David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
For cellulitis, the causative organism can be difficult to isolate, especially when there is no purulent material to culture. Therefore, treatment is usually empirical.
As a rule, nonpurulent cellulitis is usually caused by streptococci, and purulent infections are usually caused by staphylococci, including community-associated methicillin-resistant Staphylococcus aureus (MRSA).
Empirical antibiotic therapy should cover MRSA if cellulitis is associated with purulence, risk factors for MRSA are present (e.g., a history of MRSA, illicit inhalation or injection drug use, recent antibiotic use or hospitalization, or current hemodialysis or HIV infection), or the patient is severely ill or immunocompromised.
Necrotizing skin infections should be treated with emergent surgical debridement and broad spectrum antibiotics, including clindamycin to bind streptococcal toxin. Necrotizing skin infections can be recognized by the presence of several clinical findings, including pain out of proportion to examination findings, induration beyond the area of skin involvement, blisters, mottling, anesthesia, crepitus, necrosis, ecchymosis, systemic toxicity, or organ failure. Although computed tomography has shown some promise in diagnosing necrotizing skin infections, surgical exploration is the gold standard diagnostic test, and surgical consultation should not be delayed to allow for imaging when these infections are suspected.
Patients with previous percutaneous coronary interventions with coronary stents (who are outside the usual window for dual-antiplatelet therapy) seem to benefit from continuation of aspirin when undergoing noncardiac surgery.
Although there was no statistical difference in bleeding risk between patients treated with aspirin or placebo in this stented subgroup, the larger trial (including patients with and without stents) did show an increase in major bleeding with aspirin (hazard ratio, 1.22 [CI, 1.01 to 1.48]). The authors felt that this was a more accurate estimate of bleeding risk. Using this estimate, the authors calculated that the use of perioperative aspirin in 1000 patients with coronary stents would prevent 59 myocardial infarctions and cause 8 major bleeding events.
An editorial suggests that the ischemic benefit of continuing perioperative aspirin in patients with coronary stents would be negated only in surgical procedures with a baseline bleeding risk of 26% or more.
The qSOFA demonstrated lower sensitivity but higher specificity for mortality than the SIRS criteria.
Although SIRS criteria are more sensitive for mortality than qSOFA (and therefore better for identifying patients with a low mortality risk), they are plagued by poor specificity (i.e., many patients with infection meet SIRS criteria despite having a low risk for mortality).
The qSOFA was never intended to replace SIRS as a screening tool, nor as a prompt for initiating antibiotics. Rather, it was formulated to be a more accurate tool for recognizing patients at high risk for death, and it does seem to fulfill the promise of greater specificity.
An editorial suggests that qSOFA and SIRS should be considered complementary tools with different strengths.
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Wesorick DH, Chopra V. Annals for Hospitalists - 20 February 2018. Ann Intern Med. 2018;168:HO1. doi: 10.7326/AFHO201802200
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Published: Ann Intern Med. 2018;168(4):HO1.
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