HB O 2 )

Gas in Soft Tissue: Non-bacterial Causes –Trauma / Surgery –Air Injection –H 2 O 2 Irrigation Bacterial –Glucose Fermenting

Diagnosis NSTI’s: Serial exams! Soft tissue X- ray, MRI, CT Low threshold for surgery –Full thickness frozen-section Bx –Direct visualization –Gram stain

Management and Therapy: Hemodynamic stabilization, nutrition, lytes, fluid resuscitation, oxygenation Early, aggressive and repetitive debridement Hyperbaric tx A-B’s

37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A

Miscellaneous Dermatologic Manifestations of Disease: Pseudomonas folliculitis Herpetic Whitlow Herpes Gladiatorum Molluscum Contagium Seborrheic Dermatitis Secondary Syphilis

“We know too much and believe too little.” T. S. Elliot

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