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Allaire P, Elsayed NS, Berg RL, Rose W, Shukla SK. Phenome-wide association study identifies new clinical phenotypes associated with Staphylococcus aureus infections. PLoS One 2024; 19:e0303395. [PMID: 38968223 PMCID: PMC11226111 DOI: 10.1371/journal.pone.0303395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 04/23/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Phenome-Wide Association study (PheWAS) is a powerful tool designed to systematically screen clinical observations derived from medical records (phenotypes) for association with a variable of interest. Despite their usefulness, no systematic screening of phenotypes associated with Staphylococcus aureus infections (SAIs) has been done leaving potential novel risk factors or complications undiscovered. METHOD AND COHORTS We tailored the PheWAS approach into a two-stage screening procedure to identify novel phenotypes correlating with SAIs. The first stage screened for co-occurrence of SAIs with other phenotypes within medical records. In the second stage, significant findings were examined for the correlations between their age of onset with that of SAIs. The PheWAS was implemented using the medical records of 754,401 patients from the Marshfield Clinic Health System. Any novel associations discovered were subsequently validated using datasets from TriNetX and All of Us, encompassing 109,884,571 and 118,538 patients respectively. RESULTS Forty-one phenotypes met the significance criteria of a p-value < 3.64e-5 and odds ratios of > 5. Out of these, we classified 23 associations either as risk factors or as complications of SAIs. Three novel associations were discovered and classified either as a risk (long-term use of aspirin) or complications (iron deficiency anemia and anemia of chronic disease). All novel associations were replicated in the TriNetX cohort. In the All of Us cohort, anemia of chronic disease was replicated according to our significance criteria. CONCLUSIONS The PheWAS of SAIs expands our understanding of SAIs interacting phenotypes. Additionally, the novel two-stage PheWAS approach developed in this study can be applied to examine other disease-disease interactions of interest. Due to the possibility of bias inherent in observational data, the findings of this study require further investigation.
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Affiliation(s)
- Patrick Allaire
- Center for Precision Medicine Research, Marshfield Clinic Research Institute, Marshfield, Wisconsin, United States of America
| | - Noha S. Elsayed
- Center for Precision Medicine Research, Marshfield Clinic Research Institute, Marshfield, Wisconsin, United States of America
| | - Richard L. Berg
- Research Computing and Analytics, Marshfield Clinic Research Institute, Marshfield, Wisconsin, United States of America
| | - Warren Rose
- School of Pharmacy, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Sanjay K. Shukla
- Center for Precision Medicine Research, Marshfield Clinic Research Institute, Marshfield, Wisconsin, United States of America
- Computational and Informatics in Biology and Medicine Program, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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Tienpratarn W, Yuksen C, Pauly JD, Vu D, Benbourenane AN, Sangskul N. Factors and clinical prediction score for complication development after cellulitis diagnosis in adult patients. Int J Emerg Med 2024; 17:68. [PMID: 38778270 PMCID: PMC11110201 DOI: 10.1186/s12245-024-00646-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Cellulitis is defined as a bacterial infection of the skin and subcutaneous tissue that can cause multiple complications, such as sepsis and necrotizing fasciitis. In extreme cases, it may lead to multiorgan failure and death. We sought to analyze the clinical factors that contribute to the development of complicated disease, including demographics, clinical presentation, initial vital signs, and laboratory studies. METHODS Our study is a retrospective cohort study carried out in a university-based tertiary care hospital in Bangkok, Thailand. Adult patients who presented with cellulitis from January 1, 2018, to December 31, 2022, were evaluated for eligibility and inclusion in this study. All related variables for both outcomes, bacteremia and necrotizing fasciitis, were gathered from electronic medical records and analyzed using multivariable logistic regression analysis. RESULTS Of the 1,560 visits to this hospital, 47 cases reported at least one complication, with bacteremia noted in 27 visits (1.73%) and necrotizing fasciitis in 20 visits (1.27%). From the multivariable logistic regression analysis, six variables emerge as predictors of cellulitis complications. These are: Age ≥ 65 years, Body Mass Index ≥ 30 kg/m2, diabetes mellitus, body temperature ≥ 38 °C, systolic blood pressure ≤ 100 mmHg, and involvement of lower extremities. The predictive score was developed from these factors and was named the Ramathibodi Necrotizing Fasciitis/Bacteremia (RAMA-NFB) Prediction Score. Our predictive score has an accuracy of 82.93% (95% CI, 0.77-0.89). Patients in the high-risk group (RAMA NFB score > 6) have a likelihood ratio of 8.75 (95% CI, 4.41-18.12; p < 0.001) times to develop complications of cellulitis. CONCLUSION In our study, the RAMA-NFB Prediction Score predicts complications of necrotizing fasciitis and bacteremia in adult patients who present with cellulitis. External validation of this predictive score is still needed for further practical application.
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Affiliation(s)
- Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Joseph Daniel Pauly
- Yale School of Medicine, Yale New Haven Hospital Emergency Department, New Haven, CT, USA.
| | - Diana Vu
- George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Nuttamon Sangskul
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
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Stagg B, Foster-Smith E, Tam PCK. The diagnostic accuracy of Gram stain on formalin-fixed paraffin-embedded sections of skin tissue in the diagnosis of bacterial skin infection. J Cutan Pathol 2024; 51:246-250. [PMID: 37997440 DOI: 10.1111/cup.14563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/31/2023] [Accepted: 11/11/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the sensitivity, specificity, and likelihood ratios of Gram stain on formalin-fixed, paraffin-embedded (GS-FFPE) sections of skin in diagnosing bacterial skin infection. METHODS We reviewed a retrospective series of skin specimens reported at our institution wherein histopathological assessment included Gram stain and fresh tissue was concurrently submitted for microscopy and culture. The clinicopathological correlation was the reference standard, whereby the presence of infection was deduced from the final diagnosis in each patient's case notes. RESULTS Our sample included 168 cases (105 positive for infection). GS-FFPE showed a sensitivity of 0.43 (95% confidence interval 0.29, 0.57), a specificity of 0.98 (0.95, 1.01), a positive likelihood ratio of 21.50 (19.76, 23.24), and a negative likelihood ratio of 0.58 (0.41, 0.75). CONCLUSIONS GS-FFPE has poor sensitivity, and a negative result should not be used as evidence to exclude infection. In contrast, it has excellent specificity and, unless the pretest probability of infection is very low, a positive result would make infection much more likely. The value of the GS-FFPE lies in cases where sterile tissue was not submitted for microbiological studies, or sterile tissue culture was negative, and there is at least a low-to-moderate pretest probability of infection.
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Affiliation(s)
- Brendan Stagg
- Anatomical Pathology, SA Pathology, Adelaide, South Australia, Australia
- Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Erwin Foster-Smith
- Anatomical Pathology, SA Pathology, Adelaide, South Australia, Australia
| | - Patrick Chung Kay Tam
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
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Bowhay TR, Tsang T, Wei JCZ, Edwik W, Fridman A, Hubber J, Jo JY, Mckay N, O'Brien C, Osmond-Wallam J, Smythe J, Crump JA, Arnold B. Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single-centre audit of cellulitis outcomes. Intern Med J 2024; 54:320-327. [PMID: 37461382 DOI: 10.1111/imj.16173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 06/05/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Cellulitis is a common acute skin and soft tissue infection that causes substantial morbidity and healthcare costs. AIMS To audit the impact on cellulitis management, regimen tolerability and outcomes of switching from outpatient parenteral antimicrobial therapy (OPAT) using intravenous (i.v.) cefazolin once daily plus probenecid to oral beta-lactam therapy (OBLT) using oral flucloxacillin plus probenecid. METHODS We undertook a retrospective audit on cellulitis management, regimen tolerability and outcomes at the Dunedin Public Hospital Emergency Department (ED) before and after a change of the local outpatient cellulitis treatment pathway from OPAT using i.v. cefazolin once daily plus probenecid to OBLT using oral flucloxacillin plus probenecid. RESULTS OPAT was used in 97/123 (78.9%) patients with cellulitis before compared to 1/70 (1.4%) after the pathway change (odds ratio (OR), 0.04, P < 0.01). OBLT was used in 26/123 (21.1%) patients with cellulitis before and 69/70 (98.6%) after (OR, 218.8, P < 0.01). Antimicrobial change due to intolerance occurred in 4/123 (3.2%) patients with cellulitis before and 4/70 (5.7%) after (OR, 1.8, P, not significant (NS)) the pathway change. Inpatient admission within 28 days occurred in 15/123 (12.2%) cellulitis patients before and 9/70 (12.9%) after (OR, 1.1, P, NS) the pathway change. CONCLUSIONS Implementation of a change in outpatient cellulitis treatment pathway resulted in a significant change in prescribing practice. Our findings suggest that OBLT was both tolerable and had similar outcomes to OPAT.
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Affiliation(s)
- Thomas R Bowhay
- Dunedin Public Hospital, Te Whatu Ora (Health New Zealand) Southern, Dunedin, New Zealand
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Tiffany Tsang
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jeremy C Z Wei
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Wafa Edwik
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Avi Fridman
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Julia Hubber
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jae Y Jo
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Nicole Mckay
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Catherine O'Brien
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Joe Osmond-Wallam
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - James Smythe
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Brendan Arnold
- Dunedin Public Hospital, Te Whatu Ora (Health New Zealand) Southern, Dunedin, New Zealand
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Nightingale R, Yadav K, Hamill L, Glasziou P, Scott AM, Clark J, Keijzers G. Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis. J Gen Intern Med 2023; 38:2396-2404. [PMID: 37231210 PMCID: PMC10406744 DOI: 10.1007/s11606-023-08229-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses. METHODS Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome. RESULTS Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I2 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema). DISCUSSION The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics. TRIAL REGISTRATION Open Science Framework ( https://osf.io/9zt72 ).
