Early clinical assessment of response to treatment of skin and soft-tissue infections: how can it help clinicians? Perspectives from Europe

Antimicrobial cyclodextrin-assisted electrospun fibers loaded with carvacrol, citronellol and cinnamic acid for wound healing

This work aimed to explore an alternative to the use of antibiotics for prevention and treatment of wounds infection caused by two common bacterial pathogens Staphylococcus aureus and Pseudomonas aeruginosa. For this purpose, three different essential oil components (EOCs), namely carvacrol, citronellol and cinnamic acid, were loaded into electrospun fibers of poly-ε-caprolactone (PCL) aided by alpha-cyclodextrin (αCD) and hydroxypropyl-β-cyclodextrin (HPβCD). Electrospun-fibers prepared with each EOC and their mixtures were screened for antimicrobial capability and characterized regarding morphological, mechanical, thermal, surface polarity, antibiofilm and antioxidant properties. αCD formed poly(pseudo)rotaxanes with PCL and weakly interacted with EOCs, while HPβCD facilitated EOC encapsulation and formation of homogeneous fibers (500-1000 nm diameter) without beads. PCL/HPβCD fibers with high concentration of EOCs (mainly carvacrol and cinnamic acid) showed strong antibiofilm (>3 log CFU reduction) and antioxidant activity (10-50% DPPH scavenging effects). Different performances were recorded for the EOCs and their mixtures; cinnamic acid migrated to fiber surface and was released faster. Fibers biocompatibility was verified using hemolysis tests and in ovo tissue integration and angiogenesis assays. Overall, HPβCD facilitates complete release of EOCs from the fibers to the aqueous medium, being an environment-friendly and cost-effective strategy for the treatment of infected wounds.

Association of Vancomycin AUC/MIC and Trough Concentration With Early Clinical Response in Enterococcus or Coagulase-Negative Staphylococcus Infection: A Prospective Study

This study was condcuted to examine the association of area under the curve (AUC)/minimum inhibitory concentration (MIC) and trough concentration (Ctrough) of vancomycin with treatment outcome and nephrotoxicity in infections caused by Enterococcus spp. and coagulase-negative Staphylococci (CoNS). Peak and trough concentrations were used to calculate AUC in 89 patients receiving vancomycin for infections with Enterococcus spp. (n = 65) or CoNS (n = 24). Correlations between Ctrough, AUC/MIC, early clinical response (ECR), and nephrotoxicity were assessed and cutoff values were determined. Sixty-three (70.8%) patients showed improvement in ECR and 10 (11.2%) experienced nephrotoxicity. Enterococcus spp. infections displayed correlations between AUC/MIC and ECR for AUC0-24 h/MIC (r2 = 0.27, P ≤ .05) and AUC24-48 h/MIC (r2 = 0.28, P ≤ .05), but not for Ctrough (r2 = 0.21, P > .05). There were no correlations between Ctrough (r2 = 0.26, P > .05), AUC0-24 h/MIC (r2 = -0.12, P > .05), AUC24-48 h/MIC (r2 = 0.01, P > .05) and ECR for CoNS. In the CoNS group, a moderate correlation was found between ECR and Ctrough at a cutoff value of 6.9 μg/mL. In addition, nephrotoxicity is also moderately associated with AUC0-24 h and AUC24-48 h at 505.7 and 667.1 μg•h/mL, respectively. A strong correlation between nephrotoxicity and Ctrough was observed when the cutoff value was 18.9 μg/mL. AUC/MIC during the first 48 h was a determinant of vancomycin efficacy in Enterococcus infections but not for CoNS. Ctrough was not correlated with clinical outcome. Nephrotoxicity could be predicted using Ctrough and AUC for infections with both pathogens.

Real-World Use and Treatment Outcomes of Ceftaroline Fosamil in Patients with Complicated Skin and Soft Tissue Infection: A Multinational Retrospective Study

Background

Ceftaroline fosamil is approved for the treatment of complicated skin and soft tissue infections (cSSTI) and community-acquired pneumonia (CAP); however, data on its real-world use and effectiveness in Europe and Latin America are currently limited. This retrospective observational study assessed ceftaroline fosamil use and treatment outcomes in adults hospitalized with cSSTI or CAP treated with ceftaroline fosamil in a usual care setting in Europe and Latin America. Results for patients with cSSTI are reported.

Methods

Data from patients with cSSTI who received ≥4 consecutive intravenous ceftaroline fosamil doses up to May 31, 2019, were collected from sites in Brazil, Colombia, France, Greece, Italy, and Spain. Patient characteristics, clinical management, hospitalization information, microbiological diagnosis, and clinical responses were summarized descriptively. Healthcare resource use variables were evaluated by clinical response to ceftaroline fosamil.

