Probe with curved hemostat to break up loculations 6. COVID Arm: Delayed Hypersensitivity Reactions to SARS-CoV-2 Vaccines Classic autoimmune bullous diseases include pemphigus vulgaris and bullous pemphigoid . Erosions are open areas of skin that result from loss of part or all of the epidermis. 1. In one prospective study, beta-hemolytic streptococcus was found to cause nearly three-fourths of cases of diffuse cellulitis.16 S. aureus, P. aeruginosa, enterococcus, and Escherichia coli are the predominant organisms isolated from hospitalized patients with SSTIs.17 MRSA infections are characterized by liquefaction of infected tissue and abscess formation; the resulting increase in tissue tension causes ischemia and overlying skin necrosis. Diagnosis is by skin biopsy read more . Nummular lesions are circular or coin-shaped; an example is nummular eczema Nummular Dermatitis Nummular dermatitis is inflammation of the skin characterized by coin-shaped or discoid eczematous lesions. 2005;18(4):401-404. doi:10.1080/08998280.2005.11928101. Petechiae are nonblanchable punctate foci of hemorrhage. The infection may also originate from an adjacent site or from embolic spread from a distant site. Magnetic resonance imaging is highly sensitive (100%) for necrotizing fasciitis; specificity is lower (86%).24 Extensive involvement of the deep intermuscular fascia, fascial thickening (more than 3 mm), and partial or complete absence of signal enhancement of the thickened fasciae on postgadolinium images suggest necrotizing fasciitis.25 Adding ultrasonography to clinical examination in children and adolescents with clinically suspected SSTI increases the accuracy of diagnosing the extent and depth of infection (sensitivity = 77.6% vs. 43.7%; specificity = 61.3% vs. 42.0%, respectively).26, The management of SSTIs is determined primarily by their severity and location, and by the patient's comorbidities (Figure 5). The treatment failure rate at ten days (any erythema, warmth, induration, fluctuance, tenderness and/or drainage) was not different (4.1% in the TMP-SMX group and 5.3% in controls). Chapter 106. Subcutaneous Abscess Incision and Drainage Most physical exams are done in the prone or left lateral decubitus position, revealing erythema, induration, fluctuance, tenderness, and spontaneous drainage. Enter search terms to find related medical topics, multimedia and more. PDF Venous, Arterial, and Neuropathic Lower- Extremity Wounds Rash is a general term for a temporary skin eruption. Although the majority of abscesses are treated with incision and drainage, in certain cases, usually because of cosmesis, treatment with needle aspiration and antibiotics may be an option.3,7Ozseker and colleagues7found that ultrasound-guided aspiration and irrigation of breast abscesses was preferred to surgical drainage for abscesses with a Necrotizing Fasciitis. Antibiotics should be used in adjunct, and . Use a probe cover if there is any concern for drainage from the lesion. 5824 12th Ave Brooklyn, NY 11219. Bullae also may occur in inherited disorders of skin fragility. The mean number of ED visits was 1.3 in the LD group vs 1.8 in the I&D group . The primary outcome was clinical resolution at 14 days (no erythema, warmth, induration, fluctuance, tenderness, or drainage), and secondary outcomes were the number of hospital visits and complications (repeat drainage, new or different antibiotics, or admission). Skin and soft tissue infections guidelines 2021. Article Podcast. Surgical - No fluctuance - Erythema, size, and induration recedingfrom outline - Improving fever curve - Tolerating oral intake - Pain controlled withoral medications - Ability to bear weight or use involved extremity I&D using appropriate procedural pain management Meets discharge criteria - Consider PO antibiotics for overlying cellulitis, abscess >3 Skin and soft tissue infections (SSTIs) are a group of heterogeneous conditions affecting the epidermis, dermis, subcutaneous tissue, or superficial fascia.Uncomplicated infections are most commonly caused by gram-positive pathogens (Streptococcus, Staphylococcus) that infiltrate the skin after minor injuries (e.g., scratches, insect bites). Please confirm that you are a health care professional. Studies have shown that induration on the soft tissue of the feet may cause an increased risk of recurrent foot ulcers in people with diabetes because it results in a decrease in the foots ability to absorb shock when a person is bearing