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Affiliation(s)
- Rachael Nightingale
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD Australia
| | - Krishan Yadav
- Clinical Epidemiology Unit, Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
| | - Laura Hamill
- Emergency Department, Te Whatu Ora, Waitaha, Christchurch, New Zealand
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD Australia
- School of Medicine and Dentistry, and Menzies Health Institute Queensland, Griffith University, Southport, QLD Australia
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Astley RA, Mursalin MH, Coburn PS, Livingston ET, Nightengale JW, Bagaruka E, Hunt JJ, Callegan MC. Ocular Bacterial Infections: A Ten-Year Survey and Review of Causative Organisms Based on the Oklahoma Experience. Microorganisms 2023; 11:1802. [PMID: 37512974 PMCID: PMC10386592 DOI: 10.3390/microorganisms11071802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Ocular infections can be medical emergencies that result in permanent visual impairment or blindness and loss of quality of life. Bacteria are a major cause of ocular infections. Effective treatment of ocular infections requires knowledge of which bacteria are the likely cause of the infection. This survey of ocular bacterial isolates and review of ocular pathogens is based on a survey of a collection of isolates banked over a ten-year span at the Dean McGee Eye Institute in Oklahoma. These findings illustrate the diversity of bacteria isolated from the eye, ranging from common species to rare and unique species. At all sampled sites, staphylococci were the predominant bacteria isolated. Pseudomonads were the most common Gram-negative bacterial isolate, except in vitreous, where Serratia was the most common Gram-negative bacterial isolate. Here, we discuss the range of ocular infections that these species have been documented to cause and treatment options for these infections. Although a highly diverse spectrum of species has been isolated from the eye, the majority of infections are caused by Gram-positive species, and in most infections, empiric treatments are effective.
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Affiliation(s)
- Roger A Astley
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Md Huzzatul Mursalin
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Phillip S Coburn
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Erin T Livingston
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - James W Nightengale
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Eddy Bagaruka
- Department of Biology, Oklahoma Christian University, Edmond, OK 73013, USA
| | - Jonathan J Hunt
- Department of Biology, Oklahoma Christian University, Edmond, OK 73013, USA
| | - Michelle C Callegan
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Dean McGee Eye Institute, Oklahoma City, OK 73104, USA
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Voisin B, Nadella V, Doebel T, Goel S, Sakamoto K, Ayush O, Jo JH, Kelly MC, Kobayashi T, Jiang JX, Hu Y, Yan C, Nagao K. Macrophage-mediated extracellular matrix remodeling controls host Staphylococcus aureus susceptibility in the skin. Immunity 2023; 56:1561-1577.e9. [PMID: 37402364 PMCID: PMC10467568 DOI: 10.1016/j.immuni.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 03/29/2023] [Accepted: 06/08/2023] [Indexed: 07/06/2023]
Abstract
Hypodermis is the predominant site of Staphylococcus aureus infections that cause cellulitis. Given the importance of macrophages in tissue remodeling, we examined the hypodermal macrophages (HDMs) and their impact on host susceptibility to infection. Bulk and single-cell transcriptomics uncovered HDM subsets with CCR2-dichotomy. HDM homeostasis required the fibroblast-derived growth factor CSF1, ablation of which abrogated HDMs from the hypodermal adventitia. Loss of CCR2- HDMs resulted in accumulation of the extracellular matrix component, hyaluronic acid (HA). HDM-mediated HA clearance required sensing by the HA receptor, LYVE-1. Cell-autonomous IGF1 was required for accessibility of AP-1 transcription factor motifs that controlled LYVE-1 expression. Remarkably, loss of HDMs or IGF1 limited Staphylococcus aureus expansion via HA and conferred protection against cellulitis. Our findings reveal a function for macrophages in the regulation of HA with an impact on infection outcomes, which may be harnessed to limit the establishment of infection in the hypodermal niche.
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Affiliation(s)
- Benjamin Voisin
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Vinod Nadella
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Thomas Doebel
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Shubham Goel
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Keiko Sakamoto
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Otgonzaya Ayush
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jay-Hyun Jo
- Cutaneous Microbiome and Inflammation Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Michael C Kelly
- Cancer Research Technology Program, Single-Cell Analysis Facility, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Tetsuro Kobayashi
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jean X Jiang
- Department of Biochemistry and Structural Biology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ying Hu
- Cancer Informatics Branch, Center for Biomedical Informatics and Information Technology, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Chunhua Yan
- Cancer Informatics Branch, Center for Biomedical Informatics and Information Technology, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Keisuke Nagao
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA.
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Bullous skin signs and laboratory surgical indicators can quickly and effectively differentiate necrotizing fasciitis from cellulitis. Int J Infect Dis 2023; 128:41-50. [PMID: 36521588 DOI: 10.1016/j.ijid.2022.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The purpose of this prospective study was to investigate the different microorganisms associated with mortality, to evaluate the bullous skin sign, and to identify the positive predictive factors for differentiating necrotizing fasciitis (NF) from cellulitis on initial onset at the emergency department. METHODS This prospective study was conducted in 145 consecutive patients with NF and 159 patients with cellulitis. Age, sex, comorbidities, infection site, microbiological results, condition of skin lesions, laboratory findings, vital signs, and clinical outcomes were compared between the two groups at the time of admission to the emergency room. RESULTS A total of 15 patients in the NF group and two patients in the cellulitis group died, resulting in a mortality rate of 10.3% and 1.3%, respectively. The NF group had a significantly higher incidence of white blood cell counts, band form neutrophil, and C-reactive protein than the patients in the cellulitis group. Hemorrhagic bullae presentation appeared to have significantly associated with NF and death. CONCLUSION The following diagnostic indicators can be effectively used to differentiate NF from cellulitis at the initial onset: presence of hemorrhagic bullae, white blood cell counts >11,000 cells/mm3, band forms >0%, C-reactive protein >100 mg/l, and systolic blood pressure ≤90 mm Hg at the time of consultation.
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Inoculation of sonicate fluid into blood culture bottles improves microbial detection in patients with orthopedic bone and soft tissue infections of the upper and lower extremities. J Orthop Sci 2023; 28:476-483. [PMID: 34972615 DOI: 10.1016/j.jos.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/16/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The usefulness of sonicate fluid culture for biological tissues in orthopedic bone and soft tissue infections have not been reported. We assessed whether inoculating the sonicate fluid of bone and soft tissue into a blood culture bottle could increase the diagnostic accuracy for biofilm-related orthopedic infections. METHODS Twenty consecutive patients with infections (9 purulent arthritis, 4 osteomyelitis, 4 purulent tenosynovitis, 2 purulent bursitis, and 1 cellulitis) and 10 non-infected cases (6 carpal tunnel syndrome, 3 Dupuytren contracture, and 1 soft tissue tumor) between October 2018 and December 2020 were evaluated prospectively. We analyzed a total of 107 culture submissions (87 bone and tissue specimens and 20 controls); 42 intraoperative tissue specimens (32 infected samples and 10 non-infected samples) using the conventional method, 45 sonication samples (35 infected samples and 10 non-infected samples), and 20 control samples. Intraoperative infectious tissues were cultured using sonicate fluid culture in a blood culture bottle (SFC-CB). The applications of SFC-CB and the conventional culture method and the detection rate, sensitivity, and relationship between the sensitivity of the diagnostic methods and duration of administered preoperative antibiotics were assessed. RESULTS The causative microorganism was detected only by SFC-CB in five patients (25%). The sensitivity (85% vs. 60%; P = 0.077) and detection rate (80% vs. 60%; P = 0.065) were higher for SFC-CB than for the conventional culture method. The sensitivity of SFC-CB was significantly higher than that of the conventional culture method in cases in which preoperative antibiotics were administered for more than 1 week (77% vs. 39%; P = 0.047). CONCLUSIONS Using SFC-CB, the diagnostic accuracy for bone and soft tissue infection was significantly improved. As biofilms are readily formed in biological tissues, sonication may also be useful for diagnosis. SFC-CB was particularly useful for cases in which preoperative antibiotics were administered.
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10
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Cervicofacial Cellulitis due to Staphylococcus aureus with Jugular Vein Thrombosis and Multiple Septic Pulmonary Embolism: A Lemierre-Like Syndrome. Case Rep Infect Dis 2022; 2022:7805523. [PMID: 36062238 PMCID: PMC9439926 DOI: 10.1155/2022/7805523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
This is the case of a 28-year-old male patient with no particular pathological history who presented with an inflammatory swelling of the right cheek with pus in an infectious context. Cervicofacial CT with contrast injection allowed the diagnosis of a right cervicofacial cellulitis, associated with a jugular venous thrombosis extending to the superior vena cava. It also revealed septic pulmonary metastases in the form of multiple excavated pulmonary nodules. The analysis of the pus sample allowed the isolation of Staphylococcus aureus as the causative germ. This led to the diagnosis of a Lemierre-like syndrome, which is a variant of the Lemierre syndrome. Despite appropriate antibiotic treatment and anticoagulation, the patient died after 16 days of hospitalization.
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11
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Ong BS, Dotel R, Ngian VJJ. Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis? Int J Gen Med 2022; 15:6561-6572. [PMID: 35983462 PMCID: PMC9379124 DOI: 10.2147/ijgm.s326459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
Abstract
Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.
