Primary Wound Infection Research Articles

Intact Fish Skin Graft to Treat Deep Diabetic Foot Ulcers

BackgroundDiabetic foot ulcers are chronic, difficult to heal, and potentially life-threatening. Few medical devices have been studied in diabetic ulcers penetrating to bone or tendon.MethodsWe conducted an international, open-label randomized controlled trial, randomly assigning patients with diabetic ulcers penetrating to bone, joint, or tendon 1:1 to intact fish skin graft or standard wound care, with assigned treatment applied through 14 weeks. The primary end point was the proportion of ulcers healed at 16 weeks, defined as reepithelization as identified by the investigator, and confirmed 14 days later. A blinded adjudication committee confirmed healing at both time points. Healing was also assessed at 20 and 24 weeks.ResultsBetween July 2020 and November 2022, 255 patients were randomly assigned to intact fish skin graft (n=129) or standard of care (n=126). Healing was achieved in 44% of patients at 16 weeks with intact fish skin graft compared with 26% for standard of care (P<0.001, unadjusted), with additional healing at 20 weeks (46% vs. 32%) and 24 weeks (55% vs. 38%). Mean (SD) time to healing was 17.3 (0.69) weeks (95% confidence interval [CI], 15.5 to 18.7) for the intact fish skin graft group and 19.4 (0.66) weeks (95% CI, 18.1 to 20.7) for the standard of care group. In a Cox regression, intact fish skin graft was associated with faster time to healing (hazard ratio, 1.59; 95% CI, 1.07 to 2.36). Primary wound infections were the most common adverse event, occurring in 39 (30.2%) of patients in the intact fish skin graft group and 31 (24.6%) of patients in the standard of care group.ConclusionsAmong patients with deep diabetic foot ulcers, treatment with intact fish skin graft was superior to standard of care in proportion of wounds healed at 16 weeks and was associated with faster time to healing. (Funded by European Commission Fast Track to Innovation Horizon 2020, and Kerecis Ltd. ClinicalTrials.gov NCT04257370.)

Clinical Profile of Multidrug-Resistant Organisms at Burn Center Dr. Soetomo General Hospital Surabaya from June 2020 to June 2021

Background: Burns are an ideal environment for primary wound infection to occur. Burn infection can lead to the acquisition of Multidrug-Resistant Organisms (MDRO) with certain risk factors, such as the cause, degree and total body surface area (TBSA) of burns, length of stay, and invasive procedures performed. This study aims to determine the clinical profile of burn patients who experience MDRO. Method: Data was taken using medical records at the Burn Center Dr. Soetomo General Hospital Surabaya during June 2020 – June 2021 with a descriptive study and a cross sectional approach. Result: A total of 67 burn patients were included in this study. Sixteen patients were found to have burns with MDRO, and 51 other patients only had burns without MDRO which was excluded in this study. Patient in this study were dominated by men with a total of 11 patients (68.8%), most patient were in the 19–45-year age group of 8 patients (50%) with an average of 35 ± 20.58 years, and length of stay &gt;14 days in 11 patients (68.8%) with an average 32,75 ± 38.31 days. All patients had invasive procedures performed. Fire was the most common cause of burns, namely in 9 patients (56.3%). Severe burns occurred in 16 patients (100%) of the MDRO burns studied. Eleven patients (68.8%) had TBSA &gt; 30% with an average of 37.06% ± 18.59%. Acinetobacter baumannii was the most MDR bacteria cultured in this study with 15 cultures (32.6%). It is followed by Pseudomonas aeruginosa with 9 cultures (19.6%) and Klebsiella pneumoniae with 4 cultures (8.7%). A. baumannii is most commonly found in blood cultures, followed by cultures of phlegm and wounds. This is in contrast to P. aeruginosa with the most findings in wound cultures, followed by cultures of sputum and blood. Conclusion: Our study shows that MDRO infection is still a matter of concern in burns. Even so, the number of samples should be increased to see the significance and the relationship between variables in future burn studies.

Complications of the urinary incontinence system ATOMS: description of risk factors and how to prevent these pitfalls.

