WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Necrotizing soft tissue infections: a surgical narrative review

Necrotizing soft tissue infections represent a spectrum of diseases characterized by extensive necrosis involving the skin, subcutaneous tissues, fascia or muscles. These infections are generally severe and rapidly progressive, often accompanied by sepsis, septic chock, multiple organ failure and, ultimately, death. Several classifications have been developed based on multiple parameters, such as the anatomical location of the disease, the depth of the lesion or the microbiology. Numerous clinical factors predispose individuals to the development of necrotizing soft tissue infections. The clinical presentation is not always characterized by local signs and systemic symptoms of infection, which can lead to delays in both diagnosis ad treatment. Broad-spectrum antibiotic directed at the likely organisms is essential early in the treatment course, but do not substitute surgical management. Antibiotic therapy should be subsequently tailored to the etiologic micro-organism. Rapid recognition and early surgical intervention form the mainstay of management of necrotizing soft tissue infections. Initial surgical debridement should be promptly performed preferably at the presenting hospital, when adequate infrastructure and personnel are available. Transfer to a referral center may be necessary for definitive surgical and complex wound care. Most patients require more than one debridement. A multidisciplinary approach is also essential to improve the results in the treatment of these patients.

Appropriate surgical management in skin and soft tissue infections

PURPOSE OF REVIEW

To present standards and recent technical innovations in the surgical management of skin and soft tissue infections (SSTI).

RECENT FINDINGS

SSTI are a frequent cause of presentation in the acute care setting. They can range from simple and uncomplicated to severe and necrotizing infections. Surgical management plays an important role in the treatment of uncomplicated SSTI. Recent evidence indicates that a subgroup of patients (e.g. immunocompromised patients) profits from a postoperative course of antibiotic treatment of 5-7 days. In diabetic foot infections (DFI), repeated debridement to remove necrotic tissue and control infection can prevent minor and major amputation. In necrotizing soft tissue infections (NSTI), early and aggressive surgical debridement is paramount. Recent advancements have explored skin-sparing techniques in selective cases.

SUMMARY

The management of SSTIs requires a combination of surgical and antimicrobial strategies tailored to the type and severity of the infection. Further clinical research is necessary in order to define more accurately those collectives in severe SSTI who profit from a less aggressive surgical approach.

Toxin inhibition: Examining tetracyclines, clindamycin, and linezolid

PURPOSE

The purpose of this review is to discuss the role of toxin inhibition in select infections and to provide recommendations for appropriate antimicrobial selection when toxin inhibition is indicated.

SUMMARY

For select organisms, specifically Clostridioides difficile, Staphylococcus aureus, and Streptococcus pyogenes, toxin production plays an integral role in overall disease pathogenesis and progression. Some expert recommendations include utilization of an antimicrobial with toxin inhibition properties as primary or adjunctive therapy for certain infections due to these organisms, but evolving data have made the choice of antitoxin agent less clear. Clindamycin has been the long-standing standard of care agent for toxin inhibition in necrotizing S. aureus and S. pyogenes infections, but linezolid shows promise as an alternative either in the setting of drug shortages or simply when clindamycin is not optimal, while tetracyclines require further study for this indication. The role for adjunctive toxin inhibition in C. difficile infection (CDI) is less defined, as current first-line therapies already have antitoxin properties.

CONCLUSION

Toxin inhibition plays a key role in successful management of patients with infections due to toxin-producing organisms. Adjunctive therapy with a tetracycline could be considered in severe, fulminant CDI, but the associated benefit is variable. The benefit of antitoxin treatment for necrotizing S. aureus and S. pyogenes has been more consistently documented. Recent studies support linezolid as an alternative to clindamycin as an adjunctive S. aureus treatment or as monotherapy when appropriate.

Streptococcal periorbital necrotizing fasciitis: Case series on a rare but potentially life-threatening entity

Objective

Periorbital necrotizing soft tissue infection (NSTI) is a rare entity caused either by polymicrobial infection (type 1) or Streptococcus pyogenes and/or Staphylococcus species (type 2). A high level of clinical suspicion is necessary to make the diagnosis. We present 3 cases of NSTI illustrating our diagnostic and therapeutic approach.

Patients and methods

The main outcome measures were laboratory and clinical findings at initial presentation, microorganism cultured, predisposing conditions and the number of debridements needed as well as final outcomes.

Results

Biomarkers of inflammation in blood samples were elevated at admission and Streptococcus pyogenes was cultured in all three cases. Clinical suspicion of this rare disease and prompt surgical treatment was crucial to confirm the diagnosis.Imaging and laboratory workup, however, did not prove to be diagnostically helpful in our cases. We performed early and consequent debridement of necrotic tissue to control the infection alongside adequate systemic antibiotic therapy including clindamycin in all cases of suspected NSTI. As intraoperative findings revealed necrotic tissue even in an apparently quiet situs, we decided to debride the wound daily after the first surgery until there is very little or no necrotic tissue to debride seen intraoperatively.

Conclusions

Based on the negative experience with our first case, we developed a more aggressive surgical plan for cases with periorbital NSTI. After early debridement, the patient is surgically reevaluated on a daily basis until surgery is deemed to have been unnecessary. We follow this approach, as necrotic tissue is sometimes identified intraoperatively from a lack of resistance to manipulation rather than from its clinical aspect alone. At a later point, plastic surgery may be required when the infection is under control.