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Affiliation(s)
- Bin S Ong
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Ravindra Dotel
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Vincent Jiu Jong Ngian
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Biglione B, Cucka B, Kroshinsky D. Cellulitis and Its Mimickers: an Approach to Diagnosis and Management. CURRENT DERMATOLOGY REPORTS 2022. [DOI: 10.1007/s13671-022-00363-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yueh CM, Chi H, Chiu NC, Huang FY, Tsung-Ning Huang D, Chang L, Kung YH, Huang CY. Etiology, clinical features, management, and outcomes of skin and soft tissue infections in hospitalized children: A 10-year review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:728-739. [PMID: 35283045 DOI: 10.1016/j.jmii.2022.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/25/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE This study aimed to describe the etiology, clinical features, hospital course, and outcomes of hospitalized children with skin and soft tissue infections (SSTIs) and to test if clinical and laboratory variables at admission could differentiate between community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and community-acquired methicillin-sensitive S. aureus (CA-MSSA). METHODS We reviewed the clinical, laboratory, treatment, and outcome data for children hospitalized with SSTIs, aged 0-18 years at MacKay Children's Hospital between 2010 and 2019. Multivariable logistic regression was used to identify independent predictors of CA-MRSA and CA-MSSA SSTIs. RESULTS A total of 1631 patients were enrolled. Erysipelas/cellulitis (73.8%) was the most common pediatric SSTI type, followed by acute lymphadenitis (13.6%) and abscess/furuncle/carbuncle (8.6%). Among the 639 culture-positive isolates (purulent SSTIs), 142 (22.2%) were CA-MSSA and 363 (56.8%) were CA-MRSA. The age group 0-1 month (OR, 6.52; 95% CI 1.09-38.92; P = 0.04) and local lymph node reaction (OR, 2.47; 95% CI 1.004-6.08; P = 0.049) were independent factors for differentiating children with CA-MSSA from those with CA-MRSA SSTIs. MRSA isolates in our cohort were highly susceptible to glycopeptides (100%), linezolid (100%), daptomycin (100%), and sulfamethoxazole/trimethoprim (98.6%) but were significantly less susceptible to clindamycin compared with MSSA (34.2% vs. 78.2%, P < 0.001). CONCLUSION S. aureus is the leading pathogen of culture-proven SSTIs in hospitalized children with MRSA accounting for more than half. Determining the optimal empirical antibiotics in CA-SSTIs may rely on the patient's age, disease severity, and local epidemiologic data.
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Affiliation(s)
- Chih-Ming Yueh
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; Department of Pediatrics, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei, Taiwan
| | - Hsin Chi
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Fu-Yuan Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Daniel Tsung-Ning Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Lung Chang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsin Kung
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Ching-Ying Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan.
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Abdelghany S, Alshaer W, Al Thaher Y, Al Fawares M, Al-Bakri AG, Zuriekat S, Mansour RSH. Ciprofloxacin-loaded dissolving polymeric microneedles as a potential therapeutic for the treatment of S. aureus skin infections. BEILSTEIN JOURNAL OF NANOTECHNOLOGY 2022; 13:517-527. [PMID: 35812251 PMCID: PMC9235833 DOI: 10.3762/bjnano.13.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/01/2022] [Indexed: 05/09/2023]
Abstract
Microneedles have been widely studied for many topical and transdermal therapeutics due to their ability to painlessly puncture the skin, thereby bypassing the stratum corneum, the main skin barrier. In this study, ciprofloxacin (CIP) was loaded into dissolving polymeric microneedles prepared by a two-layer centrifugation method as a potential treatment of skin infections such as cellulitis. The polymers used were polyvinyl alcohol (PVA) and polyvinylpyrrolidone (PVP). Two formulations were investigated, namely CIP_MN1, composed of 10 mg ciprofloxacin incorporated into a polymer matrix of PVA and PVP with a weight ratio of (9:1), and CIP_MN2, composed of 10 mg ciprofloxacin incorporated into PVA polymer. CIP_MN1 and CIP_MN2 showed a mean microneedle height of 188 and 179 µm, respectively. Since Parafilm has been proven as a model to examine the perforation of microneedles in skin, it was used to evaluate the ability of microneedles to perforate the skin. CIP_MN1 showed almost complete perforation of Parafilm, 190 pores, compared to CIP_MN2 which created only 85 pores in Parafilm, and therefore CIP_MN1 was used for subsequent studies. Examining CIP_MN1 on agarose gel as an in vitro model of human skin showed that the formula was able to fully perforate the agarose gel. Moreover, this formula showed significantly greater antimicrobial activity (p < 0.0001) compared to a free gel of ciprofloxacin against Staphylococcus aureus in an agarose gel-based model. This was evidenced by a zone of inhibition of 29 mm for the microneedle formulation of ciprofloxacin (CIP_MN1) compared to 2 mm for the free gel of ciprofloxacin. Furthermore, the CIP_MN1 showed complete dissolution in human skin after 60 min from application. Finally, the skin deposition of CIP_MN1 was investigated in ex vivo excised human skin. CIP_MN1 showed significantly more deposition of ciprofloxacin in deeper skin layers compared to the free gel of ciprofloxacin, and the released ciprofloxacin from the microneedles tends to migrate to deeper layers with time. Collectively, these results suggest that CIP_MN1 can be a potential delivery system for the treatment of S. aureus skin infections.
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Affiliation(s)
| | - Walhan Alshaer
- Cell Therapy Center, University of Jordan, Amman, 11942, Jordan
| | - Yazan Al Thaher
- Faculty of Pharmacy, Philadelphia University, Amman, 19392, Jordan
| | | | - Amal G Al-Bakri
- School of Pharmacy, University of Jordan, Amman, 11942, Jordan
| | - Saja Zuriekat
- School of Pharmacy, University of Jordan, Amman, 11942, Jordan
| | - Randa SH Mansour
- Faculty of Pharmacy, Philadelphia University, Amman, 19392, Jordan
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Abstract
PURPOSE OF REVIEW Acute bacterial skin and skin structure infections (ABSSSI) are a leading cause of morbidity, with a considerable variety of clinical presentation and a wide range of etiological pathogens. Of importance, the spread of multidrug-resistant (MDR) strains (i.e. methicillin-resistant Staphylococcus aureus or Gram-negative bacteria) is increasingly reported in some regions. in this review, we summarize the current clinical approach to patients with ABSSSI. RECENT FINDINGS Accurate diagnosis and identification of risk factors for MDR pathogens are key determinants for administering appropriate therapy in patients with ABSSSI. In daily clinical practice, this can be critical as there are many features defining the 'high risk patient' including both disease and host-associated risk factors. SUMMARY Antibiotic therapy should be based according to the different clinical spectrum of disease belonging to the ABSSSI, on the pathogens most likely to be involved and local resistance. Careful evaluation of antibiotic therapy after 48-72 h of initial therapy could help clinicians to early identify patients with treatment failure and to consider an alternative approach. Close monitoring of patients with multiple comorbidities, drug-drug interaction or adverse host factors are also necessary.
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16
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Chan AA, Flores EA, Navarrete M, Phan Tran D, Lee DJ, Miller LG. The Effect of Systemic Antibiotics for Suppurative Skin and Soft Tissue Infections on Skin Microbiome. Open Forum Infect Dis 2022; 9:ofac141. [PMID: 35450081 PMCID: PMC9017368 DOI: 10.1093/ofid/ofac141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Skin and soft tissue infections (SSTIs) are very common bacterial infections. There are few data on the microbiome of persons with and without SSTIs and the effects of systemic antibiotic therapy. Methods We sampled the skin microbiome from 10 outpatients with acute suppurative SSTI before and after systemic antibiotic therapy and enrolled 10 matched controls. Samples were collected at 6 skin body sites (occipital scalp, axilla, interdigital hand web spaces, gluteal crease, inguinal creases, and popliteal fossa), 2 mucosal sites (throat, anterior nares), and the site of skin infection (for case subjects) at baseline and a week later after abscess incision, drainage, and oral antibiotics. Result Among 10 SSTI cases, mean age was 41.5 years and 3 had diabetes mellitus. The gluteal crease at baseline had higher α-diversity in controls vs cases (P = .039); β-diversity analysis showed significant differences in overall bacterial community composition (P = .046). However, at other body sites there were no significant differences by either α- or β-diversity. Systemic antibiotic use did not affect body site diversity indices except at the SSTI site (α-diversity increased, P = .001). Conclusions We surprisingly found no significant differences in microbiome comparing noninfected skin sites before and after systemic SSTI antibiotic therapy nor significant differences at noninfected skin sites between SSTI cases and uninfected controls. We also found minimal significant differences between microbiome diversity and bacterial signatures at noninfected skin sites between patients with acute skin infection and uninfected controls. Our findings challenge the dogma that systemic antibiotics impact the skin microbiome.
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Affiliation(s)
- Alfred A Chan
- Division of Dermatology, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Evelyn A Flores
- Division of Infectious Diseases, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Marian Navarrete
- Division of Dermatology, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Donna Phan Tran
- Division of Infectious Diseases, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Delphine J Lee
- Division of Dermatology, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Loren G Miller
- Division of Infectious Diseases, Department of Medicine, The Lundquist Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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17
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Braid HR, Ireland JL. A cross‐sectional survey of the diagnosis and treatment of distal limb cellulitis in horses by veterinary surgeons in the United Kingdom. EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- H. R. Braid
- Institute of Infection, Veterinary & Ecological Sciences Faculty of Health and Life Sciences The University of Liverpool Neston, Wirral UK
| | - J. L. Ireland
- Institute of Infection, Veterinary & Ecological Sciences Faculty of Health and Life Sciences The University of Liverpool Neston, Wirral UK
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18
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Abstract
While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.
