Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 14:

Bacterial Infections of the Skin

Common Primary Bacterial Skin Infections

Impetigo

Bullous impetigo

Folliculitis

Felons

Paronychias

Cellulitis

Causes of Bacterial Skin Infections

Staphylococcus aureus

Beta-hemolytic forms of streptococci such as Streptococcus pyogenes (group A Streptococcus, or GAS)

Streptococcus agalactiae (group B Streptococcus)

Impetigo and Ecthyma

Cause: due primarily to S. aureus

Diagnostic criteria: scattered, discrete macules that itch and spread and develop into vesicles and pustules on an erythematous base; honey-colored crust occurs

Ecthyma: chronic form of impetigo affecting deeper layers of the skin; vesicles form that then develop into shallow ulcerations often causing scarring

Contributing factors: person-to-person contact in schools or day care centers; poor hygiene, crowded living conditions

Infection involving the skin and subcutaneous layers, with the potential to spread systemically and cause serious illness

Causes: GAS or S. aureus; insect bite or wound

Methicillin-resistant S. aureus (CA-MRSA):

S. aureus organisms that are resistant to commonly used antibiotics; major cause of community-acquired skin infections; furuncle with necrotic center

Cellulitis

Erysipelas

Superficial form of cellulitis; most common in children, especially infants and the elderly, but it can occur in healthy individuals who have sustained only minor wounds.

Most commonly found on the lower extremities but can also be present on the face and scalp.

Begins as an area of sharply demarcated erythema that spreads rapidly in minutes to hours. The affected area is slightly raised, firm, warm, and tender to the touch (classic orange peel appearance).

Pustular Infections

Folliculitis

Superficial infection of the hair follicle commonly caused by S. aureus

Furunculosis and carbunculosis

Pustular infections usually caused by S. aureus. Both conditions involve deeper areas of the skin and can develop from unresolved cases of folliculitis.

Manifests as pus-filled nodule that encircles a hair follicle found in hairy areas.

Paronychia and Felon

Paronychia

Infection of tissue surrounding a nail bed

Associated with nail biting, hangnails, or finger sucking

Felon

Fingertip wound of the pulp space in the tip of a digit, which is erythematous, edematous, and tender

If left untreated, abscess/tissue necrosis can occur

Necrotizing Fasciitis

An extremely serious infection of the subcutaneous tissues that can be life threatening if not diagnosed early and treated appropriately

Management: often requires emergent surgical interventions to remove infected tissue in combination with antibiotic therapy

Occurrence: middle-aged, elderly, or seriously debilitated patients

Treatment: IV antibiotic, surgical debridement

Necrotizing Fasciitis/Diagnostic Criteria

Initial lesion is often minor.

Infection may initially appear similar to cellulitis, although severe pain, erythema, and edema are commonly present.

May be differentiated from cellulitis by its rapid spread, tissue destruction, and lack of response to usual antibiotic therapy.

Symptoms: high fever (102°F to 105°F [38.9°C to 40.6°C]), intense pain and tenderness at the site, swelling of the affected extremity.

Risk Factors for Skin Infections

Diabetes

Immune system disorders

Malnutrition from alcoholism

Circulatory compromise of arterial, venous, or lymphatic system

Question

A patient presents with a lesion on his arm that is causing intense pain, swelling of the arm, high fever, and drainage. What condition would the practitioner suspect?

Impetigo

Carbuncle

Paronychia

Necrotizing fasciitis

Answer

D. Necrotizing fasciitis

Rationale: Necrotizing fasciitis may initially appear similar to cellulitis, although severe pain, erythema, and edema are commonly present with high fever, intense pain, swelling of the extremity, and drainage. Impetigo manifests as vesicles and pustules on an erythematous base with a honey-colored crust. A carbuncle is a pus-filled nodule that encircles a hair follicle found in hairy areas, and a paronychia is an infection of the tissue surrounding a nail bed.

