Its July 30th @6:09am and it is already ~100% humidity in your bucolic bike ride through the park. You know that you are going to smell like “armpit” all day, a fact that is accentuated by a whiff of fermenting garbage from the nearby garbage truck parking lot.
Fortunately, when you arrive your malodorous ensemble is camouflaged by a patient even more pungent than you. Nonchalantly blaming the innocent man in the stretcher by the physician’s station, you feel obliged to “pick the patient up”.
You arrive to find the quintessential obese extremity, with a touch of diabetes and venous stasis.
On the medial aspect of the thigh is an 8 cm area of warm, erythematous skin with a pustule that is ready to burst at it’s center. The patient’s vital signs are stable (i.e a blood pressure of 167/71, AKA baseline). The area is not fluctuant, something that you confirm with a bedside ultrasound.
You realize that this is a non-complicated, purulent cellulitis, and that you need to cover for community acquired MRSA.
Name four different oral antimicrobial agents with MRSA coverage for uncomplicated purulent cellulitis:
(i) Clindamycin 300-450mg PO TID (complications: c.diff).
(ii) TMP-SMX 1-2 DS tabs PO BID (not safe in pregnancy, only bactericidal of the four options).
(iii) Doxycycline 100mg PO BID (not safe in children <8yo and pregnancy).
(iv) Linezolid 600mg PO BID (thrombocytopenia/leukopenia, expensive).
~ In the case of purulent cellulitis, or if there are significant risk factors, confirmed past MRSA infection or failed initial outpatient therapy, treat with MRSA coverage.
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Bonus: which of the above antibiotics can cause an elevated creatinine that is not clinically significant (i.e does not reflect eGFR)?
Trimethoprim in TMP-SMX (as well as H2 blockers) interferes with the secretory mechanism of creatinine (the active mechanism in the proximal tubule). This increases serum creatinine despite the fact that the GFR remains unchanged. Cefoxitin, flucytosine and acetoacetate in DKA interfere with some laboratory assays causing a similar effect as above. Also, eating a giant steak can cause a transient rise in creatinine, but that one is totally worth it.
What is the world’s spiciest pepper?
The Carolina Reaper of North Carolina is the spiciest pepper in the world according to the Guinness World Records, wikipedia and many other questionable sources. It is a hybrid of the Ghost Pepper and Red Habanero, both previous champions. The Reaper holds a whooping 2.2 million Scoville Heat Units (SHU), the most commonly used spiciness scale. In comparison, the Habanero chilli ranges from 100,000-350,000 SHU, while the Jalepeño only gets as high as 10,000 SHU. Capsaicin, which we use for the treatment of neuropathic pain and is the basis of the SHU scale is 16 million SHU.
References:
(1) Liu, C., A. Bayer, S. E. Cosgrove, R. S. Daum, S. K. Fridkin, R. J. Gorwitz, S. L. Kaplan, A. W. Karchmer, D. P. Levine, B. E. Murray, M. J. Rybak, D. A. Talan, and H. F. Chambers. “Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children.” Clinical Infectious Diseases 52.3 (2011): n. pag. Web.
(2) Baddour, Larry M., MD. “Cellulitis and Erysipelas.” Uptodate.com, N.p., n.d. Web.
(3) Inker, Lesley A., MD, MS, and Ronald D. Perrone, MD. “Drugs That Elevate the Serum Creatinine Concentration.” Uptodate.com, n.d. Web. 04 Aug. 2015.
(4) Peter, K.V. Handbook of Herbs and Spices. Cambridge: Woodhead, 2012. Print.
(5) Guinness World Records: Hottest Chili. Online.
Written by Itamar Carlos Itamars MD
Special thanks to Dr. Willis
Itamar
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