201
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Garg A, Lavian J, Lin G, Sison C, Oppenheim M, Koo B. Clinical characteristics associated with days to discharge among patients admitted with a primary diagnosis of lower limb cellulitis. J Am Acad Dermatol 2017; 76:626-631. [PMID: 28089727 DOI: 10.1016/j.jaad.2016.11.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Clinicians have limited ability to classify risk of prolonged hospitalization among patients with lower limb cellulitis. OBJECTIVE We sought to identify characteristics associated with days to discharge and prolonged stay. METHODS We conducted retrospective cohort analysis including patients admitted with a primary diagnosis of lower limb cellulitis at community and tertiary hospitals. RESULTS There were 4224 admissions for lower limb cellulitis among 3692 patients. Mean age of the cohort was 64.4 years. Frequencies of tobacco smoking, obesity, and diabetes mellitus were 25.1%, 44.9%, and 19.3%, respectively. Patients having decreased likelihood of discharge included those with the following: 10-year age increments 0.90 (95% confidence interval [CI] 0.88-0.92), obesity 0.90 (95% CI 0.83-0.97), diabetes mellitus 0.90 (95% CI 0.82-0.98), tachycardia 0.76 (95% CI 0.67-0.85), hypotension 0.77 (95% CI 0.65-0.90), leukocytosis 0.86 (95% CI 0.79-0.93), neutrophilia 0.80 (95% CI 0.73-0.87), elevated serum creatinine 0.74 (95% CI 0.68-0.81), and low serum bicarbonate 0.84 (95% CI 0.75-0.95). LIMITATIONS This analysis is retrospective and based on coded data. Unknown confounding variables may also influence prolonged stay. CONCLUSIONS Patients with lower limb cellulitis and prolonged stay have a number of clinical characteristics which may be used to classify risk for prolonged stay.
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Affiliation(s)
- Amit Garg
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York.
| | - Jonathan Lavian
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Gloria Lin
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Cristina Sison
- Biostatistics Unit, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York
| | - Michael Oppenheim
- Division of Infectious Diseases, Department of Medicine, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Bonnie Koo
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
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202
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Barbic D, Chenkin J, Cho DD, Jelic T, Scheuermeyer FX. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open 2017; 7:e013688. [PMID: 28073795 PMCID: PMC5253602 DOI: 10.1136/bmjopen-2016-013688] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/23/2016] [Accepted: 12/14/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The primary objective of this systematic review was to determine the accuracy of point-of-care ultrasonography (POCUS) in diagnosing abscess in emergency department (ED) patients with skin and soft tissue infections (SSTI). The secondary objective was the accuracy of POCUS in the paediatric population subgroup. SETTING Prospective studies set in emergency departments. PARTICIPANTS Emergency department patients (adult and paediatric) presenting with SSTI and suspected abscess. PRIMARY AND SECONDARY OUTCOME MEASURES This systematic review was conducted according to Cochrane Handbook guidelines, and the following databases were searched: PubMed, MEDLINE, EMBASE and the Cochrane database of systematic reviews (1946-2015). We included prospective cohort and case-control studies investigating ED patients with SSTI and abscess or cellulitis, a defined POCUS protocol, a clearly defined gold standard for abscess and a contingency table describing sensitivity and specificity. Two reviewers independently ascertained all potentially relevant citations for methodologic quality according to QUADAS-2 criteria. The primary outcome measure was the sensitivity and specificity of POCUS for abscess. A preplanned subgroup (secondary) analysis examined the effects in paediatric populations, and changes in management were explored post hoc. RESULTS Of 3028 articles, 8 were identified meeting inclusion criteria; all were rated as good to excellent according to QUADAS-2 criteria. Combined test characteristics of POCUS on the ED diagnosis of abscess for patients with SSTI were as follows: sensitivity 96.2% (95% CI 91.1% to 98.4%), specificity 82.9% (95% CI 60.4% to 93.9%), positive likelihood ratio 5.63 (95% CI 2.2 to 14.6) and negative likelihood ratio 0.05 (95% CI 0.01 to 0.11). CONCLUSIONS A total of 8 studies of good-to-excellent quality were included in this review. The use of POCUS helps differentiate abscess from cellulitis in ED patients with SSTI. TRIAL REGISTRATION NUMBER CRD42015017115.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dennis D Cho
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of South Florida, Tampa, Florida, USA
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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203
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McCool R, Gould IM, Eales J, Barata T, Arber M, Fleetwood K, Glanville J, Kauf TL. Systematic review and network meta-analysis of tedizolid for the treatment of acute bacterial skin and skin structure infections caused by MRSA. BMC Infect Dis 2017; 17:39. [PMID: 28061827 PMCID: PMC5219662 DOI: 10.1186/s12879-016-2100-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/07/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Tedizolid, the active moiety of tedizolid phosphate, is approved in the United States, the European Union, Canada and a number of other countries for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by certain susceptible bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). This network meta-analysis (NMA) evaluates the comparative effectiveness of tedizolid and other antibacterials indicated for the treatment of ABSSSI caused by MRSA. METHODS Systematic review of 10 databases was undertaken to inform an NMA to estimate the relative effectiveness of tedizolid and established monotherapy comparators (ceftaroline, daptomycin, linezolid, teicoplanin, tigecycline, vancomycin) for treating MRSA-associated ABSSSI. Randomized controlled trials enrolling adults with ABSSSI or complicated skin and skin structure infections caused by suspected/documented MRSA were eligible for inclusion. Networks were developed based on similarity of study design, patient characteristics, outcome measures and available data. Outcomes of interest included clinical response at end of therapy (EOT), post-therapy evaluation (PTE) or test-of-cure assessment and treatment discontinuations resulting from adverse events (AEs). Bayesian NMA was conducted for each outcome using fixed-effects and random effects models. RESULTS Literature searches identified 3,618 records; 15 trials met the inclusion criteria and were considered suitable for NMA comparison. In fixed-effects models, tedizolid had higher odds of clinical response at EOT (odds ratio [OR], 1.7; credible interval, 1.0, 3.0) and PTE than vancomycin (OR, 1.6; credible interval, 1.1, 2.5). No differences in odds of clinical response at EOT or PTE were observed between tedizolid and other comparators. There was no evidence of a difference among treatments for discontinuation due to AEs. Results from random effects and fixed-effects models were generally consistent. CONCLUSIONS Tedizolid was superior to vancomycin for clinical response at EOT and PTE. There was no evidence of a difference between tedizolid and other comparators and no evidence of a difference between tedizolid and all comparators when evaluating discontinuation due to AEs. These findings suggest that tedizolid provides an alternative option for the management of serious skin infections caused by suspected or documented MRSA. This study is subject to the limitations inherent in all NMAs, and the results should be interpreted accordingly.
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Affiliation(s)
- Rachael McCool
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ UK
| | - Ian M. Gould
- Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen, AB25 2ZN UK
| | - Jacqui Eales
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ UK
| | - Teresa Barata
- Quantics, 28 Drumsheugh Gardens, Edinburgh, EH3 7RN UK
| | - Mick Arber
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ UK
| | | | - Julie Glanville
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ UK
| | - Teresa L. Kauf
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033 USA
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204
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Kumar R, Deleyiannis FWB, Wilkinson C, O'Neill BR. Neurosurgical sequelae of domestic dog attacks in children. J Neurosurg Pediatr 2017; 19:24-31. [PMID: 27767903 DOI: 10.3171/2016.7.peds1646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The authors' goals in this study were to describe a series of dog attacks on children that required neurosurgical consultation and to better understand the pattern of injuries inflicted, the circumstances that place children at risk for attack, and the dog breeds involved. In addition, the authors review the surgical and medical management of these patients. METHODS The authors performed a retrospective review of all children requiring neurosurgical consultation for dog bite at a regional Level 1 pediatric trauma center over a 15-year period. RESULTS A total of 124 children with dog bites to the head, face, and neck were evaluated in the emergency department. Of these, 17 children (13.7%) incurred injuries requiring neurosurgical consultation. Fifty-three percent of victims were female. The mean age at the time of attack was 30 months. Twelve (71%) of the attacks were perpetrated by the family pet, and 13 (76%) occurred at the patient's home. Breeds involved in the attacks included German Shepherd, Pit Bull, American Bulldog, large mixed breed, Labrador Retriever, and Akita, with German Shepherds and Akitas being the most frequently involved. Neurosurgical injuries included nondepressed skull fracture in 5, depressed skull fracture in 10, intracranial hemorrhage in 5, cerebral contusions in 4, dural laceration in 4, pneumocephalus in 5, clinically evident CSF leak in 3, spinal fracture with complete spinal cord injury in 1, stroke in 2, vascular injury in 2, and cranial nerve injury (hypoglossal and facial nerve) in 1. Prophylactic antibiotics were administered in 16 patients (94%). Only 1 patient had a confirmed infection involving the site of injury. Neurosurgical intervention was required in 10 patients (59%) and ranged in severity from debridement and closure of a complex scalp wound to decompressive craniectomy. Neurological deficits, all of which were considered catastrophic, developed in 3 patients (18%). CONCLUSIONS Dog attacks on children requiring neurosurgical consultation commonly involve the family pet, which is usually a large-breed dog with no history of prior aggression. Neurosurgical injuries often involve the cranial vault, with depressed skull fractures being the most common injury pattern. Most patients do not suffer a neurological deficit, although catastrophic neurological injury may occur. Prophylactic antibiotics are commonly used and surgical intervention is required in the majority of cases.
