Inappropriate initial antibiotic treatment for complicated skin and soft tissue infections in hospitalized patients: incidence and associated factors

We analyzed 525 hospitalized adults treated with intravenous antibiotic(s) for complicated skin and soft tissue infections (cSSTIs) to assess incidence of, and risk factors associated with, inappropriate initial antibiotic treatment (IIAT). IIAT was given to 22.5% of enrolled patients. The rate of IIAT did not vary by type of facility (academic versus community) but was significantly higher in rural than urban hospitals (38.9% versus 21.3%, P = 0.02). Pathogens were exclusively gram-positive in 68% of patients, exclusively gram-negative in 13%, and mixed in 19%. Staphylococcus aureus was the most frequently isolated pathogen (in 65%), 54% of which were methicillin-resistant. Significant independent risk factors for IIAT were: admission to a rural hospital (odds ratio = 2.34; 95% confidence interval: 1.06–5.19), dialysis treatment (3.86; 1.15–12.93), cancer other than non-melanoma skin cancer (5.23; 1.78–15.36), and infection with gram-negative (3.43; 1.79–6.60) or mixed (4.52; 2.62–7.78) pathogens. IIAT for cSSTIs was relatively frequent in these hospitalized patients, especially those with selected risk factors.     

Diagnostic and therapeutic evaluation of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA) skin and soft tissue infections in the emergency department

Background

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections commonly present as skin and soft-tissue infections (SSTIs). Treatment often includes incision and drainage with or without adjunctive antibiotics. Emergency department (ED) pharmacists wished to provide specific data to emergency physicians to better inform antibiotic choices for patients with SSTIs.

Study Objectives

The objectives of this study were to describe local susceptibility trends of CA-MRSA isolates obtained from patients with SSTIs and describe diagnostic and empiric therapeutic management of CA-MRSA SSTIs among ED health care providers at University of Utah Hospitals and Clinics.

Methods

Susceptibility of all unique CA-MRSA SSTI isolates for 2008 were identified and compiled into an antibiogram. ED providers evaluated their diagnostic and treatment habits using a self-assessment questionnaire, which was verified against charted information documented in the electronic medical records for patients presenting to the ED with a CA-MRSA SSTI.

Results

The ED antibiogram indicated that 57/58 (98%) CA-MRSA SSTI isolates were susceptible to sulfamethoxazole/trimethoprim (SMX/TMP); 50/58 (86%) isolates were susceptible to tetracycline, and 47/58 (81%) isolates were susceptible to clindamycin. Incision and drainage were performed in 23/25 (92%) patient cases, which was consistent with providers’ perceived habits (100%). SMX/TMP monotherapy was preferred among 23/35 (66%) providers, however, SMX/TMP combined with cephalexin was the antibiotic regimen prescribed in 9/22 (41%) patient cases.

Conclusions

Cephalexin was often added to cover for potential cellulitis due to Streptococcus spp., however, the surrounding erythema may simply be an extension of the CA-MRSA infection. Department-specific antibiograms are useful in guiding empiric antibiotic selection and may help providers judiciously prescribe antibiotics only when necessary.     

Topical antibiotic treatment for uncomplicated skin and skin structure infections: review of the literature

Uncomplicated skin infections account for almost 200 million physician-office visits in the USA annually. Treating these infections is estimated to cost in excess of US$350 million each year. The primary etiology of these infections is Staphylococcus aureus, over 60% of which is estimated to be methicillin resistant across the USA. Therapeutic options include incision and drainage in combination with antimicrobial therapy, which may be oral, topical or occasionally parenteral. Because the effectiveness of the current oral options, such as β-lactams and other classes, is being eroded due to acquired resistance, older, untested agents such as trimethoprim–sulfamethoxazole or clindamycin are often being used. Thus, topical approaches may offer effective, localized, well-tolerated alternatives to the systemic regimen. However, their value in the management of uncomplicated skin infections is not yet clearly defined. This literature review discusses various topical antibiotic treatment options for uncomplicated skin infections, including over-the-counter and prescribed regimens.     

