Common Soft Tissue Infections Research Articles

Using Thermal Imaging to Track Cellulitis.

Cellulitis is a common soft tissue infection and a major cause of morbidity. The diagnosis is based almost exclusively on clinical history and physical exam. To improve the diagnosis of cellulitis, we used a thermal camera to track how skin temperature of the affected area changed during a hospital stay for patients with cellulitis. We recruited 120 patients admitted with a diagnosis of cellulitis. Daily thermal images of the affected limb were taken. Temperature intensity and area were analyzed from the images. Highest daily body temperature and antibiotics administered were also collected.We estimated a longitudinal linear mixed-effects model with a random intercept for the affected body area. All observations on a given day were included, and we used an integer time indicator indexed to the initial day (ie, t = 1 for the first day the patient was observed, etc.). We then analyzed the effect of this time trend on both severity (ie, normalized temperature) and scale (ie, area of skin with elevated temperature). We analyzed thermal images from the 41 patients with a confirmed case of cellulitis who had at least 3 days of photos. For each day that the patient was observed, the severity decreased by 1.63 (95% CI, -13.45 to 10.32) units on average, and the scale decreased by 0.63 (95% CI, -1.08 to -0.17) points on average. Also, patients' body temperatures decreased by 0.28°F each day (95% CI, -0.40 to -0.17). Thermal imaging could be used to help diagnose cellulitis and track clinical progress.

32. Facial cellulitis: an audit of the management

Cellulitis is a common soft tissue infection of the dermis and subcutaneous tissues. NICE guidelines recommend Co-amoxiclav as first line therapy for facial cellulitis adjecent to the nose and eyes. We reviewed prescribing practices in patients presenting with facial cellulitis or preseptal cellulitis in a busy district general hospital.

#29 Skin and Soft Tissue Infections and Associated Complications in Children Aged 0-3 Years in Two Urban Multiethnic Community Hospitals

Abstract Background Skin and soft tissue infections (SSTI) include cellulitis and abscess. Cellulitis is an infection of the deep dermis and an abscess is a collection of pus within the dermis and subcutaneous space. Complications of SSTI include bacteremia, lymphadenitis, endocarditis, septic arthritis or osteomyelitis, metastatic infection, sepsis, and toxic shock syndrome. There are no studies evaluating SSTI and complications and outcomes in children aged 0-3 years. Method This is a retrospective chart review of SSTI in children aged 0-3 years in Flushing Hospital Medical Center and Jamaica Hospital Medical Center between Jan 2015 and Oct 2021. Data extracted from EHR include demographics (age, gender, ethnicity), clinical presentation, laboratory studies, imaging studies, antibiotic used, treatment course, complications and length of stay (LOS). Data were analyzed using percentages. Results Of 206 patients admitted for SSTI, about a half (48%) were abscesses, less than half (44%) cellulitis, few impetigo (6%) and staphylococcal scalded skin syndrome (2%). Most were male (52%), Hispanic (70%) and Asian (26%). A fifth (18%) had previous SSTI and a tenth (8%) had a positive family history. Of a third (36%) who had imaging studies, three quarters (76%) had an ultrasound, less than a half (44%) confirmed an abscess and less than a third (29%) soft tissue infection. Almost all (94%) had a blood culture and most a wound culture (59%). Of the positive blood cultures (4%), majority (78%) were contaminants or normal skin flora and remainder (22%) Staphylococcus aureus. Of the positive wound cultures, most (86%) were Staphylococcus aureus. Methicillin-sensitive S. aureus (MSSA) was equal to methicillin-resistant S. aureus (MRSA) (44% vs 43%). Of the 11% having complications, the most common was lymphadenitis (6%). Clindamycin was the antibiotic of choice in most (70%) and 14% required a change in antibiotic due to susceptibility pattern. The median LOS was 3 days. Conclusion The most common SSTI in children aged 0-3 years is abscess and cellulitis. The yield of blood cultures is low. The prevalence of MRSA was equal to MSSA. Knowing the low prevalence of complications in children with SSTI, healthcare providers can provide appropriate antibiotic coverage and disposition for SSTI in our community.

Skin and soft tissue infections in hospitalized cancer patients: A retrospective study.

