脚割伤发炎 （图片若有不适，请慎入）

小熊0721

我自从怀孕以后，脚不小心割伤家里家具，就容易发红发炎。这个伤口会比较严重，因为到某家专科医院看了皮肤专科以后，尝试取脓化验。应该是这样，导致脚的细菌扩散蔓延红肿的起脓。我没有糖尿病，也没有妊娠病。去过了HTAR医院入住8天，打抗生素。妇科，骨科，皮肤科专科医生来看过。也割肉化验，只是报告：细菌感染。 一位新妈妈要忍受这样的痛，还要担心肚子里的宝宝。真的有些无助。如果大家在巴生区有知道或了解的，不防给我知道。谢谢

wjleong15

既然已在专科医院治疗，为何开帖？
这里就算是医生也回答不了你的问题
因为没有面对面检查
没有看到你的bacteriology化验报告
@jinreung 你说呢？

小熊0721

wjleong15 发表于 19-1-2017 04:20 PM
既然已在专科医院治疗，为何开帖？
这里就算是医生也回答不了你的问题
因为没有面对面检查
没有看到你的bacteriology化验报告
@jinreung 你说呢？

那可以关贴，没关系

wjleong15

小熊0721 发表于 19-1-2017 04:24 PM
那可以关贴，没关系

最重要你必须根据专科医生的指示服药
尤其是抗生素
很多抗生素都对胎儿有害

祝安康

小熊0721

wjleong15 发表于 19-1-2017 04:29 PM
最重要你必须根据专科医生的指示服药
尤其是抗生素
很多抗生素都对胎儿有害

祝安康

谢谢，因为现在是孕妇原因，所以3个部门的政府医院专科医生都看过我。因此入院，输抗生素。就是怕我发炎导致发烧或更严重。
到了专科医院：2次脓的检验报告都是：NO GROWTH （没有原因）。到了政府大医院，化验报告也是图片上，细菌感染来解释
罢了。不过脓还是有，红肿依然还有。连医生都解释不了为什么，才想看看其它新妈妈或有类似的病例的。可以给我一些明示。

jinreung

wjleong15 发表于 19-1-2017 04:20 PM
既然已在专科医院治疗，为何开帖？
这里就算是医生也回答不了你的问题
因为没有面对面检查
没有看到你的bacteriology化验报告
@jinreung 你说呢？

有幾點：
1. Swab culture是廢物，極大可能是contaminant或colonizer。
2. Unasyn對Burkholderia cepacia是無效的。
3. Skin and soft tissue infection大多都是由Gram Positive。既然已經用了Unasyn一週，已經沒有必要延長抗生素的時間，哪怕症狀惡化與否。
我比較擔心的是MRSA。
4. 樓主的主治醫生需要做的是開個小手術，拿組織化驗：至少一個tissue culture和tissue HPE。如有發燒，直接來一個blood culture。
5. 樓主可以做的是每天用心洗傷口。

wjleong15

jinreung 发表于 19-1-2017 05:18 PM
有幾點：
1. Swab culture是廢物，極大可能是contaminant或colonizer。
2. Unasyn對Burkholderia cepacia是無效的。
3. Skin and soft tissue infection大多都是由Gram Positive。既然已經用了Unasyn一週，已經 ...

1. Swab culture是廢物，極大可能是contaminant或colonizer。
不能完全这么说
虽然目前的protocol来说的确比较少findings除了contamination
之前我做的就是关于这个swab的study
研究完成以后也suggest了新的methods
但是。。。

我之前的研究发现如果用2-4%chlorhexidine来clean wound之后再swab（如果真的拿不到tissue或aspirate）
能减少contamination
现在你order你的HO用2%chlorhexidine来洗再swab看？
只是现在都用saline来clean再swab
觉得真的很浪费资源

wmkua89

jinreung 发表于 19-1-2017 05:18 PM
有幾點：
1. Swab culture是廢物，極大可能是contaminant或colonizer。
2. Unasyn對Burkholderia cepacia是無效的。
3. Skin and soft tissue infection大多都是由Gram Positive。既然已經用了Unasyn一週，已經 ...