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Affiliation(s)
- Ramesh Kumar
- Department of Neurosurgery, University of Colorado
| | | | - Corbett Wilkinson
- Department of Neurosurgery, University of Colorado.,Department of Neurosurgery, Children's Hospital Colorado; and
| | - Brent R O'Neill
- Department of Neurosurgery, University of Colorado.,Department of Neurosurgery, Children's Hospital Colorado; and
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205
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Cooper JD, Cooper SR, Wolk DM, Tice AM, Persing TF, Esolen LM. Postpartum Streptococcus pyogenes Outbreak in the Labor and Delivery Unit of a Quaternary Referral Center: a Case Series and Review of the Literature. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.clinmicnews.2016.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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206
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Gil L, Jeong K, Kim HG, Lee HD, Cho JH, Lee S. Septic pulmonary embolism resulting from soft tissue infection in a 5-year-old child. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.1.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Leehuck Gil
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Kyunguk Jeong
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Gi Kim
- Department of Radiology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Han-Dong Lee
- Department of Orthopaedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Ho Cho
- Department of Orthopaedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Sooyoung Lee
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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207
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Patrozou E. Management of Human Bites. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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208
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Kwak YG, Choi SH, Kim T, Park SY, Seo SH, Kim MB, Choi SH. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother 2017; 49:301-325. [PMID: 29299899 PMCID: PMC5754343 DOI: 10.3947/ic.2017.49.4.301] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Indexed: 12/17/2022] Open
Abstract
Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommendations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipelas and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets community-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline.
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Affiliation(s)
- Yee Gyung Kwak
- The Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Seong Ho Choi
- The Korean Society for Chemotherapy, Seoul, Korea.,Department of Internal Medicine, Chung Ang University College of Medicine, Seoul, Korea
| | - Tark Kim
- The Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicne, SoonChunHyang University Bucheon Hospital, Buchon, Korea
| | - Seong Yeon Park
- The Korean Society for Chemotherapy, Seoul, Korea.,Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Soo Hong Seo
- The Korean Dermatological Association, Seoul, Korea.,Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Min Bom Kim
- The Korean Orthopaedic Association, Seoul, Korea.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Ho Choi
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea.,Department of Infectious Diseases, Ulsan University College of Medicine, Seoul, Korea.
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209
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Using quality improvement methods to change surgical practice: a case example of pediatric soft-tissue abscesses. Qual Manag Health Care 2016; 24:84-90. [PMID: 25830617 DOI: 10.1097/qmh.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care. SUBJECTS AND METHODS Outcome measures included the proportion of STAs drained using SDs, the number of postoperative clinic visits, the proportion of patients requiring follow-up with a pediatric surgeon and other providers, and the postoperative complication rate, defined as need for an additional drainage procedure. RESULTS After beginning the QI initiative, the proportion of STAs drained by SDs increased from 23% to 78% (P < .00001) and the proportion of patients requiring a surgical follow-up clinic appointment decreased from 71% to 32% (P < .00001). The mean number of surgical clinic visits per patient decreased from 0.79 to 0.39 visits per patient (P < .00001). Complication rates were similar between drain types (RD: 2.4%; SD: 1.7%; P = .57). This QI initiative produced a rapid sustained shift in surgeon practice with increased use of SDs, decreased number of follow-up visits, and no increase in complications.
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210
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Carter MK, Ebers VA, Younes BK, Lacy MK. Doxycycline for Community-Associated Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infections. Ann Pharmacother 2016; 40:1693-5. [PMID: 16896018 DOI: 10.1345/aph.1h084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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211
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Targeting intracellular p-aminobenzoic acid production potentiates the anti-tubercular action of antifolates. Sci Rep 2016; 6:38083. [PMID: 27905500 PMCID: PMC5131483 DOI: 10.1038/srep38083] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/03/2016] [Indexed: 12/18/2022] Open
Abstract
The ability to revitalize and re-purpose existing drugs offers a powerful approach for novel treatment options against Mycobacterium tuberculosis and other infectious agents. Antifolates are an underutilized drug class in tuberculosis (TB) therapy, capable of disrupting the biosynthesis of tetrahydrofolate, an essential cellular cofactor. Based on the observation that exogenously supplied p-aminobenzoic acid (PABA) can antagonize the action of antifolates that interact with dihydropteroate synthase (DHPS), such as sulfonamides and p-aminosalicylic acid (PAS), we hypothesized that bacterial PABA biosynthesis contributes to intrinsic antifolate resistance. Herein, we demonstrate that disruption of PABA biosynthesis potentiates the anti-tubercular action of DHPS inhibitors and PAS by up to 1000 fold. Disruption of PABA biosynthesis is also demonstrated to lead to loss of viability over time. Further, we demonstrate that this strategy restores the wild type level of PAS susceptibility in a previously characterized PAS resistant strain of M. tuberculosis. Finally, we demonstrate selective inhibition of PABA biosynthesis in M. tuberculosis using the small molecule MAC173979. This study reveals that the M. tuberculosis PABA biosynthetic pathway is responsible for intrinsic resistance to various antifolates and this pathway is a chemically vulnerable target whose disruption could potentiate the tuberculocidal activity of an underutilized class of antimicrobial agents.
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212
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Phillips S, MacDougall C, Holdford DA. Analysis of Empiric Antimicrobial Strategies for Cellulitis in the Era of Methicillin-Resistant Staphylococcus aureus. Ann Pharmacother 2016; 41:13-20. [PMID: 17200425 DOI: 10.1345/aph.1h452] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The rise in community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections potentially complicates the empiric management of cellulitis. The threshold at which drugs active against MRSA, such as clindamycin and trimethoprim/sulfamethoxazole (TMP/SMX), should be incorporated into empiric therapy is unknown. Objective: To evaluate the cost-effectiveness of using cephalexin, TMP/SMX, or clindamycin for outpatient empiric therapy of cellulitis, given various likelihoods of infection due to MRSA. Methods: A decision analysis of the empiric treatment of cellulitis was performed from the perspective of a third-party payer. The model included initial therapy with cephalexin, clindamycin, or TMP/SMX, followed by treatment with linezolid in cases of clinical failure. Probability and cost estimates were obtained from clinical trials, epidemiologic data, and publicly available cost data and were subjected to sensitivity analysis. Results: Under the base-case scenario (37% probability of infection by S. aureus and a 27% MRSA prevalence), cephalexin was the most cost-effective option. Clindamycin became a more cost-effective therapy at MRSA probabilities from 41–80% when the probability of staphylococcal infection was greater than 40%. TMP/SMX was cost-effective only at very high likelihoods of MRSA infection. Variables with the most influence in the model were probability of S. aureus being methicillin-resistant, cost of linezolid, probability of a cure with cephalexin for a non-MRSA infection, and probability of infection due to S. aureus. Conclusions: Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels. Cephalexin was the most cost-effective choice over most of the modeled range of probabilities, with clindamycin becoming more cost-effective at high likelihoods of MRSA infection. TMP/SMX is unlikely to be cost-effective for treatment of simple cellulitis. Further studies of the microbiology of cellulitis, the epidemiology of MRSA, and the clinical effectiveness of clindamycin and TMP/SMX in skin and soft tissue infections are needed.
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Affiliation(s)
- Suzanne Phillips
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
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213
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Osteomyelitis following Domestic Animal Bites to the Hand: Two Case Reports and Practical Guidelines. Arch Plast Surg 2016; 43:590-594. [PMID: 27896194 PMCID: PMC5122552 DOI: 10.5999/aps.2016.43.6.590] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/23/2016] [Accepted: 07/05/2016] [Indexed: 01/22/2023] Open
Abstract
Recently, the number of cases of animal bite wounds has increased significantly in concordance with an increase in the pet population around the world. The authors report two rare cases of osteomyelitis of the phalanx following cat and dog bites. On initial physical examination, signs of a severe infection were observed. Radiographs of both patients showed the presence of osteomyelitis, and in one of the patients, the diagnosis was confirmed with a bone biopsy. After use of empirical antibiotics, intravenous antibiotic therapy that matched the identified bacterium's sensitivity was initiated, and at the same time, secure dressing including debridement was performed to induce secondary healing. In addition, the patients were closely monitored with serial X-rays, and culture and blood test follow-up. One patient fully recovered without sequelae, but the other patient suffered a loss of distal interphalangeal joint motion. When dealing with bite wounds located on the hand, it is important to visit the hospital as soon as possible and receive the appropriate treatment early. Moreover, to prevent severe complications such as osteomyelitis, it is important to administer antibiotic therapy to which the cultured bacteria are sensitive, along with proper wound management and prophylactic antibiotic treatment.