We report on our multicentre evaluation of the occurrence and management of complications with the ATOMS device (A.M.I., Austria). Between 10/09 and 09/18, a total of 187 patients with persistent postoperative stress urinary incontinence received an ATOMS device in Madrid (n = 101) or Halle (n = 86). This prospective evaluation was carried out consecutively. In addition to complications, patient age, BMI, comorbidities and previous treatments for prostate cancer and urinary incontinence were examined. Statistical analysis was performed with GraphPad Prism 7® (GraphPad Software, Inc., La Jolla, USA); p < 0.05 was considered significant. The average age of the overall population was 69.4years, with a mean CCI of 4.3. In total, 18.2% of the patients had diabetes mellitus, 21.9% were irradiated, and 14.1% and 22.9% underwent previous surgery for urinary incontinence and urethral stricture, respectively. The overall success rate of the device was 80.2%. A total of 51 postoperative complications (51/187, 27.3%) were observed, with 18 grade I (9.6%), 1 grade II (0.5%), 3 grade IIIa (1.6%) and 29 grade IIIb (15.5%) complications. The most serious postoperative complications were primary wound infection (8/187, 4.3%) and long-term cutaneous erosion with subsequent infection (15/187, 8.02%). The main risk factors for complications were previous radiotherapy (p = 0.003) and surgery for urethral stricture (p = 0.017). No other parameters were significant in bivariate analysis (p > 0.05). The most severe complications of ATOMS implantation were primary wound infection and cutaneous erosion, especially in the presence of previous radiotherapy. Particular focus on performing hygienic and accurate implantation techniques is recommended.

Dynamic magnetic resonance imaging evaluation of pelvic reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal cancer.

Extra-levator abdominoperineal excision for rectal cancer includes resection of the levator ani muscle and therefore makes pelvic reconstruction advisable. The aim of our study was to evaluate morphologic and functional long-term results of pelvic floor augmentation with porcine dermal collagen mesh by dynamic magnetic resonance imaging and clinical examination. Twenty consecutive patients underwent perineal reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal adenocarcinoma with curative intent between 2009 and 2012. Patient perioperative and postoperative data were collected prospectively. There were one cancer-related and two noncancer-related deaths in the follow-up period, and another three patients refused the dynamic magnetic resonance imaging. Fourteen patients were included in the study. The median time period from surgery to dynamic magnetic resonance imaging and clinical examination was 31 months (range 19-56). Wound infections were observed in 43% (6 of 14) of these patients in the postoperative period, but no mesh had to be removed. No focal mesh defect, no damage on the suture line, and no perineal hernia were detected on dynamic magnetic resonance imaging. Clinical examination revealed no pathological findings in any patient. The implantation of a porcine dermal collagen mesh is an effective and reliable option for pelvic floor reconstruction after extra-levator abdominoperineal excision. Despite a high incidence of primary wound infections, the healing rate was satisfactory, no mesh had to be removed, and long-term stability could be achieved.

Risk factors for wound disruption following cesarean delivery

Objective: Risk factors for post-cesarean wound infection, but not disruption, are well-described in the literature. The primary objective of this study was to identify risk factors for non-infectious post-cesarean wound disruption.Methods: Secondary analysis was conducted using data from a single-center randomized controlled trial of staple versus suture skin closure in women ≥24 weeks’ gestation undergoing cesarean delivery. Wound disruption was defined as subcutaneous skin or fascial dehiscence excluding primary wound infections. Composite wound morbidity (disruption or infection) was examined as a secondary outcome. Patient demographics, medical co-morbidities, and intrapartum characteristics were evaluated as potential risk factors using multivariable logistic regression.Results: Of the 398 randomized patients, 340, including 26 with disruptions (7.6%) met inclusion criteria and were analyzed. After multivariable adjustments, African-American race (aOR 3.9, 95% CI 1.1–13.8) and staple – as opposed to suture – wound closure (aOR 5.4, 95% CI 1.8–16.1) remained significant risk factors for disruption; non-significant increases were observed for body mass index ≥30 (aOR 2.1, 95% CI 0.6–7.5), but not for diabetes mellitus (aOR 0.9, 95% CI 0.3–2.9). Results for composite wound morbidity were similar.Conclusions: Skin closure with staples, African-American race, and considering the relatively small sample size, potentially obesity are associated with increased risk of non-infectious post-cesarean wound disruption.