1. Swab culture是廢物，極大可能是contaminant或colonizer。

未必，swab culture 也可以指明做 mrsa culture. 只是主诊医生要知不同部位一般会被什么感染（比如痰一般会见到kleb pneumo， normal flora之类)

2. Unasyn對Burkholderia cepacia是無效的


broad spec的却无效，carbapanem一类对gram neg就ok. 也许医生还没req culture就给 iv broad spec先。 另外也要考虑楼主是有孕的。


3. Skin and soft tissue infection大多都是由Gram Positive。既然已經用了Unasyn一週，已經沒有必要延長抗生素的時間，哪怕症狀惡化與否。
我比較擔心的是MRSA。
不排除是mrsa，可以culture看看。

4. 樓主的主治醫生需要做的是開個小手術，拿組織化驗：至少一個tissue culture和tissue HPE。如有發燒，直接來一個blood culture。

个人会建意有必要才做tissue culture & HPE.
5. 樓主可以做的是每天用心洗傷口。


在还没rule out cause of infection. 樓主可以做的是每天用心洗傷口。+1  dettol antiseptic wash+1

jinreung

wjleong15 发表于 19-1-2017 06:34 PM
1. Swab culture是廢物，極大可能是contaminant或colonizer。
不能完全这么说
虽然目前的protocol来说的确比较少findings除了contamination
之前我做的就是关于这个swab的study
研究完成以后也suggest了新的me ...

不能完全这么说
虽然目前的protocol来说的确比较少findings除了contamination
之前我做的就是关于这个swab的study
研究完成以后也suggest了新的methods
但是。。。

我之前的研究发现如果用2-4%chlorhexidine来clean wound之后再swab（如果真的拿不到tissue或aspirate）
能减少contamination
现在你order你的HO用2%chlorhexidine来洗再swab看？
只是现在都用saline来clean再swab
觉得真的很浪费资源

你用了chlorhexidine來clean了後再swab，基本上所有細菌都被殺死了，還用grow什麼呢？
Sorry咯，ID是不會treat swab culture的，因為significance is uncertain。

wjleong15

jinreung 发表于 19-1-2017 10:54 PM
你用了chlorhexidine來clean了後再swab，基本上所有細菌都被殺死了，還用grow什麼呢？
Sorry咯，ID是不會treat swab culture的，因為significance is uncertain。

还是能grow到
只是clean了superficial的
然后大力挤压里面的脓来swab

jinreung

wmkua89 发表于 19-1-2017 06:37 PM
1. Swab culture是廢物，極大可能是contaminant或colonizer。

未必，swab culture 也可以指明做 mrsa culture. 只是主诊医生要知不同部位一般会被什么感染（比如痰一般会见到kleb pneumo， normal flora之类)
...

未必，swab culture 也可以指明做 mrsa culture. 只是主诊医生要知不同部位一般会被什么感染（比如痰一般会见到kleb pneumo， normal flora之类)

Swab culture的最大問題是contamination。還有的是做swab culture的那個人是否真的swab正確的地方。你不會知道到底swab culture所得到的細菌是否真的導致infection。
就如樓主的情形那樣，Burkholderia cepacia這種health care facility才出現的細菌，一般上都是造成CRBSI或nosocomial lung infection，而不會是SSTI。這種情形contaminant的可能性極高。

broad spec的却无效，carbapanem一类对gram neg就ok. 也许医生还没req culture就给 iv broad spec先。 另外也要考虑楼主是有孕的。

个人会建意有必要才做tissue culture & HPE.

