[Primary soft tissue and tenosynovial tuberculosis after needlestick injury in a surgeon]

We describe the case of a surgeon, who pricked himself with a needle used to drain a paravertebral abscess in a patient from Sudan. He lost this patient at follow up. Six weeks later, the surgeon developed oedema of his left hand and wrist. He started antibiotics, amoxicillin/clavulanate plus ciprofloxacin 2 weeks, without any improvement. He came to our centre for examination, and by chance his patient had been admitted to our ward the day before, and had died during the night of disseminated tuberculosis. The surgeon was treated with rifampin, isoniazid and pyrazinamide (3 drugs 2 months, followed by rifampin plus isoniazid for further 7 months) with rapid improvement. He could start his job again after 5 months. To our knowledge, this is the first case of inoculation tuberculosis transmitted to a surgeon, while other cases in health care workers (internists, pathologists, nurses...) have already been well described.

Occult methicillin-resistant Staphylococcus aureus abscesses in 2 pediatric patients

Methicillin-resistant Staphylococcus aureus (MRSA) infections have become more common over the last decade. Recently, severe MRSA infections including necrotizing pneumonia, purpura fulminans, and rapidly progressive skin abscesses have been reported. These severe infections frequently have been associated with the virulence factor Panton-Valentine leukocidin (PVL). Two unusual cases of occult deep tissue abscesses in children who had family members with a history of severe MRSA skin abscesses are presented in this article. Both children initially presented with fever without a focus. Deep tissue MRSA (PVL positive) abscesses evolved. Empiric antibiotic therapy for MRSA should be considered for infants and children who are hospitalized with occult fever and who have a family member with a history of MRSA infection.

Deep neck infection with dental origin: analysis of 85 consecutive cases (2000-2006)

CONCLUSIONS

Diagnostic work-up should include contrast-enhanced computed tomography (CT) and mandible orthopantogram. When a dental origin of deep neck infection is suspected, the intravenous antibiotic regimen has to be active against gram-positive bacteria, both aerobes and anaerobes. Surgical exploration and drainage may be mandatory at presentation, or in cases not responding to medical therapy within the first 24 h.

OBJECTIVES

Deep neck infections are still associated with significant morbidity and mortality rates when complications occur. Despite worldwide improvement in dental care and oral hygiene, a significant prevalence of deep neck infections caused by dental infections has been described recently (> 40%).

PATIENTS AND METHODS

We analysed retrospectively 85 cases of deep neck infection with dental origin out of 206 consecutive cases of deep neck infection diagnosed in our institution between 2000 and 2006.

RESULTS

The most frequent dental source was a periapical infection of the first mandibular molar, followed by second and third molar, respectively. Submandibular space infection involvement was diagnosed in 73 of 85 patients (85.9%), masticatory space infection in 28 (32.9%); in 56 patients (65.9%) the infection involved more than one space. Twenty-four patients (28.2%) were treated only with intravenous antibiotic therapy; 61 patients (71.8%) required both medical and surgical procedures.

Epidemiology, clinical manifestations, and treatment options for skin and soft tissue infection caused by community-acquired methicillin-resistant Staphylococcus aureus

PURPOSE

This article reviews the evolving epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and the appropriate outpatient management of CA-MRSA skin and soft tissue infection. Further, the paper will provide the basis upon which an individualized patient educational plan may be developed.

DATA SOURCES

To complete this review, a search of English language publications was conducted through Medline and CINAHL databases (1966-2006).

CONCLUSIONS

The epidemiology of CA-MRSA is becoming increasingly complex. Research that addresses the impact of this organism in high-risk populations and within families is urgently needed.

IMPLICATIONS FOR PRACTICE

Nurse practitioners must remain informed of the epidemiology of common and emerging drug-resistant organisms in their patient populations.

Community associated methicillin resistant staphylococcal infections in a pediatric urology practice

PURPOSE

Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature.

MATERIALS AND METHODS

We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006.

RESULTS

A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3).

CONCLUSIONS

Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.

Antimicrobial-resistant pathogens: an emerging pediatric threat

The clinical impact of these three bacterial threats is readily apparent to any who practice pediatrics. The potential virulence of CA-MRSA and MDR pneumococci and the threat of failed antimicrobial options for MDRGN pose enormous challenges now and in the near future. With careful attention to antimicrobial stewardship, however, and knowledge of the clinical and epidemiologic factors of these organisms, one can hope to mitigate the impact on patient care and outcomes while awaiting ongoing discovery of new antimicrobial options. Most important, however, will be careful and thoughtful management of any new antimicrobial products to protect their efficacy for the future.