Case report: A case of severe lower limb necrotizing fasciitis caused by an insulin injection has been reported

Necrotizing fasciitis (NF) is a rare but life-threatening soft tissue infection, often accompanied by severe systemic toxicity. Early detection and prompt treatment are critical for survival. We report a case of NF in a 53-year-old diabetic woman following a subcutaneous insulin injection in the thigh. The patient presented with severe local pain as the initial symptom, and Escherichia coli was the sole isolated pathogen, which is seldom reported in the current literature. We combined with existing literature and clinical manifestations observed in NF patients at our hospital, offer valuable guidance for clinicians in recognizing and responding to NF.

Biochemical analysis of soft tissue infectious fluids and its diagnostic value in necrotizing soft tissue infections: a 5-year cohort study

BACKGROUND

Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs.

METHODS

This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied.

RESULTS

Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light's criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination.

CONCLUSION

Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.

Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas

Acute calculous cholecystitis (ACC) and acute biliary pancreatitis (ABP) are significant complications of gallstone disease. This review aims to provide a comprehensive analysis of current management practices for ACC and ABP. The Tokyo Guidelines (TG) and World Society of Emergency Surgery (WSES) guidelines recommend early laparoscopic cholecystectomy (ELC) as the treatment of choice for ACC. High-risk patients may benefit from alternative treatments like biliary drainage, with emerging techniques such as endoscopic drainage showing promise. ABP requires prompt diagnosis and intervention. The Revised Atlanta Classification (RAC) criteria are used for diagnosis, with endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy as primary treatments. Minimally invasive approaches are preferred for managing complications like infected pancreatic necrosis, with the endoscopic step-up method showing superior outcomes. The management of ACC and ABP continues to evolve. Future research is needed to refine guidelines further and address existing controversies, ultimately improving patient outcomes in these acute biliary conditions.

Global Antimicrobial Susceptibility Patterns of Staphylococcus aureus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

Importance

Individuals with atopic dermatitis are frequently colonized and infected with Staphylococcus aureus. Empirical antibiotic therapy for individuals with atopic dermatitis is common, but data about the antimicrobial susceptibility profiles of S aureus strains isolated from these individuals are scarce for those living in particular geographic areas.

Objective

To determine the antimicrobial susceptibility of S aureus from individuals with atopic dermatitis and analyze differences according to the income level of the country of origin and the data collection period.

Data Sources

A meta-analysis of the literature was performed from the inception of the included databases (MEDLINE, Embase, Web of Science, Scopus, and Cochrane) to June 20, 2023, using predetermined Medical Subject Headings.

Study Selection

Studies were included if they reported antibiotic susceptibility profiles of 1 or more S aureus cutaneous isolates from individuals with atopic dermatitis. Articles written in English, Spanish, French, or German were included.

Data Extraction and Synthesis

Working in pairs, 6 of the authors conducted the data extraction. The guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

Main Outcomes and Measures

The outcome of interest was antimicrobial susceptibility.

Results

A total of 61 studies reported 4091 S aureus isolates from individuals with atopic dermatitis. For 4 of the 11 commonly used antibiotics (36.4%), antimicrobial susceptibility was 85% or less, including for methicillin (binomial proportion, 0.85 [95% CI, 0.76-0.91]), erythromycin (binomial proportion, 0.73 [95% CI, 0.61-0.83]), fusidic acid (binomial proportion, 0.80 [95% CI, 0.62-0.91]), and clindamycin (binomial proportion, 0.79 [95% CI, 0.65-0.89]). Most studies (46; 75.4%) were conducted in high-income countries. Antimicrobial susceptibility to erythromycin, methicillin, and trimethoprim and sulfamethoxazole was significantly lower in lower middle-income countries and upper middle-income countries. Regarding the temporal trends, 33 studies (54.1%) reported data collected from 1998 to 2010. Antimicrobial susceptibility patterns have not changed over time.

Conclusions and Relevance

In this systematic review and meta-analysis, antimicrobial susceptibility of S aureus to β-lactams, erythromycin, clindamycin, and fusidic acid may be suboptimal for empirical use in individuals with atopic dermatitis. Significant differences in antimicrobial susceptibility patterns were found in high-income countries and in lower middle-income countries and upper middle-income countries for some antibiotics.

Necrotizing Soft Tissue Infections: A Review

Importance

Necrotizing soft tissue infections (NSTIs) are severe life- and limb-threatening infections with high rates of morbidity and mortality. Unfortunately, there has been minimal improvement in outcomes over time.