很明顯的是找錯對象。
一週的PARENTAL Unasyn理應足夠應付一般uncomplicated的細菌感染，但對樓主的情況不起作用。
這很明顯不是單存的uncomplicated細菌，理應重新開始找出源頭，如deep seated abscesses、NF等。
Tissue culture是最直接了當能夠找出什麼細菌造成這感染的，然後再根據得知的細菌進一步檢驗。
如有必要，blood culture或各種radioimaging如ultrasound也得做。

Yes，若是septic shock，carbapenem是一個選擇。
但這carbapenem用在樓主現在的身上就肯定是overkill，因為樓主還不至於septic那種地步。
再說，這種作法非常危險，因為你不知道你面對的細菌是什麼，你隨時會製造出超級細菌，到時候大羅神仙都幫不到你。這也就是為什麼需要antibiotic stewardship。

在任何細菌感染的情況，gold standard就是source control，antibiotic不是答案。

在还没rule out cause of infection. 樓主可以做的是每天用心洗傷口。+1  dettol antiseptic wash+1

其實如果樓主有很多米，可以做個procalcitonin。這是最specific的marker來分辨是否有感染。

其二的是，dettol基本上不只殺死細菌，也延遲wound healing，所以不被建議。
其實用生理鹽水來洗這種傷口，然後加上jelonet蓋上傷口，再包紮已經很足夠了。Dermasyn、duoderm或Aquacel也是其他不錯的選擇。

jinreung

wjleong15 发表于 19-1-2017 11:15 PM
还是能grow到
只是clean了superficial的
然后大力挤压里面的脓来swab

你那個叫做pus culture。。
但也得有pus你才可以這麼做，但contamination還是會有。
這只有做正統的incision and drainage得到的pus culture才行。
再不然就來個needle aspirate，但還是要aseptic precaution才行。
還是那句，antibiotic不是答案。

jinreung

說回bacteriology
樓主已經接受了一週的PARENTAL Unasyn，理應能夠cover的細菌有：
1. 大多數Gram Pos
2. Sensitive KP （simple）
3. Sensitive E coli （simple）
剩下Unasyn無法cover的有：
1. MRSA
2. ESBL KP 和ESBL E coli
3. Pseudomonas
4. Enterococcus
5. Serratia
6. Enterobacter

來看看IDSA說了些什麼：

What Is Appropriate for the Evaluation and Treatment of Erysipelas and Cellulitis?Recommendations

• Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended (strong, moderate).
• Cultures of blood are recommended (strong, moderate), and cutaneous and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (weak, moderate).
• Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci (mild; Figure 1) (strong, moderate). For cellulitis with systemic signs of infection (moderate nonpurulent SSTI; Figure 1) systemic antibiotics are indicated. Many clinicians could include coverage against MSSA (weak, low). For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, purulent drainage, or SIRS (severe nonpurulent), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate). In severely compromised patients (as defined in question 13), broad-spectrum antimicrobial coverage may be considered (weak, moderate). Vancomycin plus either piperacillin-tazobactam or imipenem-meropenem is recommended as a reasonable empiric regimen for severe infection (strong, moderate).
• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period (strong, high).
• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended (strong, moderate).
• In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate).
• Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent; Figure 1)(strong, moderate).
  
  

Evidence Summary

“Cellulitis” and “erysipelas” refer to diffuse, superficial, spreading skin infections. The term “cellulitis” is not appropriate for cutaneous inflammation associated with collections of pus, such as in septic bursitis, furuncles, or skin abscesses. For example, when cutaneous redness, warmth, tenderness, and edema encircle a suppurative focus such as an infected bursa, the appropriate terminology is “septic bursitis with surrounding inflammation,” rather than “septic bursitis with surrounding cellulitis.” This distinction is clinically crucial, for the primary treatment of cellulitis is antimicrobial therapy, whereas for purulent collections the major component of management is drainage of the pus, with antimicrobial therapy either being unnecessary or having a subsidiary role (Figure 1 and Table 2).