Results

Data for 132 patients were included (58.3% male; mean age 58.5 years). Most common lesions were cellulitis/fasciitis (62.1%), abscess (34.1%), and post-surgical wounds (19.7%). Pathogens most frequently identified were methicillin-resistant (18.2%) and methicillin-susceptible Staphylococcus aureus (17.4%). Median (range) ceftaroline fosamil treatment duration was 8 (2-60) days (daily doses of 1200 [400-2400] mg); 78 patients (59.1%) received monotherapy. In total, 75 (56.8%) patients had additional antibiotics after ceftaroline fosamil. Clinical response occurred in 118 (89.4%) patients. All-cause 30-day readmission occurred in 13 (9.8%) patients, and all-cause 30-day mortality in 7 (5.3%). Clinical response to ceftaroline was associated with >25% shorter length of hospital and intensive care stay, and with ~40% lower hospital costs, versus non-responders.

Conclusion

Ceftaroline fosamil was effective in treating adults with cSSTI and clinical response to ceftaroline fosamil was associated with reductions in healthcare resource use compared with non-responders, in Europe and Latin America.

Clinicaltrialsgov Identifier

NCT04198571.

Niobium carbide–mediated photothermal therapy for infected wound treatment

Bacterial infections of the wounds on the skin surface significantly reduce the rate of wound healing, potentially leading to serious systemic infections. Antibiotics are the first-line drugs for the treatment of these infections. However, the misuse and overuse of antibiotics have led to the emergence of bacterial resistance. Therefore, a new antimicrobial strategy is urgently needed. Photothermal therapy (PTT) is a novel efficient therapeutic technique that can produce irreversible cell damage to induce death of bacteria, possessing a great potential in infected wound healing. This work describes the use of a new photothermal agent (PTA) such as niobium carbide (NbC) nanoparticles with outstanding near-infrared (NIR) absorption property. NbC nanoparticles converted NIR laser irradiation energy into localized heat for photothermal treatment. In vitro antimicrobial experiments have revealed that NbC nanoparticles exert excellent antimicrobial effects against Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli). Moreover, NbC nanoparticles accelerated E. coli–infected wound healing process, reduced inflammatory response, and showed good biosafety in vivo. Altogether, NbC nanoparticles represent an efficient PTA for antimicrobial treatment and are a bio-safe material with low toxicity in vivo.

Cost-minimisation analysis of oritavancin for the treatment of acute bacterial skin and skin structure infections from a United Kingdom perspective

BACKGROUND

Early discharge (ED) from hospital and outpatient parenteral antibiotic therapy (OPAT) are effective approaches for the management of a range of infections, including acute bacterial skin and skin structure infections (ABSSSI). Strategies that facilitate ED, thereby reducing complications such as healthcare-acquired infection whilst enhancing patient quality of life, are being increasingly adopted in line with good antimicrobial stewardship practice. This study presents a cost-minimisation analysis for the use of oritavancin at ED versus relevant comparators from a National Health Service (NHS) and personal and social services United Kingdom perspective.

METHODS

A cost-minimisation model considering adult patients with ABSSSI with suspected or confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection, was developed based on publicly available NHS costs, practice guidelines for ABSSSI and clinical expert's opinion. Cost of treatment and treatment days were compared for oritavancin at ED to dalbavancin, teicoplanin, daptomycin and linezolid.

RESULTS

Following the empiric use of either flucloxacillin or vancomycin in the inpatient setting, oritavancin was compared to OPAT with dalbavancin, teicoplanin and daptomycin, and oral linezolid from day 4 of treatment. Oritavancin at ED reduced treatment duration by 0.8 days and led to cost savings of £281 in comparison to dalbavancin. In comparison to teicoplanin, daptomycin and linezolid, oritavancin reduced treatment duration by 5 days, with marginally higher costs (£446, £137, and £1,434, respectively).

CONCLUSION

Oritavancin, used to support ED, is associated with lower costs compared with dalbavancin and reduced treatment duration relative to all comparators. Its use would support an ED approach in MRSA ABSSSI management.

Antibiotic treatment of acute bacterial skin and skin structure infections

PURPOSE OF REVIEW

Acute bacterial skin and skin structure infections (ABSSSI) are a leading cause of morbidity, with a considerable variety of clinical presentation and a wide range of etiological pathogens. Of importance, the spread of multidrug-resistant (MDR) strains (i.e. methicillin-resistant Staphylococcus aureus or Gram-negative bacteria) is increasingly reported in some regions. in this review, we summarize the current clinical approach to patients with ABSSSI.

RECENT FINDINGS

Accurate diagnosis and identification of risk factors for MDR pathogens are key determinants for administering appropriate therapy in patients with ABSSSI. In daily clinical practice, this can be critical as there are many features defining the 'high risk patient' including both disease and host-associated risk factors.

SUMMARY

Antibiotic therapy should be based according to the different clinical spectrum of disease belonging to the ABSSSI, on the pathogens most likely to be involved and local resistance. Careful evaluation of antibiotic therapy after 48-72 h of initial therapy could help clinicians to early identify patients with treatment failure and to consider an alternative approach. Close monitoring of patients with multiple comorbidities, drug-drug interaction or adverse host factors are also necessary.

