# Infections whilst at sea



## UKEMT (Jan 8, 2011)

Right lets see what you make of this one...

Had a patient turn up complaining of an infected rash on his left calf.

after examination, it was seen to have inflammation round a small spot with, with tenderness to the area where his rigor boot had been rubbing his leg.

Slight blistering with clear fluid was also evident.

Bearing in mind the vessel we sail on was at sea and was due into port in two days it was decided to give him Ciprofloxacin 500mg twice daily with a follow up and possible referral ashore if condition worsened.(patient stated not to have penicillin based antibiotics).

Patient upon follow up was complaining of headaches / blurred vision and was told to stop taking the antibiotics given and referred ashore to a doctor, and was signed off work for 7 days.

is there anything else you would have thaught of or done in this case? asking on an experience transfer basis for future reference.


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## mycrofft (Jan 8, 2011)

*Ok.*

I presume the site was reddened, warm or hot to the touch, etc. Always note:
1. Induration diameter versus redness diameter.
2. Was it bright red, dusky red, pink, or just sorta red?
3. Crusts or scabs? Drainage into sock or dressings? Inspect the boot?
4. Fluctuant? DON'T squeeze it, but gentle and persistent swabbing with H2O2 may remove a crust and allow drainage, plus give you a better idea of depth.
5. Tender? Painful? Both? Or numb?
6. Fever?
7. General circulation status?
8. Ask patient about history (when he first saw it, has it changed, what has he done, was he told by a MD he was allergic to PCN or just thinks he might be?). 
9. Tetanus hx.

With two days to definitive care, oral or parenteral abx might be debateable unless there were systemic signs of sepsis or pt has other issues like diabetes, other circulatory issues with leg.

Note that about 10% of pt's with true PCN sensitivity will also react to Ciprofloxacin; however, the S/S you related don't sound like a typical anaphylactoid drug reaction. Better to D/C it anyway, though.

My approach as RN with protocols would be to follow the protocols, but otherwise clean and redress site daily, actually measure induration nad redness daily, characterize the color and border (stippled? serpigenous? peeling? necrotic?), and type/amount drainage at each dressing change. And do not use Telfa! If sepsis is likely or site getting worse, get him off his feet. Pass the record along to the next level of care.

Email me if you want more, or have a picture.


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## Veneficus (Jan 8, 2011)

Just to point out PCN can cause a type II hypersensitivity reaction as well as a type I.

That alters the symptomology of it.

If you look at the wound carefully, days before color change or local temperature change, Group B Strep will break down the intercellular junctions and produce a wound that looks exactly like a burn. (because infact the pathology is the same) 

Doxycycline (7 days) or cefeximine (high dose) are the preferred AB oral therapy for the group B. It is bacitracin resistant so topical application may just be bacterialstatic. (on a ship you should certainly have those 2, since they are the treatment for clamydia and ghonnorea.)

Not to pick on profession, but most wound care nurses don't understand the cellular pathology of group B strep organisms and consequently don't usually ID it before gross cellulitis.


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## mycrofft (Jan 9, 2011)

*Veneficus raises very good points.*

Especially in the two day window, diagnosis qua diagnosis is overrated. If you are not a MD and are initiating Rx, your protocols should specify signs and symptoms, then meds, not leap to diagnosis, then meds.  Vessicles and redness would suggest "erysipelas" (spelling?) caused by beta strep (PCN and Clindamysin being two good agents and emycin as the allergic detour), but the protocol should spell that out by the signs and symptoms; you don't need to make a diagnosis per se.

O-o-o-h, some folks are going to get mad. Ah, well...


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## Veneficus (Jan 9, 2011)

We are told most B Strep are PCN resistant and being discouraged from using it.

For IV, Vanc seems to be the drug of choice with cef the alternate.

PO meds listed above.


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