Deep tissue biopsy vs. superficial swab culture, including microbial loading determination, in the microbiological assessment of Skin and Soft Tissue Infections (SSTIs)

Current challenges in acute bacterial skin infection management

PURPOSE OF REVIEW

There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion.

RECENT FINDINGS

SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement.

SUMMARY

SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.

Antibiotic susceptibility patterns at the Médecins Sans Frontières (MSF) Acute Trauma Hospital in Aden, Yemen: a retrospective study from January 2018 to June 2021

Background

Antimicrobial resistance (AMR) is an urgent global health concern, especially in countries facing instability or conflicts, with compromised healthcare systems. Médecins Sans Frontières (MSF) established an acute trauma hospital in Aden, Yemen, treating mainly war-wounded civilians, and implemented an antimicrobial stewardship (AMS) programme. This study aimed to describe clinical characteristics and identify antibiotic susceptibility patterns representative of patients treated with antibiotics.

Methods

Retrospective cross-sectional study using routinely collected data from all patients treated with antibiotics in the MSF-Aden Acute Trauma hospital between January 2018 and June 2021. Routine clinical data from patients' files was entered into an AMS electronic database and microbiological data were entered into WHONET. Both databases were imported and merged in REDCap and analysed using RStudio.

Results

Three hundred and sixty-three of 481 (75%) included patients were injured by violence-related trauma. Most were men aged 19-45 years (n = 331; 68.8%). In total, 598 infections were diagnosed and treated. MDR organisms were identified in 362 (60.5%) infections in 311 (65%) patients. Skin and soft-tissue infections (SSTIs) (n = 143; 24%) were the most common, followed by osteomyelitis (n = 125; 21%) and intra-abdominal-infections (IAIs) (n = 116; 19%), and 111 (19%) secondary bloodstream infections were identified. Escherichia coli was the most frequently identified pathogen, causing IAI (n = 87; 28%) and SSTI (n = 43; 16%), while Staphylococcus aureus caused mainly osteomyelitis (n = 84; 19%). Most Gram-negatives were ESBL producers, including E. coli (n = 193; 81.4%), Klebsiella pneumoniae (n = 72; 77.4%) and Enterobacter cloacae (n = 39; 50%) while most S. aureus were methicillin resistant (n = 93; 72.6%).

Conclusions

High rates of MDR were found. This information will facilitate a comprehensive review of the empirical antibiotic treatment guidelines.

A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases

BACKGROUND

To investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures.

METHODS

The clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients' age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle-hindfoot score.

RESULTS

Patients were followed up for 16-36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12-24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle-hindfoot function score was 40.0 ± 3.8 (range, 30-52) points, and it increased to 75.0 ± 3.0 (range, 67-78) points at the last follow-up.

CONCLUSION

A unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle-hindfoot function, and improves the patient's quality of life.

Das kutane Mikrobiom bei Hautkrebs - Eine systematische Übersicht: The cutaneous microbiome in skin cancer - A systematic review

Die Hautkrebs‐Inzidenz ist über die vergangene halbe Dekade weltweit gestiegen und mit signifikanter Morbidität und Mortalität assoziiert. Jüngste Fortschritte in der molekularen Diagnostik ermöglichen ein besseres Verständnis von Mikrobiom‐Veränderungen bei diesen Erkrankungen. Allerdings ist die Literatur zum kutanen Mikrobiom bei Hautkrebs nach wie vor heterogen und spärlich. Wir führten eine systematische Überprüfung durch, um die bestehende Literatur sowie ihren Nutzen bezüglich mikrobiombasierter Biomarker zu evaluieren. Die Datenbanken (PubMed, Medline, EMBASE, GoogleScholar) wurden zwischen Juni und Juli 2022 in Übereinstimmung mit den PRISMA‐Richtlinien gesichtet.