Observations

NSTIs are characterized by their heterogeneity in microbiology, risk factors, and anatomical involvement. They often present with nonspecific symptoms, leading to a high rate of delayed diagnosis. Laboratory values and imaging help increase suspicion for NSTI, though ultimately, the diagnosis is clinical. Surgical exploration is warranted when there is high suspicion for NSTI, even if the diagnosis is uncertain. Thus, it is acceptable to have a certain rate of negative exploration. Immediate empirical broad-spectrum antibiotics, further tailored based on tissue culture results, are essential and should be continued at least until surgical debridement is complete and the patient shows signs of clinical improvement. Additional research is needed to determine optimal antibiotic duration. Early surgical debridement is crucial for improved outcomes and should be performed as soon as possible, ideally within 6 hours of presentation. Subsequent debridements should be performed every 12 to 24 hours until the patient is showing signs of clinical improvement and there is no additional necrotic tissue within the wound. There are insufficient data to support the routine use of adjunct treatments such as hyperbaric oxygen therapy and intravenous immunoglobulin. However, clinicians should be aware of multiple ongoing efforts to develop more robust diagnostic and treatment strategies.

Conclusions and Relevance

Given the poor outcomes associated with NSTIs, a review of clinically relevant evidence and guidelines is warranted. This review discusses diagnostic and treatment approaches to NSTI while highlighting future directions and promising developments in NSTI management.

Cannabinoids as Antibacterial Agents: A Systematic and Critical Review of In Vitro Efficacy Against Streptococcus and Staphylococcus

BACKGROUND

Two major bacterial pathogens, Staphylococcus aureus and Streptococcus pyogenes, are becoming increasingly antibiotic-resistant. Despite the urgency, only a few new antibiotics have been approved to address these infections. Although cannabinoids have been noted for their antibacterial properties, a comprehensive review of their effects on these bacteria has been lacking.

OBJECTIVE

This systematic review examines the antibacterial activity of cannabinoids against S. aureus, including methicillin-resistant S. aureus (MRSA) and vancomycin-resistant S. aureus (VRSA) strains, and S. pyogenes.

METHODS

Databases, including CINAHL, Cochrane, Medline, Scopus, Web of Science, and LILACS, were searched. Of 3510 records, 24 studies met the inclusion criteria, reporting on the minimum inhibitory concentration (MIC) and minimum bactericidal concentration of cannabinoids.

RESULTS

Cannabidiol (CBD) emerged as the most effective cannabinoid, with MICs ranging from 0.65 to 32 mg/L against S. aureus, 0.5 to 4 mg/L for MRSA, and 1 to 2 mg/L for VRSA. Other cannabinoids, such as cannabichromene, cannabigerol (CBG), and delta-9-tetrahydrocannabinol (Δ9-THC), also exhibited significant antistaphylococcal activity. CBD, CBG, and Δ9-THC also showed efficacy against S. pyogenes, with MICs between 0.6 and 50 mg/L. Synergistic effects were observed when CBD and essential oils from Cannabis sativa when combined with other antibacterial agents.

CONCLUSION

Cannabinoids' antibacterial potency is closely linked to their structure-activity relationships, with features like the monoterpene region, aromatic alkyl side chain, and aromatic carboxylic groups enhancing efficacy, particularly in CBD and its cyclic forms. These results highlight the potential of cannabinoids in developing therapies for resistant strains, though further research is needed to confirm their clinical effectiveness.

Synergistic effect of zinc oxide-cinnamic acid nanoparticles for wound healing management: in vitro and zebrafish model studies

Wound infections resulting from pathogen infiltration pose a significant challenge in healthcare settings and everyday life. When the skin barrier is compromised due to injuries, surgeries, or chronic conditions, pathogens such as bacteria, fungi, and viruses can enter the body, leading to infections. These infections can range from mild to severe, causing discomfort, delayed healing, and, in some cases, life-threatening complications. Zinc oxide (ZnO) nanoparticles (NPs) have been widely recognized for their antimicrobial and wound healing properties, while cinnamic acid is known for its antioxidant and anti-inflammatory activities. Based on these properties, the combination of ZnO NPs with cinnamic acid (CA) was hypothesized to have enhanced efficacy in addressing wound infections and promoting healing. This study aimed to synthesize and evaluate the potential of ZnO-CN NPs as a multifunctional agent for wound treatment. ZnO-CN NPs were synthesized and characterized using key techniques to confirm their structure and composition. The antioxidant and anti-inflammatory potential of ZnO-CN NPs was evaluated through standard in vitro assays, demonstrating strong free radical scavenging and inhibition of protein denaturation. The antimicrobial activity of the nanoparticles was tested against common wound pathogens, revealing effective inhibition at a minimal concentration. A zebrafish wound healing model was employed to assess both the safety and therapeutic efficacy of the nanoparticles, showing no toxicity at tested concentrations and facilitating faster wound closure. Additionally, pro-inflammatory cytokine gene expression was analyzed to understand the role of ZnO-CN NPs in wound healing mechanisms. In conclusion, ZnO-CN NPs demonstrate potent antioxidant, anti-inflammatory, and antimicrobial properties, making them promising candidates for wound treatment. Given their multifunctional properties and non-toxicity at tested concentrations, ZnO-CN NPs hold significant potential as a therapeutic agent for clinical wound management, warranting further investigation in human models.

