Severe and complicated soft tissue infections: a single-centre case series

OBJECTIVE

To assess the demographic and clinical characteristics, laboratory findings, and economic burden of patients with a diagnosis of complicated skin and soft tissue infection (cSSTI).

METHOD

The demographic and clinical characteristics, laboratory findings, surgical interventions, cost of treatment, and outcome of patients diagnosed with cSSTIs between January 2017 and December 2019 were retrospectively analysed.

RESULTS

A total of 24 patients with cSSTIs were included in the study. The median age was 53 (22-85) years, and 14 (58%) were female. The most common comorbidity was diabetes (54%). On admission, 75% of patients presented with sepsis, and 70% had a high-grade Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score. The causative microorganism was isolated from 21 (87%) patients, and the multidrug resistance rate of Gram-negative bacteria was 50%. The median number of debridements was 3 (1-12). In all, 11 patients were followed up in the intensive care unit, and the mortality rate was 29%. The presence of confusion (p=0.025), causative Gram-negative microorganisms (p=0.009), hyponatraemia (p=0.034), the need for intensive care (p=0.001), anti-meticillin-resistant Staphylococcus aureus antibiotics (p=0.023) and the rate of antibiotic changes during treatment (p=0.019) were significantly higher in the non-survival patient group. Hyponatraemia was a significant independent risk factor for mortality (p=0.048). The median cost of per-patient treatment was $9453 USD in the non-surviving and $1536 in the surviving group.

CONCLUSION

It is important to know possible factors and local resistance rates at the beginning of empirical antibacterial and surgical treatment. The presence of hyponatraemia, sepsis and a high LRINEC score can be considered to be the mortality predictors.

Prediagnosis of soft tissue infection that was finally diagnosed as pyoderma gangrenosum of ulcerative colitis

Pyoderma gangrenosum is a rare disorder characterized by inflammatory and ulcerative skin lesions. In this case report, we aimed to present our patient who had a prediagnosis of soft tissue infection and skin ulcers, and was eventually diagnosed with ulcerative colitis-associated pyoderma gangrenosum. A 30-year-old female patient was admitted to the emergency department with skin lesions on her kneecap and lower neck. The patient's skin lesions were considered as infective ulcers, and the patient was admitted to the infectious diseases clinic. The patient had received antibiotics of meropenem and teicoplanin in the follow-up. Surgical debridement was performed but after debridement, the wound had progressed.

Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation

INTRODUCTION

Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram.

METHODS

A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival.

RESULTS

There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge.

CONCLUSION

There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.

Gluteal Necrotizing Soft Tissue Infection and Hip Osteomyelitis due to Candida Glabrata

BACKGROUND

Necrotizing soft tissue infection (NSTI) is a rapidly progressive and often fatal infection of the soft tissue. Classically, it is attributed to bacterial infection and immunocompromised patients are particularly vulnerable. However, NSTI due to fungal infection rarely does occur, including from Candida species, and can pose a diagnostic challenge for unfamiliar providers. Expedient clinical recognition, surgical debridement, fungal tissue culture, and initiation of antifungal therapy are key.

CASE PRESENTATION

We report a 39-year-old obese male with long-standing history of poorly controlled diabetes who presented to a community hospital, noted to have NSTI of the sacrum, bilateral buttocks, and left hip, and was treated only with antibiotics. After transfer to an academic center, the patient underwent aggressive debridement and tissue diagnosis of Candida glabrata NSTI was made. He received broad-spectrum antibiotic and antifungal therapy for several months. Over the course of 4 months, his infection was cleared, and his large tissue defects were reconstructed with rotation flaps and the patient was discharged home.

CONCLUSIONS

Fungal NSTI is a rare entity, especially when due to Candida species. It can be exceedingly difficult to diagnose and manage, as these patients may suffer higher mortality than those with NSTI due to bacteria. A high index of suspicion for the entity, rapid debridement, intraoperative tissue culture, and treatment with appropriate antifungal therapy offers the greatest chance of survival.

How to manage skin and soft-tissue infections in the emergency department

PURPOSE OF REVIEW

Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures.

RECENT FINDINGS

Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods.

SUMMARY

The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.

Skin and soft tissue infections in the elderly

PURPOSE OF REVIEW

To highlight the peculiarity of skin and soft tissue infections (SSTIs) in elderly patients and to provide useful elements for their optimal management.

RECENT FINDINGS

In the COVID-19 era, early discharge from the hospital and implementation of outpatient management is of key importance.