Insgesamt wurden 1.543 Artikel ermittelt, von denen 16 in die Übersicht eingeschlossen wurden (11 Artikel zu epithelialen Hauttumoren und 5 Artikel zu Melanomen). Bei Plattenepithelkarzinomen (PEKs) und aktinischer Keratose (AK) wird im Vergleich zu gesunder Haut eine erhöhte Prävalenz von Staphylococcus (S.) aureus bei gleichzeitigem Rückgang der kommensalen Organismen festgestellt. Das Mikrobiom des Melanoms scheint sich zwar von dem der gesunden Haut zu unterscheiden, doch stehen nur wenige Daten für aussagekräftige Schlussfolgerungen zur Verfügung.

Die vorliegende Übersicht fasst die aktuellen Erkenntnisse zum Mikrobiom bei epithelialem Hautkrebs und Melanom zusammen. Sie zeigt, dass sich das Mikrobiom bei diesen Erkrankungen von dem gesunder Haut unterscheidet und dass an dieser Dysbiose sowohl pathogene als auch kommensale Organismen beteiligt sind.

The cutaneous microbiome in skin cancer - A systematic review

The overall incidence of skin cancer has risen over the past half a decade worldwide and is associated with significant morbidity and mortality. Recent advances in molecular testing have allowed us to better characterize microbiome alterations in skin cancer. However, literature specific to skin microbiome and skin cancer remain heterogenous and scattered. A systematic review was performed to identify the existing literature and its usefulness in providing microbiome-based biomarkers. A search of the databases (PubMed, Medline, EMBASE, GoogleScholar) was conducted from June to July 2022 in accordance with the PRISMA guidelines. A total of 1,543 articles were identified, of which 16 were selected for inclusion in the review (11 articles on cancer of the keratinocytes and 5 articles on melanoma). Increased Staphylococcus (S.) aureus prevalence with decline in commensal organisms is seen in squamous cell carcinoma (SCC) and actinic keratosis (AK), compared to healthy skin. While the microbiome of melanoma appears to be distinct from healthy skin, limited data is available to draw meaningful conclusions. Our review summarizes the current evidence on the microbiome of keratinocyte skin cancers and melanoma. The study establishes that the microbiome of these cancers is altered from healthy skin and that this dysbiosis involves both pathogenic and commensal organisms.

Wound swabs versus biopsies to detect methicillin resistant Staphylococcus aureus in experimental equine wounds

OBJECTIVE

To compare: (1) the load and diversity of cultivatable bacterial species isolated from tissue biopsies with cultures from surface swabs, and (2) the ability of each technique to detect methicillin-resistant Staphylococcus aureus (MRSA) in a model of MRSA-infected equine wounds.

STUDY DESIGN

Experimental in vivo study.

ANIMALS

Three light-breed adult horses.

METHODS

Four 2.5 × 2.5 cm full-thickness skin wounds were created on the dorsolateral aspect of each forelimb. Five days later, each wound was inoculated with a pure culture of MRSA (ATCC 43300). One hundred microlitres of 0, 5 × 108 , 5 × 109 or 5 × 1010 colony forming units (CFU)/ml was used to inoculate each wound. Surface swabs (Levine technique) and tissue biopsy samples (3 mm punch biopsy) were obtained at 2, 7, 14, and 21 days after inoculation. Quantitative aerobic culture was performed using routine clinical techniques.

RESULTS

A similar bacterial profile was identified from the culture of each wound-sampling technique and there was moderate correlation (R = 0.49, P < .001) between the bacterial bioburdens. Agreement was fair (κ = 0.31; 95% CI, 0.129-0.505) between the sampling techniques in identification of MRSA. Methicillin-resistant Staphylococcus aureus was isolated more frequently (P = .016) from cultures of tissue biopsies (79%; 76/96) than from surface swabs (62%; 60/96).

CONCLUSION

Bacterial load and diversity did not differ between sampling techniques but MRSA was detected more often from the cultures of tissue biopsies.

