Pertimbangan klinis

1. lapisan jaringan yg terkena, perluasan invasi

2. lokasi anatomis
3. Patogen penyebab
4. progresivitas dan manif klinis
Klasifikasi:
1. Superfisial soft tissue inf.:
a. selulitis
- ec gram (+) aerob; bisa jg gram (-) dan fungi (imunokompromise)
- Tx:
+ AB oral 3-5 hari: 1st gen sefalo or semisintetik penisilin
+ opening the wound
b. erisipelas
- more extensive forms of celulitis
- Tx:
+ debri
+ penisilin G IV 16rb-20rb U
c. furunkel
d. limfangitis
- penyebaran infeksi via drainase limfatik
- tx: AB IV utk gram positif
2. Deep soft tissue inf.
- Faktor risiko:
+ ggn sistem imun dan pertahanan host
+ compromise of fascial blood supply
+ adanya mikroba
- Ec:
+ commonly S. pyogenes or C. perfringens
+ rarely P aeruginosa or vibrio vulnificans
+ bisa jg polimikrobial (pyogenes, aureus, E coli, anaerob, fungi, dll)
- Manifestasi:
+ first sign: fever and confusion
+ drainage of watery, grayish fluid from wound or open sore
+ kulit berwarna copper
+ brawny induration
+ skin blebs or krepitasi
+ bisa juga: Sb^^, N^, TD V, syok, incipient MSOF with DIC, rabdomiolisis> ren
al failure
- PP: Ro: gas in the soft tissue
- Tx:
a. resusitasi
b. insisi-biopsi di OK, kultur pus
c. debri semua jaringan terinfeksi, pertimbangkan amputasi utk life-saving
. AB:
First line:
= penisilin G (16-20x10^6/24 jam) +
= vancomycin +
= aminoglikosida/sefalo 3rd gen +
= klindamisin/metro
Alternatives:
= vancomycin +
= broad spectrum agent (imipenem-cilastatin/ampicilin-sulbactam/ticarcilin-cl
avulanate/piperacillin-tazobactam
Amoterisin kalau curiga fungi
- Antara lain
a. necrotizing fasciitis
b. necrotizing myositis
c. parasitic muscle infections
d. pyomyositis
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Summary of Recommendations from Practice Guidelines for Dx & Tx of Skin and soft
tissue infections, infectious diseases society of america
Level I
- Impetigo
+ mupirocin as topical (kalo tunggal)
+ kalo multipel: oral
= bulous: PCN or penisilinase resistant PCN
= nonbulous: OCB or 1st gen sefa
- Erisipelas
+ PCN
+ penisilinase resistan PCN or 1st gen sefa kalo curiga stafilokokus
- selulitis
+ penisilinase resisten PCN or 1st gen sefa
+ vanko or klinda kalo alergi PCN
- abses kutan: insisi drainase
- furunkulosis:
+ rekuren: mupirosin or klinda 150 mg/day 3 bln
- MRSA: linezolide, daptomycin, vancommycin
- Necrotizing soft tissue infection: surgical intervention
- Type I NSTI: ampicilin sulbactam + cipro + klinda for community acquired
- Type II NSTI: klinda/PCN combination therapy
Level II
- Furunkulosis: eradicate staph carrier state among colonized persons
- Type I NSTI: AB for gram (+) and (-) and anaerob
- Type II NSTI: consider IVIG, kalo c. perfringens: pCN/clinda combination ther
apy
- Animal bites:
+ coamox PO or ampisilin sulbacam or ertapenem: suitable thdp pasturella multo
cida
+ alternatif: piperasilin-tazobactam, imipenem-cilastatin, meropenem
Level III:
- Abses kutan: gram stain, kultur, AB sistemik
- furunkel
- animal bites: hindari 1G sefa, penisilin resisten PCN, makrolid, dan klinda:
poor activity P. multocida
- Human bite: ampisilin-sulbaktam IV or cefoxitin