Acute Uncomplicated Cystitis and Skin and Soft-Tissue Infections (SSTIs)

Often, infections have several treatment possibilities depending on patient specific and disease specific characteristics. Below are two cases covering some of this week’s topics. Using current recommendations from sources such as Dynamed and the Infectious Disease Society of America's Treatment Guidelines, compare and contrast possible treatment options. The focus will be on safety, efficacy of the regimens and patient’s specific characteristics where available.
HT is a 31 year old female with acute, uncomplicated cystitis and no known drug allergies. She has no significant PMH or medications. Her urine culture shows a susceptible E. coli (susceptible to all treatments listed below). What would cause you to choose one option over another?
Nitrofurantoin 100 mg po BID x 7 days
TMP/SMX DS (160 mg/800 mg) po BID x 3 days
Levofloxacin 250 mg po daily x 3 days
Cephalexin 500 mg po q12hrs x 7-14 days
Jimmie Chipwood is a 19-year-old college student who presents to the ED with a new-onset “boil” on his right buttock. He noticed some pain and irritation in the right buttock area over the past week but thought it was due to having slid into second base during a baseball game. The pain gradually increased over the next few days, and he went to the student health center, where they cleaned the wound and gave him a prescription for clindamycin 300 mg QID for 7 days. They recommended he try to keep the area covered until the antibiotic began to work. Today (7 days later), Jimmie returned to the student health center for further evaluation and was referred to the ED for further care for his continued SSTI. At the ED, Jimmie says the area on his buttock is worse, and he cannot sit down for class. He reports only partial adherence to the clindamycin regimen, because he often forgets to take it and says it makes him nauseated.
PMH - Noncontributory
Surgical History - Appendectomy 4 years ago, Repair of left ACL tear 2 years ago
SH - Denies any EToH or illicit drug use.
Meds - Clindamycin 300 mg PO QID × 7 days (prescribed at student health center visit 1 week ago; patient did not complete full course).
Allergies - Penicillin (hives as a child)
Physical Examination
WDWN Caucasian man in no acute distress, but with noticeable pain when he walks and tries to sit
BP 129/74, P 81, RR 16, T 37.5°C; Wt 77.5 kg, Ht 6′0″
Lateral right gluteal area: red, erythematous, warm, and tender to touch; localized fluid collection that appears fluctuant, consistent with a carbuncle and surrounding erythema
PERRLA; EOMI, oropharynx clear
Abdomen Soft, NT/ND; (+) BS
Large 2 cm × 4 cm red swollen area over the lateral right buttock, with a localized fluid collection and surrounding erythema
Labs
Clinical Course
The patient was treated in the ED with I&D alone and was given wound care instructions. The fluid was not sent for culture and susceptibility. He returns to the ED 8 days later with a recurrent boil in the same right buttock area. On physical exam, the patient is found to have a new area of fluid collection (1 cm × 3 cm) and surrounding erythema. An MRI of the gluteal area was negative for deep tissue involvement and extension to other adjacent areas. Two sets of blood cultures were drawn and are pending, and a second I&D of the area was performed and sent for culture and susceptibility. The patient did have his nares and groin area swabbed for MRSA detection, and the results are pending. The patient reported mild fevers without chills, but he has not taken his temperature at home. His current temperature is 37.7°C, and all other vital signs are stable. Given the current information, the ED physician does not think Jimmie needs to be admitted.
Microbiology
Blood cultures × two sets: pending
Culture of abscess fluid from right buttock: pending
Nares swab: pending
Groin swab: pending
Imaging Studies
Negative for deep tissue involvement; localized area of inflammation and fluid consistent with an abscess.
What subjective and objective clinical data are consistent with the diagnosis of an SSTI?
What additional information is needed to fully assess this patient’s SSTI?
Assess the severity (mild, moderate, or severe) of this patient’s SSTI based on the subjective and objective information available.
Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.
What are the goals of pharmacotherapy in this case?
What nondrug therapies might be useful for this patient?
What feasible pharmacotherapeutic alternatives are available for treating his SSTI?
Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient’s drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.