Current international and national guidelines for managing skin and soft tissue infections

PURPOSE OF REVIEW

Skin and soft tissue infections account for a significant percentage of both community and nosocomial infections. Several nosological entities are included in this concept. However, there is a very scarce body of doctrine for their treatment based on randomised trials. Therefore, we considered it necessary to review current treatment guidelines to bring new recommendations and improvements to our colleagues. In this review of recent literature, we identified updated guidelines in this area by searching the databases PubMed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip and Sumsearch using the terms: soft tissue infection, therapy, guideline.

RECENT FINDINGS

Developments focus on using new antimicrobials and on the prescription of shorter antibiotic treatment courses.

SUMMARY

With the development of new drugs and the current evidence of their use, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life, which allows weekly administration, can reduce hospital admission and length of stay with fewer healthcare resources. Shorter courses of antibiotics are recommended. The role of stewardship programmes will continue to expand. The surgical indication and its value are evident in many patients. Therefore, management should rely on a collaborative group with experience in this disease.

Ceftaroline Fosamil for the Empiric Treatment of Hospitalized Adults with cSSTI: An Economic Analysis from the Perspective of the Spanish National Health System

Purpose

Complicated skin and soft tissue infections (cSSTI) are associated with high healthcare resource use and costs. The emergency nature of cSSTI hospitalizations requires starting immediate empiric intravenous (IV) antibiotic treatment, making the appropriate choice of initial antibiotic therapy crucial.

Patients and Methods

The use of ceftaroline fosamil (CFT) as an alternative to other IV antibiotic therapies for the empiric treatment of hospitalized adults with cSSTI (vancomycin, linezolid, daptomycin, cloxacillin, tedizolid) was evaluated through cost consequences analysis. The model structure was a decision tree accounting for four different pathways: patients demonstrating early response (ER) either discharged early (with oral antibiotic) or remaining in hospital to continue the initial therapy; non-responders either remaining on the initial IV therapy or switching to a second-line antibiotic. The model perspective was the Spanish National Health System.

Results

CFT resulted in average percentage of patients discharged early (PDE) of 24.6% (CI 19.49–30.2%) with average total cost per patient of €6763 (€6268–€7219). Vancomycin, linezolid, daptomycin and tedizolid resulted in average PDE of 22% (17.34–27.09%), 26.4% (20.5–32.32%), 28.6% (22.08–35.79%) and 26.5% (20.39–33.25%), respectively, for a total cost per patient of €6,619 (€5,902–€6,929), €6,394 (€5,881–€6,904), €6,855 (€5,800–€7,410) and €7,173 (€6,608–€7,763), respectively. Key model drivers were ER and antibiotic treatment duration, with hospital costs accounting for over 83% of the total expenditures.

Conclusion

Given its clinical and safety profile, CFT is an acceptable choice for cSSTI empiric therapy providing comparable ER and costs to other relevant antibiotic options.

Dalbavancin in Real Life: Economic Impact of Prescription Timing in French Hospitals

INTRODUCTION

The extended half-life of dalbavancin justifies a once-a-week dosing schedule and is supposed to favour early discharge. These advantages may therefore compensate for the cost of dalbavancin, but no real-life assessment has been conducted to date. We aimed to assess the real-life budget impact of dalbavancin through its impact on the length of stay in French hospitals.

METHODS

A multicentre cohort based on the French registry of dalbavancin use in 2019 was compared to the French national discharge summary database. Lengths of stay and budget impact related to the infection type, the time of introduction of dalbavancin, the type of catheter and patient subgroups were assessed. An early switch was defined when dalbavancin was administered as the first or second treatment and within less than 11 days of hospitalization.

RESULTS

A total of 179 patients were identified in the registry, and 154 were included in our study. Dalbavancin was mostly used for bone and joint infections (56.0%), infective endocarditis (19.0%) and acute bacterial skin and skin structure infections (6.0%). When compared to the data for similar patients in the national database, the length of stay was almost always shorter for patients treated with dalbavancin (up to a reduction of 13 days). The budget impact for dalbavancin was heterogeneous but frequently generated savings (up to 2257.0 €). Early switching (within less than 11 days) was associated with savings (or lesser costs), with even greater benefits within 7 days of hospitalization. Patients who required a deep venous catheter as well as the most severe patients benefited the most from dalbavancin.

CONCLUSION

Our study confirms that dalbavancin is associated with early discharge, which can offset its cost and generate savings. The greatest benefit is achieved with an early switch.

The Photocatalytic Effects of Modified Hydrothermal Nanotitania Extraction on the Skin and Behavior of Sprague-Dawley Rats

BACKGROUND

Potential antibacterial substances, such as titanium dioxide (TiO2), are being extensively studied throughout the research world. A modified hydrothermal nanotitania extraction was shown to inhibit Staphylococcus aureus growth in the laboratory. However, the toxicity effect of the extract on rats is unknown. In this study, we observed the effects of a modified hydrothermal nanotitania extraction on the skin and behavior of Sprague-Dawley rats.