Strategies to Prevent Skin Infections

Wash hands frequently to prevent spread of infecting organisms.

Clean skin twice daily with soap and water or antibacterial soap (e.g., Hibiclens, Lever 2000).

Avoid scratching.

Use warm soaks to promote drainage of pustular matter.

Avoid irritants, including tight clothing, shaving, sunscreens, and occlusive cosmetics and deodorants.

Recommended Order of Treatment for Impetigo and Ecthyma

First-line therapy

Oral antibiotic for 7 to 10 days

Second-line therapy

Alternate oral antibiotic for 7 to 10 days or refer

Recommended Order of Treatment for Cellulitis and Erysipelas

First-line therapy

Oral antibiotic for 7 to 10 days

Second-line therapy

Admit for intravenous antibiotic treatment or refer

Recommended Order of Treatment for Furuncles and Carbuncles

First-line therapy

Oral antibiotic for 7 to 10 days or refer

Second-line therapy

Alternate oral antibiotic for 7 to 10 days or refer

Recommended Order of Treatment for Paronychias

First-line therapy

Tetanus prophylaxis, as appropriate, and oral antibiotic for 7 to 10 days

Second-line therapy

Alternate oral antibiotic for 7 to 10 days or refer

Recommended Order of Treatment for Felon and Puncture Wound

First-line therapy

Tetanus prophylaxis, as appropriate, and oral antibiotic for 7 to 10 days

Second-line therapy

Continue oral antibiotic if infection continues; alternate oral antibiotic for 7 to 10 days or refer

Question

A practitioner is treating a patient who has a paronychia. What is the appropriate first-line therapy for this patient?

Oral antibiotic for 7 to 10 days

Admit for IV antibiotic treatment

Tetanus prophylaxis and oral antibiotic for 7 to 10 days

Topical antibiotic treatment

Answer

C. Tetanus prophylaxis and oral antibiotic for 7 to 10 days

Rationale: The first-line therapy for paronychias is tetanus prophylaxis and oral antibiotic for 7 to 10 days. Oral antibiotic alone for 7 to 10 days is appropriate first-line therapy for impetigo, ecthyma, cellulitis, and erysipelas. IV antibiotic treatment is second-line treatment for cellulitis and erysipelas. Topical preparations do not penetrate the nail bed well and generally are not indicated for treatment of paronychias.

Common Adverse Effects of Antibiotics

Nausea

Vomiting

Diarrhea

Rashes, allergic reactions

Urticaria

Fungal infections

Pseudomembranous colitis

Drugs Used to Treat Bacterial Infections

Broad-spectrum penicillins

First-, second-, and third-generation cephalosporins

Clindamycin

Fluoroquinolones

Vancomycin, daptomycin, telavancin, dalbavancin, oritavancin, linezolid, tedizolid, and tigecycline

Trimethoprim/sulfamethoxazole

Topical agents: mupirocin ointment, gentamicin

Monitoring Patient Response

Emphasis should be placed on controlling aggravating factors and promoting good hygiene measures.

Follow-up or referral is required if the condition spreads or does not resolve.

Secondary infection such as osteomyelitis or endocarditis is a risk in carbunculosis. For this reason, systemic antibiotics are always given after lesions are drained.

Patients with cellulitis and erysipelas should be followed closely because of the potential for a serious systemic infection.

Patient Education

Take medication around the clock to sustain the proper blood level and don’t discontinue until prescribed length of time is up.

Know common side effects of medications including predisposition to fungal infections.

Report signs of allergic reactions, unusual bleeding, or bruising.

Avoid smoking due to flammable nature of some antibiotics.

Summary

Although most bacterial skin infections are self-limiting and resolve quickly with treatment, some have the potential to become much more serious.

Patients should be taught to report symptoms such as fever, increased erythema or streaking, chills, or malaise that may indicate a worsening of their condition.

The chronic nature of some skin infections, such as folliculitis, should be emphasized so that patients understand that treatment may be long term and recurrent.