SUMMARY

Elderly patients are at high risk of SSTIs due to several factors, including presence of multiple comorbidities and skin factors predisposing to infections. Clinical presentation may be atypical and some signs of severity, such as fever and increase in C-reactive protein, may be absent or aspecific in this patients population. An appropriate diagnosis of SSTIs in the elderly is crucial to avoid antibiotic overtreatment. Further studies should explore factors associated with bacterial superinfections in patients with pressure ulcers or lower limb erythema. Since several risk factors for methicillin-resistant Staphylococcus aureus (MRSA) may coexist in elderly patients, these subjects should be carefully screened for MRSA risk factors and those with high risk of resistant etiology should receive early antibiotic therapy active against MRSA. Physicians should aim to several objectives, including clinical cure, patient safety, early discharge and return to community. SSTIs in the elderly may be managed using long-acting antibiotics, but clinical follow-up is needed.

Skin and soft tissue infections due to rapidly growing mycobacteria

PURPOSE OF REVIEW

The aim of this article is to review skin and soft tissue infections due to rapidly growing mycobacteria (RGM), with a particular focus on recently published literature (2021-2022).

RECENT FINDINGS

RGM are increasingly reported as a cause of skin and soft tissue infections, both in the community setting and as a cause of nosocomial outbreaks. Recent advances in molecular methods have expanded the number of species of RGM and resulted in increased diagnosis. New treatment options are under evaluation particularly for Mycobacterium abscessus , the most difficult-to-treat among RGM.

SUMMARY

RGM are an uncommon cause of skin and soft tissue infections and a high clinical suspicion together with advanced laboratory facilities are required for diagnosis. Species identification and antimicrobial susceptibility testing are essential to drive appropriate treatment, which combines surgical debridement with prolonged antimycobacterial combination therapy.

Rapid diagnostics for skin and soft tissue infections: the current landscape and future potential

PURPOSE OF REVIEW

Managing antimicrobial therapy in patients with complicated skin and soft tissue infections (SSTI) constitutes a growing challenge due to the wide spectrum of potential pathogens and resistance phenotypes. Today, microbiological documentation relies on cultural methods. This review summarizes the available evidence regarding the clinical input of rapid microbiological diagnostic tools (RMDT) and their impact on the management of antimicrobial therapy in SSTI.

RECENT FINDINGS

Accurate tools are already available for the early detection of methicillin-resistant Staphylococcus aureus (MRSA) in SSTI samples and may help avoiding or shortening empirical anti-MRSA coverage. Further research is necessary to develop and evaluate RMDT detecting group A streptococci (e.g., antigenic test) and Gram-negative pathogens (e.g., multiplex PCR assays), including through point-of-care utilization. Next-generation sequencing (NGS) methods could provide pivotal information for the stewardship of antimicrobial therapy, especially in case of polymicrobial or fungal SSTI and in the immunocompromised host; however, a shortening in the turnaround time and prospective data regarding their therapeutic input are needed to better appraise the clinical positioning of these promising approaches.

SUMMARY

The clinical input of RMDT in SSTI is currently limited due to the scarcity of available dedicated assays and the polymicrobial feature of certain cases. NGS appears as a relevant tool but requires further developments before its implementation in routine clinical practice.

Marjolin's ulcer in an ischial pressure sore presented with necrotizing soft tissue infection: A case report

RATIONALE

Marjolin's ulcer (MU) is a rare skin malignancy derived from a chronic wound. Pressure ulcer related MU possesses poor prognosis and high metastatic rate, and it is difficult to be differentiated, especially when superimposed infection.

PATIENT CONCERNS

Here we report a case with pressure ulcer related MU which presented as necrotizing soft tissue infection (NSTI) to demonstrate the manifestation, treatment, and prognosis of this rare disease.

DIAGNOSES

A 45-year-old male patient had spinal cord injury at age 2 years. He presented ischial pressure sore complicated with NSTI initially. After serial debridements and antibiotic treatment, the infection subsided. For the persistent verruca-like skin lesion, he underwent wide excision which revealed well-differentiated squamous cell carcinoma. Further image studies showed localized residual tumor without distant metastasis.

INTERVENTIONS

He then underwent hip disarticulation and anterior thigh fillet flap reconstruction. Local recurrence developed 3 months later, and re-wide excision and inguinal lymph node dissection were performed. No lymph node metastasis was noted and adjuvant radiotherapy was given.

OUTCOMES

He was followed for 34 months and no recurrence or metastasis was found. The patient can move with a wheelchair or a hip prosthesis, and is partially dependent for daily activities.

LESSONS

MU can masquerade as NSTI and one should be alert to its malignant potential. Due to its aggressive nature, limb sacrifice can be considered in circumstances of profound involvement. As for the reconstruction method, pedicled fillet flap provided good wound coverage.