METHODS

Sprague-Dawley (Rattus norvegicus) rats were used as the experimental animals. The skin around the dorsum of the tested animals was shaved and pasted with 0.1 mg and 0.5 mg of the nanotitania extraction. The color and condition of the pasted area and the behavior of the animals were observed.

RESULTS

0.1 mg nanotitania extraction application on the dorsum of the rat produced no skin color changes at day 1, day 3, day 5, or day 7 postapplication. There were no changes in their behavior up to day 7 with no skin rashes or skin scratches seen or fur changes. However, 0.5 mg of nanotitania extraction resulted in redness and less fur regrowth at day 7.

CONCLUSIONS

A 0.1 mg modified nanotitania extraction was observed to have no effect on the skin of Sprague-Dawley rats.

Current and future options for treating complicated skin and soft tissue infections: focus on fluoroquinolones and long-acting lipoglycopeptide antibiotics

Bacterial skin and soft tissue infections are among the most common bacterial infections and constitute a major burden for patients and healthcare systems. Care is complicated by the variety of potential pathogens, some with resistance to previously effective antimicrobial agents, the wide spectrum of clinical presentations and the risk of progression to life-threatening forms. More-efficient care pathways are needed that can reduce hospital admissions and length of stay, while maintaining a high quality of care and adhering to antimicrobial stewardship principles. Several agents approved recently for treating acute bacterial skin and skin structure infections have characteristics that meet these requirements. We address the clinical and pharmacological characteristics of the fourth-generation fluoroquinolone delafloxacin, and the long-acting lipoglycopeptide agents dalbavancin and oritavancin.

Clinical and operational factors associated with treatment duration for cellulitis in outpatient parenteral antimicrobial therapy (OPAT)

This study aims to identify factors associated with duration of intravenous (IV) and follow-on oral antibiotic therapy for cellulitis in patients treated through outpatient parenteral antimicrobial therapy (OPAT). A retrospective review of episodes of cellulitis treated over a year (January 2018-January 2019) at a large teaching hospital in Sheffield, UK. Overall, 292 OPAT episodes of cellulitis were reviewed. The mean durations of IV therapy and follow-on oral antibiotics were 5.3 days (range 1-32 days) and 6.1 days (range 2-17 days), respectively. Age, peak C-reactive protein and frequency of medical assessments during OPAT were independently associated with longer duration of IV therapy. Senior clinicians were likely to prescribe shorter courses of follow-on oral antibiotics. IV to oral conversion was more likely to occur on the first day of the work week. Our findings suggest that clinical and OPAT-related factors can influence early conversion to oral antibiotic therapy.

The clinical value of metagenomic next-generation sequencing in the microbiological diagnosis of skin and soft tissue infections

BACKGROUND

Metagenomic next-generation sequencing (mNGS), with its comprehensiveness, is widely applied in microbiological diagnosis. Etiological diagnosis is of paramount clinical importance in patients with skin and soft tissue infections (SSTIs). However, the clinical application of mNGS in SSTIs is relatively less studied.

MATERIALS AND METHODS

From April 1, 2017 to December 31, 2019, 96 SSTI cases were collected. The positive rates of pathogens detected by mNGS and culture were compared by analyzing tissue samples, pus, swabs, and/or interstitial fluids obtained from the infected parts. Modification of the antibiotic treatment strategy due to mNGS was also assessed.

RESULTS

The sensitivity of mNGS for detecting pathogens in SSTI cases was superior to that of culture testing (67.7% vs 35.4%; p < 0.01). Significantly higher identification rates for viruses (10.4% vs 0.0%; p < 0.01) and anaerobes (11.5% vs 1.0%; p < 0.01) were obtained with mNGS compared to culture. Of note, rare pathogens such as Vibrio vulnificus and Bartonella henselae were also detected by mNGS. Importantly, the proportion of multi-pathogen SSTIs detected by mNGS was higher than that of multi-pathogen SSTIs detected by culture (16.7% vs 6.3%; p = 0.035). The rate of targeted antibiotic treatment was significantly higher in mNGS-positive cases than in mNGS-negative cases (41.7% vs 3.8%; p < 0.01). In culture-negative and mNGS-positive cases, the improvement rate was higher than that in mNGS-negative cases, but this was not statistically significant (75.0% vs 73.1%; p = 0.864).

CONCLUSIONS

mNGS is a promising tool for the etiological diagnosis of SSTIs, particularly in identifying viruses, anaerobes, and multi-pathogen infections. The application of mNGS testing in clinical practice could change antibiotic treatment strategies and partly benefit clinical outcomes.

Dalbavancin for the Treatment of Complicated Gram-Positive Skin and Soft Tissue Infections

New antimicrobial agents have been developed to treat infections caused by methicillin-resistant Staphylococcus aureus and other multidrug-resistant pathogens. Dalbavancin is a novel semisynthetic lipoglycopeptide antibiotic, particularly active against methicillin-resistant Staphylococcus aureus. Due to its unique pharmacological characteristics and longer half-life, it can be administered once-weekly or every 15 days and in outpatient setting. Currently, it is indicated for complicated skin and soft tissue infections, but accumulating evidence points to its off-label efficacy in osteomyelitis and endocarditis. Further experience is still needed to increase our knowledge on the role of dalbavancin in a wider range of Gram-positive infections requiring prolonged antimicrobial treatment.