Economic outcomes of inappropriate initial antibiotic treatment for complicated skin and soft tissue infections: a multicenter prospective observational study

This study examined economic outcomes associated with inappropriate initial antibiotic treatment (IIAT) in complicated skin and soft tissue infections using data from adults hospitalized and treated with intravenous antibiotic therapy. We specifically analyzed for the subsets of patients infected with methicillin-resistant Staphylococcus aureus (MRSA), with healthcare-associated (HCA) infections, or both. Data from 494 patients (HCA: 360; MRSA:175; MRSA + HCA: 129) showed the overall mean length of stay (LOS) was 7.4 days and 15.0% had the composite economic outcome of any subsequent hospital admissions, emergency department visits, or unscheduled visits related to the study infection. A total of 23.1% of patients had IIAT; after adjustments, these patients had longer LOS than patients without IIAT in the HCA cohort (marginal LOS = 1.39 days, P = 0.03) and the MRSA + HCA cohort (marginal LOS = 2.43 days, P = 0.01) and were significantly more likely to have the composite economic outcome in all study cohorts (odds ratio: overall = 1.79; HCA = 3.09; MRSA = 3.66; MRSA + HCA = 6.92; all P < 0.05).     

Community-associated CMRSA-10 (USA-300) is the predominant strain among methicillin-resistant Staphylococcus aureus strains causing skin and soft tissue infections in patients presenting to the emergency department of a Canadian tertiary care hospital

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen first described among individuals with no contact with health care facilities. The purpose of this study was to determine the proportion of CA-MRSA, defined by pulsed field gel electrophoresis (PFGE), in MRSA skin and soft tissue infections presenting to the Emergency Department (ED). We also aimed to describe the laboratory and clinical characteristics of CA-MRSA infections. From June 1, 2001 to May 30, 2005, MRSA isolates from skin and soft tissue infections presenting to the ED were reviewed. They were characterized by antibiotic susceptibilities and PFGE, and the presence of staphylococcal cassette chromosome (SCC) mec type IVa and Panton-Valentine leukocidin (PVL) genes was assessed on representative isolates. The medical records were reviewed to define risk factors. There were 95 isolates available for analysis, of which 58 (61%) were CMRSA-10 (USA-300), the predominant clone from 2003 onward. All representative isolates (24%) tested in this group had PVL genes and SCCmec type IVa. Their antibiogram showed 100% susceptibility to trimethoprim-sulfamethoxazole, rifampin, and fusidic acid, and 79% to clindamycin. Clinical comparison of CMRSA-10 vs. hospital PFGE type strains showed 22% vs. 60%, respectively, for recent antibiotic use (p < 0.0001), 26% vs. 6%, respectively, for intravenous drug use (p < 0.05), and 57% vs. 6%, respectively, for soft tissue abscess (p < 0.001). CMRSA-10 is a major pathogen in skin and soft tissue abscesses in our ED. It has a characteristic susceptibility, and was associated with intravenous drug use, but not with recent antibiotic usage.     

大芬戈尔德菌致皮肤软组织感染4例及文献回顾

目的总结大芬戈尔德菌皮肤软组织感染的临床特点、实验室培养方法及治疗转归。方法回顾性分析民航总医院2016年5月至2019年8月检出的4例大芬戈尔德菌感染病例的临床资料、实验室检查方法、抗菌药物治疗及结局,并查阅国内外相关文献进行分析。结果4例大芬戈尔德菌感染病例发病时间均较长(2周至半年),感染初期均无明显症状,起病隐匿,脓肿增长迅速,无外伤史,1例发热(38.5℃)。感染部位有不同程度肿胀、疼痛、破溃等。除1例有基础疾病(糖尿病),其余均无明显诱因。分别抽取4例患者皮下脓液、乳腺脓液等行厌氧培养,结果均为大芬戈尔德菌,应用抗菌药物克林霉素、红霉素和阿莫西林/克拉维酸治疗1~3周,愈合好转。结论大芬戈尔德菌可致皮肤软组织感染,自多种临床标本中检出,临床医生应充分认识到厌氧菌感染的临床意义,尤其是当普通细菌培养结果为阴性时,应考虑到厌氧菌感染的可能。     

Necrotizing Soft Tissue Infections: A Review of Diagnosis,Management, and Implications for NP Practice

Skin and soft tissue infections are among the most common diagnoses seen by nurse practitioners practicing in all settings. These infections range from mild, uncomplicated cellulitis to the more severe, complicated diagnosis of necrotizing soft tissue infections (NSTI). For patients presenting with symptoms of skin and soft tissue infections, differentiating NSTIs from less insidious infections is of paramount importance. NSTIs can be difficult to diagnose because the early presentation may be misleadingly straightforward; however, it is essential that NPs carefully consider NSTIs when a patient presents with the following cardinal skin signs: erythema, swelling, and warmth.     

