Uncomplicated Skin And Soft Tissue Infections Research Articles

Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study.

We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.

Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation.

Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5-10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit.

Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics. The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI. A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted. One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study. The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Things We Do For No Reason: Blood Cultures for Uncomplicated Skin and Soft Tissue Infections in Children.

Skin and soft tissue infections (SSTIs) are common pediatric diagnoses in both outpatient and inpatient settings. Blood cultures are frequently obtained for evaluation of SSTIs. Multiple studies have demonstrated that blood cultures rarely demonstrate true pathogenic bacterial growth, and even positive cultures do not change clinical management. Obtaining blood cultures has been associated with increased length of hospital stay. In addition, false-positive blood cultures may occur and result in repeat blood cultures and increased hospital charges. Clinicians should avoid obtaining blood cultures in pediatric patients with uncomplicated SSTIs but instead should focus on obtaining wound cultures when possible.

LO53: Intravenous cefazolin plus oral probenecid vs. oral cephalexin for the treatment of skin and soft tissue infections: a randomized controlled trial

Introduction: Skin and soft tissue infections (SSTIs) are a common reason for presentation to an emergency department (ED). Although many patients with mild SSTI are managed with oral antibiotics, those with mild-moderate infections are often treated with parenteral antibiotics, managed in EDs as outpatients using once daily intravenous cefazolin combined with oral probenecid. The purpose of our study was to determine if cephalexin 500 mg orally four times daily was non-inferior to cefazolin 2 g intravenously daily plus probenecid 1 g orally daily in the management of uncomplicated mild-moderate SSTIs patients presenting to the ED.. Methods: This was a prospective, multi-center, double dummy-blind, randomized controlled non-inferiority trial conducted at two tertiary care teaching hospitals in Canada. Patients were enrolled if they presented to the ED with an uncomplicated SSTI, in a 1:1 fashion to oral cephalexin or intravenous cefazolin plus oral probenecid for up to 7 days. The primary outcome was failure of therapy at 72 hours. Clinical cure at 7 days, intravenous to oral step-down, admission to hospital and adverse events were also evaluated. Results: 206 patients were randomized with 104 patients in the cephalexin group and 102 in the cefazolin and probenecid group. The proportion of patients failing therapy at 72 hours was similar between the treatment groups (4.2% and 6.1%, risk difference 1.9%, 95% CI (-3.3% to 7.1%), p-value for non-inferiority=0.001). Clinical cure at seven days was not significantly different (100% and 97.7%, risk difference -2.3%, 95% CI (-4.9% to 0.3%), p-value for non-inferiority=0.008). Conclusion: Cephalexin at appropriate doses appears to be a safe and effective alternative to outpatient parenteral cefazolin and probenecid in the treatment of uncomplicated mild to moderate SSTIs who present to the ED.

Culture Pus, Not Blood: Decreasing Routine Laboratory Testing in Patients With Uncomplicated Skin and Soft Tissue Infections.

Blood cultures and complete blood cell counts (CBCs) are commonly used in evaluating patients with skin and soft tissue infections (SSTIs). Published data have shown that these tests may not aid in patient management. The objective of this study was to decrease the collection of blood test specimens in children with uncomplicated SSTIs. We designed a longitudinal preintervention/postintervention study that used modifications of well-known propaganda posters. These were displayed in work stations to discourage staff from ordering routine blood cultures in children being evaluated for uncomplicated SSTIs. We studied a total of 230 otherwise healthy patients with SSTIs admitted to a freestanding children's hospital between September 1, 2013, and August 31, 2014. Data were collected in 3 groups: a 4-month baseline period, a 4-month poster display period, and a 4-month follow-up period to determine practice change persistence. Data collected included baseline clinical characteristics, the number of laboratory studies obtained, and outcomes (including length of stay). Patients in the 3 groups were similar in terms of clinical characteristics. Compared with baseline, posters were associated with decreased blood cultures (47%-17%; P < .001) and CBCs (53%-36%; P = .04). This effect partially persisted for results of blood cultures (27%; P = .01) and CBCs (42%, P = .17). There was no change in median length of stay. Seven-day emergency department returns increased in the poster group (0-7%; P = .02) with no clear relation to laboratory testing, but not in the follow-up group (3%; P = .15). A simple and creative poster campaign improved staff laboratory testing practices.