Musculoskeletal infections through direct inoculation

Musculoskeletal infections consist of different clinical conditions that are commonly encountered in daily clinical settings. As clinical findings and even laboratory tests cannot always be specific, imaging plays a crucial role in the diagnosis and treatment of these cases. Musculoskeletal infections most commonly occur secondary to direct inoculation into the skin involuntarily affected by trauma, microorganism, foreign bodies, or in diabetic ulcers; direct infections can also occur from voluntary causes due to surgery, vaccinations, or other iatrogenic procedures. Hematogenous spread of infection from a remote focus can also be a cause for musculoskeletal infections. Risk factors for soft tissue and bone infections include immunosuppression, old age, corticosteroid use, systemic illnesses, malnutrition, obesity, and burns. Most literature discusses musculoskeletal infections according to the diagnostic tools or forms of infection seen in different soft tissue anatomical planes or bones. This review article aims to evaluate musculoskeletal infections that occur due to direct inoculation to the musculoskeletal tissues, by focusing on the traumatic mechanism with emphasis on the radiological findings.

Genetic Testing Technology Assisting in the Diagnosis and Treatment of Multiple Suppurative Arthritis and Extensive Migratory Skin and Soft Tissue Infections Caused by Disseminated Staphylococcus aureus Disease: A Case Report and Review

Staphylococcus aureus (S. aureus) infection is readily disseminated, yet the multiple septic arthritis and extensive migratory skin and soft tissue infections it causes are uncommon and challenging to treat. The infection can be life-threatening, with a mortality rate of 15-31%. Early, targeted antibiotic therapy is critical to improve prognosis. However, routine cultures are time-consuming and have low positivity rates, which may lead to errors in antibiotic regimen selection, depriving patients of optimal treatment. Genetic testing technologies, such as macrogenomic next-generation sequencing (mNGS) and digital polymerase chain reaction (dPCR), are now emerging as powerful tools for early pathogen diagnosis as well as pathogen diagnosis of target detectors with low microbial loads. In this study, we report a 53-year-old man who was admitted to the ICU for treatment of septic shock. The causative agent was targeted earlier as S. aureus by mNGS, and the shock was corrected more quickly with targeted antibiotic medication. However, he later developed multiple septic arthritis and an extensive migratory skin soft tissue infection with persistent fever, and at one point a gram-negative bacterial infection was suspected, and the antibiotic regimen was incorrectly changed. Blood dPCR suggested that the causative organism was still methicillin-sensitive S. aureus (MSSA), with no drug resistance gene detected, and the anti-infective regimen was readjusted, and the patient eventually recovered and was discharged from the hospital. We present this rare case and review related studies to validate the superiority of genetic testing technology in pathogen diagnosis, which deserves further application.

[Necrotizing soft tissue infections]

Necrotizing soft tissue infections are a heterogeneous group of severe infections of the skin, connective tissue and muscles in which necrotic destruction of the tissue occurs at the site of infection. Various bacteria are known as "typical" triggering pathogens and the infection can occur on the entire surface of the body. Necrotizing soft tissue infections are always a time-sensitive emergency associated with high mortality. Many affected patients are critically ill and require treatment in an intensive care unit. The rapid and radical surgical treatment is an essential part of management and in addition an adequate and timely antimicrobial treatment is of great importance. The health consequences for surviving patients are often severe, as extensive soft tissue damage leads to functional impairments. In many cases extensive plastic surgery follow-up is necessary. Therefore, necrotizing soft tissue infections are "complicated" in every phase of the disease and require interprofessional treatment. This review article provides a current overview of various aspects of the diagnostics, treatment and aftercare of necrotizing soft tissue infections.

Pathogenomic profile and clonal diversity of potential zoonotic MRSA-CC7-ST789-t091-SCCmecV from human skin and soft tissue infections

The whole genome sequence (WGS) of prevalent MRSA strains harboring mecA gene obtained from skin and soft tissue infections (SSTIs) in Nigerian hospitals were profiled for pathogenomic structure and evaluated for clonal diversity. The two MRSA strains identified among 66 isolated multi-drug resistant S. aureus from a collection of 256 clinical samples were phenotyped for antibiotic resistance and genotyped for mecA, SCCmec, and spa types. The mecA positive MRSA was analysed using whole-genome sequencing for resistomes, virulomes, phylogenomic profiles and clonal diversity. The identified MRSA-CC7-ST789-t091-SCCmecV strains from a female child (aged 1 year) with severe otorrhea and an adult male (aged 23) with purulent wound abscess showed high-level resistance to streptomycin, vancomycin, kanamycin, sulfamethoxazole and ciprofloxacin. Both strains harbored abundant resistomes, inherent plasmids, chromosomal replicons and typical seven housekeeping genes (arc3, aroE4, glpF1, gmk4, pta4, tpi6, yqiL3). The most abundant putative virulomes were pathogenesis-associated proteins (included hemolysin gamma, leucocidins, proteases, staphylococcal superantigen/enterotoxin-like genes (Set/Ssl), capsule- and biofilm-associated genes, and hyaluronate lyase). Comparative phylogenomic analysis revealed the relatedness of the two clonal strains with prevalent MRSA-CC7 pathotypes observed in Italy (2013 and 2014), Denmark (2014), Thailand (2015 and 2016), USA (2018), and Nigeria (2016 and 2020); and share high genetic similarities with livestock strains from cow milk and cattle. Identified MRSA-CC7-ST789-t091-SCCmecV pathotypes implicated in SSTIs from Nigeria harboring repertoires of antibiotic resistance and virulence genes, and genetic relatedness with livestock strains; show the possibility of gene transfer between animal and human. Adequate hospital MRSA infection control and geno-epidemiological surveillance for animal and human transfer is required.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Anti-inflammatories as adjunct treatment for cellulitis: a systematic review and meta-analysis

OBJECTIVES

Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) as adjunct cellulitis treatment improves clinical response and cure.