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214
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Faraklas I, Yang D, Eggerstedt M, Zhai Y, Liebel P, Graves G, Dissanaike S, Mosier M, Cochran A. A Multi-Center Review of Care Patterns and Outcomes in Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2016; 17:773-778. [PMID: 27834617 DOI: 10.1089/sur.2015.238] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Surgical debridement and broad-spectrum empiric antibiotics are first-line therapy for necrotizing soft tissue infections (NSTI). The objective of this multi-center retrospective review was to evaluate antimicrobial agent initiation and duration and compare outcomes in the treatment of patients with NSTI. PATIENTS AND METHODS This review included adults with NSTI, as indicated by International Classification of Diseases, 9th Edition, Clinical Modification codes 728.86, 608.33, or 040.0, who were admitted to three academic institutions between 1/1/09 and 5/15/14. Demographics, antibiotic practices, operative management, and clinical outcomes were compared. RESULTS A total of 341 patients were identified at the three centers. Subjects were comparable in age (median 53 years, p = 0.14), gender (67% male, p = 0.57) and body mass index (median 31.9 (p = 0.31) between sites. No significant difference was found in time from admission to start of empiric antibiotic therapy between the three centers (median 1 d for each, p = 0.70), but duration of antibiotic therapy was significantly different (Site A = 16 d, Site B = 12 d, Site C = 9 d, medians, p < 0.001). Although total number of operations differed between sites (median of two at Sites A and B, three at Site C, p = 0.001), sites consistently operated on the day of patient arrival to their facility, and the number of debridements did not differ (median of two for all sites, p = 0.10). Mortality rate (Site A = 22%, Site B = 18%, and Site C = 9%, p = 0.02) and length of stay for survivors (Site A = 29 d, Site B = 16 d, Site C = 19 d, medians, p = 0.001) was significantly different among centers. CONCLUSIONS Variation in antibiotic duration between centers with expertise in the care of NSTI illustrates how little is known about best care practices for patients with NSTI. Future studies should emphasize development of evidence-based practices for NSTI management to further improve the outcomes of this complex group of patients.
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Affiliation(s)
- Iris Faraklas
- 1 Department of Surgery, University of Utah , Salt Lake City, Utah
| | - Derek Yang
- 2 Department of Surgery, Texas Tech University Health Sciences Center , Lubbock, Texas
| | - Michael Eggerstedt
- 3 Department of Surgery, Loyola University Stritch School of Medicine , Maywood, Illinois
| | - Yan Zhai
- 1 Department of Surgery, University of Utah , Salt Lake City, Utah
| | - Patrick Liebel
- 1 Department of Surgery, University of Utah , Salt Lake City, Utah
| | - Gareth Graves
- 1 Department of Surgery, University of Utah , Salt Lake City, Utah
| | - Sharmila Dissanaike
- 2 Department of Surgery, Texas Tech University Health Sciences Center , Lubbock, Texas
| | - Michael Mosier
- 3 Department of Surgery, Loyola University Stritch School of Medicine , Maywood, Illinois
| | - Amalia Cochran
- 1 Department of Surgery, University of Utah , Salt Lake City, Utah
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215
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Rudkjøbing VB, Thomsen TR, Xu Y, Melton-Kreft R, Ahmed A, Eickhardt S, Bjarnsholt T, Poulsen SS, Nielsen PH, Earl JP, Ehrlich GD, Moser C. Comparing culture and molecular methods for the identification of microorganisms involved in necrotizing soft tissue infections. BMC Infect Dis 2016; 16:652. [PMID: 27821087 PMCID: PMC5100109 DOI: 10.1186/s12879-016-1976-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/26/2016] [Indexed: 12/26/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) are a group of infections affecting all soft tissues. NSTI involves necrosis of the afflicted tissue and is potentially life threatening due to major and rapid destruction of tissue, which often leads to septic shock and organ failure. The gold standard for identification of pathogens is culture; however molecular methods for identification of microorganisms may provide a more rapid result and may be able to identify additional microorganisms that are not detected by culture. Methods In this study, tissue samples (n = 20) obtained after debridement of 10 patients with NSTI were analyzed by standard culture, fluorescence in situ hybridization (FISH) and multiple molecular methods. The molecular methods included analysis of microbial diversity by 1) direct 16S and D2LSU rRNA gene Microseq 2) construction of near full-length 16S rRNA gene clone libraries with subsequent Sanger sequencing for most samples, 3) the Ibis T5000 biosensor and 4) 454-based pyrosequencing. Furthermore, quantitative PCR (qPCR) was used to verify and determine the relative abundance of Streptococcus pyogenes in samples. Results For 70 % of the surgical samples it was possible to identify microorganisms by culture. Some samples did not result in growth (presumably due to administration of antimicrobial therapy prior to sampling). The molecular methods identified microorganisms in 90 % of the samples, and frequently detected additional microorganisms when compared to culture. Although the molecular methods generally gave concordant results, our results indicate that Microseq may misidentify or overlook microorganisms that can be detected by other molecular methods. Half of the patients were found to be infected with S. pyogenes, but several atypical findings were also made including infection by a) Acinetobacter baumannii, b) Streptococcus pneumoniae, and c) fungi, mycoplasma and Fusobacterium necrophorum. Conclusion The study emphasizes that many pathogens can be involved in NSTIs, and that no specific “NSTI causing” combination of species exists. This means that clinicians should be prepared to diagnose and treat any combination of microbial pathogens. Some of the tested molecular methods offer a faster turnaround time combined with a high specificity, which makes supplemental use of such methods attractive for identification of microorganisms, especially for fulminant life-threatening infections such as NSTI.
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Affiliation(s)
- Vibeke Børsholt Rudkjøbing
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Trine Rolighed Thomsen
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark.,Life Science Division, The Danish Technological Institute, Taastrup, Denmark
| | - Yijuan Xu
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark.,Life Science Division, The Danish Technological Institute, Taastrup, Denmark
| | - Rachael Melton-Kreft
- Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburgh, USA
| | - Azad Ahmed
- Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburgh, USA
| | - Steffen Eickhardt
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Steen Seier Poulsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Halkjær Nielsen
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Joshua P Earl
- Center for Genomic Sciences, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Center for Advanced Microbial Processing, Institute for Molecular Medicine and Infectious Disease, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Philadelphia, PA, USA
| | - Garth D Ehrlich
- Center for Genomic Sciences, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Center for Advanced Microbial Processing, Institute for Molecular Medicine and Infectious Disease, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Philadelphia, PA, USA.,Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
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216
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Smith RG, Joseph WS. Antibiotic stewardship: the lower-extremity physician's prescription for effectively treating infection. J Am Podiatr Med Assoc 2016; 104:77-84. [PMID: 24504581 DOI: 10.7547/0003-0538-104.1.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.
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217
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Affiliation(s)
- Eileen P Scully
- From the Departments of Medicine (E.P.S., A.L.M., J.L.) and Orthopedics (B.E.E.), Brigham and Women's Hospital and Harvard Medical School - both in Boston
| | - Brandon E Earp
- From the Departments of Medicine (E.P.S., A.L.M., J.L.) and Orthopedics (B.E.E.), Brigham and Women's Hospital and Harvard Medical School - both in Boston
| | - Amy L Miller
- From the Departments of Medicine (E.P.S., A.L.M., J.L.) and Orthopedics (B.E.E.), Brigham and Women's Hospital and Harvard Medical School - both in Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (E.P.S., A.L.M., J.L.) and Orthopedics (B.E.E.), Brigham and Women's Hospital and Harvard Medical School - both in Boston
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218
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Snyder GM, Patel PR, Kallen AJ, Strom JA, Tucker JK, D'Agata EM. Factors associated with the receipt of antimicrobials among chronic hemodialysis patients. Am J Infect Control 2016; 44:1269-1274. [PMID: 27184209 DOI: 10.1016/j.ajic.2016.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/05/2016] [Accepted: 03/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial use is common among patients receiving chronic hemodialysis (CHD) and may represent an important antimicrobial stewardship opportunity. The objective of this study is to characterize CHD patients at increased risk of receiving antimicrobials, including not indicated antimicrobials. METHODS We conducted a prospective cohort study over a 12-month period among patients receiving CHD in 2 outpatient dialysis units. Each parenteral antimicrobial dose administered was characterized as indicated or not indicated based on national guidelines. Patient factors associated with receipt of antimicrobials and receipt of ≥1 inappropriate antimicrobial dose were analyzed. RESULTS A total of 89 of 278 CHD patients (32%) received ≥1 antimicrobial doses and 52 (58%) received ≥1 inappropriately indicated dose. Patients with tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving CHD sessions during daytime shifts were more likely to receive antimicrobials (odds ratio [OR], 5.16; 95% confidence interval [CI], 2.72-9.80; OR, 5.43; 95% CI, 1.84-16.06; OR, 4.59; 95% CI, 1.20-17.52, respectively). Patients with tunneled catheter access, receiving CHD at dialysis unit B, and with a longer duration of CHD prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose (incidence rate ratio, 2.23; 95% CI, 1.16-4.29; incidence rate ratio, 2.67; 95% CI, 1.34-5.35; incidence rate ratio, 1.11; 95% CI, 1.01-1.23, respectively). CONCLUSIONS This study of all types of antimicrobials administered in 2 outpatient dialysis units identified several important factors to consider when developing antimicrobial stewardship programs in this health care setting.
