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Bartoszko JJ, Elias Z, Rudziak P, Lo CKL, Thabane L, Mertz D, Loeb M. Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis. BMJ Open 2022; 12:e063023. [PMID: 36456018 PMCID: PMC9716873 DOI: 10.1136/bmjopen-2022-063023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS). DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies. ELIGIBILITY CRITERIA Pairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest. DATA EXTRACTION AND SYNTHESIS We performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS One randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18-64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors. CONCLUSIONS Treatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors. PROSPERO REGISTRATION NUMBER CRD42020166961.
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Affiliation(s)
- Jessica J Bartoszko
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zeyad Elias
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paulina Rudziak
- Department of Biology, Western University, London, Ontario, Canada
| | - Carson K L Lo
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Stieferman AE, Mazi P, Burnham JP. Severe Skin and Soft-Tissue Infections. Semin Respir Crit Care Med 2022; 43:3-9. [PMID: 35172354 DOI: 10.1055/s-0041-1740974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Skin and soft-tissue infections (SSTIs) are a common reason for hospital admission. Severe SSTIs, particularly necrotizing infections, often require intensive care. Source control (often with surgical debridement) and broad-spectrum antimicrobials are paramount for minimizing significant morbidity and mortality. Rapid diagnostic tests may help in selection and de-escalation of antimicrobials for SSTIs. Besides early source control and early effective antimicrobial therapy, other patient-level factors such as comorbidities and immune status play a role in clinical outcomes. Intravenous immunoglobulin continues to be studied for severe SSTI, though recruitment in trials continues to be an issue. Severe SSTIs are complex to manage, due in part to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. This review includes descriptions of source control, antimicrobial therapies, intravenous immunoglobulin, and hyperbaric oxygen therapy, as well as host factors in severe SSTIs.
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Affiliation(s)
- Addison E Stieferman
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick Mazi
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
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Mull AB, Sharma K, Yu JL, Hsueh K, Moore AM, Fox IK. Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons. Hand (N Y) 2020; 15:45-53. [PMID: 30035635 PMCID: PMC6966281 DOI: 10.1177/1558944718789410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.
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Affiliation(s)
- Aaron B. Mull
- Division of Plastic and Reconstructive
Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ketan Sharma
- Division of Plastic and Reconstructive
Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jenny L. Yu
- Division of Plastic and Reconstructive
Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Hsueh
- Division of Infectious Diseases,
Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Division of Plastic and Reconstructive
Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ida K. Fox
- Division of Plastic and Reconstructive
Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Abstract
PURPOSE OF REVIEW To review the salient features of the management of severe skin and soft tissue infections (SSTIs), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. RECENT FINDINGS For severe SSTIs, intensive care, source control, and broad-spectrum antimicrobials are required for the initial phase of illness. There is an increasing focus on the utility of rapid diagnostic tests to help in selection and de-escalation of antimicrobials for SSTIs. In addition, clinical prediction scores have shown promise in helping predict patients who do not require antimicrobials directed against methicillin-resistant Staphylococcus aureus. Immune status has been shown to be important in clinical outcomes of some, but not all types of SSTIs. The debate for benefits of intravenous immunoglobulin continues to be waged in the recent literature. SUMMARY Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well variations in host immune responses. Unique aspects of care for severe SSTIs are discussed including the role of surgical consultation and source control. The unique features of SSTIs in immunocompromised hosts are also described.
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Hua CZ, Yu H, Xu HM, Yang LH, Lin AW, Lyu Q, Lu HP, Xu ZW, Gao W, Chen XJ, Wang CQ, Jing CM. A multi-center clinical investigation on invasive Streptococcus pyogenes infection in China, 2010-2017. BMC Pediatr 2019; 19:181. [PMID: 31167650 PMCID: PMC6549372 DOI: 10.1186/s12887-019-1536-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 05/14/2019] [Indexed: 12/19/2022] Open
Abstract
Background Invasive S. pyogenes diseases are uncommon, serious infections with high case fatality rates (CFR). There are few publications on this subject in the field of pediatrics. This study aimed at characterizing clinical and laboratory aspects of this disease in Chinese children. Patients and methods A retrospective study was conducted and pediatric in-patients with S. pyogenes infection identified by cultures from normally sterile sites were included, who were diagnosed and treated in 9 tertiary hospitals during 2010–2017. Results A total of 66 cases were identified, in which 37 (56.1%) were male. The median age of these patients, including 11 neonates, was 3.0 y. Fifty-nine (89.4%) isolates were determined from blood. Fever was the major symptom (60/66, 90.9%) and sepsis was the most frequent presentation (64/66, 97.0%, including 42.4% with skin or soft tissue infections and 25.8% with pneumonia. The mean duration of the chief complaint was (3.8 ± 3.2) d. Only 18 (27.3%) patients had been given antibiotics prior to the hospitalization. Among all patients, 15 (22.7%) developed streptococcal toxin shock syndrome (STSS). No S. pyogenes strain was resistant to penicillin, ceftriaxone, or vancomycin, while 88.9% (56/63) and 81.4% (48/59) of the tested isolates were resistant to clindamycin and erythromycin respectively. Most of the patients were treated with β-lactams antibiotics and 36.4% had been treated with meropenem or imipenem. Thirteen (19.7%) cases died from infection, in which 9 (13.6%) had complication with STSS. Conclusions Invasive S. pyogenes infections often developed from skin or soft tissue infection and STSS was the main cause of death in Chinese children. Ongoing surveillance is required to gain a greater understanding of this disease.
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Affiliation(s)
- Chun-Zhen Hua
- Division of Infectious Diseases, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People's Republic of China.
| | - Hui Yu
- Division of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, 201102, People's Republic of China
| | - Hong-Mei Xu
- Division of Infectious Diseases, Chongqing Medical University Affiliated Children's Hospital, Chongqing, 400014, People's Republic of China
| | - Lin-Hai Yang
- Department of Cardiology, Shanxi Children's Hospital, Taiyuan, 030013, People's Republic of China
| | - Ai-Wei Lin
- Division of Infectious Diseases, Qilu Children's Hospital of Shandong University, Jinan, 250022, People's Republic of China
| | - Qin Lyu
- The Intensive Care Unit, Ningbo Women and Children's Hospital, Ningbo, 315012, People's Republic of China
| | - Hong-Ping Lu
- The intensive Care Unit, Taizhou Hospital of Zhejiang Province, Linhai, 317000, People's Republic of China
| | - Zhi-Wei Xu
- Division of Infectious Diseases, The Second Affiliated Hospital &Yuying Children's Hospital of Wenzhou Medicial University, Wenzhou, 325027, People's Republic of China
| | - Wei Gao
- Division of Infectious Diseases, Kaifeng Children's Hospital, Kaifeng, 475000, People's Republic of China
| | - Xue-Jun Chen
- Department of Clinical Laboratory, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People's Republic of China
| | - Chuan-Qing Wang
- Department of Clinical Laboratory, Children's Hospital of Fudan University, Shanghai, 201102, People's Republic of China
| | - Chun-Mei Jing
- Department of Clinical Laboratory, Chongqing Medical University Affiliated Children's Hospital, Chongqing, 400014, People's Republic of China
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