Acute bacterial skin and skin structure infections in internal medicine wards: old and new drugs.

Skin and soft tissue infections (SSTIs) are a common cause of hospital admission among elderly patients, and traditionally have been divided into complicated and uncomplicated SSTIs. In 2010, the FDA provided a new classification of these infections, and a new category of disease, named acute bacterial skin and skin structure infections (ABSSSIs), has been proposed as an independent clinical entity. ABSSSIs include three entities: cellulitis and erysipelas, wound infections, and major cutaneous abscesses This paper revises the epidemiology of SSTIs and ABSSSIs with regard to etiologies, diagnostic techniques, and clinical presentation in the hospital settings. Particular attention is owed to frail patients with multiple comorbidities and underlying significant disease states, hospitalized on internal medicine wards or residing in nursing homes, who appear to be at increased risk of infection due to multi-drug resistant pathogens and treatment failures. Management of ABSSSIs and SSTIs, including evaluation of the hemodynamic state, surgical intervention and treatment with appropriate antibiotic therapy are extensively discussed.

Scratching the surface: a review of skin and soft tissue infections in children.

We present data from recently conducted research on the diagnosis and management of skin and soft tissue infections (SSTIs) in children. Current research in the area of SSTIs (cellulitis and abscess) has focused on the use of ultrasound, risk factors associated with bacteremia, antibiotic choice, and incision and drainage (I&D) practices. When clinical examination is equivocal at distinguishing abscess from cellulitis, ultrasound can aid in the diagnosis and alter management. Bacteremia is rare in immunocompetent children with uncomplicated SSTIs; blood cultures may be reserved for complicated cases and for those who are systemically ill. Despite the increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), I&D without antibiotics remains the first-line therapy for abscess. Antibiotics for uncomplicated cellulitis should target β-hemolytic streptococci and methicillin-susceptible S. aureus (MSSA). There are significant variations in pain and sedation practices for I&D, with substantive evidence for the use of topical anesthetics. Wound packing after I&D may not confer significant benefit. Evidence to aid in the diagnosis and management of SSTIs in children has emerged in recent years; however, larger prospective pediatric studies are needed.

Skin and soft tissue infection management, outcomes, and follow-up in the emergency department of an urban academic hospital.

Skin and soft tissue infections (SSTIs) are among the most common infections treated by emergency department clinicians. The emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) as the cause of these infections prompted the Centers for Disease Control and Prevention and the Infectious Disease Society of America to publish guidelines for the outpatient management of SSTIs. This study describes the management and outcomes of emergency department patients treated for uncomplicated SSTIs who returned within 30 days of the initial visit. The study found that of 857 eligible patients, only 17.6% returned and of these, 80% had their wound checked or packing removed. The clinicians prescribed antibiotics for the majority of patients, and the selection of antibiotics typically was active against CA-MRSA. Of 91 lesions drained, 24 specimens were obtained for culture and sensitivity. The majority of the initial treatment of patients consisted of incision and drainage with antibiotic prescription.

