Severe Skin And Soft Tissue Infections Research Articles

Antibiotic resistance pattern of aerobic bacterial isolates from patients with skin and soft tissue infections in Karaikal

Skin and Soft Tissue Infections (SSTIs) are considered as non-fatal burden with significant morbidity and disability. The important challenge of severe SSTIs is choosing a drug for empirical treatment. From this region, only limited local antibiogram data is available. To determine the frequency of different aerobic bacteria isolated from patients with SSTIs attending dermatology and surgery departments of GH, Karaikal and to study the antibiotic resistance pattern of the isolates. This is a prospective, cross-sectional study with 100 samples. Standard protocol was followed for collection, processing, identification and antibiotic susceptibility testing. All isolates of and were screened for methicillin resistance and subsequently subjected to Oxacillin E-strip and Vancomycin E-strip to know the minimum inhibitory concentration (MIC) value. Isolates of Gram negative bacilli resistant to one or more carbapenems were tested for carbapenemase production using Modified Carbapenem Inactivation Method (MCIM) and multi drug resistant (MDR) organisms were identified. Most effective antibiotic for methicillin sensitive (MSSA) are Clindamycin (82.75%), Gentamicin (80.95%) and Cotrimoxazole (75%). The methicillin resistant (MRSA) incidence is 6.89% (2/29). Around 66.67% (4/6) of was Cefoxitin resistant. The carbapenem resistance was found to be 13.88% (5/36). Around 43.13% (22/51) Gram negative bacilli were MDR. The presence of MRSA and carbapenemase producing Gram negative bacilli are worrisome. Further, routine surveillance is needed to monitor the trends in antibiotic resistant pattern. However, this data paves way for judicious use of antibiotics for treatment and to prevent development of resistance in future.

1360. Prevalence of Bacteremia in Hospitalized Patients with Skin and Soft Tissue Infections (SSTI)

BackgroundSkin and soft tissue infections (SSTI) are common in outpatient and inpatient settings. The prevalence of positive blood cultures (BC) ranges from 2% to 52%. Because of the variations in published data, the exact prevalence of bacteremia in hospitalized patients with SSTI is unknown. Our objective is to determine the prevalence of bacteremia in hospitalized patients with SSTI.MethodsRetrospective chart review from January 2017 to December 2018. Patients older than 18 years admitted with SSTI who required BC on admission were included. Patients who met the criteria for systemic inflammatory response syndrome (SIRS)/sepsis or severe SSTI, or had an underlying immunodeficiency underwent BC collection. Patients with diabetic foot ulcer, device related SSTI, necrotizing fasciitis, and osteomyelitis were excluded. Patients were divided into 3 groups: true positive (TP) defined as a true pathogen, false positive (FP) defined as a contaminant, and true negative (TN) defined as no growth in BC. Physician assessment, microorganisms isolated, number of positive bottles/culture sets, and timing of growth were reviewed. Patients’ comorbidities, presence of SIRS, laboratory data, duration of antibiotic use, and length of stay (LOS) were compared.ResultsWe screened 583 patients and included 541 patients. The mean age was 62 ± 18.4 years, and 60% were male. 47/ 541 (8.6%) had skin abscesses. 57 patients (11%) had positive BC, of whom 32 were TP (6%), and 25 were FP (5%). 89% of patients (484) had TN BC. The organisms isolated are described in Figures 1 and 2. Patients in the FP and TN groups had prior antibiotic use, compared to TP (P< 0.05). The FP group had a longer LOS and duration of antibiotic use compared to the TN group (p< 0.05). 76% of FP had repeated BC. Beta-lactam antibiotics were mostly used, followed by anti-MRSA antibiotics (40%). We did not find risk factors to predict the likelihood of bacteremia. The outcome was not different among the 3 groups.Figure 1. Microorganisms isolated from blood cultures of patients with SSTI – True pathogens Figure 2. Microorganisms isolated from blood cultures of patients with SSTI – Isolated contaminants ConclusionThere was a low incidence of true bacteremia (6%) in hospitalized patients with SSTI. More than 90% of TP were predictable causal microorganisms, which are covered by empiric antibiotics. BC may not affect the initial treatment of SSTI. FP BC were associated with an increased LOS, longer antibiotic use, and increased healthcare cost.Disclosures All Authors: No reported disclosures

Prospective Surveillance of Primary Healthcare Presentations for Scabies and Bacterial Skin Infections in Fiji, 2018-2019.