METHODS

Systematic review and meta-analysis including randomized controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) vs. placebo or no intervention. Medline (PubMed), Embase (via Elsevier), and Cochrane CENTRAL were searched from inception to August 1, 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure.

RESULTS

Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95%CI 1.42-2.31, I2 = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95%CI 0.62-2.26), although heterogeneity was high (I2 = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (N = 3 trials) were infrequent.

CONCLUSIONS

For patients with cellulitis, the best available data suggest that oral nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies.

REGISTRATION

Open Science Framework:   https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81 .

No role for standard imaging workup of patients with clinically evident necrotizing soft tissue infections: a national retrospective multicenter cohort study

PURPOSE

To assess the diagnostic contribution of different imaging studies to diagnose necrotizing soft tissue infections (NSTIs) and the time to surgery in relation to imaging with the hypothesis that imaging studies may lead to significant delays without being able to sufficiently dismiss or confirm the diagnosis since a NSTI is a surgical diagnosis.

METHODS

A retrospective multicenter cohort study of all NSTI patients between 2010 and 2020 was conducted. The primary outcome was the number of cases in which imaging contributed to or led to change in treatment. The secondary outcomes were time to treatment determined by the time from presentation to surgery and patient outcomes (amputation, intensive care unit (ICU) admission, length of ICU stay, hospital stay, and mortality).

RESULTS

A total of 181 eligible NSTI patients were included. The overall mortality was 21% (n = 38). Ninety-eight patients (53%) received imaging in the diagnostic workup. In patients with a clinical suspicion of a NSTI, 81% (n = 85) went directly to the operating room and 19% (n = 20) underwent imaging before surgery; imaging was contributing in only 15% (n = 3) by ruling out or determining underlying causes. In patients without a clinical suspicion of a NSTI, the diagnosis of NSTI was considered in 35% and only after imaging was obtained.

CONCLUSION

In patients with clinically evident NSTIs, there is no role for standard imaging workup unless it is used to examine underlying diseases (e.g., diverticulitis, pancreatitis). In atypical presenting NSTIs, CT or MRI scans provided the most useful information. To prevent unnecessary imaging and radiation and not delay treatment, the decision to perform imaging studies in patients with a clinical suspicion of a NSTI must be made extremely careful.

Risk model for predicting mortality in patients with necrotizing soft tissue infections in the intensive care unit

BACKGROUND

The goal of this study is to look into the factors that lead to death in patients with necrotizing soft tissue infections（NSTIs） in the intensive care unit and create a mortality risk model.

METHODS

The clinical data of 106 patients with necrotizing soft tissue infections admitted to intensive care unit(ICU) of the First Affiliated Hospital of Wenzhou Medical University between January 2008 and December 2021 were retrospectively analyzed. Univariate analysis and multivariate analysis were performed to evaluate the risk factors impacting patient mortality. The regression coefficient in binary logistic regression analysis was converted into the item score in the model, and then the model score of each patient was calculated. Finally, an ROC curve was constructed to evaluate the efficiency of the model for predicting mortality. Thirteen patients with NSTIs admitted to ICU between January 2022 and November 2022 were used to validate the model.

RESULTS

The death group had 44 patients, while the survival group had 62 patients. The overall mortality was 41.5%. Binary logistic regression analysis showed that risk factors for mortality were age≥ 60 years(OR:4.419; 95%CI:1.093-17.862; P = 0.037), creatinine ≥ 132μmol/L(OR:11.166; 95%CI:2.234-55.816; P = 0.003), creatine kinase ≥ 1104 U/L(OR:4.019; 95%CI:1.134-14.250; P = 0.031), prothrombin time ≥ 24.4 s(OR:11.589; 95%CI:2.510-53.506; P = 0.002), and invasive mechanical ventilation (OR:17.404; 95%CI:4.586-66.052; P＜0.000). The AUC of the model for predicting mortality was 0.940 (95% CI:0.894-0.986). When the cut-off value for the model was 4 points, the sensitivity was 95.5% and the specificity was 83.9%.

CONCLUSION

The death risk model in this study for NSTIs patients in the intensive care unit shows high sensitivity and specificity. Patients with a score of ≥ 4 points have a higher risk of mortality.

Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review

Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.

Identifying patients with difficult-to-treat acute bacterial skin infections

PURPOSE OF REVIEW

The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs.

RECENT FINDINGS

Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection.

SUMMARY

Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.

IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS

ABSTRACT

Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.

Equipoise: an important ethical consideration when contemplating participation in a randomised controlled trial of hyperbaric oxygen treatment in necrotising soft tissue infections

A proposal for a large, multi-centre, randomised controlled trial investigating the role of hyperbaric oxygen treatment (HBOT) in necrotising soft tissue infections (NSTI) has led to much discussion locally and internationally about whether participation is ethical for a centre where stakeholders already consider HBOT standard practice. This article systematically addresses the concept of clinical equipoise specific to the role of HBOT in NSTI, and presents a series of considerations to be taken into account by key stakeholders at potential participating sites.