214例皮肤软组织感染金黄色葡萄球菌的临床分析

目的分析近3年皮肤软组织感染(SSTIs)中金黄色葡萄球菌(SAU)的分离率、临床分布和药物敏感率,为临床诊治提供参考。方法选取该院2011年9月至2014年8月临床送检的SSTIs标本分离出的214例SAU。应用Whonet 5.6软件进行统计分析。结果 2 152例感染脓性分泌物标本中,阳性标本1 228例,其中SAU 214例,占17.43%,耐甲氧西林金黄色葡萄球菌(MRSA)48例,占所有SAU的22.43%;主要分布在骨外科、烧伤整形科、乳腺外科、皮肤科,分别为40.2%、22.3%、12.1%、8.4%;对青霉素、红霉素及克林霉素的耐药率分别为96.3%,46.7%,37.4%,对万古霉素、利奈唑胺、呋西地酸、莫匹罗星有较高的敏感度。结论对于SSTIs该院外科感染率较高,临床上应按照SAU的药敏分析结果选择敏感度较高的第一、二代头孢菌素进行治疗,而万古霉素、利奈唑胺只有在严重SAU(包括MRSA)感染时才选用。     

利奈唑胺和糖肽类抗生素对复杂性皮肤及软组织感染治疗效果的荟萃分析

目的 对现已发表的利奈唑胺和糖肽类抗生素治疗革兰阳性球菌复杂性皮肤及软组织感染的文献进行综合分析,评价利奈唑胺的疗效及安全性是否优于糖肽类抗生素.方法 计算机检索Medline数据库、Embase数据库、Ovid数据库、Cochrane 图书馆及中文生物医学期刊数据库等网络资源,并查阅所有纳入的参考文献,进行荟萃分析....     

Management of necrotizing skin and soft tissue infections

Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.     

Emergency Management of Pediatric Skin and Soft Tissue Infections in the Community‐associated Methicillin‐resistant Staphylococcus aureus Era

Objectives: Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. Methods: This was a cross‐sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list‐serv. Enrollment occurred via the list‐serv over a 3‐month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. Results: In total, 366 of 606 (60.3%) list‐serv members responded. The mean (± standard deviation [SD]) duration of practice was 13.6 (±7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim‐sulfa (27.0%), and first‐generation cephalosporins (22.7%); methicillin‐sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA‐MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim‐sulfamethoxazole (TMP‐Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA‐MRSA–inactive agents. All PEPs suspected CA‐MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA‐MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA‐MRSA prevalence for even common infections. Conclusions: Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated. ACADEMIC EMERGENCY MEDICINE 2010; 17:187–193 © 2010 by the Society for Academic Emergency Medicine     

不同皮瓣在急诊口腔颌面部软组织缺损修复中的临床分析

目的：对比胸锁乳突肌皮瓣与股前外侧皮瓣在急诊口腔颌面部软组织缺损修复中的临床效果。方法：急诊口腔颌面部软组织缺损患者80例,根据修复方法的不同分为治疗组与对照组各40例,治疗组采用股前外侧皮瓣修复治疗,对照组采用胸锁乳突肌皮瓣修复治疗。结果：所有患者都皮瓣移植成功,治疗组与对照组的治愈率分别为95.0%与80.0%,组间比较差异有统计学意义（P〈0.05）。随访6个月,治疗组术后皮瓣坏死、感染、吞咽困难、切口裂开等总体并发症发生率明显少于对照组（P〈0.05）。治疗组的复发率为2.5%,而对照组为12.5%,组间比较差异有统计学意义（P〈0.05）。结论：股前外侧皮瓣在急诊口腔颌面部软组织缺损修复中的应用能提高治愈效果,减少并发症与复发情况的发生,值得推广应用。     

Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections

BackgroundPatients presenting to emergency departments with spontaneous anterior epistaxis may undergo anterior nasal packing and sometimes receive systemic prophylactic antibiotics. There has not been sufficient evidence to support or refute this practice. The main objective of this study was to compare the likelihood of clinically significant infection (CSI) between patients with or without prophylactic antibiotics for anterior nasal packing due to spontaneous epistaxis.MethodsWe performed a meta-analysis of the literature to assess whether prophylactic antibiotics prevented CSI among patients with anterior nasal packing by searching PubMed, Embase, and Scopus databases for original articles. We also looked at the secondary outcome of non-infectious complications. We reported the outcomes using random effect models. Human studies in English, randomized control trials, quasi-randomized trials, clinical trials, retrospective studies, and case series were included. We excluded studies involving patients undergoing otolaryngologic surgeries. Statistical heterogeneity was examined using the DerSimonian and Laird Q test and I² statistic.ResultsA total of 281 articles were identified. Of these, 5 articles met inclusion criteria, with 383 patients receiving anterior nasal packing. One hundred sixty (42%) patients did not receive prophylactic antibiotics while 223 (58%) received antibiotics. The proportion of CSI in the pooled cohort was 0.8% (95% CI 0.2–1.9), resulting in a number needed to treat (NNT) to prevent one infection of 571. The rate of non-infectious complications associated with epistaxis was 20% (95% CI 10–32).ConclusionsThis meta-analysis suggests that prescribing prophylactic antibiotics for anterior nasal packing may not be necessary due to the low proportion of CSIs across heterogenous patient populations. Further high-quality randomized trials are needed to support this finding.     

Ceftobiprole: a new cephalosporin for the treatment of skin and skin structure infections

Ceftobiprole is among the first of a new generation of cephalosporins with activity against aerobic Gram-negative bacilli, which extends to cefepime-sensitive Pseudomonas aeruginosa, and activity against Gram-positive organisms, which includes methicillin-resistant Staphylococcus aureus. Ceftobiprole is currently undergoing evaluation by the US FDA for the treatment of complicated skin and skin structure infections, with a decision pending further evaluation of study site monitoring. It is also being evaluated for the treatment of community-acquired and healthcare-associated pneumonia. Two Phase III multicenter trials have demonstrated noninferiority in complicated skin and skin structure infections when tested against vancomycin in primarily Gram-positive bacterial infections, and when tested against vancomycin plus ceftazidime in Gram-positive and Gram-negative bacterial infections. It is well tolerated, with the most common side effects being nausea and dysgeusia. Ceftobiprole is likely to prove useful as an empiric as well as directed monotherapy in patients with complicated skin and skin structure infections, in which both Gram-positive pathogens including methicillin-resistant S. aureus and Gram-negative pathogens including cefepime-sensitive P. aeruginosa may be involved.     

Community-associated methicillin-resistant and methicillin-sensitive Staphylococcus aureus: skin and soft tissue infections in Hong Kong

This prospective study assessed the epidemiology of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among patients with purulent skin and soft tissue infections (SSTIs) in Hong Kong. Among 298 patients with SSTIs, 10.4% (13/125) of all S. aureus isolates and 5% (12/241) of all abscesses were attributed to pvl-positive CA-MRSA. Overall, 77% and 69.9% of CA-MRSA and methicillin-sensitive S. aureus (MSSA) were susceptible to erythromycin, 77% and 74.8% to clindamycin, 100% and 97.1% to minocycline, and 100% and 98.1% to rifampin, respectively. Filipino ethnicity was the only clinical and epidemiologic factor significantly associated with CA-MRSA infection (odds ratio, 14.8; 95% confidence interval, 3.3-70.0; P < 0.001). Pulsed-field gel electrophoresis analysis showed that 6 CA-MRSA isolates belonged to the ST30-HKU100 clone, 5 belonged to the ST59-HKU200 clone, and 1 was singleton. Features of HKU100 isolates include SCCmec type IV, agr3, spa t019, and pan-susceptibility to non-beta-lactam antibiotics. In contrast, HKU200 isolates are characterized by having SCCmec type IV or V, agr4, spa t437, and variable non-beta-lactam susceptibility profiles. The major CA-MRSA spa types were shared by a minority of the MSSA.     