The term “erysipelas” has 3 different meanings: (1) for some, erysipelas is an infection limited to the upper dermis, including the superficial lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat, and on examination erysipelas putatively has more clearly delineated borders of inflammation than cellulitis; (2) for many, erysipelas has been used to refer to cellulitis involving the face only; and (3) for others, especially in European countries, cellulitis and erysipelas are synonyms [35].

These infections cause rapidly spreading areas of erythema, swelling, tenderness, and warmth, sometimes accompanied by lymphangitis and inflammation of the regional lymph nodes. The skin surface may resemble an orange peel (peau d'orange) due to superficial cutaneous edema surrounding hair follicles and causing skin dimpling because the follicles remain tethered to the underlying dermis. Vesicles, bullae, and cutaneous hemorrhage in the form of petechiae or ecchymoses may develop. Systemic manifestations are usually mild, but fever, tachycardia, confusion, hypotension, and leukocytosis are sometimes present and may occur hours before the skin abnormalities appear.

These infections arise when microbes breach the cutaneous surface, especially in patients with fragile skin or diminished local host defenses from such conditions as obesity, previous cutaneous trauma (including surgery), prior episodes of cellulitis, and edema from venous insufficiency or lymphedema [36, 37]. The origin of the disrupted skin surface may be obvious, such as trauma, ulceration, and preexisting cutaneous inflammation, but often the breaks in the skin are small and clinically unapparent. These infections are most common on the lower legs. Blood cultures are generally positive in ≤5% of cases [38]. The yield of cultures of needle aspirations of the inflamed skin ranges from ≤5% to approximately 40% [39–46]. The differences in diagnostic sensitivity and specificity are due to the variety of patient populations studied, the definitions of cellulitis, the inclusion or exclusion of cases with associated abscesses, and the determination of whether isolates are pathogens or contaminants.

Cultures of punch biopsy specimens yield an organism in 20%–30% of cases [39, 47], but the concentration of bacteria in the tissues is usually quite low [47]. Combined data from specimen cultures, serologic studies [41, 48–51], and other methods (eg, immunohistochemical staining to detect antigens in skin biopsies [51, 52]), suggests that the vast majority of these infections arise from streptococci, often group A, but also from other groups, such as B, C, F, or G. The source of these pathogens is frequently unclear, but in many cases of leg cellulitis, the responsible streptococci reside in macerated, scaly, or fissured interdigital toe spaces [53, 54]. This observation underscores the importance of detecting and treating tinea pedis, erythrasma, and other causes of toe web abnormalities. Occasionally, the reservoir of streptococci is the anal canal [55] or the vagina, especially for group B streptococcal cellulitis in patients with previous gynecologic cancer treated with surgery and radiation therapy. Staphylococcus aureus less frequently causes cellulitis, but cases due to this organism are typically associated with an open wound or previous penetrating trauma, including sites of illicit drug injection. Several other organisms can cause cellulitis, but usually only in special circumstances, such as animal bites, freshwater or saltwater immersion injuries, neutropenia, or severe cell-mediated immunodeficiency.

Cultures of blood, tissue aspirates, or skin biopsies are unnecessary for typical cases of cellulitis. Blood cultures should be obtained and cultures of skin biopsy or aspirate considered for patients with malignancy, severe systemic features (such as high fever and hypotension), and unusual predisposing factors, such as immersion injury, animal bites, neutropenia, and severe cell-mediated immunodeficiency [42].

Therapy for typical cases of cellulitis should include an antibiotic active against streptococci (Table 2). A large percentage of patients can receive oral medications from the start for typical cellulitis [56], and suitable antibiotics for most patients include penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin. In cases of uncomplicated cellulitis, a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days [57]. In a retrospective study of cellulitis and abscesses requiring hospitalization, the average duration of treatment was 2 weeks and only about one-third of patients received specific treatment for gram-positive pathogens [58]. Two-thirds received very-broad-spectrum treatment, and the failure rate of 12% was not different regardless of spectrum of treatment. In some patients, cutaneous inflammation and systemic features worsen after initiating therapy, probably because sudden destruction of the pathogens releases potent enzymes that increase local inflammation.