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219
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Hsieh CC, Lee CH, Hong MY, Hung YP, Lee NY, Ko WC, Lee CC. Propensity score-matched analysis comparing the therapeutic efficacies of cefazolin and extended-spectrum cephalosporins as appropriate empirical therapy in adults with community-onset Escherichia coli, Klebsiella spp. and Proteus mirabilis bacteraemia. Int J Antimicrob Agents 2016; 48:712-718. [PMID: 27836382 DOI: 10.1016/j.ijantimicag.2016.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 09/03/2016] [Accepted: 09/15/2016] [Indexed: 01/22/2023]
Abstract
In this study, the therapeutic efficacy of cefazolin was compared with that of extended-spectrum cephalosporins (ESCs) (cefotaxime, ceftriaxone and ceftazidime) as appropriate empirical therapy in adults with community-onset monomicrobial bacteraemia caused by Escherichia coli, Klebsiella spp. or Proteus mirabilis (EKP). Compared with cefazolin-treated patients (n = 135), significantly higher proportions of patients in the ESC treatment group (n = 456) had critical illness at bacteraemia onset (Pitt bacteraemia score ≥4) and fatal co-morbidities (McCabe classification). Of the 591 patients, 121 from each group were matched using propensity score matching (PSM) based on the following independent predictors of 28-day mortality: fatal co-morbidities (McCabe classification); Pitt bacteraemia score ≥4 at bacteraemia onset; initial syndrome of septic shock; and bacteraemia due to pneumonia. After appropriate PSM, no significant differences were observed in the early clinical failure rate (10.7% vs. 7.4%; P = 0.37), the proportion of critical illness (Pitt bacteraemia score ≥4) (0% vs. 0%; P = 1.00) and defervescence (52.6% vs. 42.6%; P = 0.13) on Day 3 between the cefazolin and ESC treatment groups. Similarly, no significant differences were observed in the mean of time to defervescence (4.1 days vs. 4.9 days; P = 0.15), late clinical failure rate (18.2% vs. 10.7%; P = 0.10) and 28-day crude mortality rate (0.8% vs. 3.3%; P = 0.37) between the two groups. These data suggest that the efficacy of cefazolin is similar to that of ESCs when used as appropriate empirical antimicrobial treatment for community-onset EKP bacteraemia.
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Affiliation(s)
- Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Chung-Hsun Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Ming-Yuan Hong
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine and Center of Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan 70043, Taiwan
| | - Nan-Yao Lee
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine and Center of Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine and Center of Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan.
| | - Ching-Chi Lee
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine and Center of Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, Tainan 72152, Taiwan; Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan 71101, Taiwan.
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220
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Bouchiat C, Curtis S, Spiliopoulou I, Bes M, Cocuzza C, Codita I, Dupieux C, Giormezis N, Kearns A, Laurent F, Molinos S, Musumeci R, Prat C, Saadatian-Elahi M, Tacconelli E, Tristan A, Schulte B, Vandenesch F. MRSA infections among patients in the emergency department: a European multicentre study. J Antimicrob Chemother 2016; 72:372-375. [PMID: 27798212 DOI: 10.1093/jac/dkw431] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND MRSA is a therapeutic concern worldwide, and a major agent of community-acquired skin and soft tissue infections (CA-SSTIs). While the US epidemiology of MRSA in CA-SSTIs is well described and reports the high prevalence of the USA300 clone, data on the European situation are lacking. OBJECTIVES To determine the prevalence and clonal characteristics of MRSA in CA-SSTIs in seven European emergency departments. PATIENTS AND METHODS From April to June 2015, patients presenting to the tertiary hospital emergency department with a Staphylococcus aureus CA-SSTI were prospectively enrolled. S. aureus isolates were characterized by antimicrobial susceptibility testing, detection of Panton-Valentine leucocidin encoding genes and spa-typing, MLST and/or DNA microarray. RESULTS Two-hundred and five cases of S. aureus-associated CA-SSTIs were included, comprising folliculitis, furuncles, abscesses, paronychia, impetigo, carbuncles and cellulitis. Of the 205 cases, we report an MRSA prevalence rate of 15.1%, with a north (0%) to south (29%) increasing gradient. Fifty-one isolates were Panton-Valentine leucocidin-positive (24.9%), whether MSSA or MRSA, with a heterogeneous distribution between countries. Clonal distribution of MSSA and MRSA showed high diversity, with no predominant circulating clone and no archetypical USA300 CA-MRSA clone. CONCLUSIONS This original prospective multicentre study highlights stark differences in European MRSA epidemiology compared with the USA, and that the USA300 CA-MRSA clone is not predominant among community-infected patients in Europe.
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Affiliation(s)
- C Bouchiat
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
| | - S Curtis
- Staphylococcus Reference Service, Public Health England, 61 Colindale Avenue London NW9 5EQ, UK
| | - I Spiliopoulou
- National Reference Laboratory for Staphylococci, University of Patras, University Campus, Rion 26504, Patras, Greece
| | - M Bes
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
| | - C Cocuzza
- Laboratory of Clinical Microbiology and Virology, University of Milano-Bicocca, Via Cadore 48, Monza, Italy
| | - I Codita
- Cantacuzino National Institute of Research, Splaiul Independentei 103, RO-050096 Bucharest, Romania
| | - C Dupieux
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
| | - N Giormezis
- National Reference Laboratory for Staphylococci, University of Patras, University Campus, Rion 26504, Patras, Greece
| | - A Kearns
- Staphylococcus Reference Service, Public Health England, 61 Colindale Avenue London NW9 5EQ, UK
| | - F Laurent
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
| | - S Molinos
- Servei de Microbiologia Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,CIBER Enfermedades Respiratorias. Carretera del Canyet s/n. 08916 Badalona, Spain
| | - R Musumeci
- Laboratory of Clinical Microbiology and Virology, University of Milano-Bicocca, Via Cadore 48, Monza, Italy
| | - C Prat
- Servei de Microbiologia Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,CIBER Enfermedades Respiratorias. Carretera del Canyet s/n. 08916 Badalona, Spain
| | - M Saadatian-Elahi
- Epidemiology unit, Hospices Civils de Lyon, Place d'Arsonval, 69008 Lyon, France
| | - E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine 1, University Hospital Tuebingen, Geissweg 3, 72076 Tuebingen, Germany
| | - A Tristan
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
| | - B Schulte
- Institut für Mikrobiologie und Infektionsmedizin, University Hospital Tuebingen, Auf der Morgenstelle 28, 72076 Tuebingen, Germany
| | - F Vandenesch
- National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France
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221
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Maleki Dizaj S, Lotfipour F, Barzegar-Jalali M, Zarrintan MH, Adibkia K. Physicochemical characterization and antimicrobial evaluation of gentamicin-loaded CaCO3 nanoparticles prepared via microemulsion method. J Drug Deliv Sci Technol 2016. [DOI: 10.1016/j.jddst.2016.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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222
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Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review. Surg Infect (Larchmt) 2016; 17:503-9. [DOI: 10.1089/sur.2016.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Brian G. Harbrecht
- The Hiram C. Polk, Jr. MD Department of Surgery and the Price Institute for Surgical Research, University of Louisville, Louisville, Kentucky
| | - Nick A. Nash
- The Hiram C. Polk, Jr. MD Department of Surgery and the Price Institute for Surgical Research, University of Louisville, Louisville, Kentucky
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223
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A randomized, double-blind, comparative study to assess the safety and efficacy of topical retapamulin ointment 1% versus oral linezolid in the treatment of secondarily infected traumatic lesions and impetigo due to methicillin-resistant Staphylococcus aureus. Adv Skin Wound Care 2016; 27:548-59. [PMID: 25396674 DOI: 10.1097/01.asw.0000456631.20389.ae] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the clinical and bacteriological efficacy of topical retapamulin ointment 1% versus oral linezolid in the treatment of patients with secondarily infected traumatic lesions (SITLs; excluding abscesses) or impetigo due to methicillin-resistant Staphylococcus aureus (MRSA). DESIGN A randomized, double-blind, double-dummy, multicenter, comparative study (NCT00852540). SETTING Patients recruited from 36 study centers in the United States. PATIENTS Patients 2 months or older with SITL (including secondarily infected lacerations or sutured wounds) or impetigo (bullous and nonbullous) suitable for treatment with a topical antibiotic, with a total Skin Infection Rating Scale score of 8 or greater, including a pus/exudate score of 3 or greater. INTERVENTIONS Patients received retapamulin ointment 1% (plus oral placebo), twice daily for 5 days or oral linezolid (plus placebo ointment) 2 or 3 times daily for 10 days. MAIN OUTCOME MEASURE Primary end point: clinical response (success/failure) at follow-up in patients with MRSA at baseline (per-protocol population). Secondary efficacy end points: clinical and microbiologic response and outcome at follow-up and end of therapy; therapeutic response at follow-up. MAIN RESULTS The majority of patients had SITL (70.4% [188/267] and 66.4% [91/137] in the retapamulin and linezolid groups, respectively; intent-to-treat clinical population). Clinical success rate at follow-up was significantly lower in the retapamulin versus the linezolid group (63.9% [39/61] vs 90.6% [29/32], respectively; difference in success rate -26.7%; 95% CI, -45.7 to -7.7). CONCLUSIONS Clinical success rate at follow-up in the per-protocol MRSA population was significantly lower in the retapamulin versus the linezolid group. It could not be determined whether this was related to study design, bacterial virulence, or retapamulin activity.