weight. Treatment of induration of skin varies greatly depending on the underlying cause. Uncomplicated purulent SSTIs in easily accessible areas without overlying cellulitis can be treated with incision and drainage only; antibiotic therapy does not improve outcomes. Induration. Skin induration is a deep thickening of the skin that can result from edema, inflammation, or infiltration, including by cancer. + Deep TissueInjury Intact or non-intact skin with localized area of persistent non- blanchable deep red, maroon, purple e.g. Multiple factors contribute, including read more , seborrheic dermatitis Seborrheic Dermatitis Seborrheic dermatitis is a common inflammatory condition of skin regions with a high density of sebaceous glands (eg, face, scalp, sternum). Examples include freckles, flat moles, tattoos, and port-wine stains Capillary Malformations Capillary malformations are present at birth and appear as flat, pink, red, or purplish lesions. Ischemic skin appears purple to gray in color. The trusted provider of medical information since 1899, Last review/revision Dec 2021 | Modified Sep 2022. 0/5- flaccid, limp. The hardening of a normally soft tissue or organ, especially the skin, due to inflammation, infiltration of a neoplasm, or accumulation of blood. Stevens DL, Bisno AL, Chambers HF, et al. Hidradenitis suppurativa Hidradenitis Suppurativa Hidradenitis suppurativa is a chronic, scarring, acnelike inflammatory process that occurs in the axillae, groin, and around the nipples and anus. -1+ = hypoactive. Chapter 13: Ultrasound Assessment of Abscess and Cellulitis - MHMedical.com 1. Soft . Pilar cysts are usually on the scalp and may be familial. On physical examination, abscesses are typically tender, indurated, erythematous, and fluctuant. According to a Baylor University Medical Center study, staphylococcus aureus is responsible for the majority of skin and soft tissue infections. The presence of fluctuance was assessed to determine if the use of Irrisept reduced or eliminated the need for oral antibiotics in uncomplicated abscesses. Ulceration can be a complication. Diagnosis read more and bullous pemphigoid Bullous Pemphigoid Bullous pemphigoid is a chronic autoimmune skin disorder resulting in generalized, pruritic, bullous lesions in older patients. Skin and soft tissue infections - Knowledge @ AMBOSS Diabetes can cause a condition called recurrent plantar ulcers, which are ulcers or sores on the bottom of the feet (due to poor circulation to the lower extremities). Vitiligo Vitiligo Vitiligo is a loss of skin melanocytes that causes areas of skin depigmentation of varying sizes. Induration: Localized hardening of soft tissue of the body. Treatment is usually unnecessary. . Mucous membrane involvement is rare. Verrucous lesions have an irregular, pebbly, or rough surface. This photo shows a small hyperpigmented read more . Search dates: May 7, 2014, through May 27, 2015. Study with Quizlet and memorize flashcards containing terms like Expand the following abbreviation into the full medical term. Indurated skin has a hard, resistant feeling. Crusts (scabs) consist of dried serum, blood, or pus. Purpura may indicate a coagulopathy. Causes include venous stasis dermatitis Stasis Dermatitis Stasis dermatitis is inflammation, typically of the skin of the lower legs, caused by chronic edema. External signs are minimal and may include erythema, induration, or fluctuance. Medical Editor: Charles Patrick Davis, MD, PhD. The spectrum of bacterial diseases of the skin ranges from superficial, localized, easily recognized and easily treated skin eruptions to deep, aggressive, gangrenous, and necrotizing infections that might seem innocuous at first but quickly become life-threatening. Infection during read more , measles Measles Measles is a highly contagious viral infection that is most common among children. Lipomas are very common, benign, and usually read more , and fibromas Dermatofibromas Dermatofibromas are firm, red-to-brown, small papules or nodules composed of fibroblastic tissue. As the skin gets infected redness and induration develop. Moving in waves. Black eschars are collections of dead skin that can arise from infarction, which may be caused by infection (eg, anthrax Anthrax Anthrax is caused by the gram-positive Bacillus anthracis, which are toxin-producing, encapsulated, facultative anaerobic organisms. Cutaneous abscesses are painful, tender, indurated, and usually erythematous. Using an 11 or 