MRSA is an unusual cause of typical cellulitis. A prospective study of patients with cellulitis in a medical center with a high incidence of other MRSA-related SSTIs demonstrated that treatment with β-lactams, such as cefazolin or oxacillin, was successful in 96% of patients, suggesting that cellulitis due to MRSA is uncommon and treatment for that organism is usually unnecessary [50]. However, coverage for MRSA may be prudent in cellulitis associated with penetrating trauma, especially from illicit drug use, purulent drainage, or with concurrent evidence of MRSA infection elsewhere. Options for treatment of MRSA in those circumstances (Table 2) include intravenous drugs (vancomycin, daptomycin, linezolid, or telavancin) or oral therapy with doxycycline, clindamycin, or SMX-TMP. If coverage for both streptococci and MRSA is desired for oral therapy, options include clindamycin alone or the combination of either SMX-TMP or doxycycline with a β-lactam (eg, penicillin, cephalexin, or amoxicillin). The activity of doxycycline and SMX-TMP against β-hemolytic streptococci is not known, and in the absence of abscess, ulcer, or purulent drainage, β-lactam monotherapy is recommended. This is further substantiated by a recent double-blind study showing that a combination of SMX-TMP plus cephalexin was no more efficacious than cephalexin alone in pure cellulitis [59]. Elevation of the affected area hastens improvement by promoting gravity drainage of edema and inflammatory substances. Patients should also receive therapy for any predisposing conditions, such as tinea pedis, trauma, or venous eczema (“stasis dermatitis”).

http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full

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懷孕，加上failed empirical treatment，已經不是simple SSTI那麼簡單了。
進一步的檢查已經是indicated的了。
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radiata12

既然大家都是医生/学医，发言就不要太偏激，什么废物无用垃圾就少讲了。
全马全吉隆坡有那么多ID,每个人都有自己的一套，有一个标准程序但人人都有一套自己的方式，每一个案例不同，每一个方案不同，应该从中学习。ortho有他们的最爱 unasyn, ID等发烧等culture，woundteam就不出声等人做决定，ONG就等zinnaf,
楼主既然在HTAR，可以建议ONG refer马大medical讲师看看，（HTAR是马大第三年医学生的训练基地,每天都有讲师去的）
要antibiotic，简单咯一直加着上，不好就换，（知道为什么要culture吗？因为antibiotic都不便宜，尤其是high end的，所以如果有一个culture positive，管他有没有发烧，给个理由我就可以开始了，至少我可以defend我自己的决定）

这样比较有帮助吗？

要帮助楼主，我个人觉得最好进ot,叫ortho做wound debridement，再送culture，HPE bla bla bla,就像robot那样什么 （你要什么test都可以），做了完整的debridement，我们再来谈dressing and wound care, 再加antibiotic，相信会好一点。
可惜楼主是孕妇 （最没有人想动的病人，因为有宝宝 （更正确来说是怕mortality in pregnancy，所以大家都打太极，可以推就推），所以你进ot的机率，可以和中toto安慰奖比，很小，但不是非常小）
我个人觉得infection source不很重要，重要是找出为什么poor healing，可能会是kidney问题?，protein loss nephrotic in pregnancy是存在的。还有，wound care， esbl pseudomonas是比mrsa几率高的，所以unasyn不很好

procalcitonin我个人觉得没什么帮助，procalcitonin高你才觉得是sepsis/infection吗？伤口不会好了整十天，当然是infection咯，还要用procalcitonin来证明吗？
procalcitonin低，就排除infection/sepsis吗？伤口那么烂又那么多天不会好，你敢因为procalcitonin低就说不是infection,敢停antibiotic？当然是不敢咯。。。
酱procalcitonin有帮到什么吗？除了花一笔钱去sungai buloh化验之外，我觉得没什么好处..如果在我的立场，当然希望procalcitonin高，给我一个大大稳稳的理由去start antibiotic，除此之外就没有用了。（可是就算没有procalcitonin，我也一样会start antibiotic),妈妈怀孕多少周了？
到最后你还是没有帮助到病人。