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224
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Scarlini S, Gandolfo M, Pietrangelo A. Sudden Onset of Lower Abdominal Pain Without Peritonitis or Ileus. Eur J Case Rep Intern Med 2016; 3:000444. [PMID: 30755894 PMCID: PMC6346772 DOI: 10.12890/2016_000444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/22/2016] [Indexed: 11/13/2022] Open
Abstract
A patient presented with sudden, unexplained lower abdominal pain without peritonism or signs of infection or inflammatory reaction, but with recent bloody stools and a history of radiation therapy, diabetes and immunosuppression. Plain abdominal x-ray showed only air-fluid levels and air distention of the colon, but a later abdominal CT scan revealed extensive gas gangrene of the colon. The patient's clinical status rapidly worsened. Elective surgical rectosigmoid debridement did not prevent the patient's death. In conclusion, the diagnosis of 'spontaneous' life-threatening gas gangrene requires a high degree of clinical suspicion and allows life-saving surgical intervention. LEARNING POINTS Sudden and rapidly worsening lower abdominal pain without peritonitis or ileus can indicate gas gangrene from distal bowel perforation.Bloody stools or other symptoms and/or procedures reported previously and apparently resolved could indicate hidden perforation.Diagnostic gas detection, clinically or radiologically, occurs too late to prevent fatal consequences, so early signs of infection and inflammation should be sought for and evaluated as early surgery is life saving.
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Affiliation(s)
- Stefania Scarlini
- Unit of Internal Medicine 2, University Hospital Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Gandolfo
- Unit of Internal Medicine 2, University Hospital Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonello Pietrangelo
- Unit of Internal Medicine 2, University Hospital Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy
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225
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Perciaccante A, Rühli FJ, Galassi FM, Bianucci R. Gangrene, amputation, and allogeneic transplantation in the fifth century ad: A pictorial representation. J Vasc Surg 2016; 64:824-5. [DOI: 10.1016/j.jvs.2016.04.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/19/2016] [Indexed: 01/22/2023]
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226
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Hashem NG, Hidayat L, Berkowitz L, Venugopalan V. Management of skin and soft-tissue infections at a community teaching hospital using a severity-of-illness tool. J Antimicrob Chemother 2016; 71:3268-3275. [PMID: 27494908 DOI: 10.1093/jac/dkw263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/28/2016] [Accepted: 06/01/2016] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Skin and soft-tissue infections (SSTIs) encompass a diverse range of infections of varying severity. The Clinical Resource Efficiency Support Team (CREST) scoring system stratifies patients into four classes (I = least severe to IV = most severe) based on the Standardized Early Warning Score (SEWS). The objective of this study was to apply CREST to hospitalized patients with SSTIs in order to quantify disease severity and evaluate appropriateness of antibiotic management. METHODS This was a retrospective, hypothesis-generating, single-centre evaluation of hospitalized patients with SSTIs admitted in 2011. Based on CREST classification, the empirical antimicrobial choices were categorized as appropriate, over-treatment or under-treatment. RESULTS A total of 369 patients were screened and 200 met the inclusion criteria. The majority of patients were classified as either CREST class I (n = 68) or class II (n = 102). Over-treatment was more common in the less severe classes (88% and 32% in class I and class II, respectively; P < 0.05). Sixty-three percent of class I (n = 43) were over-treated due to both the use of intravenous antibiotics when oral therapy was sufficient and use of unnecessarily broad-spectrum antibiotics. In contrast, 25% (n = 26) of class II were over-treated due to use of unnecessarily broad-spectrum antibiotics. Overall clinical failure rates remained low with only 1%, 4% and 17% of patients unable to achieve initial response in class II, class III and class IV. CONCLUSIONS Retrospective application of CREST identified opportunities to improve the management of SSTIs. CREST can be of great value in discriminating less-severe SSTIs, which can be treated on an outpatient basis.
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Affiliation(s)
| | - Levita Hidayat
- Pharmacy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA.,Touro College of Pharmacy, New York, NY, USA
| | - Leonard Berkowitz
- Internal Medicine Department - Infectious Diseases Subdivision. The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Veena Venugopalan
- Pharmacy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA
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227
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Gunderson CG. Overtreatment of nonpurulent cellulitis. J Hosp Med 2016; 11:587-90. [PMID: 27480889 DOI: 10.1002/jhm.2593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Craig G Gunderson
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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228
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Estrada A, Wright DL, Anderson AC. Antibacterial Antifolates: From Development through Resistance to the Next Generation. Cold Spring Harb Perspect Med 2016; 6:a028324. [PMID: 27352799 PMCID: PMC4968165 DOI: 10.1101/cshperspect.a028324] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The folate cycle is one of the key metabolic pathways used by bacteria to synthesize vital building blocks required for proliferation. Therapeutic agents targeting enzymes in this cycle, such as trimethoprim and sulfamethoxazole, are among some of the most important and continually used antibacterials to treat both Gram-positive and Gram-negative pathogens. As with all antibacterial agents, the emergence of resistance threatens the continued clinical use of these life-saving drugs. In this article, we describe and analyze resistance mechanisms that have been clinically observed and review newer generations of preclinical compounds designed to overcome the molecular basis of the resistance.
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Affiliation(s)
- Alexavier Estrada
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, Connecticut 06269
| | - Dennis L Wright
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, Connecticut 06269
| | - Amy C Anderson
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, Connecticut 06269
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229
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Agarwal N, Aroor S, Saini P, Gupta A, Kaur N. Pyomyositis: Are We Missing the Diagnosis? Surg Infect (Larchmt) 2016; 17:615-21. [PMID: 27463090 DOI: 10.1089/sur.2015.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Pyomyositis (PY) is a primary infection of the skeletal muscles, leading to inflammation of the muscle fibers followed by pus formation and even necrosis in late stages. Because of overlap in presentation of intermuscular abscess (IM) and PY, the exact incidence and severity of PY is under-appreciated. PATIENTS AND METHODS We conducted a prospective analytical study in a tertiary care center in North India from October 2011 to January 2013, recruiting patients with abscesses involving the chest wall, abdomen (parietal wall including back), and extremities. Subcutaneous, hepatic, intra-abdominal abscess, and secondary abscesses were excluded. Primary PY was defined as a primary infection of skeletal muscle without any foci from adjacent skin, soft tissue, or bone. Clinical, radiologic, pathologic, and operative findings suggested diagnosis; loss of striations and lymphocytic infiltration in the muscle fibers was confirmatory. The chief outcome variables were death and length of hospital stay. RESULTS Thirty patients with a mean age of 29.5 y (IM: 29.7 ± 16.7, PY: 25.28 ± 17.6) were classified as IM (18/30, 60%) or PY (12/30, 40%). Most PY occurred in the lower limb (41.7% had multi-site involvement); most had a history of trauma or immunocompromised state. Fever, tachycardia, tachypnea, hypotension, pallor, and hyperesthesia were significantly higher (p < 0.05) in PY. Mean Sequential Organ Failure Assessment (SOFA) score was 0.33 for IM, 2.5 for PY. Staphylococcus aureus was predominant in both groups; however, all four patients with methicillin-resistant S. aureus (MRSA) were in the PY group. Both deaths also occurred in the PY group. The mean duration of hospital stay was 3.22 ± 1.11 d for IM and 10.27 ± 2.32 d for PY patients (p = 0.03). CONCLUSION PY is a specific and potentially fatal infection, which is common in our country and must be differentiated from IM. A high index of suspicion and early institution of specific antibiotics followed by operation is therapeutic.
