Skin Structure and SSTIs

• The skin is the largest organ in the body.
• It has two main layers: epidermis and dermis.
• Epidermis: Outer layer that protects.
• Dermis: Inner layer that supports and nourishes epidermis.
• Subcutaneous tissue: Underneath, contains fat, connective tissue, vessels, nerves, anchors the skin, and provides insulation and cushioning.
• Natural flora, normal bacteria on skin, keeps you safe from harmful germs.
• Skin damage from sun, injuries, or long-term illnesses makes you more vulnerable to infections.

SSTIs (Skin and Soft Tissue Infections)

• SSTIs are classified by depth, tissue affected, and needed treatments.
• The FDA classifies SSTIs as uncomplicated or complicated.
• Uncomplicated SSTIs include superficial cellulitis, folliculitis, impetigo, furuncles (boils), simple abscesses, minor wound infections
• Minor wound infections respond well to antibiotics or surgical drainage.
• Complicated SSTIs involve deeper tissues and often require debridement, occurring with systemic diseases affecting therapy response.
• Necrotizing infections (NSTIs) include dead tissue.
• Dead tissue promotes bacterial growth, worsening infections.
• NSTIs always require surgery to remove dead tissue.
• Infections can affect dermis, subcutaneous tissues, fascia (necrotizing fasciitis), and muscle.
• The depth/severity of the infection is hard to tell when you first see it.
• Treatment is challenging due to the kind of infection and how to treat it.
• Uncomplicated skin infections are common and not too serious, involving various bacteria.
• Main bacteria in most skin infections include gram-positive bacteria like Staphylococcus aureus and Streptococcus pyogenes.
• MRSA infections are from the community (CA-MRSA) or healthcare settings (HA-MRSA), CA-MRSA is more common.
• CA-MRSA infections may be related to the opioid epidemic, especially drug injectors.
• CA-MRSA often starts as local infections in healthy people, usually from skin breaks.
• Both CA-MRSA and HA-MRSA spread through direct contact with infected skin/surfaces.
• About 80% of CA-MRSA cases show up as uncomplicated skin infections like cellulitis, folliculitis, impetigo, or abscesses.
• Risk of MRSA after surgery is usually low.
• Post-operative MRSA infections: surgical site infections, chest infections, and bloodstream infections (bacteremia).
• The likelihood of surgical site MRSA infections ranges from 1% to 33%, depending on surgery type, and if the patient has S. aureus.
• There's no clear best way to prevent MRSA after surgery.
• There's no evidence using multiple or long-term antibiotics prevents MRSA after surgery.
• MRSA infections are treated with antibiotics the MRSA bacteria aren't resistant to.
• Strategies to lower surgical site infection rates include decolonizing people who carry S. aureus with mupirocin ointment and using chlorhexidine gluconate baths.
• SSTIs are often polymicrobial, caused by more than one type of microorganism.
• In complicated but non-necrotizing SSTIs, gram-positive bacteria like methicillin-sensitive organisms are involved.
• Staphylococcus aureus (MSSA) and Streptococcus pyogenes are often found in skin infections, about 50% of the time.
• Other bacteria: anaerobes/gram-negative bacteria like Pseudomonas, Enterobacteriaceae, and Clostridium.
• Necrotizing infections: aerobic bacteria (streptococci, enterococci, staphylococci) and anaerobic bacteria (Bacteroides and Peptostreptococci).
• Mixed infections make it harder to choose the right antibiotics initially (empiric therapy).
• Necrotizing soft tissue infections have a high mortality rate, ranging from 25% to 70%
• Factors increasing infection risk: skin ulcers, fungal infections, chronic venous insufficiency (poor blood flow in veins), lymphedema (swelling due to lymph blockage), and obesity. Risk factors for necrotizing infections include diabetes, trauma, alcohol use, injecting drugs, and using NSAIDs.
• MRSA infections are often linked to poor hygiene, overcrowded living, close skin contact, sharing contaminated items, previous MRSA infection, and trauma.
• CA-MRSA can also infect young, healthy people.
• CA-MRSA can live on objects.
• Overcrowding and close contact help MRSA spread.
• High-risk groups for MRSA include children, young adults, minorities, low-income groups, homosexual men, athletes, prisoners, daycare workers, and tattoo recipients.
• MRSA often lives in the nose and can cause repeat infections and spread to others.
• 20-40% of people in the US have MRSA in their nose.
• 80-90% of patients with MRSA in their blood or surgical sites also have it in their nose.
• Non-necrotizing Cellulitis Cause: when bacteria, especially streptococcus and staphylococcus, enter through breaks in the skin.
• Initial Signs of Bacterial Skin Infections: redness (erythema), warmth, swelling (edema), and pain in one area.
• How Cellulitis is Identified: quickly spreading redness (erythema), warmth, localized pain, swelling (edema), and possible swollen lymph nodes nearby.
• Severity: Necrotizing soft tissue infections (NSTIs) are extremely dangerous and can be deadly.
• Rapid Spread: They spread very quickly.
• Tissue Destruction: These infections destroy a large amount of tissue.
• Infection Spread: These infections can spread through various layers of tissue
• Fascial Infections: These infections in the fascia (tissue layer) are more common due to poor blood supply and a limited immune response
• Allows germs to spread quickly.
• Initial Symptoms: At first, symptoms of NSTIs throughout the body might be mild
• Worsening Symptoms: Serious symptoms: fever, tachycardia, severe pain, confusion, lethargy, and hypotension, signs of the infection getting worse and spreading.
• Necrotizing Fasciitis Sign: In necrotizing fasciitis, the skin may feel firm when touched
• Advanced Effects: Necrotizing infections can cause edema, ischemia, tissue death, and sepsis
• Common Locations: Abdomen, lower extremities, and perineum
• Fournier's Gangrene: This is a specific type of necrotizing fasciitis
• Table 50.2 has more information on the symptoms of different skin and soft tissue infections
• Treatment Duration Varies: There aren't specific guidelines
• Uncomplicated Infections: treated with a short course of therapy .
• Complicated Infections: treatment length changes based on patient's overall health, severity, and infection's cause.
• Aggressive Approach: Widespread Infection treated quickly
• Initial Tests: Blood culture, Complete blood count (CBC), serum electrolytes, and C-reactive protein.
• Immediate Action: Hospitalization, IV fluids, surgical evaluation, and broad-spectrum antibiotics.
• Checking for Gas: Some bacteria create gas in the tissues under the skin
• If gas is suspected: A CT scan is used