A necrotising fasciitis: case report

Necrotizing fasciitis is one of the most common soft tissue infections, with a high risk of major amputation and a mortality ranging from 6 to 33% which has not changed in the past 20 years. Early surgical resection of necrotic tissue plays a key role in determining the prognosis. Nawijn et al. identified an optimal 6 hours window from presentation to surgery. Symptoms of necrotizing fasciitis mimic those of common skin infections, such as erysipelas and cellulitis, making rapid surgical management difficult. In this context, the aid of point-of-care-ultrasound is a valuable tool for early diagnosis, detecting the presence of subcutaneous thickening, gas and perifascial liquid. Other characteristic ultrasound findings include the "cobblestone" appearance of the subcutaneous soft tissues and reverberation artifacts due to hyperechoic outbreaks, defined as "snow globes" due to the presence of heterogeneous swirling material, and "dirty shadowing" due to the foggy shadow created by the gas.

Primary Cutaneous Mucormycosis: A Necrotising Soft Tissue Infection with Poor Prognosis

BACKGROUND

Cutaneous mucormycosis is an unusual fungal infection that continues to occur. It needs aggressive surgical debridement and timely administration of antifungals due to its high fatality rate. High clinical suspicion on the part of a surgeon is required to prevent the same.

CASE PRESENTATION

We present two cases of cutaneous mucormycosis in which the patients succumbed to death, highlighting the seriousness of the condition. One patient had a lower leg ulcer and was diabetic, and the other patient had a gluteal abscess following an intramuscular injection. Tissue samples grew Rhizopus arrhizus and Apophysomyces sp., respectively. Both patients were treated with amphotericin B, and extensive debridement was performed.

DISCUSSION

Cutaneous mucormycosis can be reported in immunocompetent people, and there is a need for early recognition of the entity as a differential diagnosis of any nonhealing necrotic ulcer.

CONCLUSION

Proper training and education of technical and clinical staff should be done at peripheral primary and secondary care centres so as not to miss out on cases of mucormycosis and for better prognosis in a cutaneous variety of mucormycosis in surgical patients.

Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study

PURPOSE

The purpose of this paper was to investigate patterns of health care utilization leading up to diagnosis of necrotizing soft tissue infections of the genitalia and to identify risk factors associated with potential diagnostic delay.

MATERIALS AND METHODS

IBM MarketScan Research Databases (2001-2020) were used to identify index cases of necrotizing soft tissue infections of the genitalia. We identified health care visits for symptomatically similar diagnoses (eg, penile swelling, cellulitis) that occurred prior to necrotizing soft tissue infections of the genitalia diagnosis. A change-point analysis identified the window before diagnosis where diagnostic opportunities first appeared. A simulation model estimated the likelihood symptomatically similar diagnosis visits represented a missed opportunity for earlier diagnosis. Patient and provider characteristics were evaluated for their associations with delay.

RESULTS

We identified 8,098 patients with necrotizing soft tissue infections of the genitalia, in which 4,032 (50%) had a symptomatically similar diagnosis visit in the 21-day diagnostic window, most commonly for "non-infectious urologic abnormalities" (eg, genital swelling; 64%): 46% received antibiotics; 16% saw a urologist. Models estimated that 5,096 of the symptomatically similar diagnosis visits (63%) represented diagnostic delay (mean duration 6.2 days; mean missed opportunities 1.8). Risk factors for delay included urinary tract infection history (OR 2.1) and morbid obesity (OR 1.6). Visits to more than 1 health care provider/location in a 24-hour period significantly decreased delay risk.

CONCLUSIONS

Nearly 50% of insured patients who undergo debridement for, or die from, necrotizing soft tissue infections of the genitalia will present to a medical provider with a symptomatically similar diagnosis suggestive of early disease development. Many of these visits likely represent diagnostic delay. Efforts to minimize logistic and cognitive biases in this rare condition may lead to improved outcomes if they lead to earlier interventions.

Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.

Finger Test for the Diagnosis of a Critically Ill Patient with Necrotizing Fasciitis

BACKGROUND

Necrotizing fasciitis is a life-threatening soft-tissue infection, often characterized by soft-tissue destruction, systemic toxicity, and high mortality. No single laboratory value can diagnose necrotizing fasciitis; ultimately, necrotizing fasciitis is a clinical diagnosis and therefore presents a diagnostic dilemma for many physicians. The finger probe test is useful in confirming the diagnosis when imaging studies are unobtainable or nondiagnostic.