CLINICAL SIGNIFICANCE

Tissue biopsy should be preferred to culture swab in wounds where MRSA is suspected.

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients

BACKGROUND

Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites.

MATERIALS AND METHODS

We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue.

RESULTS

A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries.

DISCUSSION AND CONCLUSIONS

From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.

Evaluation of Bacteria and Fungi DNA Abundance in Human Tissues

Whereas targeted and shotgun sequencing approaches are both powerful in allowing the study of tissue-associated microbiota, the human: microorganism abundance ratios in tissues of interest will ultimately determine the most suitable sequencing approach. In addition, it is possible that the knowledge of the relative abundance of bacteria and fungi during a treatment course or in pathological conditions can be relevant in many medical conditions. Here, we present a qPCR-targeted approach to determine the absolute and relative amounts of bacteria and fungi and demonstrate their relative DNA abundance in nine different human tissue types for a total of 87 samples. In these tissues, fungi genomes are more abundant in stool and skin samples but have much lower levels in other tissues. Bacteria genomes prevail in stool, skin, oral swabs, saliva, and gastric fluids. These findings were confirmed by shotgun sequencing for stool and gastric fluids. This approach may contribute to a more comprehensive view of the human microbiota in targeted studies for assessing the abundance levels of microorganisms during disease treatment/progression and to indicate the most informative methods for studying microbial composition (shotgun versus targeted sequencing) for various samples types.

Comparison of bacteriologic culture results for skin wound swabs and skin wound biopsy specimens

OBJECTIVE

To compare bacteriologic culture results for superficial swab and tissue biopsy specimens obtained from dogs with open skin wounds.

ANIMALS

52 client-owned dogs.

PROCEDURES

For each dog, 1 wound underwent routine preparation prior to collection of 2 specimens, 1 by superficial swab (Levine) technique and 1 by tissue biopsy. Specimens were processed for bacteriologic culture. Two observers determined whether any detected difference in culture results for the 2 types of specimen would have resulted in differing treatment plans.

RESULTS

Culture results of swab and tissue biopsy specimens were identical in 11/52 (21.2%) cases. Tissue biopsy specimen and swab cultures yielded positive results for 44 (84.6%) and 40 (76.9%) wounds, respectively. With regard to mean recovery rates of bacteria from wounds with positive culture results, both the biopsy specimens and swabs yielded 3.4 bacterial species/wound. All wounds for which swab cultures yielded no growth also had negative culture results for biopsy specimens. Biopsy specimen and swab culture results were in agreement with regard to the most common bacteria cultured. In 7/52 (13%) wounds, the observers would have treated the patient differently on the basis of the results of the 2 cultures.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that culture of a swab collected by the Levine technique is an appropriate noninvasive alternative to culture of a tissue biopsy specimen. A negative result obtained from culture of a swab is likely to be reliable. Disagreement between the results of swab and tissue biopsy specimen cultures is likely of low clinical importance.

The influence of microclimate conditions on ozone disinfection efficacy in working places

In recent years, the sanitization of environments, devices, and objects has become mandatory to improve human and environmental safety, in addition to individual protection and prevention measures. International studies considered ozone one of the most useful and easy sanitization methods for indoor environments, especially hospital environments that require adequate levels of disinfection. The purpose of this work was to evaluate the microclimate influence on sanitizing procedure for indoor settings with ozone, to prevent infections and ensure the safe use of the environments. The concentration of ozone was measured during sanitization treatment and estimation of microorganisms' survival on the air and different contaminated plates after the sanitization operations were performed. The results demonstrated a significant reduction in the microbial count that always fell below the threshold value in different conditions of distance, temperature, and relative humidity.

