Name:
A 32-year-old with Thigh Pain
Description:
A 32-year-old with Thigh Pain
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T00H05M32S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: [Handy] Hi. Welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy...
CHARLIE: And I'm Charlie Wiener, and we're coming to you from The Johns Hopkins School of Medicine.
CATHY: Episode 12: A 32-year-old with Thigh Pain
CHARLIE: Cathy, today's question deals with empiric antibiotics for a potentially severe infection. The question reads: "A 32-year-old woman is admitted to the hospital complaining of right thigh pain. She has fever and tenderness and redness over the lateral right thigh. Doppler examination shows no deep venous thrombosis. She's treated empirically with oxacillin intravenously for a cellulitis. The admitting physician notes that the degree of pain appears to be disproportionate to the amount of overlying cellulitis.
CHARLIE: Over the course of the next 24 hours, the patient develops septic shock complicated by hypotension, acute renal failure, and evidence of disseminated intravascular coagulation." So let's stop here for a second, Cathy. What do you think so far?
CATHY: The patient described is a young female, but she doesn't have any risk factors for cellulitis. Somehow she develops it anyway, and it's severe enough to start treating with IV antibiotics. The typical organisms that I would think about here are staph and strep, and oxacillin provides good coverage for those but doesn't cover methicillin-resistant staph aureus, which we know is becoming more common, especially in health care settings. Typical symptoms of cellulitis can include some pain.
CATHY: But if the patient has severe pain that's out of proportion to what can be seen on physical exam, like what's described here, it would really warrant further workup and potentially imaging. We hear that she got worse quickly, which makes me think that this is more than just cellulitis. The other findings that I'd look for on physical exam would be crepitus, swelling outside of the visible red area, or bulla, and that would make me think of necrotizing fasciitis or a deeper infection.
CHARLIE: The question continues: "A CT scan of her right leg demonstrates a collection of fluid with gas in the deep fascia of her right leg. Emergent surgical evacuation is planned. What changes to the patient's initial antibiotic therapy should be recommended at this time?" And the options are: A, "Continue oxacillin and add clindamycin." Option B, "Continue the oxacillin and add clindamycin and gentamicin." Option C is, "Discontinue the oxacillin and start clindamycin and gentamicin." Option D is, "Discontinue the oxacillin and add piperacillin/tazobactam and vancomycin." And, finally, Option E is, "Discontinue the oxacillin and add vancomycin and gentamicin." Cathy, what do you think now?
CATHY: The CT findings that you described are necrotizing fasciitis. We haven't been told of any additional risk factors. But if she had diabetes, IV drug use, or some recent trauma where there was penetration of the skin, or a bad peripheral vascular disease, or is immunocompromised, then I would think of that earlier in her disease course. When thinking about antibiotics for this patient, again, we want to consider the most common causative microbes. So, for necrotizing fasciitis, I think of group A strep or mixed facultative or anaerobic flora.
CATHY: More recently, methicillin-resistant staph aureus or MRSA has been implicated in an increasing number of cases. So it's important to remember, mostly, that mortality rate is high for necrotizing fasciitis. It can be up to 34%, and even higher if toxic shock syndrome is present.
CHARLIE: So, amongst management and antibiotic choices, how would you approach this patient at this point? (Cindy) Well, the primary treatment for this really is surgery, and you need debridement of the affected tissues. Without that, the mortality rate is nearly 100%, regardless of what you do with the antibiotics. It's important for the surgeon to visualize the deep structures, remove any necrotic tissue, make sure that compartment pressures are reduced, and also get a sample for cultures to help guide your antibiotic treatment.
CHARLIE: In any case, you definitely want to continue the antibiotics, and the initial regimen will need to be broad enough to cover the common microbes, including MRSA. This is where it's best to have the infectious disease teams involved.
CHARLIE: So, in the absence of a known organism which will allow you to tailor your therapy directed on what you get at culture, what would you suggest as a reasonable initial empiric regimen?
CATHY: The most-recent guidelines from 2014 from the Infectious Disease Society of America recommends that initial therapy for necrotizing fasciitis be vancomycin or linezolid, combined with piperacillin/tazobactam or carbapenem. They make this recommendation because the etiology can be polymicrobial, and the initial therapy should include activity against MRSA. So, from the choices given in this question, I would go with answer D, Piperacillin/tazobactam and vancomycin, along with stopping the oxacillin.
CHARLIE: So, the teaching point here is to suspect necrotizing fasciitis in a patient that appears to have something more complex than a simple cellulitis. And the primary therapy is rapid and immediate surgery, along with initial empiric antibiotics that focus on the suspected bugs that could be causing this necrotizing fasciitis. Once you have your definitive cultures, you can tailor your therapy to the bugs that you find at your surgical cultures.
CATHY: For more information on this topic, refer to Harrison's chapter on infections of the skin, muscles, and soft tissues. You can also refer to the 2014 Infectious Disease Society of America recommendations published in Clinical Infectious Diseases, Volume 59, Page 10. ♪ (music) ♪