Objectives:To assess the clinical and epidemiological characteristics of hospitalized cancer patients with skin and soft-tissue infections (SSTIs).Methods:An observational retrospective study was conducted between March 2016 and December 2020 at the Oncology Department of King Saudi Medical City, Riyadh, Saudi Arabia. Patients with complicated and uncomplicated SSTIs were included.Results:A total of 204 cancer patients with SSTIs were evaluated. The incidence of SSTIs was 1.67% (204/12,203). Breast cancer (39%) was the most common solid tumor in all patients with SSTIs. Exit site infection (n=84, 41.2%) was the most common SSTI in cancer patients, followed by wound infection (n=72, 35.3%), and cellulitis (n=44, 21.5%). The majority of patients received appropriate antimicrobial therapy (n=150, 73.5%).Conclusion:This study has shown a modest incidence of SSTIs in hospitalized cancer patients, with many of the patients received appropriate antimicrobial therapy.

#4: Antibiotic Durations for Skin and Soft Tissue Infections in Pediatric Urgent Care Clinics

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5–7 days for most diagnoses. Objectives To determine the baseline percentage of patients receiving antibiotic prescriptions for >7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations. Methods We built a report that extracted patient encounters from the three UCCs based on International Classification of Diseases (ICD)-10 codes for common SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Data was pulled from June 2019 through June 2020. The report included patient age, concomitant diagnoses, antibiotics prescribed and their duration. We excluded encounters if the patient was transferred to the emergency department or admitted, the patient was younger than 3 months of age, no antibiotics were prescribed, or if there was a concurrent infectious diagnosis affecting antibiotic duration. We sent a 22-question survey to UCC providers to understand prescribing habits particularly focusing on factors prompting administration of longer antibiotic courses. Findings From June 2019-June 2020, we reviewed 2,575 encounters; we excluded 208 of those (8%). 823 (35%) of patients received >7 days of antibiotics for SSTIs while 1181 (50%) received 5–7 days and 35 (1%) received <5 days of antibiotics. 328 (14%) received topical therapy only. Most common antibiotics prescribed included cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. A mild improvement in the 5–7 days duration was noted through our study period (Figure 1). The survey was sent to 50 providers with 27 responding (54% response rate). Of providers surveyed, 5 (19%), 7 (26%), and 8 (29%), expressed being uncomfortable with a 5-day treatment course for cellulitis, erysipelas, and abscesses respectively. Barriers for shorter treatment courses included concern for acute rheumatic fever development, parental pressure, fear of complications, and accustomed antibiotic duration. Conclusion A third of children with SSTIs in our UCCs receive long courses of antibiotics. A mild improvement noted in our study period may be due to existing antibiotic stewardship interventions. Specific provider concerns leading to overprescribing will be targeted by quality improvement efforts.

The Epidemiological Study, Clinical Signs, Complications, and Treatment of Cellulities in Children

Background and Aim: Cellulite is the most common soft tissue infection in children. Children are prone to cellulite because they are more disposed to trauma, insect or animal bites, wounds, and scratches. This study aimed to determine the frequency of causes, complications, and cellulite treatment in children referred to Hazrat Masoumeh Hospital in Qom City, Iran. Materials and Methods: This descriptive study was performed on all patients admitted to Hazrat Masoumeh Hospital in Qom during 2013-2020. The study data were extracted from patients’ medical records and statistically analyzed. Results: The Mean±SD age of the patients was 42.94±38.15 months. Their male/female sex ratio was almost one. The most affected areas were the lower extremities (43%), the upper extremities (26.5%), and the face and eyes (6.6%). The most common clinical manifestations were edema (75%), redness (62%), and fever (38%). The most commonly prescribed antibiotics were ceftriaxone (47%), cloxacillin (34.7%), and clindamycin (28%). The most common underlying causes were bites (16%), trauma (10%), and previous wounds (9%). Complications were abscesses (10%) and osteomyelitis (1.6%). Their Mean±SD values of erythrocyte sedimentation rate, C-reactive protein, and white blood count were 32.46±26.03 (mm/h), 24.14±23.07 (mg/dl), 12261±4587 (cell/μL), respectively. Preference was seen with Polymorphonuclear leukocytes (PMNs) in 80.5% of the cases. Blood culture was positive in 8% of the patients. According to the antibiogram response, the highest resistance was seen against cefazolin and then ceftriaxone, and the highest sensitivity to imipenem and ceftazidime. Conclusion: Finally, due to the limitations of retrospective research in collecting information, future research should focus on evaluating specific treatments and diagnostic methods for diseases such as cellulite in Iran. Future research can determine the prevalence of organisms involved in our country, as well as the type of appropriate treatment for all inpatients and outpatients.