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Affiliation(s)
- Vivek K Bilolikar
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Asif M Ilyas
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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19
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Abstract
Cellulitis is a common infection of the skin and subcutaneous tissue caused predominantly by gram-positive organisms. Risk factors include prior episodes of cellulitis, cutaneous lesions, tinea pedis, and chronic edema. Cellulitis is a clinical diagnosis and presents with localized skin erythema, edema, warmth, and tenderness. Uncomplicated cellulitis can be managed in the outpatient setting with oral antibiotics. Imaging often is not required but can be helpful. Recurrent cellulitis is common and predisposing conditions should be assessed for and treated at the time of initial diagnosis. For patients with frequent recurrences despite management of underlying conditions, antimicrobial prophylaxis can be effective.
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Affiliation(s)
- Rachel J Bystritsky
- Department of Medicine, Infectious Diseases, University of California-San Francisco, 350 Parnassus, Rm 808B, UCSF Box 0654, San Francisco, CA 94117, USA.
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20
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostischer Wert von Laborparametern zur Unterscheidung zwischen Erysipel und begrenzter Phlegmone. J Dtsch Dermatol Ges 2020; 18:1417-1425. [PMID: 33373139 DOI: 10.1111/ddg.14252_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Cord Sunderkoetter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle/Saale
| | - Jan Ehrchen
- Klinik und Poliklinik für Hautkrankheiten, Universität Münster
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21
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Abstract
Staphylococcus aureus is the most common bacteria causing purulent skin and soft tissue infections. Many disease-causing S aureus strains are methicillin resistant; thus, empiric therapy should be given to cover methicillin-resistant S aureus. Bacterial wound cultures are important for characterizing local susceptibility patterns. Definitive antibiotic therapy is warranted, although there are no compelling data demonstrating superiority of any one antibiotic over another. Antibiotic choice is predicated by the infection severity, local susceptibility patterns, and drug-related safety, tolerability, and cost. Response to therapy is expected within the first days; 5 to 7 days of therapy is typically adequate to achieve cure.
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22
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostic value of laboratory parameters for the discrimination between erysipelas and limited cellulitis. J Dtsch Dermatol Ges 2020; 18:1417-1424. [PMID: 33035396 DOI: 10.1111/ddg.14252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Erysipelas, caused by beta-hemolytic streptococci, and limited cellulitis, frequently caused by Staphylococcus aureus or other bacteria, are skin and soft tissue infections characterized by typical clinical signs. However, despite the therapeutical relevance they are often not differentiated (e.g in clinical trials). Erysipelas are efficiently treated with penicillin, while limited cellulitis is treated with more wide-spectrum antibiotics. This study investigates whether parameters such as CRP, blood counts or novel parameters like immature granulocytes could serve as biomarkers to distinguish between these entities. PATIENTS AND METHODS For this retrospective analysis 163 patients were included. We compared laboratory markers in patients with erysipelas (n = 68) to those with limited cellulitis (n = 41) of the leg. Both erysipelas and limited cellulitis were defined clinically, with an additional aspect for erysipelas being a prompt response to penicillin. RESULTS Erysipelas were characterized by higher levels of inflammation. CRP and leukocyte counts are the best parameters to discriminate between both infections. A CRP value ≥ 3.27 mg/dl indicated the diagnosis of erysipelas with 75 % sensitivity and 73.2 % specificity. CONCLUSIONS Our results support the thesis that erysipelas and limited cellulitis are distinct infections as defined in the German guidelines and that an assessment of CRP and leukocytes is useful for differential diagnosis.
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Affiliation(s)
- Christian Drerup
- Department of Dermatology, University of Muenster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Cord Sunderkoetter
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Jan Ehrchen
- Department of Dermatology, University of Muenster, Muenster, Germany
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23
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Aldrich MB, Rasmussen JC, Fife CE, Shaitelman SF, Sevick-Muraca EM. The Development and Treatment of Lymphatic Dysfunction in Cancer Patients and Survivors. Cancers (Basel) 2020; 12:E2280. [PMID: 32823928 PMCID: PMC7466081 DOI: 10.3390/cancers12082280] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/07/2020] [Accepted: 08/12/2020] [Indexed: 02/08/2023] Open
Abstract
Breast-cancer-acquired lymphedema is routinely diagnosed from the appearance of irreversible swelling that occurs as a result of lymphatic dysfunction. Yet in head and neck cancer survivors, lymphatic dysfunction may not always result in clinically overt swelling, but instead contribute to debilitating functional outcomes. In this review, we describe how cancer metastasis, lymph node dissection, and radiation therapy alter lymphatic function, as visualized by near-infrared fluorescence lymphatic imaging. Using custom gallium arsenide (GaAs)-intensified systems capable of detecting trace amounts of indocyanine green administered repeatedly as lymphatic contrast for longitudinal clinical imaging, we show that lymphatic dysfunction occurs with cancer progression and treatment and is an early, sub-clinical indicator of cancer-acquired lymphedema. We show that early treatment of lymphedema can restore lymphatic function in breast cancer and head and neck cancer patients and survivors. The compilation of these studies provides insights to the critical role that the lymphatics and the immune system play in the etiology of lymphedema and associated co-morbidities.
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Affiliation(s)
- Melissa B. Aldrich
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, TX 77030, USA; (M.B.A.); (J.C.R.)
| | - John C. Rasmussen
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, TX 77030, USA; (M.B.A.); (J.C.R.)
| | - Caroline E. Fife
- Department of Geriatrics, Baylor College of Medicine, Houston, TX 77030, USA;
- The Wound Care Clinic, CHI St. Luke’s Health, The Woodlands Hospital, The Woodlands, TX 77381, USA
| | - Simona F. Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Eva M. Sevick-Muraca
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, TX 77030, USA; (M.B.A.); (J.C.R.)
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Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bissett B. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med 2020; 383:630-639. [PMID: 32786188 DOI: 10.1056/nejmoa1917197] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness. METHODS In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments. RESULTS A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial. CONCLUSIONS In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).
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Affiliation(s)
- Elizabeth Webb
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Teresa Neeman
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Francis J Bowden
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Jamie Gaida
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Virginia Mumford
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Bernie Bissett
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
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25
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Salatin S, Jelvehgari M. Desirability function approach for development of a thermosensitive and bioadhesive nanotransfersome-hydrogel hybrid system for enhanced skin bioavailability and antibacterial activity of cephalexin. Drug Dev Ind Pharm 2020; 46:1318-1333. [PMID: 32598186 DOI: 10.1080/03639045.2020.1788068] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cellulitis is a common bacterial infection of the skin and soft tissues immediately beneath the skin. Despite the successful use of antibiotics in the treatment of infectious diseases, bacterial infections continue to impose significant global health challenges because of the rapid emergence of antibiotic resistance. The aim of this work was to develop an in situ hydrogel forming system containing highly permeable cephalexin-loaded nanotransfersomes (NTs), suitable for antibacterial drug delivery. Response surface design was applied for the optimization of NTs. Cephalexin NTs were prepared using thin-film hydration method and then embedded into a 3D hydrogel network. The in vitro antibacterial activity of the optimized NTs was assayed against indicator bacteria of Staphylococcus aureus (S. aureus). The drug permeation was evaluated using an ex vivo rat skin model. The in vivo efficacy of the cephalexin NT hydrogel was also determined against rat skin infection. The resulting data verified the formation of NTs, the size of which was approximately 192 nm. The cephalexin NTs exhibited higher antibacterial activity against S. aureus as compared to the untreated drug. The NT hydrogel improved drug penetration through the skin after 8 h. When applied on the rat skin for 10 days, the cephalexin NT hydrogel exhibited superior antibacterial activity with normal hair growth and skin appearance as compared with the plain drug hydrogel. These findings suggest that the cephalexin NT-hydrogel system can serve as a valuable drug delivery platform against bacterial infections.
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Affiliation(s)
- Sara Salatin
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mitra Jelvehgari
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
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26
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Dekaboruah E, Suryavanshi MV, Chettri D, Verma AK. Human microbiome: an academic update on human body site specific surveillance and its possible role. Arch Microbiol 2020; 202:2147-2167. [PMID: 32524177 PMCID: PMC7284171 DOI: 10.1007/s00203-020-01931-x] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022]
Abstract
Human body is inhabited by vast number of microorganisms which form a complex ecological community and influence the human physiology, in the aspect of both health and diseases. These microbes show a relationship with the human immune system based on coevolution and, therefore, have a tremendous potential to contribute to the metabolic function, protection against the pathogen and in providing nutrients and energy. However, of these microbes, many carry out some functions that play a crucial role in the host physiology and may even cause diseases. The introduction of new molecular technologies such as transcriptomics, metagenomics and metabolomics has contributed to the upliftment on the findings of the microbiome linked to the humans in the recent past. These rapidly developing technologies are boosting our capacity to understand about the human body-associated microbiome and its association with the human health. The highlights of this review are inclusion of how to derive microbiome data and the interaction between human and associated microbiome to provide an insight on the role played by the microbiome in biological processes of the human body as well as the development of major human diseases.
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Affiliation(s)
- Elakshi Dekaboruah
- Department of Microbiology, Sikkim University, Gangtok, Sikkim, 737102, India
| | | | - Dixita Chettri
- Department of Microbiology, Sikkim University, Gangtok, Sikkim, 737102, India
| | - Anil Kumar Verma
- Department of Microbiology, Sikkim University, Gangtok, Sikkim, 737102, India.