Retrospective Real-World Evaluation of Outcomes in Patients with Skin and Soft Structure Infections Treated with Tedizolid in an Outpatient Setting

INTRODUCTION

Outcomes data for patients who received tedizolid for acute bacterial skin and skin-structure infections (ABSSSIs) are scant. We provide a real-world analysis of economic and clinical outcomes following tedizolid use in the outpatient setting.

METHODS

This retrospective study of adults with skin infections treated with tedizolid (index period: 1 July 2014-31 May 2016) used data from the Optum Research and Impact National Benchmark databases.

RESULTS

Ninety-one patients received tedizolid for the treatment of skin infections (with complications, n = 18; without complications, n = 73). Some patients had > 1 complication and infection site. Among patients with complications, pre-index complications during the [index date - 30] through [index date + 1] period included osteomyelitis (44.4%), septicemia (44.4%), and prosthetic joint/device/graft infection (16.7%). For the [index date - 7] through [index date + 1] period, the infection site included abscesses (55.6%) and chronic ulcers (38.9%). Mean (standard deviation [SD]) days supplied for the index tedizolid claim was 6.8 (2.3) days. Healthcare resource utilization (HCRU) during the 30-day post-index period included ≥ 1 ambulatory visit (100.0%), ≥ 1 emergency department (ED) visit (16.7%), and ≥ 1 hospitalization (22.2%). Median 30-day post-index all-cause costs were $11,098 [lower quartile (Q1), $5688; upper quartile (Q3), $16,246; mean (SD), $14,637 ($11,435)]. Among patients without complications, the pre-index infection site from ([index date - 7] through [index date + 1]) included abscesses (60.3%), chronic ulcers (37.0%), and cellulitis (2.7%). Mean (SD) days supplied for the index tedizolid claim was 6.6 (2.5) days. Thirty-day post-index HCRU included ≥ 1 ambulatory visit (91.8%), ≥ 1 ED visit (17.8%), and ≥ 1 hospitalization (5.5%). Median 30-day post-index all-cause costs were $3230 (Q1, $2345; Q3, $6847; mean [SD], $6898 [$11,129]).

CONCLUSIONS

Patients treated with tedizolid in the outpatient setting experienced a short duration of therapy, low hospital admission, and modest post-index HCRU indicators, suggesting its utility for outpatient therapy of ABSSSIs.

Antimicrobial potentials of medicinal plant's extract and their derived silver nanoparticles: A focus on honey bee pathogen

Infectious (or Communicable) diseases are not only the past but also the present problem in developing as well as developed countries. It is caused by various pathogenic microbes like fungi, bacteria, parasites and virus etc. The medicinal plants and nano-silver have been used against the pathogenic microbes. Herbal medicines are generally used for healthcare because they have low price and wealthy source of antimicrobial properties. Like medicinal plants, silver nanoparticles also have emergent applications in biomedical fields due to their immanent therapeutic performance. Here, we also explore the various plant parts such as bark, stem, leaf, fruit and seed against Gram negative and Gram-positive bacteria, using different solvents for extraction i.e. methanol, ethyl acetate, chloroform, acetone, n. hexane, butanol, petroleum ether and benzene. Since ancient to date most of the countries have been used herbal medicines, but in Asia, some medicinal plants are commonly used in rural and backward areas as a treatment for infectious diseases. In this review, we provide simple information about medicinal plants and Silver nanoparticles with their potentialities such as antiviral, bactericidal and fungicidal. Additionally, the present review to highlights the versatile applications of medicinal plants against honey bee pathogen such as fungi (Ascosphaera apis), mites (Varroa spp. and Tropilaelaps sp.), bacteria (Melissococcus plutonius Paenibacillus larvae), and microsporidia (Nosema apis and Nosema ceranae). In conclusion, promising nonchemical (plant extracts) are innocuous to adult bees. So, we strongly believed that this effort was made to evaluate the status of medicinal plants researches globally.

Potential savings through single-dose intravenous Dalbavancin in long-term MRSA infection treatment - a health economic analysis using German DRG data

Complicated infections such as osteomyelitis, skin and soft tissue infections or endocarditis often require antibiotic therapies that can last up to several weeks. The prolonged hospital length of stay (LOS) leads to a dramatic increase in costs. Single-dose intravenous Dalbavancin is a novel antimicrobial agent for the treatment of acute bacterial skin, skin structure and soft tissue infections (ABSSSI) that allows an earlier discharge of patients, resulting in potential savings. Joint, bone and prostheses infections (JBPI) are also related with long LOS. The aim of this study is to determine the economic effects of single-dose intravenous Dalbavancin in suitable patients with Methicillin-resistant Staphylococcus aureus infections in Germany. For this purpose, an analysis with real-world patient treatment data was performed, which was subsequently validated in a large German hospital. In total, ABSSSI patients with MRSA infections could stay 6.45 days shorter and 2,865 € could be saved while JBPI patients could be discharged eventually 10.6 days earlier and 3,909 € could be saved. Single-dose intravenous Dalbavancin is thus an option for patients with ABSSSI and JBPI who are eligible for discharge.