Seasonality, clinical types and prognostic factors of Vibrio vulnificus infection

Vibrio vulnificus infection, an uncommon but life-threatening illness, manifests as two main types, primary septicemia and primary wound infections. Little information regarding the seasonality of V. vulnificus infections in tropical areas and prognostic factors of primary V. vulnificus wound infections is available. This retrospective study was conducted to include 159 V. vulnificus-infected admissions at our institution in southern Taiwan, 63 with primary septicemia (Group 1) and 96 with primary wound infections (Group 2), from 1999 to 2008, for analysis. The case-fatality rate was 24%. Eighty-eight percent of these cases occurred during April to November. During December to March, patients in Group 2 were less likely to have acquired the infection compared with those in Group 1. Group 1 was more likely to have comorbidities and a higher case-fatality rate compared to Group 2. In multivariate analysis, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.024), lesions involving two or more limbs (P=0.043), and shock on admission (P=0.015) were related to an increased mortality risk, while surgery < 24 hours after admission (P=0.001) was related to a decreased mortality risk in Group 1; however, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.045) was the only prognostic factor in Group 2. The presence of hemorrhagic bullous lesion/necrotizing fasciitis is the main prognostic factor for primary septicemia or primary wound infections caused by V. vulnificus. Persons with an underlying immunocompromised status should avoid consuming raw/undercooked seafood or exposing wounds to seawater and should wear clothing during handling of seafood/fishing, especially in warmer months.

A comparison of teicoplanin versus cephradine plus metronidazole in the prophylaxis of post-operative infection in vascular surgery

A total of 272 patients were enrolled into this prospective, unblinded, randomized comparison of single-dose teicoplanin vs three doses of cephradine plus metronidazole as prophylaxis for vascular surgery at St James's and Seacroft Hospitals, Leeds, UK. In all, 71·3% of patients (194/272) were enrolled at St James's University Hospital. Patients received either a single dose of teicoplanin, 6 mg/kg i.v., or cephradine, 1 g i.v. with metronidazole, 1 g rectally, at induction of anaesthesia followed by two further 1 g doses of cephradine and metronidazole 8 and 16 hours later. There were 136 patients in each treatment group. The most common operations were femoropopliteal grafts (96) and aortic aneurysm repairs (47). In the ‘Intention-to-treat’ analysis, primary wound infections were seen in 4·4% of patients (6/136) receiving teicoplanin and 5·9% of patients (8/136) receiving cephradine plus metronidazole (95% CI −6·7%, +3·8%). Other disturbances to wound healing occurred in 23 patients (11 in the teicoplanin and 12 in the cephradine plus metronidazole group). Secondary respiratory tract infections occurred in 17 patients (8 receiving teicoplanin and 9 receiving cephradine plus metronidazole). In the evaluable patients analysis, primary wound infections occurred in 3·5% of patients (4/114) receiving telcoplanin and 5·1% of patients (6/117) receiving cephradine plus metronidazole. Staphylococcus aureus and Proteus sp. were the most common pathogens in primary wound infections. Despite the absence of Gramnegative cover in the teicoplanin group, Gram-negative infections occurred more often in the cephradine plus metronidazole group. Surgery of the lower extremities carried the highest risk of post-operative infection. Rates of infection were significantly higher at Seacroft Hospital ( P= 0001), and significantly higher for cephradine plus metronidazole between the two hospitals ( P= 00008). Adverse events occurred in 40 patients receiving teicoplanin (294%) and 39 patients receiving cephradine plus metronidazole (28·7%). In 19 patients receiving teicoplanin (14%) and 15 receiving cephradine plus metronidazole (11%) these events were considered to be related to the study drugs. The most often reported events were infections, cardiac events and vascular phenomena (haematoma or emboli). Marked changes in haematological parameters and liver function tests were noted seven days after operation in patients in each treatment group, but these resolved quickly as the effects of the operation subsided. ESR remained elevated in both groups at the six-month follow-up assessment. It is concluded from this two-centre study that a single dose of teicoplanin shows similar efficacy to a three-dose regimen of cephradine plus metronidazole as prophylaxis for wound infection in vascular surgery. Both regimens were well tolerated, and there was an equal incidence of adverse events in the two regimens, which reflected the poor general health status of this elderly study population.