Blood Cultures in the Evaluation of Uncomplicated Skin and Soft Tissue Infections

Blood cultures are often obtained in children hospitalized with skin and soft tissue infections (SSTIs). Because little evidence exists to validate this practice, we examined the yield of blood cultures in the evaluation of immunocompetent children with SSTIs. Medical records were reviewed for all children admitted between January 1, 2007 and December 31, 2009 after emergency department evaluation and diagnosis of cellulitis or abscess. We compared patients with SSTIs (n = 482) with those with complicated SSTIs (cSSTIs; n = 98). A cSSTI was defined as surgical or traumatic wound infection, need for surgical intervention, or infected ulcers or burns. The SSTI group included patients without complicating factors. None of the patients in the SSTI group had a positive blood culture. In the cSSTI group, 12.5% of blood cultures were positive. The mean length of hospital stay (LOHS) of children with SSTIs was shorter than that of those with cSSTIs (P < .001). In the SSTI group, obtaining a blood culture was associated with a higher mean LOHS (P = .044). Blood cultures are not useful in evaluating immunocompetent children who are admitted to the hospital with uncomplicated SSTIs, and they are associated with a nearly 1-day increase in mean LOHS.

Treatment Failure and Costs in Patients With Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections: A South Texas Ambulatory Research Network (STARNet) Study

To measure the incidence of treatment failure and associated costs in patients with methicillin-resistant Staphylococcus aureus skin and soft tissue infections (SSTIs). This was a prospective, observational study in 13 primary care clinics. Primary care providers collected clinical data, wound swabs, and 90-day follow-up information. Patients were considered to have "moderate or complicated" SSTIs if they had a lesion ≥5 cm in diameter or diabetes mellitus. Treatment failure was evaluated within 90 days of the initial visit. Cost estimates were obtained from federal sources. Overall, treatment failure occurred in 21% of patients (21 of 98) at a mean additional cost of $1,933.71 per patient. In a subgroup analysis of patients who received incision and drainage, those with moderate or complicated SSTIs had higher rates of treatment failure than those with mild or uncomplicated SSTIs (36% vs. 10%; P=.04). One in 5 patients presenting to a primary care clinic for a methicillin-resistant S. aureus SSTI will likely require additional interventions at an associated cost of almost $2,000 per patient. Baseline risk stratification and new treatment approaches are needed to reduce treatment failures and costs in the primary care setting.

Randomized Controlled Trial of Cephalexin Versus Clindamycin for Uncomplicated Pediatric Skin Infections

To compare clindamycin and cephalexin for treatment of uncomplicated skin and soft tissue infections (SSTIs) caused predominantly by community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA). We hypothesized that clindamycin would be superior to cephalexin (an antibiotic without MRSA activity) for treatment of these infections. Patients aged 6 months to 18 years with uncomplicated SSTIs not requiring hospitalization were enrolled September 2006 through May 2009. Eligible patients were randomly assigned to 7 days of cephalexin or clindamycin; primary and secondary outcomes were clinical improvement at 48 to 72 hours and resolution at 7 days. Cultures were obtained and tested for antimicrobial susceptibilities, pulsed-field gel electrophoresis type, and Panton-Valentine leukocidin status. Of 200 enrolled patients, 69% had MRSA cultured from wounds. Most MRSA were USA300 or subtypes, positive for Panton-Valentine leukocidin, and clindamycin susceptible, consistent with CA-MRSA. Spontaneous drainage occurred or a drainage procedure was performed in 97% of subjects. By 48 to 72 hours, 94% of subjects in the cephalexin arm and 97% in the clindamycin arm were improved (P = .50). By 7 days, all subjects were improved, with complete resolution in 97% in the cephalexin arm and 94% in the clindamycin arm (P = .33). Fevers and age less than 1 year, but not initial erythema > 5 cm, were associated with early treatment failures, regardless of antibiotic used. There is no significant difference between cephalexin and clindamycin for treatment of uncomplicated pediatric SSTIs caused predominantly by CA-MRSA. Close follow-up and fastidious wound care of appropriately drained, uncomplicated SSTIs are likely more important than initial antibiotic choice.

Newer treatment options for skin and soft tissue infections.