When to switch to an oral treatment and/or to discharge a patient with skin and soft tissue infections

PURPOSE OF REVIEW

Skin and soft tissue infections prevalence is increasing and represent a frequent cause of hospital admission. New guidelines have become available in order to better define these infections and their response to antimicrobial treatment. Gram-positive bacteria, in particular Staphylococcus aureus, remain the most frequently isolated pathogens in skin and soft tissue infections. To treat complicated forms and infections caused by drug-resistant bacteria, hospital admission and administration of intravenous antibiotics are often required, impacting on healthcare costs and patients' morbidity.

RECENT FINDINGS

New therapeutic options offer efficacy against drug-resistant Gram-positive bacteria as well as potential to favor early patients' discharge, including the possibility for intravenous to oral switch and infrequent drug administration because of prolonged drug half-life. Although data from real-world studies on new antimicrobials is awaited, clinicians need clear direction on how to optimize the treatment of skin and soft tissue infections in order to avoid prolonged hospitalizations and extra costs. Early assessment of patient's clinical conditions and response to treatment appear useful in order to facilitate patients' discharge.

SUMMARY

We have reported the evidence for early intravenous to oral switch and early hospital discharge for patients with skin and soft tissue infections. New therapeutic options that represent promising tools in promoting an optimized management of these infections have also been reviewed.

The optimal duration of treatment for skin and soft tissue infections and acute bacterial skin and skin structure infections

PURPOSE OF REVIEW

To summarize the current finding on SSTIs/ABSSSIs treatment duration.

RECENT FINDINGS

In 2013, the FDA approved the definition of acute bacterial skin and skin structure infections (ABSSSIs). From a clinical point of view, the new definition may present some advantages: the definition of the severity of the disease, the measurement of reduction in lesion size, and effectiveness of treatment primary endpoint at 48-72 h after treatment initiation. New therapeutic options with improved efficacy, safety, and/or pharmacodynamics are available for ABSSSIs and so far, several questions still need to be addressed for the management of these infections, including treatment duration.

SUMMARY

There is a wide variation of duration of antimicrobial treatment in skin and soft tissue infections. Plenty of published data available suggest that we should focus on the early response to shorten duration of treatment, and that the antimicrobial stewardship perspective is extremely helpful in underscoring the need for composite outcomes in clinical practice, as multiple tools are available to increase cost-efficacy, including reduction of treatment changes, early oral switch, early discharge (even from the Emergency Department), outpatient antimicrobial treatment, long-acting antibiotics, and all together, de-escalation treatment strategies.

Early discharge criteria in patients with acute bacterial skin and skin structure infections in a large tertiary-care teaching hospital in Florence, Italy

The study is aimed at retrospectively estimating the percentage of inpatients with severe acute bacterial skin and skin structure infections (ABSSSI) who met the early discharged (ED) criteria adapted from Nathwani et al. (Int J Antimicrob Agents. 2016 Aug;48(2):127-36) and to calculate the number of hospitalization days that could be potentially saved. A retrospective study was conducted in a tertiary care hospital in Florence, Italy. We included all patients admitted for cellulitis and post-surgical infections from 2014 to 2017. Demographic and clinical data were obtained from electronic medical records. We a priori defined the following as a risk factor for non-adherence (RFNA): active or on methadone intravenous drug users, homeless, migrants without health care assistance, and patients who need a caregiver to take prescribed medications. One hundred sixty-two subjects were enrolled. Of them, 94 (58.0%) were male, and 113 (69.7%) had cellulitis/erysipelas. A microbiological isolate was obtained in 51 patients (31.4%); Staphylococcus aureus was the most frequent (47%). Eighty-four (51.8%) were ED suitable, with 258 (49.0%) patient days potentially saved. Among the 78 not ED suitable patients, the most common reason for prolonged length of stay (LOS) was having at least one RFNA (34.6%). Fourteen (18.0%) had one RFNA. Half of the patients admitted in our hospital met the ED criteria with a sparing close to 50% in terms of hospitalization days. Unstable social and personal factors were the most frequent causes for prolonged LOS. In this selected subset of patients, more recent and easier to administer treatments, including long-acting agents, could be proposed.

Open-Label Randomized Trial of Early Clinical Outcomes of Ceftaroline Fosamil Versus Vancomycin for the Treatment of Acute Bacterial Skin and Skin Structure Infections at Risk of Methicillin-Resistant Staphylococcus aureus

Introduction

Acute bacterial skin and skin structure infections (ABSSSIs) remain among the most common infectious processes seen in the clinical setting. For patients with complicated ABSSSIs deemed to require intravenous antibiotics, vancomycin remains the mainstay therapy. Ceftaroline has been shown to be non-inferior to vancomycin and may result in faster resolution of signs of infection.