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Baude J, Bastien S, Gillet Y, Leblanc P, Itzek A, Tristan A, Bes M, Duguez S, Moreau K, Diep BA, Norrby-Teglund A, Henry T, Vandenesch F. Necrotizing Soft Tissue Infection Staphylococcus aureus but not S. pyogenes Isolates Display High Rates of Internalization and Cytotoxicity Toward Human Myoblasts. J Infect Dis 2020; 220:710-719. [PMID: 31001627 DOI: 10.1093/infdis/jiz167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) caused by group A Streptococcus (GAS) and occasionally by Staphylococcus aureus (SA) frequently involve the deep fascia and often lead to muscle necrosis. METHODS To assess the pathogenicity of GAS and S. aureus for muscles in comparison to keratinocytes, adhesion and invasion of NSTI-GAS and NSTI-SA isolates were assessed in these cells. Bloodstream infections (BSI-SA) and noninvasive coagulase-negative staphylococci (CNS) isolates were used as controls. RESULTS NSTI-SA and BSI-SA exhibited stronger internalization into human keratinocytes and myoblasts than NSTI-GAS or CNS. S. aureus internalization reached over 30% in human myoblasts due to a higher percentage of infected myoblasts (>11%) as compared to keratinocytes (<3%). Higher cytotoxicity for myoblasts of NSTI-SA as compared to BSI-SA was attributed to higher levels of psmα and RNAIII transcripts in NSTI-SA. However, the 2 groups were not discriminated at the genomic level. The cellular basis of high internalization rate in myoblasts was attributed to higher expression of α5β1 integrin in myoblasts. Major contribution of FnbpAB-integrin α5β1 pathway to internalization was confirmed by isogenic mutants. CONCLUSIONS Our findings suggest a factor in NSTI-SA severity is the strong invasiveness of S. aureus in muscle cells, a property not shared by NSTI-GAS isolates.
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Affiliation(s)
- Jessica Baude
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France
| | - Sylvère Bastien
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France
| | - Yves Gillet
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France.,Centre National de Référence des Staphylocoques, Institut des Agents Infectieux, Hospices Civils de Lyon, France
| | - Pascal Leblanc
- NeuroMyoGene Institute, Université de Lyon, CNRS UMR5310, INSERM U1217, France
| | - Andreas Itzek
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | - Anne Tristan
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France.,Centre National de Référence des Staphylocoques, Institut des Agents Infectieux, Hospices Civils de Lyon, France
| | - Michèle Bes
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France.,Centre National de Référence des Staphylocoques, Institut des Agents Infectieux, Hospices Civils de Lyon, France
| | - Stephanie Duguez
- Northern Ireland Center for Stratified Medicine, Biomedical Sciences Research Institute, Londonderry, United Kingdom
| | - Karen Moreau
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France
| | - Binh An Diep
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Thomas Henry
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France
| | - François Vandenesch
- Centre International de Recherche en Infectiologie, Université de Lyon; Inserm U1111; Ecole Normale Supérieure de Lyon; Université Lyon 1, CNRS, UMR5308; Lyon, France.,Centre National de Référence des Staphylocoques, Institut des Agents Infectieux, Hospices Civils de Lyon, France
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Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States. PLoS One 2020; 15:e0234055. [PMID: 32497101 PMCID: PMC7272072 DOI: 10.1371/journal.pone.0234055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/17/2020] [Indexed: 11/28/2022] Open
Abstract
Objective Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. Study design Eighteen institutions from the Children’s ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. Results 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. Conclusion At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 ‘rule-out’ MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution’s pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.
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Edwards G, Freeman K, Llewelyn MJ, Hayward G. What diagnostic strategies can help differentiate cellulitis from other causes of red legs in primary care? BMJ 2020; 368:m54. [PMID: 32051117 DOI: 10.1136/bmj.m54] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Karoline Freeman
- Warwick Medical School, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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30
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Fusco NM, Nichols K. Common bacterial infections and their treatment in hospitalized pediatric patients. Am J Health Syst Pharm 2020; 76:1521-1531. [PMID: 31532502 DOI: 10.1093/ajhp/zxz164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Common bacterial infections in pediatric patients that the hospital pharmacist may encounter are reviewed, and guidance on the safe and effective use of antibiotics to treat those infections is provided. SUMMARY Pharmacists play a key role in evaluating and creating antibiotic treatment plans for patients with infections. Bacterial infections are a common reason for hospital admission in pediatric patients, and pharmacists working in hospitals may be consulted to provide treatment and monitoring recommendations. It is important for pharmacists to be aware of similarities and differences in adult and pediatric populations with regard to presenting signs and symptoms of bacterial infections, common causative pathogens, and antibiotic selection, dosing, and monitoring. This article reviews current approaches to treatment of common bacterial infections in pediatric patients and also provides general suggestions for antibiotic use. CONCLUSION Pharmacists have an opportunity to positively impact the care of pediatric patients with bacterial infections. Especially at facilities where pediatric patients are not regularly treated, pharmacists can potentially improve care through provision of recommendations for optimal antibiotic selection, dosing, and monitoring.
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Affiliation(s)
- Nicholas M Fusco
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY
| | - Kristen Nichols
- Butler University College of Pharmacy and Health Sciences, Indianapolis, IN
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31
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Tedijanto C, Grad YH, Lipsitch M. Potential impact of outpatient stewardship interventions on antibiotic exposures of common bacterial pathogens. eLife 2020; 9:52307. [PMID: 32022685 PMCID: PMC7025820 DOI: 10.7554/elife.52307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/28/2020] [Indexed: 01/30/2023] Open
Abstract
The relationship between antibiotic stewardship and population levels of antibiotic resistance remains unclear. In order to better understand shifts in selective pressure due to stewardship, we use publicly available data to estimate the effect of changes in prescribing on exposures to frequently used antibiotics experienced by potentially pathogenic bacteria that are asymptomatically colonizing the microbiome. We quantify this impact under four hypothetical stewardship strategies. In one scenario, we estimate that elimination of all unnecessary outpatient antibiotic use could avert 6% to 48% (IQR: 17% to 31%) of exposures across pairwise combinations of sixteen common antibiotics and nine bacterial pathogens. All scenarios demonstrate that stewardship interventions, facilitated by changes in clinician behavior and improved diagnostics, have the opportunity to broadly reduce antibiotic exposures across a range of potential pathogens. Concurrent approaches, such as vaccines aiming to reduce infection incidence, are needed to further decrease exposures occurring in ‘necessary’ contexts.
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Affiliation(s)
- Christine Tedijanto
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, United States
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, United States
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, United States.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, United States
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32
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Karakonstantis S. Is coverage of S. aureus necessary in cellulitis/erysipelas? A literature review. Infection 2019; 48:183-191. [PMID: 31845187 DOI: 10.1007/s15010-019-01382-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/06/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Empirical treatment of patients with cellulitis/erysipelas usually targets both streptococci and methicillin-sensitive S. aureus (MSSA). However, the recommendation to empirically cover MSSA is weak and based on low-quality evidence. METHODS AND OBJECTIVE A systematic review was conducted in PubMed and clinical trial registries to assess the role of S. aureus in cellulitis/erysipelas and the need for empirical MSSA coverage. RESULTS Combined microbiological and serological data, and response to penicillin monotherapy suggest that streptococci are responsible for the vast majority of cases of cellulitis/erysipelas. However, most cases are non-culturable and the specificity of microbiological and serological studies is questionable based on recent studies using molecular techniques. According to epidemiological data and three randomized controlled trials, empirical coverage of methicillin-resistant S. aureus (MRSA) is not recommended for most patients, despite the high prevalence of MRSA in many areas. If MRSA is indeed not an important cause of uncomplicated cellulitis/erysipelas, then the same may apply to MSSA. Based on indirect comparison of data from clinical studies, cure rates with penicillin monotherapy (to which most MSSA are resistant) are comparable to the cure rates reported in many studies using wider-spectrum antibiotics. CONCLUSION Considering the limitations of microbiological studies in identifying the pathogens responsible for cellulitis/erysipelas, treatment needs to be guided by clinical trials. Trials comparing penicillin or amoxicillin monotherapy to MSSA-covering regimens are needed to definitively answer whether empirical coverage of MSSA is needed and to identify the subset of patients that can be safely treated with penicillin or amoxicillin monotherapy.
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Affiliation(s)
- Stamatis Karakonstantis
- Infectious Diseases Unit, School of Medicine, University of Crete, Voutes, Heraklion, Postal code 71110, Greece.
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33
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Abstract
A red swollen face can be a skin sign of a potentially life-threatening condition. We present in detail the main clinical presentations, diagnostic tests, and management of some of the most severe conditions that can frequently present as a red and swollen face: acute or recurrent angioedema, mast cell-driven or bradykinin-mediated angioedema, nonhereditary and hereditary angioedema, allergic or photoallergic facial contact dermatitis, contact urticaria, severe adverse drug reactions (particularly drug reaction with eosinophilia and systemic symptoms [DRESS]), skin infections (erysipelas, cellulitis, necrotizing fasciitis), and autoimmune diseases (dermatomyositis). There are many other conditions that also have to be considered in the differential diagnosis of a red swollen face.
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Affiliation(s)
- Mariana Batista
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal
| | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal; Clinic of Dermatology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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34
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Kim JJ, Ellett F, Thomas CN, Jalali F, Anderson RR, Irimia D, Raff AB. A microscale, full-thickness, human skin on a chip assay simulating neutrophil responses to skin infection and antibiotic treatments. LAB ON A CHIP 2019; 19:3094-3103. [PMID: 31423506 PMCID: PMC6776466 DOI: 10.1039/c9lc00399a] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Human skin models are essential for understanding dermatological diseases and testing new treatment strategies. The use of skin biopsies ex vivo is the most accurate model. However, their use is expensive and exposes the donor to pain and scarring. While bioengineered skin samples provide a cheaper alternative, they have limitations due to their simple structure and functionality compared to human skin. Here, we present a skin-on-a-chip device designed to study neutrophil responses to Staphylococcus aureus skin infections. We integrate human skin microcolumns, which have a cross-section that is ∼100 times smaller than traditional skin biopsies, are full-thickness, and are collected using minimally invasive skin sampling techniques. We use human neutrophils directly from one drop of blood, without the need for blood separation. Using the skin-on-a-chip device with skin and blood samples from healthy donors, we show that the neutrophil responses correlate with the bacteria-load in the skin. A pre-incubation step increases the number of migrating neutrophils in response to a low concentration of bacteria. Antibiotic treatment of S. aureus-infected skin samples reduces the number of neutrophils migrating towards the skin. Overall, we validate a skin on a chip model that enables the study of neutrophil migration to the skin in the presence of microbes and following the administration of antibiotics, two situations relevant to clinical cases of human skin and soft tissue infections.