More SSTI Treatments

• Immediate surgical exploration and debridement are done
• Localized Infections: For skin infections like cellulitis that are contained to one area, blood cultures and biopsies aren't usually needed.
• Cellulitis Treatment: Cellulitis typically responds to antibiotics that target staph and strep bacteria.
• The nose being colonized by MRSA is connected to getting repeat MRSA skin infections. Also, a positive nasal swab for MRSA is often connected to wound infections caused by MRSA.
• Regular antibiotics taken by mouth/IV often don't kill nasal MRSA well enough.
• Mupirocin Treatment: If someone has MRSA in their nose and is getting new/repeat MRSA infections, they can be treated with mupirocin ointment in the nostrils twice daily for 5 days
• Some hospitals use antiseptic washes for patients
• Hospitalized Patients with Complicated SSTIs surgical debridement, broad-spectrum antibiotics, and consideration of empiric MRSA therapy.
• Recurrent SSTIs: For patients with recurring skin infections offer decolonization strategies and reinforce hygiene practices
• Decolonization Strategies mupirocin in the nose twice daily for 5-10 days and topical antiseptic washes (like chlorhexidine) for 5-14 days/dilute bleach baths
• Open Wounds and Culturing: clear if you need to take a culture to test for infection, need to test for infection

When to Suspect Infection

• Highly suspicious:
• Dead tissue(necrotic tissue)
• Foreign object inside The wound is large and deep
• Open wound for a long time
• Wound contaminated with stool/urine
• Quantity of Organisms: Without obvious infection signs, the organism count determines infection.
• Best Culture Specimen: A tissue tests for shows interior growth, not just surface.
• Gold Standard: A biopsy of tissue below surface is most accurate
• Infection Threshold: An infection is usually present in a tissue sample tests high for bacteria and/or types of strep bacteria.
• Surface Swabs: Doctors use it due to being quick, easy, cheap and less painful.
• Surface Swab Usefulness: Can identify and treat a wound infection can tissue biopsy findings
• Debridement for Certain Wounds: Necrosis, thick or devitalized tissue require removal for underlying examination.