15 blade scalpel make incision over point of max fluctuance (Langers lines) 4. A dedicated probe cover or an exam glove can be used to cover the . Symptoms, usually severe, include headache, nausea, vomiting, photophobia read more ), calciphylaxis Calciphylaxis All patients undergoing long-term renal replacement therapy (RRT) develop accompanying metabolic and other disorders. Induration refers to the thickening and hardening of soft tissues of the body, specifically the skin, and is the result of an inflammatory process caused by various triggering factors. Last Editorial Review: 3/29/2021. Symptoms include pruritus and read more , linear epidermal nevi, and lichen striatus. Bullae are clear fluid-filled blisters > 10 mm in diameter. Monomicrobial necrotizing fasciitis caused by streptococcal and clostridial infections is treated with penicillin G and clindamycin; S. aureus infections are treated according to susceptibilities. Symptoms are high fever, severe headache, and rash. Medical Definition of Induration. Multiple factors contribute, including read more frequently affects the scalp, extensor surfaces of the elbows and knees, umbilicus, and the gluteal cleft. Pustules are common in bacterial infections and folliculitis and may arise in some inflammatory disorders including pustular psoriasis Subtypes of Psoriasis . Deep dermal nevi appear blue. The primary underlying causes of skin induration include: The precise physiological process that results in many conditions that cause skin induration includes the inflammatory process and infiltration of the skin by certain types of cancer cells. A 22-year-old woman presents with pain and swelling of the plantar surface of her foot. Dermatographism (dermographism) is the appearance of an urticarial wheal after focal pressure (eg, stroking or scratching the skin) in the distribution of the pressure. (See also Overview of Vascular Bleeding read more ) or after long-term therapy with topical fluorinated corticosteroids. Pustules are vesicles that contain pus. Diagnosis is clinical. Common severe infections include encephalitis read more . Complications: A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Multiple factors contribute, including read more and granuloma annulare Granuloma Annulare Granuloma annulare is a benign, chronic, idiopathic condition characterized by papules or nodules that expand peripherally to form a ring around normal or slightly depressed skin. (See also Overview of Effects of Sunlight.) -investigated by pronator drift-visual. druid hill park crime; james stevens obituary michigan; dave ramsey real estate investing Reflexes 2+ and symmetric vs. -0 = absent. These include Patch testing Biopsy Scrapings Examination read more .). (See also Evaluation of the Dermatologic Patient Evaluation of the Dermatologic Patient History and physical examination are adequate for diagnosing many skin lesions. Lymphangitis =nflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel abnml skin exam. ( See Figure 1.) The cause of seborrheic keratosis is unknown, but genetic mutations read more . Papules are elevated lesions usually < 10 mm in diameter that can be felt or palpated. Plaques may be flat topped or rounded. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Induration or drainage suggests a fistula or abscess. The four classical signs of inflammation, originally recorded by the Roman encyclopedist Celsus in the 1st century A.D. Readings in the 5mm categories were considered to have "induration present,". Condyloma, thrombosed or prolapsed hemorrhoids, anal skin tags, or fissures can be identified from external inspection. The mTST - An mHealth approach for training and quality - PLOS ty dot phrase fall A lilac color of the eyelids or heliotrope eruption is characteristic of dermatomyositis Autoimmune Myositis Autoimmune myositis is characterized by inflammatory and degenerative changes in the muscles (polymyositis, necrotizing immune-mediated myopathy) or in the skin and muscles (dermatomyositis) read more . Skin and Soft Tissue Infections | Obgyn Key The choice is based on the presumptive infecting organisms (e.g., Aeromonas hydrophila, Vibrio vulnificus, Mycobacterium marinum).5, In patients with at least one prior episode of cellulitis, administering prophylactic oral penicillin, 250 mg twice daily for six months, reduces the risk of recurrence for up to three years by 47%.38. 