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Affiliation(s)
- Nitin Agarwal
- Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital , Delhi, India
| | - Shashank Aroor
- Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital , Delhi, India
| | - Pradeep Saini
- Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital , Delhi, India
| | - Arun Gupta
- Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital , Delhi, India
| | - Navneet Kaur
- Department of Surgery, University College of Medical Sciences and Guru Tegh Bahadur Hospital , Delhi, India
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Karve S, Hackett J, Levinson J, Gibson E, Battersby A. Ceftaroline fosamil treatment outcomes compared with standard of care among hospitalized patients with complicated skin and soft tissue infections. J Comp Eff Res 2016; 5:393-405. [PMID: 26946948 DOI: 10.2217/cer-2015-0024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
AIM Compare clinical and cost outcomes associated with ceftaroline fosamil with other commonly used antibiotics in complicated skin and soft tissue infections. METHODS Retrospective analysis of hospital records from 2010 to 2013 in Premier's Perspective comparative database for adults with complicated skin and soft tissue infection treated with intravenous ceftaroline fosamil, vancomycin, daptomycin, linezolid or tigecycline. Length of stay, inpatient costs and mortality were compared between propensity score-matched treatment groups. RESULTS & CONCLUSION Compared with the other commonly used antibiotics, matched patients in the ceftaroline fosamil treatment group had an equivalent (1%) or lower (compared with linezolid, 2%) in-hospital mortality rate, and significantly lower (p < 0.001) average unadjusted and regression-adjusted length of stay and inpatient costs (savings of $3398.80 compared with daptomycin).
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Özgenç O. Methodology in improving antibiotic implementation policies. World J Methodol 2016; 6:143-53. [PMID: 27376019 PMCID: PMC4921945 DOI: 10.5662/wjm.v6.i2.143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 02/12/2016] [Accepted: 03/17/2016] [Indexed: 02/06/2023] Open
Abstract
The basic requirements of antibiotic prescribing are components of methodology; knowledge, logical reasoning, and analysis. Antimicrobial drugs are valuable but limited resources, different from other drugs and they are among the most commonly prescribed drugs all over the world. They are the only drugs which do not intentionally affect the patient. They affect the pathogens which invade the host. The emergence and spread of antibiotic-resistant pathogens are accelerated by heavy antibiotic usage. The effective antimicrobial stewardship and infection control program have been shown to limit the emergence of antimicrobial-resistant bacteria. In this respect, education for antibiotic prescribing could be designed by going through the steps of scientific methodology. A defined leadership and a coordinated multidisciplinary approach are necessary for optimizing the indication, selection, dosing, route of administration, and duration of antimicrobial therapy. In scenarios, knowledge is also as important as experience for critical decision making as is designated. In this setting, the prevalence and resistance mechanisms of antimicrobials, and their interactions with other drugs need to be observed. In this respect, infectious disease service should play an important role in improving antimicrobial use by giving advice on the appropriate use of antimicrobial agents, and implementing evidence-based guidelines.
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Changchien CH, Chen SW, Chen YY, Chu C. Antibiotic susceptibility and genomic variations in Staphylococcus aureus associated with Skin and Soft Tissue Infection (SSTI) disease groups. BMC Infect Dis 2016; 16:276. [PMID: 27287530 PMCID: PMC4902997 DOI: 10.1186/s12879-016-1630-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 06/07/2016] [Indexed: 01/22/2023] Open
Abstract
Background Staphylococcus aureus is associated with human skin and soft tissue infections (SSTIs); however, the involvement of virulence factors in different clinical presentations is unclear. Methods We analyzed methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) strains from Taiwan to determine correlations among the clinical characteristics of SSTIs, antimicrobial susceptibility and virulence factors of S. aureus with specific genetic backgrounds. Results We identified 177 MRSA isolates and 130 MSSA isolates among the 307 SSTI-associated S. aureus isolates. Hospital-acquired (HA)- and community-acquired (CA)-MRSA isolates accounted for 61.6 % and 38.4 % of the isolates, respectively. Clinical presentations in SSTI patients differed significantly for the disease groups. Deep-seated MRSA infections presented with higher amputation rate than MSSA infections. MRSA isolates were all susceptible to linezolid, teicoplanin, and vancomycin, and >94 % of isolates were erythromycin- and clindamycin-resistant. Staphylococcal cassette chromosome (SCCmec) types IV, V, and VII were the most frequent in the CA-MRSA group (n = 68); types III, IV and V were the most frequent in the HA-MRSA group (n = 109). Panton-Valentine leukocidin (PVL) genes were significantly more frequent in CA-MRSA strains (75.0 %) than in HA-MRSA (33.0 %) and MSSA (24.6 %) and were found in 66.7 % (74/111) strains isolated from the abscess group. Exfoliatin A genes were more common in catheter-related exit-site MSSA infections (37.5 %) compared with other MSSA disease groups (P < 0.05). Exfoliatin B and superantigen exotoxin genes were uncommon in all SSTI disease types. Pulsotypes A (ST239), C, and D (ST59) were the predominant MRSA genotypes in deep-seated infections. Conclusions If not treated appropriately, deep-seated MRSA-associated infections present with higher amputation rates than deep-seated MSSA-associated infections. PVL-positive MRSA strains caused more frequently pus-forming lesions and less bacteremia and invasive diseases. Methods for discriminating CA-MRSA from HA-MRSA strains are now unreliable due to circulation of both ST 239 and ST 59 strains in the community and nosocomial settings. Initial antibiotic treatments should consider MRSA for patients with SSTIs in areas where MRSA is prevalent.
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Affiliation(s)
- Chih-Hsuan Changchien
- Department of Plastic and Reconstructive Surgery, Chiayi Christian Hospital, 539 Jhongsiao Rd., Chiayi City, 60002, Taiwan, Republic of China
| | - Shu-Wun Chen
- Department of Microbiology, Immunology, and Biopharmaceuticals, National Chiayi University, No 300, University Road, Chiayi, 60004, Taiwan, Republic of China
| | - Ying-Ying Chen
- Department of Plastic and Reconstructive Surgery, Chiayi Christian Hospital, 539 Jhongsiao Rd., Chiayi City, 60002, Taiwan, Republic of China
| | - Chishih Chu
- Department of Microbiology, Immunology, and Biopharmaceuticals, National Chiayi University, No 300, University Road, Chiayi, 60004, Taiwan, Republic of China.
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Ghezala HB, Feriani N. [Postoperative necrotizing fasciitis: a rare and fatal complication]. Pan Afr Med J 2016; 23:123. [PMID: 27279950 PMCID: PMC4885698 DOI: 10.11604/pamj.2016.23.123.8734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/18/2016] [Indexed: 11/18/2022] Open
Abstract
Les complications pariétales post opératoire peuvent être exceptionnellement majeures et graves menaçant le pronostic vital. La fasciite nécrosante est une infection rare de la peau et des tissus sous-cutanés profonds, se propageant le long des fascias et du tissu adipeux. Elle est surtout causée par le streptocoque du groupe A Streptococcus pyogènes mais également par d'autres bactéries telles que Vibrio vulnificus, clostridium perfringens ou Bacteroides fragilis. La fasciite nécrosante est une véritable urgence médicochirurgicale. Nous rapportons dans ce travail une observation très rare d'une gangrène pariétale abdominale survenant chez une patiente de 75 ans au cinquième jour post-opératoire d'un kyste de l'ovaire. L’évolution était marquée par l'installation d'un état de choc septique réfractaire rapidement fatal à J3 de la prise en charge.
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Affiliation(s)
- Hassen Ben Ghezala
- Service de Réanimation Médicale, Faculté de Médecine de Tunis, Hôpital de Zaghouan, Zaghouan, Tunisie
| | - Najla Feriani
- Service de Chirurgie Générale à la Faculté de Médecine de Tunis, Hôpital de Zaghouan, Zaghouan, Tunisie
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Guervil DJ, Klinker KP, Reardon NT, Alnuaimat HM, Borgert SJ, Ramphal R. Measuring Quality Metrics to Identify and Monitor Antimicrobial Stewardship Program Quality Improvement Efforts. Infect Control Hosp Epidemiol 2016; 35:101-3. [DOI: 10.1086/674403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Kumar Y, Khaleel M, Boothe E, Awdeh H, Wadhwa V, Chhabra A. Role of Diffusion Weighted Imaging in Musculoskeletal Infections: Current Perspectives. Eur Radiol 2016; 27:414-423. [PMID: 27165135 DOI: 10.1007/s00330-016-4372-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 02/27/2016] [Accepted: 04/14/2016] [Indexed: 01/22/2023]
Abstract
Accurate diagnosis and prompt therapy of musculoskeletal infections are important prognostic factors. In most cases, clinical history, examination and laboratory findings help one make the diagnosis, and routine magnetic resonance imaging (MRI) is useful to identify the extent of the disease process. However, in many situations, a routine MRI may not be specific enough especially if the patient cannot receive contrast intravenously, thereby delaying the appropriate treatment. Diffusion-weighted imaging (DWI) can help in many such situations by providing additional information, accurate characterization and defining the extent of the disease, so that prompt treatment can be initiated. In this article, we illustrate the imaging findings of the spectrum of musculoskeletal infections, emphasizing the role of DWI in this domain. KEY POINTS • Abscess in background cellulitis is detected on DWI. • Infectious tenosynovitis shows diffusion restriction as compared to mechanical tenosynovitis. • Pyomyositis with abscess can be differentiated from diabetic myonecrosis on DWI. • Intraosseous abscess is bright on DWI versus devitalized tissue, sequestrum and air. • DWI can be used to differentiate spine infection from simple Modic changes.