Scabies, impetigo, and other skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low-middle income settings, but information regarding their burden of disease is scarce. We conducted surveillance of presentations of scabies and SSTIs, including impetigo, abscesses, cellulitis, and severe SSTI, to primary health facilities in Fiji. We established a monthly reporting system over the course of 50 weeks (July 2018-June 2019) for scabies and SSTIs at all 42 public primary health facilities in the Northern Division of Fiji (population, ≈131,914). For each case, information was collected regarding demographics, diagnosis, and treatment. There were 13,736 individual primary healthcare presentations with scabies, SSTI, or both (108.3 presentations per 1000 person-years; 95% confidence interval [CI], 106.6-110 presentations). The incidence was higher for males than for females (incidence rate ratio [IRR], 1.15; 95% CI, 1.11-1.19). Children younger than 5 years had the highest incidence among all age groups (339.1 per 1000 person-years). The incidence was higher among the iTaukei (indigenous) population (159.9 per 1000 person-years) compared with Fijians of Indian descent (30.1 per 1000 person-years; IRR, 5.32; 95% CI, 5.03-5.61). Abscess was the condition with the highest incidence (63.5 per 1,000 person-years), followed by scabies (28.7 per 1,000 person-years) and impetigo (21.6 per 1,000 person-years). Scabies and SSTIs impose a substantial burden in Fiji and represent a high incidence of primary health presentations in this population. The incidence in low-middle income settings is up to 10-times higher than that in high-income settings. New public health strategies and further research are needed to address these conditions.

The eternal dilemma of antitoxin antibiotics for skin and soft tissue infection.

In standard clinical practice, combined antibiotic treatment is used to treat severe skin and soft tissue infections (SSTIs), whereby one of the drugs is usually a protein synthesis inhibitor antibiotic. However, evidence for this practice is only based on data from 'in vitro' studies, animal models and case reports. There are no randomized controlled trials. In the light of several new drugs marketed for the treatment of these infections, there is a need to revise the state of the art. New reviews and systematic appraisals of the literature exist on the use of protein synthesis inhibitor antibiotics to treat severe SSTI. Several 'in vitro' studies have assessed the efficacy of some of the new drugs. Combination therapy, including an adjuvant protein synthesis inhibitor antibiotic for toxin suppression, should be used both in patients with severe SSTI and in those with moderate infection and risk factors for methicillin-resistant positive- or Panton-Valentine leukocidin positive-Staphylococcus aureus infection.

Evaluation of Linezolid Pharmacokinetics in Critically Ill Obese Patients with Severe Skin and Soft Tissue Infections.

Linezolid standard dosing is fixed at 600 mg every 12 h (q12h) for adults. Literature suggests critically ill, obese patients require higher doses. The study aim is 2-fold: (i) to describe linezolid pharmacokinetics (PK), and (ii) to evaluate if PK/pharmacodynamic (PD) target attainment is achieved with standard dosing in critically ill, obese patients with severe skin and soft tissue infections (SSTIs). Adult patients with a body mass index (BMI) of ≥30 kg/m2 and receiving intravenous (i.v.) linezolid from August 2018 to April 2019 were eligible for consent in this prospective study. Severe SSTIs were defined as necrotizing fasciitis, myonecrosis, or SSTI with sepsis syndrome. Four blood samples were collected at steady state at 1, 3, 5 h postinfusion and as a trough. Target attainment was defined as achieving area under the concentration-time curve from 0 to 24 h to MIC (AUC0-24h/MIC) of ≥100 h*mg/liter. Monte Carlo simulations were used to determine the probability of target attainment (PTA). Eleven patients were included in the study. The median BMI was 45.7 kg/m2, and median total body weight (TBW) was 136.0 kg. Seven patients received standard linezolid doses, and four received 600 mg q8h. A one-compartment model described linezolid PK. Based on AUC0-24h/MIC targets, for noncirrhotic patients at 140 kg, the PTA with standard linezolid doses was 100%, 98.8%, 34.1%, and 0% for MICs of 0.5, 1, 2, and 4 mg/liter, respectively. In conclusion, target attainment of ≥90% is not achieved with standard linezolid doses for noncirrhotic patients ≥140 kg with MICs of ≥2 mg/liter. This study adds to accumulating evidence that standard linezolid doses may not be adequate for all patients.