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Affiliation(s)
- Jae Jung Kim
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospital for Children, Boston, Massachusetts, USA
| | - Felix Ellett
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospital for Children, Boston, Massachusetts, USA
| | - Carina N. Thomas
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatemeh Jalali
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospital for Children, Boston, Massachusetts, USA
| | - R. Rox Anderson
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Irimia
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospital for Children, Boston, Massachusetts, USA
| | - Adam B. Raff
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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35
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Osowicki J, Azzopardi KI, Baker C, Waddington CS, Pandey M, Schuster T, Grobler A, Cheng AC, Pollard AJ, McCarthy JS, Good MF, Walker MJ, Dale JB, Batzloff MR, Carapetis JR, Smeesters PR, Steer AC. Controlled human infection for vaccination against Streptococcus pyogenes (CHIVAS): Establishing a group A Streptococcus pharyngitis human infection study. Vaccine 2019; 37:3485-3494. [PMID: 31101422 DOI: 10.1016/j.vaccine.2019.03.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 12/17/2022]
Abstract
Group A Streptococcus (GAS) is a highly-adapted and human-restricted pathogen responsible for a high global burden of disease across a diverse clinical spectrum. Vaccine development has been impeded by scientific, regulatory, and commercial obstacles. Human infection studies (HIS) are increasingly contributing to drug, diagnostics, and vaccine development, reducing uncertainty at early stages, especially for pathogens with animal models that incompletely reproduce key elements of human disease. We review the small number of historical GAS HIS and present the study protocol for a dose-ranging inpatient study in healthy adults. The primary objective of the study is to establish a new GAS pharyngitis HIS with an attack rate of at least 60% as a safe and reliable platform for vaccine evaluation and pathogenesis research. According to an adaptive dose-ranging study design, emm75 GAS doses manufactured in keeping with principles of Good Manufacturing Practice will be directly applied by swab to the pharynx of carefully screened healthy adult volunteers at low risk of severe complicated GAS disease. Participants will remain as closely monitored inpatients for up to six days, observed for development of the primary outcome of acute symptomatic pharyngitis, as defined by clinical and microbiological criteria. All participants will be treated with antibiotics and followed as outpatients for six months. An intensive sampling schedule will facilitate extensive studies of host and organism dynamics during experimental pharyngitis. Ethics approval has been obtained and the study has been registered at ClinicalTrials.gov (NCT03361163).
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Affiliation(s)
- Joshua Osowicki
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Victoria, Australia.
| | - Kristy I Azzopardi
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Ciara Baker
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Claire S Waddington
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, Australia; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manisha Pandey
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Anneke Grobler
- Department of Paediatrics, University of Melbourne, Victoria, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom; National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - James S McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Michael F Good
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, St Lucia, Queensland, Australia
| | - James B Dale
- University of Tennessee Health Science Center, Department of Medicine, Memphis, TN, USA
| | - Michael R Batzloff
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, Australia
| | - Pierre R Smeesters
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Victoria, Australia
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Impact of health care-associated community-onset cellulitis in Korea: a multicenter study. Eur J Clin Microbiol Infect Dis 2019; 38:545-552. [PMID: 30680560 DOI: 10.1007/s10096-018-03456-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
Abstract
We conducted a multicenter study to determine the clinical and microbiological characteristics of health care-associated (HCA) cellulitis in Korea. We retrospectively reviewed the medical records of patients who had been diagnosed with community-onset cellulitis. Of the 2208 cellulitis patients, 232 (10.5%) had HCA cellulitis, 1243 (56.3%) patients were hospitalized, and 15 (0.7%) died in hospital. Compared with community-acquired (CA) cellulitis, patients with HCA cellulitis were older and more frequently presented with comorbidity and septic shock. A total of 355 microorganisms were isolated from 314 patients (14.2%). Staphylococcus aureus (134 isolates) was the most common organism, followed by Streptococcus spp. (86 isolates) and Gram-negative fermenters (58 isolates). Methicillin-resistant S. aureus (MRSA) accounted for 29.1% (39/134) of S. aureus infections. None of the Gram-negative fermenters were resistant to carbapenem. The antibiotic susceptibility pattern of isolated microorganisms was not different between HCA and CA cellulitis. In patients with HCA cellulitis, S. aureus (11.2% [26/232] vs. 5.5% [108/1976], p = 0.001), including MRSA (4.3% [10/232] vs. 1.5% [29/1976], p = 0.003) and Gram-negative fermenters (6.0% [14/232] vs. 2.3% [44/1976], p = 0.002), were more common causative organisms than in CA-cellulitis patients. Age ≥ 65 years, septic shock, and HCA infection were statistically significant factors associated with in-hospital mortality.
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37
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Baek YS, Song JY, Jeong KM, Jeon J. Late-onset extensive haematoma mimicking cellulitis. Int Wound J 2018; 16:297-299. [PMID: 30379405 DOI: 10.1111/iwj.13014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022] Open
Abstract
Cellulitis is a microbial infection of the deep dermis and the subcutaneous tissue. Several non-infectious disorders, such as contact dermatitis, insect bites, stasis dermatitis, and lipodermatosclerosis, masquerade as infectious cellulitis. There are no specific criteria for the diagnosis of cellulitis; thus, it is challenging to correctly diagnose true cellulitis. For previously assumed cellulitis cases that were refractory to conventional antimicrobial treatment, thoroughly investigating the circumstances of symptom initiation, recording the medical history, and performing an attentive physical examination of the patient is critical for distinguishing true cellulitis from conditions that mimic cellulitis. The inquiry should be personalised according to the patient's age and the prescribed medication. Furthermore, imaging studies, including ultrasonography and magnetic resonance imaging, should be considered on certain occasions to non-invasively aid the differential diagnosis.
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Affiliation(s)
- Yoo S Baek
- Department of Dermatology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jin Y Song
- Department of Dermatology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung M Jeong
- Department of Dermatology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jiehyun Jeon
- Department of Dermatology, Korea University College of Medicine, Seoul, Republic of Korea
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Cannon JW, Jack S, Wu Y, Zhang J, Baker MG, Geelhoed E, Fraser J, Carapetis JR. An economic case for a vaccine to prevent group A streptococcus skin infections. Vaccine 2018; 36:6968-6978. [PMID: 30340879 DOI: 10.1016/j.vaccine.2018.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/22/2018] [Accepted: 10/01/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Group A streptococcus (GAS) causes an exceptionally diverse range of diseases, raising questions about the optimal product characteristics of a commercially viable vaccine. The objectives of this study were to (1) estimate the current health and economic burdens caused by 24 diseases attributable to GAS each year in Australia and (2) use these estimates to explore the value of a GAS vaccine for different clinical indications, age schedules, and population groups. METHODS For objective 1, we estimated the population heath and economic burdens by synthesising data from administrative databases, nationally representative surveys, literature reviews, public reimbursement schedules, and expert opinion. For objective 2, we modelled the prospective lifetime burden of GAS for all infants from birth, for children from 5 years of age, and for adults from 65 years of age. A vaccine was assumed to reduce each GAS disease by 70% for a period of 10 years, and the difference in outcomes between vaccinated and non-vaccinated cohorts were used to calculate the cost-effective value of vaccination. RESULTS The annual health and economic burdens of GAS diseases totalled 23,528 disability-adjusted life years and AU$185.1 million in healthcare costs respectively; approximately half of each measure was due to cellulitis, followed by other skin infections and throat infections. Reducing the incidence of throat infections, skin infections, and cellulitis in non-Indigenous cohorts resulted in 30%, 33%, and 28% of the total vaccine value for an infant schedule (cost-effective vaccine price AU$260 per course); 47%, 26%, and 22% of the value for a child schedule (AU$289); and 2%, 15% and 74% for an adult schedule (AU$489). CONCLUSIONS A vaccine that prevents GAS cellulitis and other skin infections, in addition to throat infections, would maximise its value and commercial viability, with a cost-effective price in line with other recently-licensed and funded vaccines in Australia.
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Affiliation(s)
- Jeffrey W Cannon
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Susan Jack
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Yue Wu
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Jane Zhang
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Elizabeth Geelhoed
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - John Fraser
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia, and Perth Children's Hospital, 15 Hospital Avenue, Nedlands, Western Australia 6009, Australia.
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Abstract
This article covers the diagnosis and treatment of skin and soft tissue infections commonly encountered in the emergency department: impetigo, cutaneous abscesses, purulent cellulitis, nonpurulent cellulitis, and necrotizing skin and soft tissue infections. Most purulent infections in the United States are caused by methicillin-resistant Staphylococcus aureus. For abscesses, we emphasize the importance of incision and drainage. Nonpurulent infections are usually caused by streptococcal species and initial empiric antibiotics need not cover methicillin-resistant Staphylococcus aureus. For uncommon but potentially lethal necrotizing skin and soft tissue infections, the challenge is rapid diagnosis in the emergency department and prompt surgical exploration and debridement.