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK.

BackgroundSkin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.MethodsWe used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.ResultsWe recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.ConclusionsAbscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.

1525. Epidemiology, Management, and Outcomes of Skin and Soft-Tissue Infections in Well-Appearing Infants Less Than 60 Days of Age

BackgroundSkin and soft-tissue infections (SSTIs) in children are increasingly common. The IDSA has published guidelines for SSTI treatment in children, adolescents, and adults but data in infants less than 2 months is sparse despite their higher risk of concomitant serious bacterial infection (SBI). Clinical work-up and management of these patients varies widely with little evidence to guide providers.MethodsWe retrospectively identified 536 patients, from 2007 to 2017, seen at our EDs or hospital-associated clinic and diagnosed with SSTI by ICD9/10 code. We excluded those with ill-appearance, prematurity, known immunodeficiency, skin disorder, previous SSTI, or previous procedure at infection site. Remaining patient’s medical records were reviewed to confirm a SSTI. The total included study population was 182 (Figure 1). Data collected included demographics, type/location of infection, laboratory/imaging studies obtained, procedures performed, disposition, treatment, and treatment failure.ResultsDemographics are reported in Table 1. Mean age was 24.2 days (range 2–57 days). Of 182 patients, 13% had fever. 34% had a superficial infection (impetigo or pustulosis), 24% had cellulitis/scalded skin, 35% had an abscess/paronychia, and 7% had periorbital cellulitis. The most common SSTI locations were perineal/genital (30%) and head/scalp/face (23%). 63% of infants had a blood culture obtained and 4/114 grew a pathogenic bacteria. 52% had a wound culture and 72/95 grew a pathogenic bacteria. No infants had bacterial meningitis or a UTI (Table 2). 25% underwent incision/drainage and 93% received any antibiotic. The most commonly prescribed antibiotics were clindamycin and mupirocin. Of 80 non-admitted infants, 21% had an unscheduled return visit within 2 weeks (Table 3): 9% for treatment failure, 6% unrelated to SSTI, and 1% for missed SBI (1 patient with GAS bacteremia).ConclusionMost well-appearing infants with SSTI were afebrile. The majority of studied infants had blood cultures obtained but rates of clinically significant bacteremia were low. Management varied considerably and antibiotics were commonly administered. However, overall rates of SBI were low and there was only 1 case of missed SBI. Extensive evaluation of well-appearing infants with SSTI may be unnecessary. Disclosures All authors: No reported disclosures.

450. Evaluation of Linezolid Pharmacokinetics in Obese Patients with Severe Skin and Soft-Tissue Infections

BackgroundLinezolid is an oxazolidinone antibiotic with broad activity against Gram-positive bacteria and serves as an option for treating severe skin and soft-tissue infections (SSTIs). Adult FDA-labeled dosing is fixed at 600 mg IV/PO twice daily. Although conflicting, current literature is suggestive that critically ill, obese patients require increased doses. Based on this literature, our institutional guidelines recommend linezolid 600 mg every 8 hours for patients ≥150 kg. This study aimed to determine whether obese patients receiving linezolid for severe SSTI attain pharmacokinetic/pharmacodynamic (PK/PD) targets.MethodsAdult patients with a body mass index (BMI) ≥30 who were hospitalized and receiving IV linezolid were eligible for consent in this prospective cohort study. A severe SSTI was defined by one of the following: necrotizing fasciitis, myonecrosis, or SSTI with sepsis based on qSOFA score or SIRs criteria. Four blood samples were collected at steady state, after at least 3 linezolid doses, at 2, 4, and 6 hours after the dose and as a trough before the next dose. Linezolid serum concentrations were determined by HPLC. Non-compartmental methods in Phoenix-WinNonlin (Version 6.4) were used to estimate individual PK parameters. The PK parameters were used to determine the concentration-time profile assuming one-compartment kinetics. Target attainment was defined as achieving a 24-hour area under the curve (AUC0–24)/minimum inhibitory concentration (MIC) ≥100 or time above the MIC ≥ 85%.ResultsEleven patients were included in the study. The median BMI was 45.7 (34.6–72.7) and median total body weight was 141.3 kg (99.9–188). Necrotizing fasciitis was the most common SSTI type at 45.5%. Four patients received linezolid 600 mg every 8 hours, 3 patients of which were ≥150 kg. Two patients received renal replacement therapy at the time levels were drawn. Based on non-compartmental analysis, the mean AUC0–24 was 208.1 hr*mg/L (± 85.3). All but one patient, who grew E. faecalis with a MIC of 2, met PK/PD targets based on AUC/MIC ≥100. All patients achieved concentrations above MIC for 100% of the dosing interval.ConclusionAll patients met defined PK/PD targets with linezolid doses received. This study validates current institutional dosing guidelines for patients with severe SSTIs. Disclosures All authors: No reported disclosures.