Lower Respiratory Tract Pathogens and Their Antimicrobial Susceptibility Pattern: A 5-Year Study

Lower respiratory tract infections (LRTIs) are the most common infections in humans. It is estimated that 2.74 million deaths worldwide occur each year due to LRTIs. The aim of the study was to determine the frequency and antibiotic susceptibility pattern of microorganisms isolated from respiratory samples of patients with LRTIs. Between January 2015 and December 2019, a total of 7038 sputum and bronchoaspirate samples from suspected LRTI patients were collected. Among them, 2753 samples (39.1%) showed significant microbial growth on culture media. The LRTI rate was higher in patients with male gender (67.1%) and with age between 40–59 years (48.6%). The microorganism identification and antibiotic susceptibility testing were performed with Vitek 2. Out of 4278 isolates species, 3102 (72.5%) were Gram-negative bacteria, 1048 (24.5%) were Gram-positive bacteria, and 128 (3.0%) were Candida spp. Major microorganisms isolated were Acinetobacter baumannii (18.6%), Staphylococcus aureus (15.2%), Pseudomonas aeruginosa (14.2%), and Klebsiella pneumoniae (10.9%). In antimicrobial susceptibility testing, Staphylococcus aureus isolates were mostly resistant to Penicillin G (84.1%) and Oxacillin (48.1%), whereas they demonstrated maximum sensitivity to Tigecycline (100%) and Linezolid (99.5%). Among Gram-negative isolates, Acinetobacter baumannii showed maximum sensitivity to Colistin but was resistant to other antibiotics (95–99%). Klebsiella pneumoniae isolates were mostly resistant to Cefotaxime (72.7%) and sensitive to Gentamicin (54.3%), and Pseudomonas aeruginosa was resistant to Ciprofloxacin (40.3%) and sensitive to Amikacin (85.9%). Gram-negative bacteria represented the species most commonly isolated. A high rate of antimicrobial resistance was observed in this study. In conclusion, the correct identification of causative microorganisms and their susceptibility patterns to antibiotics is crucial for choosing targeted and effective antibiotic therapy in LRTIs, and to prevent the emergence of multidrug-resistant bacteria.

Effectiveness of ultrasonic debridement on reduction of bacteria and biofilm in patients with chronic wounds: A scoping review

Chronic wounds are defined as “hard‐to‐heal” wounds that are caused by disordered mechanisms of wound healing. Chronic wounds have a high risk of infection and can form biofilms, leading to the release of planktonic bacteria, which causes persistent infections locally or remotely. Therefore, infection control and removal of the biofilm in chronic wounds are essential. Recently, ultrasonic debridement was introduced as a new method to reduce infection and promote the healing of chronic wounds. This scoping review aimed to evaluate the effectiveness of ultrasonic debridement on the changes in bacteria and biofilms, and consequently the wound healing rate of chronic wounds. A total of 1021 articles were identified through the database search, and nine papers were eligible for inclusion. Findings suggest that non‐contact devices are useful for wound healing as they reduce the inflammatory response, although the bacterial load is not significantly changed. Ultrasonic debridement devices that require direct contact with the wound promote wound healing through reduction of biofilm or bacterial load. The optimum settings for ultrasonic debridement using a non‐contact device are relatively consistent, but the settings for devices that require direct contact are diverse. Further studies on ultrasonic debridement in chronic wounds are required.

What's new in the epidemiology of skin and soft tissue infections in 2018?

PURPOSE OF REVIEW

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

RECENT FINDINGS

Staphylococcus aureus and streptococci predominate and methicillin-resistant S. aureus (MRSA) poses additional challenges; community-acquired-MRSA in some areas is superseding methicillin-susceptible S. aureus and multidrug resistance is evolving. Incidence data of SSTIs from United States show a decreasing trend, whereas trends of hospitalization rates were increasing. Despite low mortality associated with SSTIs, high rates of treatment failure and relapses are of concern. Diagnosis and management decisions in the emergency department (ED) lack validated tools for prediction of clinical response particularly among elderly, immunocompromised, obese, and patients with comorbidities. A variety of modifiable and nonmodifiable risk factors of the host and data from local epidemiology should be considered to prevent recurrence and treatment failure.