In vitro activity of ceftaroline against bacterial isolates causing skin and soft tissue and respiratory tract infections collected in Latin American countries, ATLAS program 2016-2020

OBJECTIVES

Ceftaroline, a broad-spectrum cephalosporin, has activity against Gram-positive and several Gram-negative bacteria (GNB). This study aimed to evaluate the antimicrobial activity of ceftaroline and comparators against isolates causing skin and soft tissue infections (SSTIs) and respiratory tract infections (RTIs) collected in Latin America (LATAM) in 2016-2020 as part of the Antimicrobial Testing Leadership and Surveillance program (ATLAS).

METHODS

Minimum inhibitory concentrations were determined using both Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria.

RESULTS

Ceftaroline demonstrated potent activity against methicillin-susceptible Staphylococcus aureus (CLSI/EUCAST: MIC90 0.25 mg/L; susceptibility 100%), whereas activity against methicillin-resistant S. aureus varied for SSTIs (MIC90 1 mg/L; susceptibility 92.5%) and RTIs isolates (MIC90 2 mg/L; susceptibility 72.9%) isolates. For Streptococcus pneumoniae, particularly penicillin-resistant isolates commonly causing respiratory infections, high ceftaroline activity (MIC90 0.25 mg/L; susceptibility 100%/98.4%) was noted. All isolates of β-hemolytic streptococci were susceptible to ceftaroline (S. agalactiae: MIC90 0.03 mg/L [SSTIs]; MIC90 0.015 mg/L (RTIs); susceptibility 100%; S. pyogenes: MIC90 0.008 mg/L; susceptibility 100%). Ceftaroline was highly active against Haemophilus influenzae, including β-lactamase positive isolates (MIC90 0.06 mg/L; susceptibility 100%/85.7%). Ceftaroline demonstrated high activity against non-ESBL-producing GNB (E. coli: MIC90 0.5 mg/L, susceptibility 91.9%; K. pneumoniae: MIC90 0.25 mg/L, susceptibility 95.1%; K. oxytoca, MIC90 0.5 mg/L; susceptibility 95.7%).

CONCLUSION

Ceftaroline was active against the recent collection of bacterial pathogens commonly causing SSTIs and RTIs in LATAM. Local and regional surveillance of antimicrobial resistance patterns are crucial to understand evolving resistance and guide treatment management.

Efficacy and safety of omadacycline for treating complicated skin and soft tissue infections: a meta-analysis of randomized controlled trials

OBJECTIVE

In the present study, we aimed to compare the clinical efficacy and safety of omadacycline (OMC) with its comparators for the treatment of complicated skin and soft tissue infections (cSSTIs) in adult patients.

METHODS

Randomized controlled trials (RCTs) evaluating OMC for cSSTIs were searched in databases of PubMed, Embase, Cochrane, Web of Science, and Clinical Trial, up to July 2022. The primary outcomes were clinical efficacy and microbiological response, with secondary outcome was safety.

RESULTS

Four RCTs consisting of 1,757 patients were included, with linezolid (LZD) as a comparator drug. For clinical efficacy, OMC was not inferior to LZD in the modified intent-to-treat (MITT) (OR: 1.24, 95% Cl: [0.93, 1.66], P = 0.15) and clinically evaluable (CE) populations (OR: 1.92, 95% Cl: [0.94, 3.92], P = 0.07). For microbiological response, OMC was numerically higher than LZD in the microbiologically evaluable (ME) (OR: 1.74, 95% Cl: [0.81, 3.74], P = 0.16) and microbiological MITT (micro-MITT) populations (OR: 1.27, 95% Cl: [0.92, 1.76], P = 0.14). No significant difference was found in subpopulations of monomicrobial or polymicrobial mixed infection populations. The mortality and adverse event rates were similar between OMC and LZD.

CONCLUSIONS

OMC was as good as LZD in terms of clinical efficacy and microbiological response, and has similar safety issues in treating cSSTIs. OMC might be a promising option for treating cSSTIs in adult patients.

Toxic Shock Syndrome: A Literature Review

Toxic shock syndrome (TSS) is a rare, life-threatening, toxin-mediated infectious process linked, in the vast majority of cases, to toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. The pathophysiology, epidemiology, clinical presentation, microbiological features, management and outcome of TSS are described in this review. Bacterial superantigenic exotoxins induces unconventional polyclonal lymphocyte activation, which leads to rapid shock, multiple organ failure syndrome, and death. The main described superantigenic exotoxins are toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes. Staphylococcal TSS can be menstrual or nonmenstrual. Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection. Management of TSS is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration. The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation. Scientific literature on TSS mainly consists of observational studies, clinical cases, and in vitro data; although more data on TSS are required, additional studies will be difficult to conduct due to the low incidence of the disease.