Methods

Multicenter, prospective, open-label, randomized trial of ceftaroline versus vancomycin for the treatment of adult patients admitted for management of ABSSSIs from April 2012 to May 2016; 166 patients in the clinically evaluable (CE) group were needed to determine a 20% difference in primary outcome of clinical response at day 2 or 3 of antibiotics. Clinical response was defined as cessation of spread of lesion and improvement in systemic signs/symptoms of infection. A secondary outcome was a ≥ 20% reduction in lesion size at day 2 or 3 of antibiotics.

Results

One hundred seventy-four patients were enrolled in the intention-to-treat (ITT) group and 108 were CE. Among CE patients, 54 were randomized to ceftaroline and 54 to vancomycin. Baseline characteristics were similar except patients in the ceftaroline arm were older and had a non-significantly higher degree of comorbidities (median Charlson score 2 vs. 4, respectively). Cellulitis was the most common type of ABSSSI (85.2% vs. 79.6%, respectively). Rapid diagnostic testing of available cultures (n = 55) demonstrated high agreement with clinical microbiology for identification of Staphylococcus aureus (100%) and MRSA (100%). There was no significant difference in primary outcome of day 2 or 3 clinical response (50.0% vs. 51.9%).

Conclusion

Early clinical response between vancomycin- and ceftaroline-treated ABSSSIs was similar. Patients with ABSSSIs rarely remained hospitalized for > 2–3 days, thus limiting our ability to critically assess clinical outcomes.

Trial Registration

ClinicalTrials.gov identifier, NCT02582203.

Funding

Allergan plc.

Treatment of acute bacterial skin and skin structure infection with single-dose dalbavancin in persons who inject drugs

Background

Persons who inject drugs (PWID) are at increased risk of acute bacterial skin and skin structure infections (ABSSSIs), a growing healthcare concern. Multiple medical, social, and economic issues, including adherence and comorbidities, complicate the medical care of the PWID population, adversely affecting patient outcomes.

Methods

We assessed demographics and outcomes for the PWID population in a double-blind trial of 698 patients randomized to dalbavancin 1500 mg as a single intravenous (IV) infusion or as a 2-dose regimen (1000 mg IV on day 1; 500 mg IV on day 8) for ABSSSI. The primary endpoint was ≥20% reduction in erythema at 48–72 hours in the intent-to-treat population; clinical status was also assessed at days 14 and 28.

Results

There were 212/698 (30.4%) patients with a history of injection drug use in this clinical trial. Dalbavancin efficacy was similar between the single- and 2-dose therapy groups in the PWID and non-PWID populations at all timepoints. Dalbavancin was well tolerated in the PWID population, with similar rates of adverse events as the non-PWID population.

Conclusion

Dalbavancin as a single-dose or 2-dose regimen had similar efficacy for the treatment of ABSSSI at all timepoints in the PWID and non-PWID populations. A single 30-minute IV infusion would eliminate the need for indwelling IV access. The convenience of a single dose supervised in a health setting may also optimize treatment adherence in the PWID population.

Role of pharmacists in antimicrobial stewardship programmes

Antimicrobial resistance is a growing public health problem of global concern and, unless action is taken, the burden of death could reach 10 million per year by 2050. Resistance has been associated with increasing mortality, treatment failure and healthcare costs. In order to help combat this, antimicrobial stewardship programmes, have been implemented in many countries. These stewardship programmes can help, reduce inappropriate prescription and broad-spectrum use of antimicrobials, improve, clinical outcomes for the population as a whole, slow down the emergence of antimicrobial resistance and conserve healthcare resources. Pharmacists are an integral part of the stewardship team and have an important role in tackling antimicrobial resistance. This article aims to review the role of pharmacists within antimicrobial stewardship programmes and the opportunities for pharmacist-driven antimicrobial stewardship strategies in hospital and community settings.

Attitudes of physicians from 10 European countries on adherence and how treatment modalities in ABSSSI affect adherence: results from a Delphi survey

To explore the attitudes of European physicians on adherence and how treatment modalities impact adherence in complicated forms of soft skin and skin structure infections, now referred as acute bacterial skin and skin structures infections (ABSSSI). After literature review, a questionnaire was prepared. Topics focused on (1) the importance of adherence, (2) the importance of administration regimen on adherence, (3) the importance of drug selection on adherence, (4) the importance of complexity on choice of drug for treatment, (5) the role of adherence in drug resistance, and (6) the role of adherence in administration of long-acting antibiotics (ABs). The questionnaire was administered to 323 European infectious diseases specialists, of whom 74% responded. A modified Delphi method was used to obtain the highest consensus. Results varied by countries. We found a high degree of agreement of the importance of adherence in ABSSSI treatment. Experts agreed that complexity of patient’s conditions, drug selection, drug resistance, the type of regimen, and the number of infusions impact adherence. Two items linking oral switching and adherence did not reach consensus. Adherence for ABSSSI therapies appears a crucial factor for therapeutic management and reduces the risk of AB resistance. Among new treatment opportunities, long-acting agents, with their characteristics, may represent an interesting options.