Periocular necrotizing fasciitis following retrobulbar injection

Necrotizing fasciitis is a rare, rapidly progressive severe bacterial soft tissue infection with a high mortality rate. While necrotizing fasciitis classically involves the trunk, groin/perineum, lower limbs, and postoperative wound sites, primary involvement of the eyelids is a rare but well known entity. We present a 33-year-old female patient who developed periocular necrotizing fasciitis after local retrobulbar anesthesia injection and facial block for cataract surgery in the left eye and canthotomy/cantholysis for treatment of moderate retrobulbar hemorrhage in the same eye. Surgical debridement was done and necrotic foul-smelling eyelid and deep orbital tissues were removed, and culture grew Staphylococcus aureus. Despite initial surgical debridement and intravenous antibiotic therapy, the disease progressed rapidly; orbital exenteration was considered, but the patient declined the surgery and self-discharged. Periocular necrotizing fasciitis remains predominantly a clinical diagnosis, and is often missed early in its presentation because of the difficulty in distinguishing it from other common soft tissue infections, especially in the presence of surgical wounds and retrobulbar hemorrhage. A high index of suspicion, early recognition, and prompt therapeutic interventions are indispensable for optimal visual outcome and patient survival.

A Case of Postsurgical Necrotizing Fasciitis Invading the Rectus Abdominis Muscle and Review of the Literature

Necrotizing fasciitis is a life-threatening, soft tissue infection and an early diagnosis is needed to permit a prompt surgical and medical intervention. Due to the high fatal potential of the disease complications, the radiologist should distinguish necrotizing fasciitis from the most common soft tissue infections, in order to permit a prompt surgical and medical treatment. We present a case of a wide necrotizing fasciitis who presented at our emergency department and we also provide the basic tools, through a review of the literature, for the general radiologist to distinguish, with computed tomography and magnetic resonance imaging, necrotizing fasciitis from the most common infections that could present during our routine practice.

Ocular necrotizing fasciitis due to Pseudomonas aeruginosa in a non-neutropenic patient

Eyelid necrosis is a very rare disease, usually secondary to trauma or infections. Pseudomonas aeruginosa (PA) eyelid necrosis remains principally a clinical diagnosis and it is often missed early in its presentation because of the difficulty in differentiating it from more common soft tissue infections. However, when the diagnosis is made we must act quickly due to the fatal evolution if not handled properly. We present the case of a non-neutropenic 53-year-old male patient with a history of alcoholism, smoking habit and lung cancer under chemotherapy treatment who developed ocular necrotizing fasciitis due to PA with perforation of his left eye and severe bilateral sclera ischemia despite intensive antibiotic treatment and surgical debridement.

Necrotizing Fasciitis

Necrotizing fasciitis (NF) is a rare, rapidly progressive bacterial soft tissue infection with a high risk for morbidity and mortality. Although more common in adults, NF also affects the pediatric population. Many bacterial organisms can cause NF, but group A Streptococcus is the most common monomicrobial cause of disease. Necrotizing fasciitis remains principally a clinical diagnosis, and it is often missed early in its presentation because of the difficulty in differentiating it from more common soft tissue infections. The criterion standard for diagnosis and the mainstay of therapy are surgical debridement. Time to initiation and completion of therapy remains the most important factor in patient outcome, highlighting the importance of early recognition and intervention in this potentially devastating disease.