Harm reduction for the treatment of patients with severe injection-related infections: description of the Jackson SIRI Team

IntroductionHospitalizations for severe injection-related infections (SIRI), such as endocarditis, osteomyelitis, and skin and soft tissue infections (SSTI) are increasingly common. People who inject drugs (PWID) experiencing SIRIs often receive inadequate substance use disorder (SUD) treatment and lack of access to harm reduction services. This translates into lengthy hospitalizations with high rates of patient-directed discharge, readmissions, and post-hospitalization mortality. The purpose of this study was to describe the development of an integrated “SIRI Team” and its initial barriers and facilitators to success.Materials and methodsThe Jackson SIRI Team was developed to improve both hospital and patient-level outcomes for individuals hospitalized with SIRIs at Jackson Memorial Hospital, a 1550-bed public hospital in Miami, Florida, United States. The SIRI Team provides integrated infectious disease and SUD treatment across the healthcare system starting from the inpatient setting and continuing for 90-days post-hospital discharge. The team uses a harm reduction approach, provides care coordination, focuses on access to medications for opioid use disorder (MOUD), and utilizes a variety of infection and addiction treatment modalities to suit each individual patient.ResultsOver the initial 8-months of the SIRI Team, 21 patients were treated with 20 surviving until discharge. Infections included osteomyelitis, endocarditis, bacteraemia/fungemia, SSTIs, and septic arthritis. All patients had OUD and 95% used stimulants. All patients were discharged on MOUD and 95% completed their prescribed antibiotic course. At 90-days post-discharge, 25% had been readmitted and 70% reported taking MOUD.ConclusionsA model of integrated infectious disease and SUD care for the treatment of SIRIs has the potential to improve infection and addiction outcomes. Providing attentive, patient-centered care, using a harm reduction approach can facilitate engagement of this marginalized population with the healthcare system.

KEY MESSAGES

• Integrated infectious disease and addiction treatment is a novel approach to treating severe injection-related infections.
• Harm reduction should be applied to treating patients with severe injection-related infections with a goal of facilitating antibiotic completion, remission from substance use disorder, and reducing hospital readmissions.

     

Iclaprim: a differentiated option for the treatment of skin and skin structure infections

ABSTRACT

Introduction: Iclaprim is a selective bacterial dihydrofolate reductase (DHFR) inhibitor. Although there are alternative options for the treatment of acute bacterial skin and skin structure infections (ABSSSI), iclaprim is differentiated from other available antibiotics.

Areas covered: Iclaprim is under clinical development for ABSSSI. This review summarizes the mechanism of action, pharmacokinetics, microbiology, clinical development program, and the differentiation of iclaprim from other antibiotics.

Expert commentary: Iclaprim has a different mechanism of action (DHFR inhibitor) compared to most other antibiotics, is active and rapidly bactericidal against Gram-positive pathogens including antibiotic-resistant pathogens, and suppresses bacterial exotoxins (alpha hemolysin, Panton Valentine leukocidin, and toxic shock syndrome toxin-1). Compared to trimethoprim, iclaprim has lower MIC_90s, can be given without a sulfonamide, overcomes select trimethoprim resistance, and does not cause hyperkalemia. Iclaprim is administered as a fixed dose, does not require dose adjustment in renally-impaired or obese patients, and was not associated with nephrotoxicity in the Phase 3 pivotal REVIVE studies. Iclaprim represents a novel, alternative option for the treatment of severe skin and skin structure infections due to Gram-positive bacteria, particularly in patients at risk of acute kidney injury.     

Haemodynamically stimulated and in vivo generated axially vascularized soft‐tissue free flaps for closure of complex defects: Evaluation in a small animal model

The arteriovenous (AV) loop model permits the creation of significant volumes of axially vascularized tissue that represents an alternative to conventional free flaps, circumventing their common limitations. However, such AV loop‐based flaps have never before been examined in standardized animal models with respect to their suitability for reconstruction of critical bone‐exposing defects. In the course of our preliminary studies, we implemented a novel defect model in rats that provides standardized and critical wound conditions and evaluated whether AV loop‐generated flaps are suitable for free microsurgical transfer and closure of composite defects. We compared three groups of rodents with similar scapular defects: one received the AV flap, whereas controls were left to heal by secondary intention or with supplementary acellular matrix alone. To create the flaps, AV loops were placed into subcutaneous Teflon chambers filled with acellular matrix and transferred to the thigh region. Flap maturation was evaluated by histological analysis of angiogenesis and cell migration at days 14 and 28 after loop creation. Flap transfer to the scapular region and microsurgical anastomoses were performed after 14 days. Postoperative defect closure and perfusion were continually compared between groups. Within the AV flap chamber, the mean vessel number, cell count and the proportion of proliferating cells increased significantly over time. The novel defect model revealed that stable wound coverage with homogeneous vascular integration was achieved by AV loop‐vascularized soft‐tissue free flaps compared with controls. In summary, our study indicates for the first time that complex composite defects in rats can successfully be treated with AV loop‐based free flaps.