The Curbsiders 'Hot Takes'

Human Bites and Recurrent Cellulitis: SSTI Treatment Tips

The Curbsiders


January 20, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Frank Watto, here with my two great friends, Dr Stuart Brigham and Dr Paul Nelson Williams. We are board-certified internists.

Paul N. Williams, MD: Today we are going to share our favorite pearls from our podcast episode on cellulitis and bite wounds, which featured the amazing Dr Boghuma Titanji. Stuart, why don't you lead us off and tell us one of the clinical pearls you took away from this episode?

Stuart K. Brigham, MD: What I wanted to talk about is nonpharmacologic treatment for cellulitis. We don't often think about this when we talk about how to treat cellulitis. By "nonpharmacologic treatment" I mean rest, elevation, and all the conservative things we don't necessarily foot-stomp but can be extremely helpful in treating cellulitis by helping to improve venous return. For patients with recurrent cellulitis, especially in the lower extremities, it's also important to consider compression therapy in order to prevent stasis and skin breakdown.

One of the things I talk to my trainees about is knowing which home care skilled nursing companies provide direct patient education and good wound care to prevent recurrence of cellulitis.

Watto: Dr Titanji pointed out that the recommendation for compression is evidence-based therapy. There was an article in 2020 advocating this, which is great to know, because it's something we can do for many of our patients. Just make sure that they don't have severe peripheral arterial disease so we aren't choking off whatever little blood flow they have. But many of our patients can be helped by compression therapy.

Williams: They actually stopped that study early because the benefit was so significant, so it's not a minor thing.

We've probably all treated someone who has had a bite wound on their fist from some sort of altercation in which their fist got into somebody's mouth. Dr Titanji made the point that we should take these bite wounds very seriously, because human mouths are filthy places. She has a very low threshold for admitting these patients to the hospital because by their nature, these wounds cross multiple joints, and the hands are nothing to mess around with.

Even for minor and seemingly noninfected bites, she will prescribe prophylactic medication. She will make sure she's covering Eikenella, which is an anaerobe. If the patient is being admitted, she recommends intravenous ampicillin-sulbactam, and if you want to treat with oral antibiotics for prophylaxis, she likes amoxicillin-clavulanate.

Watto: The other thing she said was that she has a pretty low threshold to get imaging of bite wounds because foreign bodies can be involved, particularly teeth, and it's likely that the patient will need surgery. She mentioned the clenched fist injuries, which tend to present a bit later.

Something that will be practice-changing for me is that I always try to think, How many days of antibiotics should I give this patient? Do I think it will be better in 5 days, or should I give them 7 or 10 days? Dr Titanji said that she prescribes a range, perhaps 5-7 days if the patient is not as sick, or up to 10 days if she feels that the patient is going to be a bit slower to heal. She then sees the patient to follow up with the wound sometime during that period and flexes the antibiotic duration, either longer or shorter, as needed. I thought that was a really great tip. That way, if the patient isn't better by day 5, they don't have to call you and get a new prescription. They have the antibiotics there. So as long as you have a patient you can work with and who can follow instructions, that's a really great pearl.

If you would like to hear our full and extensive conversation with Dr Boghuma Titanji, click on #246 Take a Bite out of Cellulitis. You can also find The Curbsiders' podcasts on iTunes, and join our mailing list to get a weekly copy of our show notes.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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