说到有得罪不好插我

radiata12

Burkholderia cepacia不是一个笑话吗？

jinreung

radiata12 发表于 20-1-2017 12:34 AM
既然大家都是医生/学医，发言就不要太偏激，什么废物无用垃圾就少讲了。
全马全吉隆坡有那么多ID,每个人都有自己的一套，有一个标准程序但人人都有一套自己的方式，每一个案例不同，每一个方案不同，应该从中学习。 ...

很明顯這是腳，WD可以做under regional block，可以降低孕婦對anasthetic的風險。這方面我想O&G會比較急過Ortho，因為這問題一天不解決，等到臨盆的時候mortality可能更大。

Procalcitonin只是一個guide來說這是否是dealing with systemic infection。這製造多一個藉口讓primary team去push for further evaluation。
當然，如我之前所說，這是若樓主有很多米的時候才做；沒米的話就把這筆錢省下來好些。

擒賊先擒王。你不去直淘賊窩（Source control），卻跑去問為什麼城牆一直是破的（poor healing的原因），你覺得有用嗎？

Poor healing的其中一個原因就是on going infection。先解決了infection，再去談wound healing，才是正道。
我並不是說找出poor healing的原因不重要。懷孕本身就是高分泌狀態。各種荷爾蒙都會升高，包括皮質醇。這些都可以是抑制免疫系統和wound healing。
加上營養不足（平時的飲食或許不足以應付孕婦本身+胎兒），也可以是poor wound healing的原因。
至於Dressing和wound care，都是source control重要的一環，尤其是當沒人願意去承擔對孕婦動刀的風險。

Burkholderia cepacia的確是個笑話。這也就是為什麼swab culture是廢物。ID的人也從來不treat swab culture，因為contamination機會高，而且極大可能是colonizer。
只能說，那些treat swab culture的人，都只是在treat the clinicians，而非treat patient。

bixbuy

go pharmacy buy:1) hydrogen peroxide HO ; 2) fucidin cream.

1) pour HO slowly on wound, don use cotton.  pour till the wound no bubbles.  
2) dry wound use dry air or fan air, make sure clean.  
3) quickly apply fucidin on to it, cover it a layer till cannot see.
let it on cool & dry place.  

避忌： egg, chicken, fish, milk/cheese, sugar.  water contact.

鼓励： vitaminC,

p98h

怒我冒昧。。。
觉得从照片中细看和综合大家的陈述。
小弟我认为楼主的伤口应该还残留着家具的残留物。
敢问被弄伤的家具是竹类吗？

everyonecan

bixbuy 发表于 20-1-2017 10:16 AM
go pharmacy buy:1) hydrogen peroxide HO ; 2) fucidin cream.

1) pour HO slowly on wound, don use cotton.  pour till the wound no bubbles.  
2) dry wound use dry air or fan air, make sure clean.  
...

请看五楼

wmkua89

radiata12 发表于 20-1-2017 12:34 AM
既然大家都是医生/学医，发言就不要太偏激，什么废物无用垃圾就少讲了。
全马全吉隆坡有那么多ID,每个人都有自己的一套，有一个标准程序但人人都有一套自己的方式，每一个案例不同，每一个方案不同，应该从中学习。 ...

既然大家都是医生/学医，发言就不要太偏激。




这我赞成， 每个人都是从自己的知识和工作上的经验来帮忙解决楼主的苦难。 恕我如果发言偏激。




全马全吉隆坡有那么多ID,每个人都有自己的一套，有一个标准程序但人人都有一套自己的方式，每一个案例不同，每一个方案不同，应该从中学习。


对，医学/学医 就是不断从中学习。有空就来聚聚喝茶聊案件学习也是不错下。。。