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Affiliation(s)
- Yogesh Kumar
- Department of Radiology, Yale New Haven Health System at Bridgeport Hospital, Bridgeport, CT, USA
| | - Mohammad Khaleel
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9178, USA
| | - Ethan Boothe
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Haitham Awdeh
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Vibhor Wadhwa
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Avneesh Chhabra
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9178, USA. .,Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA.
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Jindal A, Kumar M, Bhadoria AS, Maiwall R, Sarin SK. A randomized open label study of 'imipenem vs. cefepime' in spontaneous bacterial peritonitis. Liver Int 2016; 36:677-87. [PMID: 26474358 DOI: 10.1111/liv.12985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/05/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Spontaneous bacterial peritonitis (SBP), in the presence of bacterial resistance or failure of third generation cephalosporins (3rd GC) has poor outcome. Empirical antibiotic(s) options are limited in these scenarios. METHODS Consecutive cirrhotics with SBP because of hospital acquired SBP (>48 h of admission), microbial resistance or non-response (no resolution of SBP at 48 h) were randomized to Cefepime (n = 88) or Imipenem (n = 87) plus standard medical therapy. We assessed for 'response at 48 h' (reduction in ascitic fluid absolute neutrophil count (ANC) by >25% at 48 h), resolution of SBP (<250 cu/mm ANC at day 5) and their clinical outcome. RESULTS Of 957 paracentesis in 1200 hospitalized cirrhotics, 253 (26.4%) had SBP and 175 (69.6%) were randomized. Baseline parameters were comparable in two groups. Response at 48 h (58.6% vs. 51.7%; P = 0.4) and resolution of SBP in those with response at 48 h were comparable with no difference in mortality at week 2, month 1 and 3. Patients with 'No response at 48 h' had higher mortality compared with responders (73.8% vs. 25%; P < 0.001). Resolution of SBP was associated with 'response at 48 h' and septic shock, latter being main pre-terminal event. AKI at enrolment [Hazard ratio (HR), 2.6], pneumonia [HR, 2.9], septic shock [HR, 2.2] and response at 48 h [HR, 4.6] predicted poor outcome. CONCLUSIONS In hospitalized cirrhotics with SBP and risk factors for treatment failure, cefepime showed comparable efficacy and survival to imipenem. Non-response to therapy at 48 h is a reliable predictor of treatment failure and mortality. Antibiotic combinations and novel options are needed for these patients.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Ajeet S Bhadoria
- Department of epidemiology and clinical research, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India.,Special Centre for Molecular Medicine, Jawaharlal Nehru University (JNU), New Delhi, India
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Kocutar T, Snoj Ž, Salapura V. Complicated acute haematogenous osteomyelitis with fatal outcome following a closed clavicle fracture-a case report and literature review. BJR Case Rep 2016; 2:20150389. [PMID: 30363605 PMCID: PMC6180849 DOI: 10.1259/bjrcr.20150389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/23/2015] [Accepted: 12/30/2015] [Indexed: 12/18/2022] Open
Abstract
Among adults, post-traumatic osteomyelitis following a closed fracture is a rarely described entity in the literature, with the involvement of the clavicle bone being particularly uncommon. Early diagnosis and treatment of clavicular osteomyelitis is crucial to prevent serious consequences such as sepsis, mediastinitis and haemorrhage from the great vessels. A 54-year-old male patient presented to the emergency department complaining of fatigue and limited mobility after having fallen and hit his head and right shoulder 10 days previously. No major injury was found during the diagnostic procedure, and the patient was discharged. 2 weeks later, the patient returned with clinical signs of right upper arm cellulitis and probable sepsis. Diagnostic ultrasound imaging and MRI of the right upper arm, as well as re-examination of the X-ray image, confirmed acute complex osteomyelitis of the right clavicle following an overlooked clavicle fracture. Microbiological analysis confirmed clavicular osteomyelitis caused by Escherichia coli septicaemia. Despite prompt treatment with i.v. antibiotics and surgery, the patient's condition rapidly deteriorated and he passed away. Our case demonstrates the critical importance of early diagnosis and appropriate treatment of a closed fracture. Late diagnosis may lead to severe complications, such as complicated osteomyelitis and sepsis, and even a fatal outcome. Furthermore, a brief literature review is presented of previously reported acute osteomyelitis following a closed fracture, including evidence of affected bone and isolated pathogens. Although uncommon, osteomyelitis should be considered a possible cause of a deteriorating clinical condition in patients with a history of recent trauma.
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Affiliation(s)
- Tina Kocutar
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Žiga Snoj
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vladka Salapura
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Kalin-Hajdu E, Cadet N, Boulos PR. Controversies of the lacrimal system. Surv Ophthalmol 2016; 61:309-13. [DOI: 10.1016/j.survophthal.2015.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 12/04/2015] [Accepted: 12/07/2015] [Indexed: 01/22/2023]
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Drug-induced modulation of T lymphocytes as a potential mechanism of susceptibility to infections in patients with multiple myeloma during bortezomib therapy. Cell Biochem Biophys 2016; 71:457-64. [PMID: 25343940 PMCID: PMC4289524 DOI: 10.1007/s12013-014-0224-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Bortezomib is effective in the therapy of multiple myeloma (MM), but causes infections that are different from those associated with conventional chemotherapy. It is important to identify the risk factors that facilitate infections associated with bortezomib therapy. In the present report, we sought to (1) define the features of the infections associated with this therapy and (2) identify the immune mechanisms responsible for the observed susceptibility to these infections. We first retrospectively analyzed the clinical data of 143 patients who had received bortezomib therapy for MM. We then prospectively assessed the modulation of T lymphocyte status during this therapy, and evaluated potential relationships between infections and T lymphocyte changes. The infection rates peaked during the first cycle of bortezomib therapy (47.6 %) in patients with MM (p < 0.05 vs. subsequent cycles). Bortezomib therapy was associated with higher incidence rates of viral and fungal infections (15.8 %, p < 0.05 vs. conventional chemotherapy). In addition, patients with the IgG immunophenotype showed higher bacterial and viral infection rates (respectively, p = 0.008 and 0.009). The T lymphocyte numbers significantly decreased after bortezomib therapy (p < 0.05), and the same was true for the Th1/Th2 ratio (p < 0.01). Patients with MM who have decreased lymphocyte counts, while on bortezomib therapy are more likely to develop bacterial or viral infections. In addition, an imbalance in T lymphocyte subsets is also associated with bacterial or viral infections in these patients.
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In Vitro Susceptibility to Ceftazidime-Avibactam of Carbapenem-Nonsusceptible Enterobacteriaceae Isolates Collected during the INFORM Global Surveillance Study (2012 to 2014). Antimicrob Agents Chemother 2016; 60:3163-9. [PMID: 26926648 DOI: 10.1128/aac.03042-15] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 02/18/2016] [Indexed: 12/26/2022] Open
Abstract
The activity of ceftazidime-avibactam was assessed against 961 isolates of meropenem-nonsusceptible Enterobacteriaceae Most meropenem-nonsusceptible metallo-β-lactamase (MBL)-negative isolates (97.7%) were susceptible to ceftazidime-avibactam. Isolates that carried KPC or OXA-48-like β-lactamases, both alone and in combination with extended-spectrum β-lactamases (ESBLs) and/or AmpC β-lactamases, were 98.7% and 98.5% susceptible to ceftazidime-avibactam, respectively. Meropenem-nonsusceptible, carbapenemase-negative isolates demonstrated 94.7% susceptibility to ceftazidime-avibactam. Ceftazidime-avibactam activity was compromised only in isolates for which carbapenem resistance was mediated through metallo-β-lactamases.