In vitro antibacterial effects of statins against bacterial pathogens causing skin infections

With financial considerations impeding research and development of new antibiotics, drug repurposing (finding new indications for old drugs) emerges as a feasible alternative. Statins are extensively prescribed around the world to lower cholesterol, but they also possess inherent antimicrobial properties. This study identifies statins with the greatest potential to be repurposed as topical antibiotics and postulates a mechanism of action for statins' antibacterial activity. Using broth microdilution, the direct antibacterial effects of all seven parent statins currently registered for human use and three selected statin metabolites were tested against bacterial skin pathogens Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Serratia marcescens. Simvastatin and pitavastatin lactone exerted the greatest antibacterial effects (minimum inhibitory concentrations of 64 and 128 μg/mL, respectively) against S. aureus. None of the statins tested were effective against E. coli, P. aeruginosa, or S. marcescens, but simvastatin hydroxy acid acid might be active against S. aureus, E. coli, and S. marcescens at drug concentrations > 256 μg/mL. It was found that S. aureus may exhibit a paradoxical growth effect when exposed to simvastatin; thus, treatment failure at high drug concentrations is theoretically probable. Through structure-activity relationship analysis, we postulate that statins' antibacterial action may involve disrupting the teichoic acid structures or decreasing the number of alanine residues present on Gram-positive bacterial cell surfaces, which could reduce biofilm formation, diminish bacterial adhesion to environmental surfaces, or impede S. aureus cell division.

What is new in the management of skin and soft tissue infections in 2016?

PURPOSE OF REVIEW

Skin and soft tissue infections (SSTIs) are the most frequent infectious cause of referrals to emergency departments and hospital admissions in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology and management of SSTIs.

RECENT FINDINGS

Incidence trends of SSTIs were increasing worldwide with Staphylococcus aureus and streptococci predominating and methicillin-resistant S. aureus (MRSA) posing additional challenges, because of high rates of treatment failure and relapse. Development of new antimicrobials was associated with an appraisal of regulatory definitions and endpoints. Prediction of clinical response can be very tricky, because of variable risk factors for recurrence or treatment failure, depending mostly on the host. Precise indications for new antimicrobials should be established; their integration into clinical practice algorithms may serve reduction of unnecessary admissions, overtreatment and total costs.

SUMMARY

New antimicrobials with activity against MRSA have been recently launched. Long-acting agents, mainly oritavancin and dalbavancin, provide the opportunity of single-dose treatment and early discharge. Further outpatient treatment options include new per os antibiotics such as oxazolidinones. Validated assessment tools are urgently needed to support decision-making toward rational resource utilization and delivery of optimal treatment.

Management of acute bacterial skin and skin structure infections with a focus on patients at high risk of treatment failure

Over the last 25 years, the terminology of skin and soft tissue infections, as well as their classification for optimal management of patients, has changed. The so-called and recently introduced term 'acute bacterial skin and skin structure infections' (ABSSSIs), a cluster of fairly common types of infection, including abscesses, cellulitis, and wound infections, require an immediate effective antibacterial treatment as part of a timely and cautious management. The extreme level of resistance globally to many antibiotic drugs in the prevalent causative pathogens, the presence of risk factors of treatment failure, and the high epidemic of comorbidities (e.g. diabetes and obesity) make the appropriate selection of the antibiotic for physicians highly challenging. The selection of antibiotics is primarily empirical for ABSSSI patients which subsequently can be adjusted based on culture results, although rarely available in outpatient management. There is substantial evidence suggesting that inappropriate antibiotic treatment is given to approximately 20-25% of patients, potentially prolonging their hospital stay and increasing the risk of morbidity and mortality. The current review paper discusses the concerns related to the management of ABSSSI and the patient types who are most vulnerable to poor outcomes. It also highlights the key management time-points that treating physicians and surgeons must be aware of in order to achieve clinical success and to discharge patients from the hospital as early as possible.

Diagnosis and management of skin and soft-tissue infections (SSTI). A literature review and consensus statement: an update

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges. Fourteen members of the Italian Society of Infectious Diseases, after a careful review of the most recent literature using Medline database and their own clinical experience, updated a previous paper published in 2011 by preparing a draught manuscript of the statements. The manuscript was successively reviewed by all members and ultimately re-formulated the present manuscript during a full day consensus meeting. The microbiological and clinical aspects together with diagnostic features were considered for necrotizing and not necrotizing SSTIs in the light of the most recent guidelines and evidences published in the last five years. The antimicrobial therapy was considered as well - both empirical and targeted to methicillin-resistant Staphylococcus aureus and/or other pathogens, also taking into account the epidemiological and bacterial resistance data and the availability of new antibacterial agents.