Complications

• Antibiotic Overuse: Using too many antibiotics or incorrect use.
• Treatment Without Cultures: Treating infections can cause side effects from antibiotics and make antibiotic resistance worse.
• Simple Treatments: Sometimes, antibiotics aren't even needed. Warm compresses or draining can be enough.
• Incorrect Culturing: Wrong cultures can lead to identifying the wrong bacteria, worsen infection and cause blood infection
• It's very important for healthcare workers to know how to do swab cultures correctly.
• Avoiding Unnecessary Biopsies: This avoid giving patients the wrong antibiotics which can cause more pain and infection risk
• Diagnostic Challenges: Complicated soft tissue infections are hard to diagnose correctly
• Clinical Judgement: Doctors need to use their best judgment to treat aggressively.
• Importance of Debridement: Quickly removing infected tissue with surgery is critical.
• Consequences of Delay if treatment is delayed include significant tissue loss, more surgeries in the future, and possible death.
• Surgical Risks: Any surgery has risks with risk of infection itself
• Symptoms of bacterial infections depend on the bacteria type, how deep the infection is, how long has it been and the patient's age/health
• Always consider open wounds as contaminated with microorganisms.
• Wound Infection: Wound with unable immune system control microorganisms to multiply
• Infected wound indications: Drainage that contains pus or has a bad smell, Skin around the wound that's red
• NSG Interventions Assessmente

Assessments

• Acute/chronic pain, due to pressure and swelling from wound infection
• Compromised Tissue Integrity: Open wound has damaged/damaged underlying tissues
• Fluid imbalance risk: Losing large amounts of fluid through wound site or surgery
• Infection Risk: Potential to spread to others
• Bacteremia Risk: Potential for bacteria to enter the blood

Vital Signs

• Check blood pressure, heart rate, temperature, mental status and pain level
• Low blood pressure, fast heart rate, high/low temp, confusion, lethargy, and severe pain indicates infection is worsening or developing
• Low blood volume can cause low blood pressure and high heart rate

Wound and Skin

• Know look of surroundings to see differences in treatment
• Skin: if pain worse than looks may be tissue damage
• Complete Blood Count (CBC): High white count is infection
• Culture Results: Wound, nose and blood
• Swab cultures help determine what antibiotics will work best and that MRSA in the nose can lead to repeat infection
• Needed Blood tests if the infection has spread throughout the body
• Helps nutritional assessment especially protein

Actions

• Give antibiotics determined by culture results
• Correct antibiotics kill the infection and reduces the chance of resistance
• Wound Care Follow orders: Clean, changed dressings, prevent irritation
• Surgical Evaluation Needed: figure out treatment
• Why: to figure out surgery to be needed this often includes surgery
• The nurse's actions include teaching important hygiene habits wash hands and preventing infection spread with well care

Clinical Manifestations Of Infection

• Educate caregivers about infections and to take off dressings safely and why improves it helps the outcome of infection so improve:
• Know signs of infection for Seeking treatment early can help with earlier diagnosis, prevent complications, and decrease morbidity

Evaluation

• With Correct antibotics and wounds can heal properly at home.
• Patient and Family with instructions to care wound to be safe including knowing to the recognize the signs to seek quickly the correct to not and better to provide the proper support to you

Necrotizing Infections

• Quick and Complete Evaluation:
• Are critical for good outcomes
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Herpes Simplex Virus

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• They both last long can spread it without showing at all

Epidemiology

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• With Asymptomatic Spread: Can have herpes which spreads and have symptoms
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• Risk Group: People with active herpes lesions elsewhere on themselves are also at higher
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