Gram stain and culture strongly recommended but not

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Gram stain and culture strongly recommended but not required Bulllous and nobullous lesions of impetigo may be treated orally or topically Oral preferred for numerous lesions or outbreaks Ecthmya should be treated orally Topical mupirocin or retapamulin BID x 7D Oral therapy for strep species and MSSA Use MRSA agents (doxy, clinda, bactrim) when suspected or confirmed Purulent SSTI Management Incision and drainage key modality Gram stain and culture recommended but not required C and S for severe and moderate Antibiotics (w/ MRSA coverage) appropriate: SIRS criteria (septic patients) Immunocompromised patients Non-purulent SSTI: cellulitis/erysipelas Mild outpatient cases managed with anti-streptococcal agent +/- anti-staph coverage Cephalexin good initial option Clindamycin reasonable for allergic patients
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Community-Associated MRSA Usually manifests as SSTI More virulent than HA-MRSA Susceptible to more antibiotics than HA-MRSA Who is susceptible to CA-MRSA Patients with contact/crowding Football, rugby, soccer, jails, wrestlers, students Treatment of CA-MRSA SSTIs Surgical drainage is key I and D required for 80% of patients with purulent SSTIs Many patients cured with I and D alone Clindamycin Excellent coverage for staph and and strep PO with excellent BA Good option for pediatric patients Most data in SSTIs Usual dosage (adults): 600-900 mg IV q6-8h 300-450 mg po q6h Suppresses PVL toxin production and other endotoxins Resistance rated vary widely depending on geography In-vitro susceptibility must be confirmed with D-test Bactrim Widely used for CA-MRSA SSTIs Dosage: 1-2 tabs BID (8-10 mg/kg/day of trimethoprim) Excellent BA In vitro activity around 95% vs CA-MRSA Poor activity against streptococci Adverse Effects Rash (SJS) Hyperkalemia Interaction with warfarin (severe) Bone marrow suppression Nephrotoxicity Lab interaction with SCr more common Avoid in late term pregnancy or first trimester Failures May depend on tissue damage and organism burden Pus inhibits sulfonamides MRSA releases thymidine from DNA which antagonizes TMP and SMX Clindamycin vs Bactrim Cure rates similar Adverse effects similar Including diarrhea and rash Clindamycin D test
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Tetracyclines Susceptible against ~90% of CA-MRSA isolates Doxycycline or minocycline Data limited to SSTIs 100 mg BID Not recommended for children < 8 y.o. Pregnancy Cat D Lack activity against Group A strep Tolerability Can be significant Primarily GI toxicity N/V Pill esophagitis Neurotoxicity (minocyline) Phototoxicity Vancomycin Overview Glycopeptide, cell wall active antimicrobial Exhibits time-dependent PK’s Slowly bactericidal except for enterococcus (bacteriostatic) Only active against gram-positive
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  • Fall '19
  • Tetracycline, UTI, Ceftriaxone

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