Treatment of severe skin and soft tissue infections: a review.

To review the salient features of the management of severe skin and soft tissue infections (SSTIs), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. For severe SSTIs, intensive care, source control, and broad-spectrum antimicrobials are required for the initial phase of illness. There is an increasing focus on the utility of rapid diagnostic tests to help in selection and de-escalation of antimicrobials for SSTIs. In addition, clinical prediction scores have shown promise in helping predict patients who do not require antimicrobials directed against methicillin-resistant Staphylococcus aureus. Immune status has been shown to be important in clinical outcomes of some, but not all types of SSTIs. The debate for benefits of intravenous immunoglobulin continues to be waged in the recent literature. Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well variations in host immune responses. Unique aspects of care for severe SSTIs are discussed including the role of surgical consultation and source control. The unique features of SSTIs in immunocompromised hosts are also described.

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. Guidelines, expert opinion, and local institutional policies were reviewed. Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described. We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.

Aeromonas veronii septicemia in an immunocompetent patient

We present a 29-year-old healthy man who fell into an industrial auger, sustaining acrushed, open pelvic injury, multiple comminuted fractures of the right leg, and traumaticamputation of his left foot. Blood and wound cultures were positive for Aeromonasspp and vancomycin resistant Enterococcus. Treatment included cefepime, levofloxacin,daptomycin, and metronidazole. Aeromonas veronii is a Gram negative bacillus usuallyfound in fresh and brackish water in warm climates. It can cause severe skin andsoft tissue infections, typically after injured tissue is exposed to contaminated water.Aeromonas septicemia is uncommon and is usually associated with underlying diseases,such as malignancy, cirrhosis, diabetes, or immunosuppression. It rarely occurs in ahealthy host.

Treatment of MRSA soft tissue infections: An overview

MRSA is becoming increasingly common worldwide. With the emergence of new highly spreadable strains (community associated or CA-MRSA) novel presentation skin and soft tissue infections (SSTI) are being seen. Recurrent SSTI, including folliculitis, furunculosis and abscesses account for an increasing proportion of SSTI seen in the emergency department. Empirical antimicrobial management choices can be difficult, but clues to the nature of the MRSA may be gleaned from the history and clinical presentation. More severe SSTI due to necrotising fasciitis and purpura fulminans are emerging and warrant the broadest possible empirical Gram-positive cover, ideally with antimicrobials that stop exotoxin production, and sometimes intravenous immunoglobulin to neutralise exotoxins already produced.

Presence of the epidemic European fusidic acid-resistant impetigo clone (EEFIC) of Staphylococcus aureus in France