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Cells to Surgery Quiz: October 2018. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abrego MO, Saba JES, Halliburton C, Taype DRE, Sancineto CF. Fasciitis and Streptococcal Toxic-shock Syndrome: The Importance of Early Diagnosis and Surgical Management. J Orthop Case Rep 2018; 8:57-60. [PMID: 30740378 PMCID: PMC6367280 DOI: 10.13107/jocr.2250-0685.1212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Fasciitis of the limb and toxic-shock syndrome due to Streptococcus Pyogenes infection is considered a surgical emergency. This condition may occur in previously healthy patients. It is a life-threatening condition with high morbidity rates when treatment is delayed due to poor diagnosis and non-surgical intervention. Case Report: 17-year-old male patient sustained a minor ankle trauma while skating. Initials findings were a 1cm wound in relation with his left lateral malleolus and moderate swelling. About 6 h later, the patient was admitted at the emergency room with disproportionate limb pain, increased swelling, persistent fever, paleness, tachycardia, and hypotension. The patient was intubated due to his unstable hemodynamic condition and underwent fasciotomy of the limb. A vacuum-assisted closure device was used. After the first surgical procedure, patient’s condition radically improved. He was extubated with good clinical prognosis. He underwent several surgical procedures in a 3-weeks lapse until the wound finally healed. Conclusion: Streptococcal toxic-shock syndrome and limb fasciitis have no specific early signs or symptoms. It seems that clinical dissociation (disproportionate pain together with a minor wound) should become an alarm sign to trauma surgeons. It is important to contemplate this serious condition as differential diagnosis in every patient undergoing trauma with torpid evolution. Aggressive surgical management is the gold standard treatment and should not be delayed.
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Affiliation(s)
- Mariano Oscar Abrego
- Department of Orthopedics and Trauma, Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Juan D. PeronStreet 4190, C1181ACH, Ciudad Autónoma de Buenos Aires, Argentina
| | - Javier Eduardo Sanchez Saba
- Department of Orthopedics and Trauma, Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Juan D. PeronStreet 4190, C1181ACH, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carolina Halliburton
- Department of Orthopedics and Trauma, Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Juan D. PeronStreet 4190, C1181ACH, Ciudad Autónoma de Buenos Aires, Argentina
| | - Danilo Roger Eric Taype
- Department of Orthopedics and Trauma, Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Juan D. PeronStreet 4190, C1181ACH, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carlos Federico Sancineto
- Department of Orthopedics and Trauma, Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Juan D. PeronStreet 4190, C1181ACH, Ciudad Autónoma de Buenos Aires, Argentina
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Gardiner SJ, Drennan PG, Begg R, Zhang M, Green JK, Isenman HL, Everts RJ, Chambers ST, Begg EJ. In healthy volunteers, taking flucloxacillin with food does not compromise effective plasma concentrations in most circumstances. PLoS One 2018; 13:e0199370. [PMID: 30001392 PMCID: PMC6042703 DOI: 10.1371/journal.pone.0199370] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/13/2018] [Indexed: 11/18/2022] Open
Abstract
It is usually recommended that flucloxacillin is given on an empty stomach. The aim of this study was to compare total and free flucloxacillin concentrations after oral flucloxacillin, given with and without food, based on contemporary pharmacokinetic and pharmacodynamic targets. Flucloxacillin 1000 mg orally was given to 12 volunteers, after a standardised breakfast and while fasting, on two separate occasions. Flucloxacillin concentrations over 12 hours were measured by liquid chromatography-tandem mass spectrometry. Pharmacokinetic parameters, and pharmacodynamic endpoints related to target concentration achievement, were compared in the fed and fasting states. For free flucloxacillin, the fed/fasting area under the concentration-time curve from zero to infinity (AUC0-∞) ratio was 0.80 (p<0.01, 90% CI 0.70-0.92), the peak concentraton (Cmax) ratio 0.51 (p<0.001, 0.42-0.62) and the time to peak concentration (Tmax) ratio 2.2 (p<0.001, 1.87-2.55). The ratios for total flucloxacillin concentrations were similar. The mean (90% CI) fed/fasting ratios of free concentrations exceeded for 30%, 50% and 70% of the first 6 hours post-dose were 0.74 (0.63-0.87, fed inferior p<0.01), 0.95 (0.81-1.11, bioequivalent) and 1.15 (0.97-1.36, fed non-inferior), respectively. Results for 8 hours post-dose and those predicted for steady state were similar. Comparison of probability of target attainments for fed versus fasting across a range of minimum inhibitory concentrations (MICs) were in line with these results. Overall, this study shows that food reduced the AUC0-∞ and Cmax, and prolonged the Tmax of both free and total flucloxacillin concentrations compared with the fasting state, but achievement of free concentration targets associated with efficacy was in most circumstances equivalent. These results suggest that taking flucloxacillin with food is unlikely to compromise efficacy in most circumstances.
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Affiliation(s)
- Sharon J. Gardiner
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
- Pharmacy Services, Christchurch Hospital, Christchurch, New Zealand
- * E-mail:
| | - Philip G. Drennan
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Ronald Begg
- Department of Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Mei Zhang
- Department of Medicine, University of Otago-Christchurch, Christchurch, New Zealand
- Toxicology, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Jared K. Green
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Heather L. Isenman
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | | | - Stephen T. Chambers
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
- Department of Pathology, University of Otago-Christchurch, Christchurch, New Zealand
| | - Evan J. Begg
- Department of Medicine, University of Otago-Christchurch, Christchurch, New Zealand
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Cannon J, Rajakaruna G, Dyer J, Carapetis J, Manning L. Severe lower limb cellulitis: defining the epidemiology and risk factors for primary episodes in a population-based case-control study. Clin Microbiol Infect 2018; 24:1089-1094. [PMID: 29427797 DOI: 10.1016/j.cmi.2018.01.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/24/2018] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the epidemiology and risk factors for primary episodes of severe lower leg cellulitis (LLC). METHODS This was a longitudinal cohort study using state-wide data linkage of adults presenting to Western Australian (WA) hospitals with a first ever LLC from January 2002 to December 2013. The study aimed at determining risk factors, medical records from the index patient, together with comparable data from controls matched by age, sex, postcode, and month of admission. RESULTS During the period, 36 276 patients presented with their first episode of LLC. The incidence increased by 4.7% per annum, reaching 204.8 (95% CI 198.6-211.1) per 100 000 population by December 2013. Analysis of 29 062 case-control pairs showed several conditions with lower limb pathology were independently associated with LLC, including varicose veins (AOR 2.95, 95% CI 2.50-3.48, p < 0.001), lymphoedema (AOR 2.65, 95% CI 1.71-4.10, p < 0.001), tinea pedis (AOR 3.05, 95% CI 1.45-6.42, p 0.003), and saphenous vein harvest during coronary artery bypass grafting (AOR 1.74, 95% CI 1.32-2.30, p < 0.001). Also associated with LLC was obesity (AOR 2.05, 95% CI 1.82-2.31, p < 0.001), renal disease (AOR 1.28, 95% CI 1.14-1.44, p < 0.001), rheumatologic conditions (AOR 2.12, 95% CI 1.72-2.60, p < 0.001), hemiplegia/paraplegia (AOR 1.31, 95% CI 1.13-1.52, p < 0.001), and liver disease (AOR 1.77, 95% CI 1.51-2.06, p < 0.001). CONCLUSIONS LLC presents a major burden to the health sector and is increasing with an ageing population. Given the high rates of recurrence, long-term morbidity, and economic impact, efforts to reduce primary episodes should be incorporated into the infectious diseases and healthy ageing research agenda.
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Affiliation(s)
- J Cannon
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - G Rajakaruna
- Infectious Diseases Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - J Dyer
- Infectious Diseases Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - J Carapetis
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; Perth Children's Hospital, Perth, Western Australia, Australia
| | - L Manning
- Infectious Diseases Department, Fiona Stanley Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.
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Pulido-Cejudo A, Guzmán-Gutierrez M, Jalife-Montaño A, Ortiz-Covarrubias A, Martínez-Ordaz JL, Noyola-Villalobos HF, Hurtado-López LM. Management of acute bacterial skin and skin structure infections with a focus on patients at high risk of treatment failure. Ther Adv Infect Dis 2017; 4:143-161. [PMID: 28959445 DOI: 10.1177/2049936117723228] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Over the last 25 years, the terminology of skin and soft tissue infections, as well as their classification for optimal management of patients, has changed. The so-called and recently introduced term 'acute bacterial skin and skin structure infections' (ABSSSIs), a cluster of fairly common types of infection, including abscesses, cellulitis, and wound infections, require an immediate effective antibacterial treatment as part of a timely and cautious management. The extreme level of resistance globally to many antibiotic drugs in the prevalent causative pathogens, the presence of risk factors of treatment failure, and the high epidemic of comorbidities (e.g. diabetes and obesity) make the appropriate selection of the antibiotic for physicians highly challenging. The selection of antibiotics is primarily empirical for ABSSSI patients which subsequently can be adjusted based on culture results, although rarely available in outpatient management. There is substantial evidence suggesting that inappropriate antibiotic treatment is given to approximately 20-25% of patients, potentially prolonging their hospital stay and increasing the risk of morbidity and mortality. The current review paper discusses the concerns related to the management of ABSSSI and the patient types who are most vulnerable to poor outcomes. It also highlights the key management time-points that treating physicians and surgeons must be aware of in order to achieve clinical success and to discharge patients from the hospital as early as possible.
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Affiliation(s)
| | | | - Abel Jalife-Montaño
- Department of General Surgery, Hospital General de México, México City, México
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Rath E, Skrede S, Mylvaganam H, Bruun T. Aetiology and clinical features of facial cellulitis: a prospective study. Infect Dis (Lond) 2017; 50:27-34. [PMID: 28768452 DOI: 10.1080/23744235.2017.1354130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis. METHODS Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages. RESULTS Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities. CONCLUSIONS Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.