Double-blind comparison of single-dose alatrofloxacin and cefotetan as prophylaxis of infection following elective colorectal surgery

Background: Alatrofloxacin, the prodrug of trovafloxacin, is a novel fluoroquinolone antimicrobial agent with a broad spectrum, including activity against gram-positive and gram-negative aerobes and anaerobes. Its pharmacokinetic properties (long half-life, excellent tissue distribution, and good safety profile) suggest a role in surgical prophylaxis. This prospective, multicenter, double-blind trial compared alatrofloxacin with cefotetan, an approved drug for surgical prophylaxis, in reducing postoperative infections. Methods: The efficacy and safety of a single 200- mg intravenous dose of alatrofloxacin were compared to a single 2-g intravenous dose of cefotetan in 492 patients undergoing elective colorectal surgery. The efficacy of alatrofloxacin as a prophylaxis for wound, intra-abdominal, or remote-site postoperative infectious complications was compared with cefotetan in 317 clinically evaluable patients; 161 received alatrofloxacin and 156 received cefotetan. The patients were monitored for infections and safety for 30 days postoperatively. Results: No statistically significant between-treatment difference was detected in successful clinical response rates at the end of the study (72% for each group). The incidence of primary wound infections at the time of hospital discharge was also similar: 21% in patients treated with alatrofloxacin and 18% in those treated with cefotetan. Safety, established by the incidence of adverse events, did not differ statistically between the groups. Conclusions: A single intravenous dose of alatrofloxacin given within 4 hours prior to surgery was as effective as an intravenous dose of cefotetan in the prevention of postoperative infectious complications in patients undergoing elective colorectal surgery. The safety profiles of the two medications were similar.

Early-onset prosthetic valve endocarditis.

Endocarditis following cardiac valve implantation is a rare but serious complication. To determine the risk and outcome of early-onset prosthetic valve endocarditis (EO-PVE) in adult patients at The Cleveland Clinic. Retrospective review of a 5-year case series of patients who acquired bloodstream infections within 60 days of surgery identified through a prospective surveillance program. Sixty-eight of approximately 2100 patients acquired bloodstream infections; 16 (24%) contracted EO-PVE and 52 (76%) did not. Risk factors for EO-PVE included younger age, at least three sets of positive blood culture results, and an organism other than a gram-negative bacillus. The majority of patients with EO-PVE had a recognized source of infection (wound or vascular catheter site), but no infections were attributed to a pulmonary or urinary tract site. Eleven patients (69%) were cured, including six who underwent emergent second operations. Patients with multiple blood cultures positive for organisms other than gram-negative bacilli are at risk of EO-PVE, even when a primary wound infection or vascular catheter site infection is recognized and treated.

Ceftizoxime versus Vancomycin and Gentamicin in Neurosurgical Prophylaxis

In a prospective, randomized, blinded study, 826 patients undergoing clean neurosurgical procedures received single intravenous doses of ceftizoxime (2 g) (n = 422) or a combination of vancomycin (1 g) and gentamicin (80 mg) (n = 404) 1 hour before an incision was made. Patients with infected or contaminated wounds and those receiving shunts or other implants were excluded. Primary wound infections occurred within 30 days in five patients in each group and were most common after spinal surgery and procedures through previous incisions. Secondary infections (pneumonias, urinary tract infections, and intravenous line-related bacteremia) occurred in 24 patients in the ceftizoxime group and 25 in the vancomycin/gentamicin group. The infection rates after transsphenoidal procedures (n = 129) were remarkably low in both groups. Ceftizoxime caused no adverse drug reactions, but six patients in the vancomycin/gentamicin group had clinically significant infusion-related hypotension or flushing. Placement of a temporary external drain, use of an operating microscope, preoperative steroids, and diabetes were not associated with increased infection rates. Analysis of routinely encountered ventricular cerebrospinal fluid and simultaneously obtained peripheral blood showed low but detectable levels of all three antibiotics within 2 hours; only ceftizoxime, however, achieved cerebrospinal fluid levels sufficient to inhibit the staphylococcus and Gram-negative bacilli most often associated with postneurosurgical infections. We conclude that ceftizoxime is as effective as vancomycin and gentamicin in neurosurgical prophylaxis but is less toxic and penetrates cerebrospinal fluid better.