CASE REPORT

We present the case of a 70-year-old woman presenting nonverbal and obtunded with a soft-tissue infection of the right lower extremity. The only pertinent positive vital sign was tachypnea with a respiratory rate of 22 breaths/min. Physical examination revealed nonpitting edema, cold-to-touch lower extremity, and Nikolsky-positive hemorrhagic bullae. Initial laboratory test results showed white blood cell count of 38 x 10⁹/L and lactic acid of 8.2 mg/dL. Advanced imaging was unobtainable, given the patient's worsening clinical status, and the decision was made to perform the finger probe test, which revealed absence of bleeding and presence of friable tissue and "dishwater" discharge. Consequently, the general surgery team took the patient to the operating room and performed an above-the-knee amputation and surgical debridement. Postoperative report noted nonviable tissue consistent with necrotizing fasciitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Necrotizing fasciitis is a life-threatening emergency that can destroy soft-tissue at a rate of 1 inch/h. When imaging is unobtainable or nondiagnostic, the finger probe test can be used in select patients to aid with diagnosis.

Current Challenges in the Management of Skin and Soft Tissue Infections and Community-Acquired Pneumonia

Skin and soft tissue infections (SSTI) and community-acquired pneumonia (CAP) are major public health problems that are commonly encountered in the primary care setting. Establishing the severity of disease is an important step in the diagnosis of SSTI and CAP, because this can affect decisions about optimal management, including level of care. Due to antibiotic resistance, allergies, and adverse effect profiles of current therapies, there is a need for new treatment options for both SSTI and CAP. Improved utilization of oral outpatient antibiotic treatments can also minimize the risk of serious adverse effects or nosocomial infections, leading to better patient outcomes. As these infections are mostly treated in outpatient settings, primary care clinicians are best suited to implement changes such as use of oral antibiotics, where appropriate, to reduce hospitalization, with its associated costs and risks to the patient.

Necrotizing Soft Tissue Infections of the Hand and Wrist

Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.

Diagnosis and treatment of surgical skin and soft tissue infections - current status

Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.

Global patterns of necrotizing soft tissue infections: A systematic review and meta-analysis

BACKGROUND

Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe.

METHODS

Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors.

RESULTS

One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P < .001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality.

CONCLUSION

Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.

Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter

BACKGROUND

During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase.

METHODS

A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality.

RESULTS

A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045).

CONCLUSION

Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population.

LEVEL OF EVIDENCE

Epidemiological, level IV.

[Non-Necrotizing Acute Dermo-Hypodermal Infections: Erysipela and Infectious Cellulitis]

Non-necrotizing acute dermo-hypodermal infections are infectious processes that include erysipela and infectious cellulitis, and are mainly caused by group A β-haemolytic streptococcus. The lower limbs are affected in more than 80% of cases and the risk factors are disruption of cutaneous barrier, lymphoedema and obesity. Diagnosis is clinical and in a typical setting we observe an acute inflammatory plaque with fever, lymphangitis, adenopathy and leucocytosis. Bacteriology is usually not helpful because of low sensitivity or delayed positivity. In case of atypical presentations, erysipela must be distinguished from necrotizing fasciitis and acute vein thrombosis. Flucloxacillin and cefradine remain the first line of treatment. Recurrence is the main complication, so correct treatment of the risk factors is crucial.

Infections associated with diabetic-care devices

BACKGROUND AND AIMS

There are more than 463 million people living with diabetes with this number expected to increase to 700 million people by 2045. Diabetes is a risk factor for patients developing various comorbidities including, but not limited to, diabetic neuropathy, retinopathy, chronic kidney disease, vascular impediments, and infections. Due to the continuous invasiveness of monitoring and/or treatment of this disease, site for infections are elevated.

METHODS

Information was primarily gathered by employing various PubMed scholarly articles for real-world examples in addition to data extraction from supplementary manuscripts. Key search words employed were: diabetes, insulin site infection, lancing infections, insulin pump associated infections, and continuous glucose monitoring infections.

RESULTS

Diabetic care devices used for blood glucose monitoring and insulin administration are an integral part of the disease management and/or treatment in various settings including patient homes, assisted living facilities, community centers, and hospitals. These invasive devices leave a diabetic patient with a small open wound which may get infected or aid in blood borne pathogen transmission. Since diabetes itself has a morbidity and mortality burden, it is important to also study complications arising from the management of diabetes.

CONCLUSION

Although cases exist of infections, either by pathogen transmission or direct inoculation of the prick site, these are a very small percentage and thus should not undermine the confidence in diabetes management. This review highlights the instances of these infections and where they most often occur.

[Necrotising soft-tissue infections]

Necrotising soft-tissue infections (NSTI) is a new term for infections by bacteria, which cause ischaemia and necrosis of the affected tissue. Scientific advances during the past decade have expanded our knowledge of the epidemiology, pathophysiology, prognosis and treatment of NSTI. Early, correct diagnosis and elimination of delay to surgical debridement is crucial for survival. The recommended antimicrobial treatment has recently been updated. This review summarises the latest advances concerning NSTI, and it is important, that all Danish clinicians are up to date on these.