1. The Skin and Beyond: Skin and Soft Tissue Infections Presentation to: Infectious Disease Update for the Primary Care Physician Methodist Healthcare 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

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

3. In General: Skin Lesions   Tumors Rashes

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

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

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

14. 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

19. 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

30. Edwardsiella: Treatment All edwardsiella naturally sensitive to: Tetracyclis, aminoglycosides, most B-Lactams, quinolones, antifolates, chloramphenicol, nitrofurantoin, and fosfomycin All edwardsiella naturally resistant to: Macrolides, lincosamides, streptogramins, glycopeptides, rifampin, fusidic acid, and oxacillin Stock I, Wiedemann B. Natural Antibiotic Susceptibilities of Edwardsiella tarda, E. ictaluri, and E. hoshinae. Antimicrob Agents Chemother, 2001 August; 45 (8): 2245-2255. Harrison's Principles of Internal Medicine, 16th Edition. Kasper D, Braunwald E, Fauci A, et al, Eds. 134: 6. 2006

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

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

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

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

42. 37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A

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

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

55. END