Ceftizoxime versus Vancomycin and Gentamicin in Neurosurgical Prophylaxis

In a prospective, randomized, blinded study, 826 patients undergoing clean neurosurgical procedures received single intravenous doses of ceftizoxime (2 g) (n = 422) or a combination of vancomycin (1 g) and gentamicin (80 mg) (n = 404) 1 hour before an incision was made. Patients with infected or contaminated wounds and those receiving shunts or other implants were excluded. Primary wound infections occurred within 30 days in five patients in each group and were most common after spinal surgery and procedures through previous incisions. Secondary infections (pneumonias, urinary tract infections, and intravenous line-related bacteremia) occurred in 24 patients in the ceftizoxime group and 25 in the vancomycin/gentamicin group. The infection rates after transsphenoidal procedures (n = 129) were remarkably low in both groups. Ceftizoxime caused no adverse drug reactions, but six patients in the vancomycin/gentamicin group had clinically significant infusion-related hypotension or flushing. Placement of a temporary external drain, use of an operating microscope, preoperative steroids, and diabetes were not associated with increased infection rates. Analysis of routinely encountered ventricular cerebrospinal fluid and simultaneously obtained peripheral blood showed low but detectable levels of all three antibiotics within 2 hours; only ceftizoxime, however, achieved cerebrospinal fluid levels sufficient to inhibit the staphylococcus and Gram-negative bacilli most often associated with postneurosurgical infections. We conclude that ceftizoxime is as effective as vancomycin and gentamicin in neurosurgical prophylaxis but is less toxic and penetrates cerebrospinal fluid better.

Antibiothérapie prophylactique par céfapirine dans la chirurgie de l'ulcère duodénal : essai clinique randomisé

A randomized clinical trial of antibiotic prophylaxis in patients undergoing gastroduodenal surgery for stenosing or bleeding duodenal ulcer was carried out from February 1990 to February 1991. Seventy-two patients were randomly assigned to either Group I (n = 33) and given 1 g of cefapirine intravenously every eight hours, four times, starting at induction of anaesthesia ; or to Group II (n = 39), and not given any antibiotic. The surgical dressing was changed on the third postoperative day, and thereafter every two days in patients with fever. The efficiency of prophylaxis was assessed on the incidence of superficial or deep primary infection, and the length of hospital stay. Primary wound sepsis occurred in 7 Group II patients, and in none in Group I (n = 0.01). The results for those patients with stenosing ulcer (n = 53) were also significant : there was no primary wound infection in Group I (n = 25), whereas five occurred in Group II (n = 28) (p = 0.03). Hospital stay was shorter in Group I than in Group II (7 vs 9.5 days). Antibiotic prophylaxis also seemed to be efficient in patients with bleeding duodenal ulcers (n = 19), but their group was too small to reach levels of statistical significance. Again hospital stay was shorter in Group I than in Group II (8.5 vs 12.2 days). The efficiency of antibiotic prophylaxis was therefore confirmed for patients undergoing gastroduodenal surgery for stenosing duodenal ulcer.

Prophylactic parenteral antibiotics in clean neurosurgical procedures: a review.

Clean surgical procedures carry a risk of postoperative wound infection that is less than 5% in most hospitals. The use of prophylactic antibiotic agents in clean neurosurgical cases is controversial, and the neurosurgical literature through 1980 contains no controlled clinical trials to study its effectiveness in such cases. A report of 1732 consecutive procedures without a single postoperative wound infection in patients receiving systemic gentamicin, vancomycin, and streptomycin irrigation fluids is often quoted by neurosurgeons; however, these results have not yet been duplicated by others. Since 1980, there have been several controlled trials that support the use in clean neurosurgical cases of prophylactic antibiotics, including the vancomycin/gentamicin/streptomycin regimen and the first-generation cephalosporins. A report in 1986 of 1602 cases without a primary wound infection supports the use of a single perioperative dose of cefazolin. A review of causative organisms in postoperative wound infections demonstrates the preponderance of Gram-positive pathogens. Therefore, when antibiotic prophylaxis is indicated, adequate Gram-positive bacterial coverage, including protection against Staphylococcus infection, is required. With consideration of the present data, the cost of antibiotic therapy, and the danger of drug toxicity, a short perioperative regimen of cefazolin as prophylaxis is preferred in clean neurosurgical cases.

Toxic shock syndrome: a review.