Recent Advancement in Novel Wound Healing Therapies by Using Antimicrobial Peptides Derived from Humans and Amphibians

The skin is the biggest organ in the human body. It is the first line of protection against invading pathogens and the starting point for the immune system. The focus of this review is on the use of amphibian-derived peptides and antimicrobial peptides (AMPs) in the treatment of wound healing. When skin is injured, a chain reaction begins that includes inflammation, the formation of new tissue, and remodelling of existing tissue to aid in the healing process. Collaborating with non-immune cells, resident and recruited immune cells in the skin remove foreign invaders and debris, then direct the repair and regeneration of injured host tissues. Restoration of normal structure and function requires the healing of damaged tissues. However, a major issue that slows wound healing is infection. AMPs are just one type of host-defense chemicals that have developed in multicellular animals to regulate the immune response and limit microbial proliferation in response to various types of biological or physical stress. Therefore, peptides isolated from amphibians represent novel therapeutic tools and approaches for regenerating damaged skin. Peptides that speed up the healing process could be used as therapeutic lead molecules in future research into novel drugs. AMPs and amphibian-derived peptides may be endogenous mediators of wound healing and treat non-life-threatening skin and epithelial lesions. Thus, the present article was drafted with to incorporate different peptides used in wound healing, their method of preparation and routes of administration.

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

Infection Management for the Hand Surgeon

Infections of the upper extremity can be challenging to diagnose and treat because of the complex anatomy and range of offending pathogens. Early recognition of infections that require an emergent surgical intervention, such as necrotizing fasciitis and septic joints, is imperative for good clinical outcomes. In addition, prompt diagnosis and intervention for deep closed space infections, such as deep abscesses or flexor tenosynovitis, is necessary to avoid chronic pain and dysfunction. Complicating factors such as underlying osteomyelitis, atypical pathogens, and immunocompromised states of patients should always be considered when treating upper-extremity infections.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

Staphylococcus aureus in Polymicrobial Skinand Soft Tissue Infections: Impact of Inter-Species Interactionsin Disease Outcome

Polymicrobial biofilms provide a complex environment where co-infecting microorganisms can behave antagonistically, additively, or synergistically to alter the disease outcome compared to monomicrobial infections. Staphylococcus aureus skin and soft tissue infections (Sa-SSTIs) are frequently reported in healthcare and community settings, and they can also involve other bacterial and fungal microorganisms. This polymicrobial aetiology is usually found in chronic wounds, such as diabetic foot ulcers, pressure ulcers, and burn wounds, where the establishment of multi-species biofilms in chronic wounds has been extensively described. This review article explores the recent updates on the microorganisms commonly found together with S. aureus in SSTIs, such as Pseudomonas aeruginosa, Escherichia coli, Enterococcus spp., Acinetobacter baumannii, and Candida albicans, among others. The molecular mechanisms behind these polymicrobial interactions in the context of infected wounds and their impact on pathogenesis and antimicrobial susceptibility are also revised.

Marine Resources Offer New Compounds and Strategies for the Treatment of Skin and Soft Tissue Infections

Bioprospecting of the marine environment for drug development has gained much attention in recent years owing to its massive chemical and biological diversity. Drugs for the treatment of skin and soft tissue infections have become part of the search, mainly with respect to enlarging the number of available antibiotics, with a special focus on multidrug-resistant Gram-positive bacteria, being the major causative agents in this field. Marine resources offer novel natural products with distinct biological activities of pharmaceutical importance, having the chance to provide new chemical scaffolds and new modes of action. New studies advance the field by proposing new strategies derived from an ecosystemic understanding for preventive activities against biofilms and new compounds suitable as disinfectants, which sustain the natural flora of the skin. Still, the development of new compounds is often stuck at the discovery level, as marine biotechnology also needs to overcome technological bottlenecks in drug development. This review summarizes its potential and shows these bottlenecks and new approaches.

Diagnosis and Management of Severe Water-Related Skin and Soft Tissue Sepsis: A Summative Review of the Literature

BACKGROUND

Skin and soft tissue infections (SSTIs) are common presentations in the emergency department. However, this is less common after contact with contaminated saltwater or freshwater. This review presents the diagnosis and management of water-related soft tissue sepsis in this vulnerable and difficult-to-treat subgroup of necrotizing soft tissue sepsis.

METHODS

A summative literature overview is presented regarding bacterial and fungal SSTI after contact with contaminated water, with practical diagnostic and management aspects.

RESULTS

The literature indicates that these wounds and infections remain difficult to treat. An approach using appropriate diagnostic tools with both medical and surgical management strategies is provided.

CONCLUSIONS

SSTIs due to water contamination of wounds involve unusual organisms with unusual resistance patterns, and require a nuanced and directed diagnostic approach with an adaptation of the usual antibiotic or antifungal selection to achieve a successful cure, along with aggressive debridement and wound care.

Antibiotic Management of Uncomplicated Skin and Soft Tissue Infections in the Real World

Background: Skin and soft tissue infections are one of the main causes of consultations worldwide. The objective was to determine the treatment of a group of patients with uncomplicated skin and soft tissue infections in Colombia. Methods: Follow-up study of a cohort of patients with skin infections who were treated in the Colombian Health System. Sociodemographic, clinical and pharmacological variables were identified. Treatments were evaluated using clinical practice guidelines for skin infections. Results: A total of 400 patients were analyzed. They had a median age of 38.0 years and 52.3% were men. The most commonly used antibiotics were cephalexin (39.0%), dicloxacillin (28.0%) and clindamycin (18.0%). A total of 49.8% of the subjects received inappropriate antibiotics, especially those with purulent infections (82.0%). Being cared for in an outpatient clinic (OR: 2.09; 95% CI: 1.06-4.12), presenting pain (OR: 3.72; 95% CI: 1.41-9.78) and having a purulent infection (OR: 25.71; 95% CI: 14.52-45.52) were associated with a higher probability of receiving inappropriate antibiotics. Conclusions: Half of patients with uncomplicated skin and soft tissue infections were treated with antibiotics that were not recommended by clinical practice guidelines. This inappropriate use of antibiotics occurred in the vast majority of patients with purulent infections because the antimicrobials used had no effect on methicillin-resistant Staphylococcus aureus.