In recent years, serious skin and soft tissue infections (SSTIs) caused by multidrug resistant pathogens have become more common. While the majority of SSTIs are caused by Staphylococcus aureus or beta-haemolytic streptococci that are methicillin/oxacillin susceptible, the emergence of methicillin-resistant and vancomycin-resistant community-acquired and nosocomial Gram-positive pathogens has created a need for different therapeutic agents, such as linezolid, quinupristin/dalfopristin, daptomycin, and newer generation carbapenems and fluoroquinolones. This review focuses on agents presently in clinical development for the treatment of SSTIs caused by Gram-positive pathogens such as staphylococci, streptococci and enterococci including methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE). Newer-generation carbapenems, such as meropenem and ertapenem, are characterised by a broad-spectrum of activity against Gram-positive and -negative aerobes and anaerobes, and are resistant to hydrolysis by many beta-lactamases. Current-generation fluoroquinolones, such as levofloxacin, moxifloxacin and gatifloxacin, have demonstrated better eradication rates for S. aureus than conventional penicillin and cephalosporins. These antimicrobial agents can be used to treat methicillin-susceptible staphylococcal and streptococcal strains. Oxazolidinones, streptogramin combinations and cyclic lipopeptides have novel mechanisms of action and have been studied in several multinational phase III clinical trials in the treatment of complicated and uncomplicated SSTIs. They possess a broad spectrum of activity against multidrug-resistant pathogens, including MRSA and VRE. Linezolid has been shown to be active against a wide variety of community-acquired and nosocomial antimicrobial-resistant pathogens with comparability to vancomycin, as well as resulting in reduced lengths of hospital stay. Cyclic lipopeptides such as daptomycin have a unique mechanism of action by disruption of bacterial membrane electric potentials with less likelihood for development of cross-resistance. Daptomycin has recently been US FDA approved for the treatment of complicated SSTI. However, rapid development of resistance to some of these newer agents has already been reported and this trend magnifies the importance of further need for effective antimicrobial agents. Several investigational agents, such as dalbavancin, oritavancin and tigecycline, are in advanced stages of development and are likely to proceed to licensing in the next few years. With their long half-lives, these agents have an advantage of less frequent dose administration with more rapid bactericidal activity and less likelihood for development of resistance. However, because of their proven activity against highly resistant organisms, these antibacterial agents should be reserved only for life-threatening situations and/or when resistant pathogens are suspected. Rational antimicrobial use coupled with awareness of infection control measures is paramount to avert the emergence of multidrug-resistant organisms.

Associations of HLA-DRB and -DQB genes with two and five year outcome in rheumatoid arthritis.

To evaluate the clinical usefulness of genomic HLA typing during the first five years of established rheumatoid arthritis (RA). The HLA-DRB and -DQB alleles were determined by restriction length polymorphisms and polymerase chain reaction amplification with sequence specific primers in 99 Swedish patients with RA. Clinical features after two and five years disease duration were related to the genetic pattern. Seventy four patients were seropositive, 25 had nodules, 90 developed erosions, and 15 required joint replacements. Twelve patients were in remission after five years. Disability was assessed by health assessment questionnaire, and radiographic damage in hands and feet by the Larsen method. Eighty seven per cent of the patients carried the conserved third hypervariable region sequence (HVR3), 32% had DRB1*04 on one allele, and 26% had DRB1*04 on both alleles (all frequencies significantly greater than in controls). Frequencies of DRB1*04 associated DQB*0301 and *0302 were normal. Patients carrying DRB1*04 on both alleles tended to have more radiographic changes after two years, but this difference had diminished after five years. Disability did not vary with regard to the genotype. Homozygous HVR3 patients had about three times greater risk of undergoing joint replacement. Homozygosity for HVR3 and presence of DQB*0302 both tended to be associated with erosive disease. We confirmed a strong association of disease with the presence of the shared epitope on one or two alleles. However, genotype was not strongly associated with disease severity after two and five years disease duration, and thus the value of genomic typing to select patients for early aggressive therapy is questionable.