TSS is a recently described acute febrile illness characterized by hypotension, rash, desquamation, and multisystemic involvement. While most common in menstruating women, TSS also occurs in men and non-menstruating women. It is now known that the disease is caused by one or more toxins produced by the S aureus organism. Treatment of TSS consists primarily of fluid resuscitation and supportive care. Anti-staphylococcal antibiotics are indicated primarily to reduce the rate of recurrence in menstrually related cases. In wound-related TSS, antibiotics are necessary to treat the primary wound infection and to prevent recurrent disease. Currently, the case fatality rate is stable at less than 3% and the major long-term complication of survivors is the risk of recurrence.

Pathogenesis of caseous lymphadenitis in sheep and goats.

The progress of caseous lymphadenitis in sheep and goats is described as involving primary wound infection, lymphatic and haematogenous dissemination, and secondary infection of lymph nodes and various visceral organs. This is followed by elimination or containment of infection, the latter being represented by the characteristic caseous lesions. Resistance to infection is complex involving components of both the specific and non-specific host response. The role of these in pathogenesis is discussed. Bacterial factors including the phospholipase exotoxin and cytotoxic lipid contribute to pathogenesis at a local level with little likelihood of systemic effect in the natural disease. In a disease such as caseous lymphadenitis, lesion site, size or number do not indicate severity of disease but rather, reflect the ability of the host to mount a cellular response to infection.

Prevention of primary wound infection in neurosurgical patients: a 10-year study.

Two neurosurgeons in private practice at three community hospitals followed a regimen of antimicrobial prophylaxis for 10 years. No primary wound infection occurred in a series of 2000 consecutive major operations. The study gives rise to certain recommendations for the prevention of postoperative sepsis in neurosurgical patients.

Prevention of primary wound infection in neurosurgical patients

Prevention of primary wound infection in neurosurgical patients

Antimicrobial prophylaxis in canine surgery

ABSTRACTIn 1961, Burke showed that antibiotics affect primary wound infections favourably only if they are administered before or shortly after bacterial contamination. The effect is optimal if there is already an effective tissue concentration at the time of contamination. During surgery the animal's resistance is strongly reduced, and consequently an infection may be caused by an inoculum present in a rather low concentration, at least lower than in normal circumstances. This reduced resistance lasts until only a few hours after operation. Prophylactic use of antibiotics therefore needs to be continued only for a short time after the final stage of the operation. A great number of clinical trials in human surgery have shown that short term peri‐operative prophylactic use of antibiotics causes a reduction in the incidence of post‐operative septic complications, in certain categories of operations and in selected groups of patients.Until properly designed, prospective, randomized and controlled clinical trials have been done in small animal clinics, it seems sensible to apply the abundant results from research with experimental animals and from clinical trials in human medicine to small animal surgery.Prophylactic use of antibiotics is indicated if the infection risks or dangers of possible complications are greater than the disadvantages of regular use of antibiotics.The risk factors in the development of wound infections and the choice of antibiotics are discussed.

Rationale for prophylactic antibiotics and neurosurgery.

A program of antimicrobial prophylaxis for neurosurgical patients was implemented at three community hospitals after review of the previously recorded cases of postoperative sepsis and the antibiotic sensitivity of the prevailing pathogen, Staphylococcus. No primary wound infections occurred in a series of 1000 consecutive operations. The rational basis for prophylactic antibiotics is discussed.

Aeromonas hydrophila Infection of the Skin

<i>A eromonas hydrophila</i>, a motile Gram-negative bacterium, has been only rarely reported as the cause of human disease. The organism was previously thought to be an opportunistic pathogen of low virulence often associated with polymicrobic infections and infections in debilitated patients, particularly those with neoplasms.¹More recent reports describe an increasing incidence of serious diseases resulting from primary infection with<i>A hydrophila</i>. These include septicemia, osteomyelitis, necrotizing myositis, endocarditis, meningitis, and wound infections.^2,3 Although skin and soft-tissue infections caused by<i>Aeromonas</i>sp rank second in frequency only to gastrointestinal tract infections, they are not well recognized and reported in the dermatology literature. Cutaneous manifestations may be accompanied by fever, malaise, and leukocytosis and include cellulitis, pustular eruptions, furunculosis, wound abscesses,³gas gangrene, and extensive ecthyma gangrenosum-like lesions, the latter occurring in patients with underlying malignant neoplasms. A few reports of primary wound infections describe intense local muscle