Prevention and treatment of recurrent cellulitis

PURPOSE OF REVIEW

Recurrent cellulitis is a challenging clinical condition affecting up to 47% of patients after the first episode, especially those with predisposing risk factors. The purpose of this review is to describe the state of the art of literature evidence and to highlight recent developments in its management.

RECENT FINDINGS

Recurrent cellulitis can occur after successful treatment of cellulitis. Conditions that commonly increase the risk of cellulitis include local and systemic modifiable and nonmodifiable factors. A rigorous approach to the management of risk factors and treatment of acute infection is important as the risk of recurrence rises with repeated episodes. Risk factors, if present, need to be targeted in association with antibiotic prophylaxis. Penicillin V is the preferred antibiotic for prevention but other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure.

SUMMARY

Recurrent cellulitis is associated with short term and long-term morbidity as well as significant healthcare costs. Management of underlying predisposing conditions is crucial to prevent recurrence in addition with evaluation of pharmacological measures, but specialized and multidisciplinary skills are needed. More efforts are needed to prevent and treat this underestimated problem.

The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis

BACKGROUND

To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence.

METHODS

Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05).

CONCLUSION

The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.

The impact of necrotizing soft tissue infections on the lives of survivors: a qualitative study

PURPOSE

Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved.

METHODS

Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11).

RESULTS

The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on 'mistakes' in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important.

CONCLUSION

This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.

Antimicrobial Management of Skin and Soft Tissue Infections among Surgical Wards in South Africa: Findings and Implications

Skin and soft tissue infections (SSTIs) are one of the most common infectious diseases requiring antibiotics. However, complications of SSTIs may lead to the overprescribing of antibiotics and to subsequent antibiotic resistance. Consequently, monitoring the prescribing alignment with the current recommendations from the South African Standard Treatment Guidelines (STG) is necessary in order to improve future care. This study involved reviewing pertinent patients with SSTIs who were prescribed antimicrobials in the surgical ward of a leading South African tertiary public hospital from April to June 2021 using an adapted data collection tool. Sixty-seven patient files were reviewed. Among the patients with SSTIs, hypertension and chronic osteomyelitis were the most frequent co-morbidities at 22.4% and 13.4%, respectively. The most diagnosed SSTIs were surgical site infections (35.1%), wound site infections (23%), and major abscesses (16.2%). Blood cultures were performed on 40.3% of patients, with Staphylococcus aureus (32.7%) and Enterococcus spp. (21.2%) being the most cultured pathogens. Cefazolin was prescribed empirically for 46.3% of patients for their SSTIs. In addition, SSTIs were treated with gentamycin, ciprofloxacin, and rifampicin at 17.5%, 11.3%, and 8.8%, respectively, with treatment fully complying with STG recommendations in 55.2% of cases. Overall, the most common cause of SSTIs was Staphylococcus aureus, and empiric treatment is recommended as the initial management. Subsequently, culture sensitivities should be performed to enhance adherence to STGs and to improve future care.

Population Pharmacokinetics and Dosage Optimization of Vancomycin in Pediatric Patients with Skin and Soft Tissue Infections, Bone, and Joint Infections

Vancomycin is recommended for the treatment of skin and soft tissue infections (SSTI) and bone and joint infections (BJI). However, a detailed investigation of the pharmacokinetic profile and optimal dosing regimens of vancomycin in pediatric patients with SSTI and BJI is lacking. We successfully developed a new PopPK model of vancomycin in this population by using scavenged blood samples with the typical values for clearance (CL) of 0.14 L/h/kg and volume of distribution (V) of 0.5 L/kg. Body weight was confirmed as the significant covariate on CL and V. The optimal dosing regimens of 75 mg/kg/day and 80 mg/kg/day were recommended for this specific population.

Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.

Vibrio vulnificus necrotizing fasciitis with sepsis presenting with pain in the lower legs in winter: a case report

Background

Vibrio vulnificus infections develop rapidly and are associated with a high mortality rate. The rates of diagnosis and treatment are directly associated with mortality.

Case presentation

We describe an unusual case of a 61-year-old male patient with chronic liver disease and diabetes who presented with a chief complaint of pain in both lower legs due to V. vulnificus infection in winter. Within 12 h of arrival, typical skin lesions appeared, and the patient rapidly developed primary sepsis. Despite prompt appropriate antibiotic and surgical treatment, the patient died 16 days after admission.

Conclusion

Our case findings suggest that V. vulnificus infection should be suspected in patients with an unclear infection status experiencing pain of unknown origin in the lower legs, particularly in patients with liver disease or diabetes, immunocompromised status, and alcoholism.