718-302-0040. grandma's home essential oils Panniculitis is an inflammation within the fat tissue of the body. Differentiating Necrotizing Fasciitis from other soft tissue infections Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD read more ), infections, and vasculitis Cutaneous Vasculitis Cutaneous vasculitis refers to vasculitis affecting small- or medium-sized vessels in the skin and subcutaneous tissue but not the internal organs. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections.8. Diagnosis of skin induration is made by palpation (feeling the area) and assessing whether the raised area has a hard, resistant feeling. Vasculitis can affect any blood vesselarteries, arterioles, veins, venules, or capillaries read more . 3. Skin abscess - WikEM Descubr lo que tu empresa podra llegar a alcanzar. Zosteriform describes lesions clustered in a dermatomal distribution similar to those of herpes zoster Herpes Zoster Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. In rare cases, it can run in families. Lesion Configuration (Secondary Morphology), Overview of Rickettsial and Related Infections, Mastocytosis and Mast Cell Activation Syndrome, Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), Amzeeq, Arestin, Dynacin, Minocin, minolira, Myrac, Solodyn, Ximino, Zilxi. The typical wheal lasts < 24 hours. Verywell Health's content is for informational and educational purposes only. Skin Lesion (Bullae) Without adequate evacuation of this pus, the infection will continue to to accumulate and can lead to disseminated or systemic infection. For an abscess, the treatment of choice may be antibiotics, incision, or drainage. A recent article in American Family Physician provides further details about prophylaxis in patients with cat or dog bites (https://www.aafp.org/afp/2014/0815/p239.html).37, Simple SSTIs that result from exposure to fresh water are treated empirically with a quinolone, whereas doxycycline is used for those that occur after exposure to salt water. Diagnosis of panniculitis is most often made by visual examination, in combination with a biopsy for confirmation. Clinicians recorded whether fluctuance was present for each subject initially and after 48 hours. Complicated infections extending into and involving the underlying deep tissues include deep abscesses, decubitus ulcers, necrotizing fasciitis, Fournier gangrene, and infections from human or animal bites7 (Figure 4). Distribution is random or patterned, symmetric or asymmetric. https://www.aafp.org/afp/2014/0815/p239.html. Serpiginous lesions have linear, branched, and curving elements. The Laboratory Risk Indicator for Necrotizing Fasciitis score uses laboratory parameters to stratify patients into high- and low-risk categories for necrotizing fasciitis (Table 4); a score of 6 or higher is indicative, whereas a score of 8 or higher is strongly predictive (positive predictive value = 93.4%).19, Blood cultures are unlikely to change the management of simple localized SSTIs in otherwise healthy, immunocompetent patients, and are typically unnecessary.20 However, because of the potential for deep tissue involvement, cultures are useful in patients with severe infections or signs of systemic involvement, in older or immunocompromised patients, and in patients requiring surgery.5,21,22 Wound cultures are not indicated in most healthy patients, including those with suspected MRSA infection, but are useful in immunocompromised patients and those with significant cellulitis; lymphangitis; sepsis; recurrent, persistent, or large abscesses; or infections from human or animal bites.22,23 Tissue biopsies, which are the preferred diagnostic test for necrotizing SSTIs, are ideally taken from the advancing margin of the wound, from the depth of bite wounds, and after debridement of necrotizing infections and traumatic wounds. Fluctuance. All Rights Reserved. Symptoms include pruritus and read more , and drug reactions. Complicated infections have a higher tendency to be . Skin and soft tissue infections guidelines 2021. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Cellulitis, abscess, or both are among the most common skin and soft tissue infections [].Cellulitis (which includes erysipelas) manifests as an area of skin erythema, edema, and warmth; it develops as a result of bacterial entry via breaches in the skin barrier [].A skin abscess is a collection of pus within the dermis or subcutaneous space. Lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied read more frequently arises on the wrists, forearms, genitals, and lower legs. Examples include warts Warts Warts are common, benign, epidermal lesions caused by human papillomavirus infection. Monday to Friday. These infections are often associated with superficial or deep layers of the skin or in the follicular hair (pyoderma). Patient information: See related handout on skin and soft tissue infections, written by the authors of this article. (See also Erythema read more , some skin infections, and cutaneous metastatic cancers. induration ( 2 cm in diameter), or tenderness; and (4) evidence of lobulated fluid at time of enrollment Clinical cure: at the 1-week follow-up visit if there was resolution of the following signs and symptoms: purulent wound drainage, erythema, fluctuance, localized warmth, pain/tenderness, and edema/induration Lichenification is thickening of the skin with accentuation of normal skin markings; it results from repeated scratching or rubbing. -4+ = unsustained clonus. Other Outcome Measures: Examples include nevi, warts, lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied read more , insect bites, seborrheic keratoses Seborrheic Keratoses Seborrheic keratoses are superficial, often pigmented, epithelial lesions that are usually warty but may occur as smooth papules. Induration Skin Hardening Signs and Causes. Medicine Capable of being moved or compressed. Ulcers result from loss of the epidermis and at least part of the dermis. Medical Definition of Induration - MedicineNet Simple infections are usually monomicrobial and present with localized clinical findings. Superficial Infections: Cellulitis and Erysipelas. 2023 Dotdash Media, Inc. All rights reserved. It is considered to be an autoimmune disease, in which the immune system attacks healthy tissues, but what triggers it isn't clear. fluctuance vs induration. Hardening, abnml skin. Calor, dolor, rubor, and tumor: Heat, pain, redness, and swelling. Abscess incision and drainage - SAEM Infections can be classified as simple (uncomplicated) or complicated (necrotizing or nonnecrotizing), or as suppurative or nonsuppurative. Diagnosis is clinical. The lower extremities are most commonly involved.9 Induration is characteristic of more superficial infections such as erysipelas and cellulitis. Description of Skin Lesions - Merck Manuals Professional Edition These may be caused by burns, bites, irritant contact dermatitis or allergic contact dermatitis , and drug reactions. Induration is characteristic of panniculitis Panniculitis Panniculitis describes inflammation of the subcutaneous fat that can result from multiple causes. Medical Definition of Calor, dolor, rubor, and tumor - MedicineNet Macules represent a change in color and are not raised or depressed compared to the skin surface. Sonoguide // Abscess Evaluation - American College of Emergency Physicians Linear lesions take on the shape of a straight line and are suggestive of some forms of contact dermatitis Contact Dermatitis Contact dermatitis is inflammation of the skin caused by direct contact with irritants (irritant contact dermatitis) or allergens (allergic contact dermatitis). According to guidelines from the Infectious Diseases Society of America, initial management is determined by the presence or absence of purulence, acuity, and type of infection.5, Topical antibiotics (e.g., mupirocin [Bactroban], retapamulin [Altabax]) are options in patients with impetigo and folliculitis (Table 5).5,27 Beta-lactams are effective in children with nonpurulent SSTIs, such as uncomplicated cellulitis or impetigo.28 In adults, mild to moderate SSTIs respond well to beta-lactams in the absence of suppuration.16 Patients who do not improve or who worsen after 48 hours of treatment should receive antibiotics to cover possible MRSA infection and imaging to detect purulence.16, Adults: 500 mg orally 2 times per day or 250 mg orally 3 times per day, Children younger than 3 months and less than 40 kg (89 lb): 25 to 45 mg per kg per day (amoxicillin component), divided every 12 hours, Children older than 3 months and 40 kg or more: 30 mg per kg per day, divided every 12 hours, For impetigo; human or animal bites; and MSSA, Escherichia coli, or Klebsiella infections, Common adverse effects: diaper rash, diarrhea, nausea, vaginal mycosis, vomiting, Rare adverse effects: agranulocytosis, hepatorenal dysfunction, hypersensitivity reactions, pseudomembranous enterocolitis, Adults: 250 to 500 mg IV or IM every 8 hours (500 to 1,500 mg IV or IM every 6 to 8 hours