SSTI, Bone and Joint ID

This page includes following topics:

Non-healing Ulcer 
Prosthetic Joint Infection 
Native Bone / Joint Infection

Skin Decolonization Recommendation
  1. Hibiclens (Chlorhexidine 4 % ) scrub 
  2. Cetaphil (Triclosan 0.3 % ) antibacterial bar soap : used in the face and in the genital area for 5 days or longer to also reduce colonization in those areas since we don't like to use Hibiclens and the facial regions because of his ability to irritate cornea and the eye structures 
  3. Bactroban (Mupiricin 2 % ointment) Nasal should be used for 5 days as well to reduce nasal colonization. 
  4. Household fomite reduction

  • Purulent- Mild / Moderate / Severe - If Moderate and Severe, will need I and D
  • Non-Purulent -  Mild / Mod / Severe - If Severe, will need emergent surgical exploration

Trimethoprim-sulfamethoxazole has a poor activity against group A streptococci and may contribute to a high failure rate among patients with cellulitis.

Antibiotics for surgical site infection 

DM and SSTI 

Diabetic Foot Infection (DFI): Classification (see below Table 2) of DFI (Mild / Mod / Severe or Imminent Limb - Threatening (see below Table 12) ) - 2/2 - Evaluate at 3 level - Patient as a whole, affected limb (Vascularity, Venous Congestion, Peripheral Neuropathy etc), and then the wound - Obtain Culture or tissue biopsy (see below Table 5, 9) - Antibiotic  based on Clinical Severity  (see below Table 6, 8, 7, 11)-  Wound Debridement and wound care - consider Imaging Study (Xray, MRI if clinically indicated for evaluation of DFO) - Vascular and ID consultation if necessary

Also, see below for 
Approach to DF Osteomyelitis: Table 10
Approach to Non-response or recurrence : Table 10 (under non-healing ulcer) 
Interpretation of ABI: Table 13

Case Based Learning 

54 yo M with DM, PAD, COPD, HTN, HLD is seen in the clinic for non-healing ulcer of Left 3rd metatarsal area 2 months duration. Patient initially received Clindamycin for 2 weeks. 1 month later patient had MRI done and did not have Osteomyelitis, and was prescribed Ciprofloxacin for 10 days. Patient has also had narrowing of the left anterior tibial artery, and had angioplasty with balloon dilatation. No stents were placed. Was started on ASA, Statin, and Cilastazole. Due to the concern of osteomyelitis, ESR and XR is done. ESR is 45 (1 months back it was 39). X-ray foot is negative for Osteo. What should you do next. 
  • 1. Continue wound debridement, and obtain culture from the debrided tissue for appropriate abx selection
  • 2. Reassess for vascular supply of the leg. 
  • 3. Do MRI as Osteomyletitis is still a concern.  
  • 4. Both 1 and 2
Ans: Initial plan was to do #4. Given some concern of Osteomyeltis, MRI was obtained, and it showed Osteomyeltis. 

Learning Lesson: 
Xray cannot rule out osteomyelitis. Likewise, ESR cannot be the best way to assess osteomyelitis. In an appropriate patient, with poor blood flow, and long standing non-healing ulcer, go for MRI.