Necrotizing skin and soft-tissue infections associated with septicemia: 7 cases report and review

The authors report seven cases of necrotizing skin and soft-tissue infections, with clinical presenting as hemorrhagic bullae, gangrenous cellulitis or necrotizing fasciitis, in association with septicemia, between January 2003 and January 2007 in Hat Yai Hospital. Six were male and the majority of the lesions, six cases, occurred in the lower extremities. The average age of the patients was 50.0 +/- 11.019 years old. All patients presented with watery diarrhea, severe abdominal pain, high fever and sepsis. The skin lesions were begun with erythema, tender and swelling with formation of hemorrhagic bullae, gangrene and necrosis within 24-48 hours. Three of them were caused by Streptococcus spp., another three by Halophilic Vibrios, and only one by Aeromonas hydrophila. Furthermore, the literatures related with clinical manifestations of necrotizing skin and soft-tissue infections, etiologic pathogens, histological finding, management in setting of sepsis, comorbid conditions, complications and patients' outcome were reviewed.

Necrotizing soft tissue infections: APACHE II score, dissemination, and survival

BACKGROUND

First described more than a century ago, necrotizing soft tissue infections (NSTIs) continue to cause high mortality and morbidity. The aim of this study was to elucidate the factors affecting the outcome of patients presenting with an NSTI.

METHODS

To determine the factors affecting mortality from NSTIs, the records of 67 patients were retrospectively assessed for the following parameters: age, sex, time between initiation of symptoms and admission to the clinic, presence of systemic coexisting disease, APACHE II score, origin of infection, dissemination of the NSTI, and method of therapy.

RESULTS

The patients were 41 men (61.2%) and 26 women (38.8%) with a mean age of 54.9 +/- 1.73 years. The overall mortality rate was 49% (33/67). Multivariate analysis determined that APACHE II scores of 13 or higher (p = 0.001) and NSTI dissemination (p = 0.02) were risk factors affecting the mortality of patients with NSTIs.

CONCLUSION

By considering these two factors, more accurate outcome prediction may be possible, which may be useful for directing the management of patients with NSTIs.

[Complicated skin and soft tissue infections]

Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. Diagnostics include rapid evaluation of locally limited or diffuse spreading extent of the disease. In complicated skin and soft tissue infections, surgical intervention with debridement and necronectomy is indicated. Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.

Complicated skin and soft-tissue infections: diagnostic approach and empiric treatment options

Skin and soft-tissue infections are common and generally are uncomplicated at the time of initial presentation. However, these infections can worsen quickly when there are delays in presentation and treatment. Upon encountering these infections, physicians must respond quickly with an appropriate therapeutic plan and be aware of trends in microbial resistance in order to optimize patient care.

Necrotizing soft tissue infections

PURPOSE OF REVIEW

The purpose of this review is to consider recent advances in the definition, pathogenesis, diagnostic criteria, and treatment of necrotizing soft tissue infections.

RECENT FINDINGS

The efficacy of early surgical debridement combined with antimicrobial therapy, close monitoring and physiologic support is strongly demonstrated. Novel therapeutic strategies including vacuum-assisted wound-closure therapy and intravenous immunoglobulin have been described.

SUMMARY

Necrotizing soft-tissue infection is a rare infection of the subcutaneous tissue and fascia that is often associated with sepsis and can progress rapidly with a possible fatal outcome. Although the cause is not yet understood fully, patients often have a prior history of a small, trivial trauma, wound, or scratch. Establishing the diagnosis can be the main challenge in treating patients, and knowledge of all available tools is key for early and accurate diagnosis.

Assessment of Musculoskeletal Infection in Rats to Determine Usefulness of SPIO-Enhanced MRI

OBJECTIVE

The objective of our study was to evaluate the usefulness of superparamagnetic iron oxide (SPIO)-enhanced MRI in experimental models of infectious disease and to analyze the intracellular uptake of SPIO.

MATERIALS AND METHODS

Nine rats with infectious arthritis of the knee or soft-tissue infection were imaged on an MRI unit on days 4-6 after i.v. injection of a bacterial suspension. All animals were imaged on a T2-weighted fast spin-echo sequence before and 24 hours after administration of SPIO. The nine rats were classified into two groups according to the dose of SPIO. We calculated the relative signal-to-noise ratio (SNR) change and compared the relative SNR change with the histologic findings. We analyzed iron-loaded cells and the intracellular uptake of iron particles according to the dose of SPIO.

RESULTS

The SNR value decreased in proportion to the increase in the number of iron-laden macrophages or fibroblasts in the wall of the soft-tissue abscess (p < 0.01). The intracellular uptake of iron particles was shown in fibroblasts as well as in macrophages, and their uptake in the fibroblasts was greater than that in the macrophages (p < 0.05). There was no statistically significant difference in the intracellular uptake of iron particles according to the dose of SPIO (p > 0.1).

CONCLUSION

SPIO-enhanced MRI can be useful in evaluating infectious disease of the joint or soft tissue and is influenced by the uptake of iron particles in fibroblasts as well as macrophages.