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Ferreira A, Bolland MJ, Thomas MG. Meta-analysis of randomised trials comparing a penicillin or cephalosporin with a macrolide or lincosamide in the treatment of cellulitis or erysipelas. Infection 2016; 44:607-15. [PMID: 27085865 DOI: 10.1007/s15010-016-0895-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/04/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE Beta-lactam antibiotics, such as penicillin, flucloxacillin or cephalexin, are widely considered first-line treatment for cellulitis and erysipelas, while macrolides and lincosamides, such as erythromycin, azithromycin or clindamycin, are widely considered second-line agents. We attempted to determine whether outcomes differed between patients treated either with a beta-lactam or with a macrolide or lincosamide. METHODS We conducted a meta-analysis of published trials in which patients with cellulitis or erysipelas were randomised to treatment either with a beta-lactam or with a macrolide or lincosamide. We searched PUBMED, EMBASE, MEDLINE and SCOPUS (up to March 2014) using the terms: cellulitis/erysipelas, penicillin/beta-lactam, macrolide/lincosamide, random*/controlled*/trial* as keywords. We included randomised trials that compared monotherapy with a beta-lactam with monotherapy with a macrolide or lincosamide for cellulitis or erysipelas. RESULTS We identified 15 studies, 9 in patients with cellulitis or erysipelas and 6 in patients with various skin and soft tissue infections including cellulitis and erysipelas. The efficacy of treatment of cellulitis or erysipelas was similar with a beta-lactam [27/221 (12 %) not cured] and a macrolide or lincosamide [21/241 (9 %) not cured, RR 1.24, 95 % CI 0.72-2.41, p = 0.44]. Treatment efficacy was also similar for skin or soft tissue infections including cellulitis and erysipelas (RR 1.28, 95 % CI 0.96-1.69, p = 0.09). Risk of adverse effects was similar for beta-lactams [148/1295 (11 %) not cured] and macrolides or lincosamides [228/1737 (13 %) not cured, RR 0.86, 95 % CI 0.64-1.16, p = 0.31]. CONCLUSION Treatment with a macrolide or lincosamide for cellulitis or erysipelas has a similar efficacy and incidence of adverse effects as treatment with a beta-lactam.
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Affiliation(s)
- Athena Ferreira
- Department of Infectious Diseases, Auckland City Hospital, Auckland, 1142, New Zealand
| | - Mark J Bolland
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142, New Zealand
| | - Mark G Thomas
- Department of Infectious Diseases, Auckland City Hospital, Auckland, 1142, New Zealand.
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142, New Zealand.
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Monedero Mira MJ, Sales MB, Domingo CG, Monedero Mira MJ, Saura BP, Mallen GR, Porcar LT. Tratamiento empírico de las infecciones del adulto. FMC : FORMACION MEDICA CONTINUADA EN ATENCION PRIMARIA 2016; 23:9-71. [PMID: 32288498 PMCID: PMC7144499 DOI: 10.1016/j.fmc.2015.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/15/2015] [Accepted: 12/20/2015] [Indexed: 12/12/2022]
Affiliation(s)
- María José Monedero Mira
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | - Manuel Batalla Sales
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | | | - María José Monedero Mira
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | - Belén Persiva Saura
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón, España
| | | | - Lledó Tárrega Porcar
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón, España
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Rapid Emergence and Evolution of Staphylococcus aureus Clones Harboring fusC-Containing Staphylococcal Cassette Chromosome Elements. Antimicrob Agents Chemother 2016; 60:2359-65. [PMID: 26856837 PMCID: PMC4808225 DOI: 10.1128/aac.03020-15] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 01/22/2016] [Indexed: 01/12/2023] Open
Abstract
The prevalence of fusidic acid (FA) resistance among Staphylococcus aureus strains in New Zealand (NZ) is among the highest reported globally, with a recent study describing a resistance rate of approximately 28%. Three FA-resistant S. aureus clones (ST5 MRSA, ST1 MSSA, and ST1 MRSA) have emerged over the past decade and now predominate in NZ, and in all three clones FA resistance is mediated by the fusC gene. In particular, ST5 MRSA has rapidly become the dominant MRSA clone in NZ, although the origin of FA-resistant ST5 MRSA has not been explored, and the genetic context of fusC in FA-resistant NZ isolates is unknown. To better understand the rapid emergence of FA-resistant S. aureus, we used population-based comparative genomics to characterize a collection of FA-resistant and FA-susceptible isolates from NZ. FA-resistant NZ ST5 MRSA displayed minimal genetic diversity and represented a phylogenetically distinct clade within a global population model of clonal complex 5 (CC5) S. aureus. In all lineages, fusC was invariably located within staphylococcal cassette chromosome (SCC) elements, suggesting that SCC-mediated horizontal transfer is the primary mechanism of fusC dissemination. The genotypic association of fusC with mecA has important implications for the emergence of MRSA clones in populations with high usage of fusidic acid. In addition, we found that fusC was colocated with a recently described virulence factor (tirS) in dominant NZ S. aureus clones, suggesting a fitness advantage. This study points to the likely molecular mechanisms responsible for the successful emergence and spread of FA-resistant S. aureus.
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Gunderson CG, Holleck J, Chang JJ, Lin S, Merchant N, Gupta S. Clinical characteristics and outcomes of veterans hospitalised with purulent soft tissue infections with and without systemic signs of infection. Infect Dis (Lond) 2016; 48:503-8. [DOI: 10.3109/23744235.2016.1154599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Miller JM. Poorly Collected Specimens May Have a Negative Impact on Your Antibiotic Stewardship Program. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.clinmicnews.2016.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Common and Dangerous Skin Infections. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis. Pediatr Infect Dis J 2016; 35:269-74. [PMID: 26569189 DOI: 10.1097/inf.0000000000000992] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The benefits of treating children at home or in an ambulatory setting have been well documented. We aimed to describe the characteristics and evaluate the outcomes of children with moderate/severe cellulitis treated at home with intravenous (IV) ceftriaxone via direct referral from the Emergency Department to a hospital-in-the-home (HITH) program. METHODS Patients aged 3 months to 18 years with moderate/severe cellulitis referred from a tertiary pediatric Emergency Department to HITH from September 2012 to January 2014 were prospectively identified. Data collection included demographics, clinical features, microbiological characteristics and outcomes. To ensure home treatment did not result in inferior outcomes, these patients were retrospectively compared with patients who were hospitalized for IV flucloxacillin, the standard-of-care over the same period. The primary outcome was home treatment failure necessitating hospital admission. Secondary outcomes included antibiotic changes, complications, length of stay and cost. RESULTS Forty-one (28%) patients were treated on HITH and 103 (72%) were hospitalized. Compared with hospitalized patients, HITH patients were older (P < 0.01) and less likely to have periorbital cellulitis (P = 0.01) or fever (P = 0.04). There were no treatment failures under HITH care. The rate of antibiotic changes was similar in both groups (5% vs. 7%, P = 0.67), as was IV antibiotic duration (2.3 vs. 2.5 days, P = 0.23). CONCLUSION Older children with moderate/severe limb cellulitis without systemic symptoms can be treated at home. To ascertain if this practice can be applied more widely, a comparative prospective, ideally randomized, study is needed.
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Li X, Chen Y, Gao W, Ouyang W, Wei J, Wen Z. Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections among Inpatients in Southern China from 2008 to 2013. PLoS One 2016; 11:e0149960. [PMID: 26918456 PMCID: PMC4769280 DOI: 10.1371/journal.pone.0149960] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/08/2016] [Indexed: 01/07/2023] Open
Abstract
Complicated skin and soft tissue infections (cSSTI) are some of the most commonly treated infections in hospitals, and place heavy economic burdens on patients and society. Here we report the findings from an analysis of cSSTI based on a retrospective study which was conducted within the Chinese inpatient population. We focused our research on the analysis of the patient population, antibiotic treatment, clinical outcome and economic burden. The study population comprised 527 selected patients hospitalized between 2008 and 2013. Among the hospitalizations with microbiological diagnoses, 61.41% (n = 113) were diagnosed as infected with Gram-positive bacteria, while 46.20% (n = 85) were infected with Gram-negative bacteria. The most commonly found Gram-positive bacteria was Staphylococcus aureus (40.76%, n = 75), and the most common Gram-negative bacteria was Escherichia coli (14.13%, n = 26). About 20% of the Staphylococcus aureus were methicillin-resistant. The resistance rate of isolated Staphylococcus aureus or Escherichia coli to penicillin was around 90%; in contrast, the resistance rate to vancomycin, linezolid or imipenem was low (<20%). A large percentage of patients were treated with cephalosporins and fluoroquinolones, while vancomycin and imipenem were also included to treat drug-resistant pathogens. Over half of the hospitalizations (58.43%, n = 336) experienced treatment modifications. The cost to patients with antibiotic modifications was relatively higher than to those without. In conclusion, our study offers an analysis of the disease characteristics, microbiological diagnoses, treatment patterns and clinical outcomes of cSSTI in four hospitals in Guangdong Province, and sheds lights on the current clinical management of cSSTI in China.
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Affiliation(s)
- Xiaoyan Li
- Key Unit of Methodology in Clinical Research, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou 510120, China
| | - Yunqin Chen
- R & D information China, AstraZeneca, 199 Liangjing Road, Pudong, Shanghai, 201203, China
| | - Weiguo Gao
- R & D information China, AstraZeneca, 199 Liangjing Road, Pudong, Shanghai, 201203, China
| | - Wenwei Ouyang
- Key Unit of Methodology in Clinical Research, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou 510120, China
| | - Jia Wei
- R & D information China, AstraZeneca, 199 Liangjing Road, Pudong, Shanghai, 201203, China
- * E-mail: (JW); (ZW)
| | - Zehuai Wen
- Key Unit of Methodology in Clinical Research, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou 510120, China
- * E-mail: (JW); (ZW)
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