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Affiliation(s)
- Eivind Rath
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Steinar Skrede
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Haima Mylvaganam
- c Department of Microbiology and Immunology , Haukeland University Hospital , Bergen , Norway
| | - Trond Bruun
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Dalal A, Eskin‐Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L, Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database Syst Rev 2017; 6:CD009758. [PMID: 28631307 PMCID: PMC6481501 DOI: 10.1002/14651858.cd009758.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. OBJECTIVES To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. SEARCH METHODS We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. SELECTION CRITERIA Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. MAIN RESULTS We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. AUTHORS' CONCLUSIONS In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.
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Affiliation(s)
- Adam Dalal
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Marina Eskin‐Schwartz
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Daniel Mimouni
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Walford Days
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Emmilia Hodak
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine EKaplan StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Moran GJ, Krishnadasan A, Mower WR, Abrahamian FM, LoVecchio F, Steele MT, Rothman RE, Karras DJ, Hoagland R, Pettibone S, Talan DA. Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial. JAMA 2017; 317:2088-2096. [PMID: 28535235 PMCID: PMC5815038 DOI: 10.1001/jama.2017.5653] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Emergency department visits for skin infections in the United States have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). For cellulitis without purulent drainage, β-hemolytic streptococci are presumed to be the predominant pathogens. It is unknown if antimicrobial regimens possessing in vitro MRSA activity provide improved outcomes compared with treatments lacking MRSA activity. OBJECTIVE To determine whether cephalexin plus trimethoprim-sulfamethoxazole yields a higher clinical cure rate of uncomplicated cellulitis than cephalexin alone. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, randomized superiority trial in 5 US emergency departments among outpatients older than 12 years with cellulitis and no wound, purulent drainage, or abscess enrolled from April 2009 through June 2012. All participants had soft tissue ultrasound performed at the time of enrollment to exclude abscess. Final follow-up was August 2012. INTERVENTIONS Cephalexin, 500 mg 4 times daily, plus trimethoprim-sulfamethoxazole, 320 mg/1600 mg twice daily, for 7 days (n = 248 participants) or cephalexin plus placebo for 7 days (n = 248 participants). MAIN OUTCOMES AND MEASURES The primary outcome determined a priori in the per-protocol group was clinical cure, defined as absence of these clinical failure criteria at follow-up visits: fever; increase in erythema (>25%), swelling, or tenderness (days 3-4); no decrease in erythema, swelling, or tenderness (days 8-10); and more than minimal erythema, swelling, or tenderness (days 14-21). A clinically significant difference was defined as greater than 10%. RESULTS Among 500 randomized participants, 496 (99%) were included in the modified intention-to-treat analysis and 411 (82.2%) in the per-protocol analysis (median age, 40 years [range, 15-78 years]; 58.4% male; 10.9% had diabetes). Median length and width of erythema were 13.0 cm and 10.0 cm. In the per-protocol population, clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 165 (85.5%) of 193 in the cephalexin group (difference, -2.0%; 95% CI, -9.7% to 5.7%; P = .50). In the modified intention-to-treat population, clinical cure occurred in 189 (76.2%) of 248 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 171 (69.0%) of 248 in the cephalexin group (difference, 7.3%; 95% CI, -1.0% to 15.5%; P = .07). Between-group adverse event rates and secondary outcomes through 7 to 9 weeks, including overnight hospitalization, recurrent skin infections, and similar infection in household contacts, did not differ significantly. CONCLUSIONS AND RELEVANCE Among patients with uncomplicated cellulitis, the use of cephalexin plus trimethoprim-sulfamethoxazole compared to cephalexin alone did not result in higher rates of clinical resolution of cellulitis in the per-protocol analysis. However, because imprecision around the findings in the modified intention-to-treat analysis included a clinically important difference favoring cephalexin plus trimethoprim-sulfamethoxazole, further research may be needed. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00729937.
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Affiliation(s)
- Gregory J. Moran
- Department of Emergency Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
- Division of Infectious Diseases, Department of Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - William R. Mower
- Department of Emergency Medicine, Ronald Reagan Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Fredrick M. Abrahamian
- Department of Emergency Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Frank LoVecchio
- Department of Emergency Medicine, Maricopa Medical Center, University of Arizona and Mayo Graduate School of Medicine, Phoenix
| | - Mark T. Steele
- Department of Emergency Medicine, Truman Medical Center, University of Missouri–Kansas City School of Medicine, Kansas City
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David J. Karras
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | | | | | - David A. Talan
- Department of Emergency Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
- Division of Infectious Diseases, Department of Medicine, Olive View–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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Huys G, Purohit P, Tan CH, Snauwaert C, Vos PD, Saffar HA, Obaid IA, Busse HJ, Seemann T, John Albert M. Sphingobacterium cellulitidis sp. nov., isolated from clinical and environmental sources. Int J Syst Evol Microbiol 2017; 67:1415-1421. [DOI: 10.1099/ijsem.0.001832] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Geert Huys
- Laboratory of Microbiology & BCCM Bacteria Collection, Faculty of Sciences, Ghent University, Gent, Belgium
| | | | - Chuan Hao Tan
- Singapore Centre on Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore
| | - Cindy Snauwaert
- Laboratory of Microbiology & BCCM Bacteria Collection, Faculty of Sciences, Ghent University, Gent, Belgium
| | - Paul De Vos
- Laboratory of Microbiology & BCCM Bacteria Collection, Faculty of Sciences, Ghent University, Gent, Belgium
| | - Huda Al Saffar
- Assad Al Hamad Dermatology Center, Al-Sabah Hospital, Kuwait
| | - Ina'am Al Obaid
- Department of Medical Microbiology, Al-Sabah Hospital, Kuwait
| | - Hans-Jürgen Busse
- Institut für Mikrobiologie, Veterinärmedizinische Universität Wien, Wien, Austria
| | - Torsten Seemann
- Victorian Life Sciences Computation Initiative, The University of Melbourne, Victoria, Australia
| | - M John Albert
- Department of Microbiology, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
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Carlson JN, Hostler D, Guyette FX, Pinchalk M, Martin-Gill C. Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation. West J Emerg Med 2017; 18:662-672. [PMID: 28611887 PMCID: PMC5468072 DOI: 10.5811/westjem.2017.1.32938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/04/2016] [Accepted: 01/28/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Endotracheal intubation (ETI) in the prehospital setting poses unique challenges where multiple ETI attempts are associated with adverse patient outcomes. Early identification of difficult ETI cases will allow providers to tailor airway-management efforts to minimize complications associated with ETI. We sought to derive and validate a prehospital difficult airway identification tool based on predictors of difficult ETI in other settings. Methods We prospectively collected patient and airway data on all airway attempts from 16 Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January 2011 to October 2014. Cases that required more than two ETI attempts and cases where an alternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETI attempt were categorized as “difficult.” We used a random allocation sequence to split the data into derivation and validation subsets. Using backward elimination, factors with a p<0.1 were included in the multivariable regression for the derivation cohort and then tested in the validation cohort. We used this model to determine the area under the curve (AUC), and the sensitivity and specificity for each cut point in both the derivation and validation cohorts. Results We collected data on 1,102 cases with 568 in the derivation set (155 difficult cases; 27%) and 534 in the validation set (135 difficult cases; 25%). Of the collected variables, five factors were predictive of difficult ETI in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): Glasgow coma score [GCS] >3 (2.15, 1.19–3.88), limited neck movement (2.24, 1.28–3.93), trismus/jaw clenched (2.24, 1.09–4.6), inability to palpate the landmarks of the neck (5.92, 2.77–12.66), and fluid in the airway such as blood or emesis (2.25, 1.51–3.36). This was the most parsimonious model and exhibited good fit (Hosmer-Lemeshow test p = 0.167) with an AUC of 0.68 (95% CI [0.64–0.73]). When applied to the validation set, the model had an AUC of 0.63 (0.58–0.68) with high specificity for identifying difficult ETI if ≥2 factors were present (87.7% (95% CI [84.1–90.8])). Conclusion We have developed a simple tool using five factors that may aid prehospital providers in the identification of difficult ETI.
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Affiliation(s)
- Jestin N Carlson
- Allegheny Health Network, Department of Emergency Medicine, Erie, Pennsylvania.,University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - David Hostler
- University at Buffalo, Department of Exercise and Nutrition Sciences, Buffalo, New York.,University at Buffalo, Department of Emergency Medicine, Buffalo, New York
| | - Francis X Guyette
- University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Mark Pinchalk
- Pittsburgh Emergency Medical Services, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, Pennsylvania
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Cook IF. Sepsis, parenteral vaccination and skin disinfection. Hum Vaccin Immunother 2016; 12:2546-2559. [PMID: 27295449 PMCID: PMC5084982 DOI: 10.1080/21645515.2016.1190489] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/25/2016] [Accepted: 05/12/2016] [Indexed: 11/21/2022] Open
Abstract
ASBSTRACT Disinfection should be required for all skin penetrative procedures including parenteral administration of vaccines. This review analyses medically attended infectious events following parenteral vaccination in terms of their microbiological aetiology and pathogenesis. Like 'clean' surgical site infections, the major pathogens responsible for these events were Staphylococcal species, implicating endogenous con-tamination as a significant source of infection. As 70% isopropyl alcohol swabbing has been shown to effectively disinfect the skin, it would be medico-legally difficult to defend a case of sepsis with the omission of skin disinfection unless the very low risk of this event was adequately explained to the patient and documented prior to vaccination. There was a significant cost-benefit for skin disinfection and cellulitis. Skin disinfection in the context of parenteral vaccination represents a new paradigm of medical practice; the use of a low cost intervention to prevent an event of very low prevalence but of significant cost.
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Affiliation(s)
- Ian F. Cook
- University of Newcastle, Callaghan, New South Wales, Australia
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