Microbiology and management of soft tissue and muscle infections

This review summarizes the microbiological aspects and management of soft tissue and muscle infections. The infections presented are: impetigo, folliculitis, furunculosis and carbuncles, cellulitis, erysipelas, infectious gangrene (includes necrotizing fasciitis or streptococcal gangrene, gas gangrene or clostridium myonecrosis, anaerobic cellulites, progressive bacterial synergistic gangrene, synergistic necrotizing cellulitis or perineal phlegmon, gangrenous balanitis, and gangrenous cellulitis in the immunocompromised patient), secondary bacterial infections complication skin lesions, diabetic and other chronic superficial skin ulcers and subcutaneous abscesses and myositis. These infections often occur in body sites or in those that have been compromised or injured by foreign body, trauma, ischemia, malignancy or surgery. In addition to Group A streptococci and Staphylococcus aureus, the indigenous aerobic and anaerobic cutaneous and mucous membranes local microflora usually is responsible for polymicrobial infections. These infections may occasionally lead to serious potentially life-threatening local and systemic complications. The infections can progress rapidly and early recognition and proper medical and surgical management is the cornerstone of therapy.

Schmerzhafte Weichteilschwellung am Oberarm

Cat-scratch disease is an infection by Bartonella henselea and resolves spontaneously. We present a case of untypical Bartonella infection which was misinterpreted by MRI as a soft-tissue sarcoma of the upper arm. The histological findings of an incision biopsy were unspecific, without signs of malignancy. The tumor was excised completely and the final histology, however, showed no evidence of malignant changes. The Bartonella henselae infection could be confirmed by polymerase chain reaction. The untypical presentation of cat-scratch disease should be considered in the differential diagnosis of clinically suspected soft tissue sarcoma.

First detected case of community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infection in Italy

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) have been increasingly frequently isolated from patients in many areas of the United States, and have started to replace hospital-acquired MRSA (HA-MRSA) as a cause of healthcare-associated infections. This article, describes the first Italian case of CA-MRSA skin and soft tissue infection (SSTI).

Community MRSA

Additional to epidemic methicillin resistant Staphylococcus aureus (haMRSA) which had been disseminated in and between hospitals, MRSA emerged in the community independent upon the nosocomial setting (caMRSA). caMRSA possess the capacity to form Panton-Valentine-Leukocidin (PVL) as a special virulence factor. In general PVL-positive S. aureus isolates are associated with necrotizing skin and soft tissue infections as well as with necrotizing pneumonia. caMRSA are less "broad" resistant against different groups of antibiotics as haMRSA and require special attention when performing antimicrobial susceptibility testing. Prevention of further dissemination of caMRSA requires appropriate diagnosis, therapy and sanitation of the carrier state. Hygienic measures have not only to be taken in ambulant treatment but also in households of affected patients.

Community-Onset Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infections: Impact of Antimicrobial Therapy on Outcome

BACKGROUND

Conflicting data exist on the role of antimicrobial therapy for the treatment of uncomplicated community-onset methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infections (SSTIs).

METHODS

We performed a retrospective cohort study of 492 adult patients with 531 independent episodes of community-onset MRSA SSTIs, which consisted of abscesses, furuncles/carbuncles, and cellulitis, at 2 tertiary care medical centers. The purpose of the study was to determine the impact of active antimicrobial therapy (i.e., the use of an agent to which the organism is susceptible) and other potential risk factors on the outcome for patients with uncomplicated community-onset MRSA SSTIs. Treatment failure was the primary outcome of interest and was defined as worsening signs of infection associated with microbiological and/or therapeutic indicators of an unsuccessful outcome. Bivariate analyses and logistic regression analyses were preformed to determine predictors of treatment failure.

RESULTS

An incision and drainage procedure was performed for the majority of patients. Treatment failure occurred in 45 (8%) of 531 episodes of community-onset MRSA SSTI. Therapy was successful for 296 (95%) of 312 patients who received an active antibiotic, compared with 190 (87%) of 219 of those who did not (P=.001 in bivariate analysis). Use of an inactive antimicrobial agent was an independent predictor of treatment failure on logistic regression analysis (adjusted odds ratio, 2.80; 95% confidence interval, 1.26-6.22; P=.01).

CONCLUSIONS

Our findings suggest that certain patients with SSTIs that are likely caused by MRSA would benefit from treatment with an antimicrobial agent with activity against this organism.

[Soft tissue infections treatable in the doctor's office]

A good number of infections requiring only minor surgery can be treated in the GP's office, simply and adequately. Of importance, however, is the physician's ability to recognize when a patient needs to be referred to a specialist. Provided the principles listed here are adhered to, treatment is usually successful. All other courses indicate a multifactorial pathology and belong in the hands of an experienced specialist.

Patterns of Bone and Soft-Tissue Injury at the Symphysis Pubis in Soccer Players: Observations at MRI

OBJECTIVE

The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other.

MATERIALS AND METHODS

One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test.

RESULTS

Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001).

CONCLUSION

In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.