for moderate to severe infections), Children: 25 to 100 mg per kg per day IV or IM in 3 or 4 divided doses, For MSSA infections and human or animal bites, Common adverse effects: diarrhea, drug-induced eosinophilia, pruritus, Rare adverse effects: anaphylaxis, colitis, encephalopathy, renal failure, seizure, Stevens-Johnson syndrome, Children: 25 to 50 mg per kg per day in 2 divided doses, For MSSA infections, impetigo, and human or animal bites; twice-daily dosing is an option, Rare adverse effects: anaphylaxis, angioedema, interstitial nephritis, pseudomembranous enterocolitis, Stevens-Johnson syndrome, Adults: 150 to 450 mg orally 4 times per day (300 to 450 mg orally 4 times per day for 5 to 10 days for MRSA infection; 600 mg orally or IV 3 times per day for 7 to 14 days for complicated infections), Children: 16 mg per kg per day in 3 or 4 divided doses (16 to 20 mg per kg per day for more severe infections; 40 mg per kg per day in 3 or 4 divided doses for MRSA infection), For impetigo; MSSA, MRSA, and clostridial infections; and human or animal bites, Common adverse effects: abdominal pain, diarrhea, nausea, rash, Rare adverse effects: agranulocytosis, elevated liver enzyme levels, erythema multiforme, jaundice, pseudomembranous enterocolitis, Adults: 125 to 500 mg orally every 6 hours (maximal dosage, 2 g per day), Children less than 40 kg: 12.5 to 50 mg per kg per day divided every 6 hours, Children 40 kg or more: 125 to 500 mg every 6 hours, Common adverse effects: diarrhea, impetigo, nausea, vomiting, Rare adverse effects: anaphylaxis, hemorrhagic colitis, hepatorenal toxicity, Children 8 years and older and less than 45 kg (100 lb): 4 mg per kg per day in 2 divided doses, Children 8 years and older and 45 kg or more: 100 mg orally 2 times per day, For MRSA infections and human or animal bites; not recommended for children younger than 8 years, Common adverse effects: myalgia, photosensitivity, Rare adverse effects: Clostridium difficile colitis, hepatotoxicity, pseudotumor cerebri, Stevens-Johnson syndrome, Adults: ciprofloxacin (Cipro), 500 to 750 mg orally 2 times per day or 400 mg IV 2 times per day; gatifloxacin or moxifloxacin (Avelox), 400 mg orally or IV per day, For human or animal bites; not useful in MRSA infections; not recommended for children, Common adverse effects: diarrhea, headache, nausea, rash, vomiting, Rare adverse effects: agranulocytosis, arrhythmias, hepatorenal failure, tendon rupture, 2% ointment applied 3 times per day for 3 to 5 days, For MRSA impetigo and folliculitis; not recommended for children younger than 2 months, Rare adverse effects: burning over application site, pruritus, 1% ointment applied 2 times per day for 5 days, For MSSA impetigo; not recommended for children younger than 9 months, Rare adverse effects: allergy, angioedema, application site irritation, Adults: 1 or 2 double-strength tablets 2 times per day, Children: 8 to 12 mg per kg per day (trimethoprim component) orally in 2 divided doses or IV in 4 divided doses, For MRSA infections and human or animal bites; contraindicated in children younger than 2 months, Common adverse effects: anorexia, nausea, rash, urticaria, vomiting, Rare adverse effects: agranulocytosis, C. difficile colitis, erythema multiforme, hepatic necrosis, hyponatremia, rhabdomyolysis, Stevens-Johnson syndrome, Mild purulent SSTIs in easily accessible areas without significant overlying cellulitis can be treated with incision and drainage alone.29,30 In children, minimally invasive techniques (e.g., stab incision, hemostat rupture of septations, in-dwelling drain placement) are effective, reduce morbidity and hospital stay, and are more economical compared with traditional drainage and wound packing.31, Antibiotic therapy is required for abscesses that are associated with extensive cellulitis, rapid progression, or poor response to initial drainage; that involve specific sites (e.g., face, hands, genitalia); and that occur in children and older adults or in those who have significant comorbid illness or immunosuppression.32 In uncomplicated cellulitis, five days of treatment is as effective as 10 days.33 In a randomized controlled trial of 200 children with uncomplicated SSTIs primarily caused by MRSA, clindamycin and cephalexin (Keflex) were equally effective.34, Inpatient treatment is necessary for patients who have uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics (Figure 6).
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