Evaluation of microbiological spectrum and risk factors of cellulitis in hospitalized patients

Background and design: Cellulitis is a common soft tissue infection and the severity of disease vary from mild to life threatening. The aim of the present retrospective study was to evaluate age, sex, site of infection, microbiological spectrum and the risk factors of cellulitis in hospitalized patients.Materials and methods: The data were retrospectively obtained by the review of 185 hospitalized patients who were diagnosed as cellulitis between 2003 and 2009 in the departments of dermatology, infectious diseases, internal medicine and surgery clinics of Haydarpasa Numune Training and Research Hospital (Istanbul, Turkey). The diagnosis was done by infectious diseases and dermatology specialists in all patients who were included to this study. Demographic findings, wound-blood cultures and risk factors of the patients with cellulitis were evaluated.Results: Eighty-six were female, 99 were male of total 185 patients, and the mean age of them was 48 ± 27 (14–85). The leg was the involved site in 69% of the patients. The most frequent isolated bacteria from wound cultures were methicillin-sensitive Staphylococcus aureus 31.5%, Pseudomonas aeruginosa 12.6%, and Escherichia coli 12.3%. However, methicillin-sensitive S. aureus 32.5%, methicillin-resistant S. aureus 22.5%, coagulase-negative staphylococci 17.5% were detected from blood cultures. There was not any underlying risk factor in 104 (55.3%) patients. The risk factors observed in the other 81 patients were previous surgery or open wound 29 (35.8%), diabetes mellitus 19 (26.6%), cardiovascular diseases 16 (19.7%), immunosuppression 11 (13.5%), lymphoedema 6 (7.4%).Conclusion: In the patients hospitalized for cellulitis, the most frequently isolated microorganism from the wound and blood cultures was S. aureus and the most frequently detected risk factors were to have an open wound and previous surgery. Especially when the patients had risk factors, it was observed that the bacterial spectrum was broader and the clinical presentation was severe. The wound and blood cultures should be performed simultaneously for the microbiological diagnosis and the appropriate management of cellulitis.

Unusual associations of necrotizing fascitis: A case series report from a tertiary care hospital

Necrotizing fasciitis is a rapidly progressive, potentially fatal infection of the superficial fascia and subcutaneous tissue. It is rare in children. We report three such cases in which differentiating from common soft tissue infection was challenging. High index of suspicion is important as management initiated at an early stage is rewarding.

Necrotizing soft-tissue infections.

Necrotizing fasciitis is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen, or perineum. Necrotizing fasciitis typically begins with trauma; however, the inciting event may be as seemingly innocuous as a simple contusion, minor burn, or insect bite. Differentiating necrotizing infections from common soft-tissue infections, such as cellulitis and impetigo, is both challenging and critically important. A high degree of suspicion may be the most important aid in early diagnosis. Prompt diagnosis is imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death. Although group A Streptococcus is the most common bacterial isolate, a polymicrobial infection with a variety of Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is more common. Orthopaedic surgeons are often the first physicians to evaluate patients with such infections and therefore need to be familiar with this potentially devastating disease and its management. Prompt diagnosis, immediate administration of broad-spectrum antibiotic coverage, and emergent aggressive surgical debridement of all compromised tissues are critical to reduce the morbidity and mortality of these rapidly progressing infections.

Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A.

There is concern that group A streptococci, which have caused less serious infections in developed countries in recent decades, may be acquiring greater virulence. We describe 20 patients from the Rocky Mountain region who had group A streptococcal infections from 1986 to 1988 that were remarkable for the severity of local tissue destruction and life-threatening systemic toxicity. Among the 20 patients (median age, 36), necrotizing fasciitis with or without myositis was the most common soft-tissue infection (55 percent). Nineteen patients (95 percent) had shock, 16 (80 percent) had renal impairment, and 11 (55 percent) had acute respiratory distress syndrome. The mortality rate was 30 percent. All patients but 1 had positive tissue cultures for Streptococcus pyogenes; 12 had positive blood cultures. Most of the patients had no underlying disease; 2 used intravenous drugs. Strains of group A beta-hemolytic streptococci isolated from 10 patients were not of a single M or T type; however, 8 of the 10 strains produced pyrogenic exotoxin A (scarlet fever toxin A, a classic erythrogenic toxin), which has rarely been observed in recent years. From our study of this cluster of severe streptococcal infections with a toxic shock-like syndrome, we conclude that in our region, more virulent group A streptococci have reappeared that produce the pyrogenic toxin A associated with scarlet fever.