Sir, Denton et al. recently reported the results of the EPISA study, which compared the susceptibility of Staphylococcus aureus causing community-acquired skin and soft tissue infections (SSTIs) in three European countries. They highlighted in particular that the resistance rate to fusidic acid was significantly lower in French (6.3%) than in Irish (31.4%) or British (24.4%) isolates. This difference was attributed by the authors to the likely spread of a fusidic acid-resistant clone, named the epidemic European fusidic acid-resistant impetigo clone (EEFIC) in the latter two countries. This clone, initially described in Scandinavia, had so far been reported sporadically in the UK. It is characterized by: (i) agr allelic group 4, spa type t171 [or single-locus variants (t408, t659, t874, t875)], sequence type (ST) 123, clonal complex 121; (ii) the presence of the eta (exfoliative toxin A) gene with the majority of strains also carrying the etb (exfoliative toxin B) gene; (iii) resistance to fusidic acid (MIC of 2–8 mg/L) related to the expression of the fusB gene; and (iv) strong association with impetigo. In the same issue, Larsen et al. reported the molecular characterization of all these fusidic acid-resistant isolates (n 1⁄4 136) collected during the EPISA study. The results confirmed that the EEFIC represented 63% (34/54) of fusidic acid-resistant strains in the UK and 49% (34/69) in Ireland, but was not detected in France (0%, 0/13). These results seemed to indicate that the EEFIC was not present in France. We were puzzled by this unexpected and surprising French epidemiology and decided to screen a part of the collection of the French national reference centre for staphylococci (Lyon, France) for the presence of the EEFIC. First, between December 2003 and August 2004, corresponding to the appropriate period of the EPISA study, we identified 19 isolates harbouring agr allelic group 4 and the eta gene, characteristics matching the EEFIC. We then performed a fusidic acid susceptibility test using disc diffusion (using the breakpoint from the BSAC) and fusB PCR on these isolates. Four strains (21%, 4/19) appeared to be resistant and PCR-positive, strongly suggesting that they belonged to the EEFIC. Second, we applied the same screening to all S. aureus isolates collected from October 2000 to November 2003 (before the EPISA study) and from September 2004 to December 2007 (after the EPISA study). The agr allelic group 4 and eta positive strains represented a total of 256 isolates. Forty-four of these isolates were randomly selected to undergo the fusidic acid susceptibility test and fusB PCR. Six isolates (14%, 6/44) were detected as resistant to fusidic acid and positive for fusB PCR. Finally, the fusidic acid MICs (determined by Etest) and spa types were determined for the 10 isolates thus screened. All revealed MICs between 4 and 8 mg/L and belonged to spa type t171 or a related spa type (t171, n 1⁄4 8; t408, n 1⁄4 2) corresponding to ST123, which definitively confirmed that they belonged to the EEFIC. The 10 isolates were collected from eight different hospitals and over a long period (2000–07), confirming the geographical and temporal dissemination of the EEFIC in France. As expected, the clinical data for the 10 patients indicated that impetigo or its generalized form were the motives for consultation. Even if we are not presently able to establish the proportion of the EEFIC within fusidic acid-resistant S. aureus in our collection, because of the design of our screening procedure, these data definitively demonstrated that the EEFIC is present in France and likely represents 15% to 20% of all French S. aureus isolates harbouring exfoliative toxin A. In the EPISA study, the low rate of impetigo in the French patients (12.2%) compared with British patients (33.3%) could partly explain the underrepresentation of the EEFIC in the French data. The low number in the series is probably due to the French practice of consulting a specialist (paediatrician or dermatologist) or hospital emergency wards for impetigo, rather than a general practitioner as would tend to be the case in the UK and Ireland. So, the fact that the EPISA inclusion criterion was ‘patient attending a general practice clinic in the community with SSTIs’, probably introduced a recruitment bias in the French isolates implicated in impetigo and more generally in severe SSTIs. Conversely, the French national reference centre for staphylococci collects S. aureus strains of clinical interest with recruitment from hospitals as well as non-hospital community laboratories, thereby avoiding the bias found in the EPISA study and allowing us to detect the presence of the EEFIC in France in the 2000–07 period.

Severe skin and soft tissue infections and associated critical illness

Skin and soft tissue infections (SSTIs) span a broad spectrum of clinical entities from limited cellulitis to rapidly progressive necrotizing fasciitis, which may be associated with septic shock or a toxic shock-like syndrome. These infections may be the primary instigators of critical illness requiring hospitalization and management in the intensive care unit. Alternatively, these infections may arise from metastatic spread of microorganisms from a distant focus. Regardless of the source, SSTIs may lead to critical illness. The complex interplay of environment, host, and pathogen are important to consider when evaluating SSTIs and planning therapy. This second of a two-part review focuses on severe SSTIs due to Clostridium spp, microorganisms associated with water sources, and polymicrobial/mixed infections. The key to a successful outcome is early identification of risk factors for specific pathogens and early initiation of empiric antimicrobial therapy. For some SSTIs, surgical intervention for diagnosis and/or therapy is also required.