POTD: How to Treat Cellulitis...and Leishmaniasis

You diagnose a patient with cellulitis and you reach the old, familiar mental roadblock: which antibiotic do I use? Sure, you treated your last cellulitis patient with Keflex, but this patient has a small, mild abscess — do we use a different antibiotic?

UptoDate is tedious, and you’ve called the ED pharmacy 15 billion times today already for other med recommendations. Is there a better way?

B  E  H  O  L  D :  The IDSA Practice Guidelines

https://www.idsociety.org/practiceguidelines#/name_na_str/ASC/0/+/

From treating cellulitis to combat-related infections to leishmaniasis, the IDSA has the most current recommendations for you, the practitioner.

Back to our patient's skin infection. A quick search will yield this handy chart:

Our patient is young, with no comorbidities, and he has a mild, superficial, purulent infection with no systemic symptoms. According to this chart, we could treat with I & D and NO ANTIBIOTICS AT ALL. However, the same patient with a more deep-seated infection, systemic symptoms, or any risk factors would warrant empiric treatment with doxy or bactrim.

IN SUM: The IDSA practice guidelines exist. Use them.

Treating Laryngospasm

LARYNGOSPASM
You’re doing a procedural sedation in pediatrics. Despite your attending’s forewarning, you push that IV ketamine a bit too quickly. Suddenly, you hear a loud “crowing” or “squeaking” sound and look up at the monitor to see a flat line on capnography. Your heart sinks as it dawns upon you that you caused the much-dreaded laryngospasm.

WHAT DO I DO?!
1. Stop all procedures
2. Perform Larson’s maneuver - this is a modified jaw thrust maneuver where pressure is applied towards the top of the ramus of the mandible

3. Use a bag valve mask with PEEP valve and 100% oxygen to provide continuous positive airway pressure
4. Ask your team to prepare for intubation
5. Deepen anesthesia with IV propofol (0.5mg/kg IV push)

Most cases of laryngospasm will resolve with these maneuvers and propofol. In the rare event it doesn’t…

6. Give an IV paralytic (rocuronium 1mg/kg IV or succinylcholine 1.5mg/kg IV) and proceed to intubate.

Sources: Justin Morgenstern, "Managing laryngospasm in the emergency department", First10EM blog, March 3, 2016. Available at: https://first10em.com/laryngospasm/.

Alejandro Romero

EM PGY-3

Antibiotic Selection for Strep Pharyngitis in Adults

Antibiotic Selection for Strep Pharyngitis in Adults

23 year old male. Rapid strep is positive.

Which antibiotic do you prescribe?

• Amoxicillin 1g daily x 10d or 500mg q12 x 10d
• Penicillin VK 500mg QID x 10d

What if my patient in non-compliant, or has limited access to resources?

• Penicillin G Benzathine (Bicillin L-A) IM 1 time dose

What if my patient has an allergy to penicillin?

• Cephalexin 500mg bid x 10d

Why are you recommending that I give Keflex to my patient with a penicillin allergy? I thought there was cross-allergy between cephalosporins and penicillin due to their similar molecular structure?

Evidence is inconclusive and the often quoted “10% cross-allergy between penicillin-allergic patients who take a cephalosporin” is a myth. HOWEVER, it is best to avoid even a small risk of cross-allergy in the subset of patients with a true and severe allergy (anaphylaxis) to penicillin.

What if my patient has a severe allergy (hx of anaphylaxis) to penicillin?

• Clindamycin 300mg q8 x 10d
• Clarithromycin 250mg q12 x 10d
• Azithromycin 500mg daily x 5d

So, again, why not just give one of the agents listed above and avoid even a tiny risk of an allergic reaction in patients who say they have an allergy to penicillin?

Resistance of GAS to clarithromycin and azithromycin is well known and these are not the best agents to use when superior alternatives can be given. Clindamycin has many side effects and should be avoided if other agents can reasonably be given.