SUMMARY

An evolving epidemiology of SSTIs make microbiologic documentation and surveillance of local data imperative. New assessment algorithms with potential use in the ED are a priority. The universal applicability of international guidelines is questioned in this setting.

The what, when and how in performing and interpreting microbiological diagnostic tests in skin and soft tissue infections

PURPOSE OF REVIEW

To summarize and classify the most recent and relevant microbiological studies for each type of skin and soft tissue infection (SSTI).

RECENT FINDINGS

Following Infectious Diseases Society of America and Food and Drug Administration classifications of SSTIs, we differentiate between two large groups, the superficial or uncomplicated infections and the complicated infections with deep involvement. It is not usually necessary to obtain microbiological samples in uncomplicated infections, except in cases of recurrences or for epidemiological control purposes. In the case of complicated infections, the samples are of two different types: those obtained from the affected area (surgical samples, punctures of abscesses or swabs) and systemic samples (i.e. blood cultures). The clinical condition also determines the type of samples to be obtained. In cases of systemic involvement, blood cultures are mandatory. For immunocompromised patients, who may present atypical infections, detection of antigens, serologies or molecular biology techniques may be helpful. The rapid diagnosis is currently the goal to be pursued by implementing techniques such as matrix assisted laser desorption ionization-time of flight, commercial real-time PCR or the promising metagenomics.

SUMMARY

Microbiological diagnosis is one of the cornerstones of the management of SSTIs. Prompt obtaining and processing of the necessary samples, depending on the clinical situation of the patient, is of relevance in the decision-making process. Rapid and fluid reporting of the results (identification, mechanisms of resistance and antibiogram) will improve the management of these patients.

Management of bacterial skin and skin structure infections with polymicrobial etiology

INTRODUCTION

Skin and Soft Tissue Infections (SSTIs) are some of the most commonly occurring bacterial infections, with a wide range of possible etiological pathogens and a considerable variety of clinical presentations and severity; from mild to severe life-threatening infections. Several classifications have been proposed based on a specific variable, such as anatomical localization, skin extension, progression rate, clinical presentation, severity, and etiological agent. Areas covered: The last criteria allows the differentiation of SSTIs as monomicrobial and polymicrobial. Among them, especially those infections with a long lasting or chronic course can be sustained by multiple microbial etiology. Most polymicrobial SSTIs can be included in the following: diabetes foot infections (DFIs), pressure ulcers infection, burn infection, and infected chronic ulcers. Expert commentary: The medical management of these infections comprises the administration of wide a spectrum antibiotic, taking into consideration the frequent occurrence of multidrug resistant microorganisms as responsible agents. An appropriate deep tissue specimen for microbiological examination is a very important issue, especially for polymicrobial infections, sometimes permitting the distinction between real pathogens and contaminants avoiding more complex antibiotic treatments. This aspect must be strongly emphasized, as frequently superficial swabs remain the specimen of choice because they are easy to obtain.

Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry

Skin and soft tissue infections (SSTIs) represent a wide range of clinical conditions characterized by a considerable variety of clinical presentations and severity. Their aetiology can also vary, with numerous possible causative pathogens. While other authors previously published analyses on several types of SSTI and on restricted types of patients, we conducted a large nationwide surveillance programme on behalf of the Italian Society of Infectious and Tropical Diseases to assess the clinical and microbiological characteristics of the whole SSTI spectrum, from mild to severe life-threatening infections, in both inpatients and outpatients. Twenty-five Infectious Diseases (ID) Centres throughout Italy collected prospectively data concerning both the clinical and microbiological diagnosis of patients affected by SSTIs via an electronic case report form. All the cases included in our database, independently from their severity, have been managed by ID specialists joining the study while SSTIs from other wards/clinics have been excluded from this analysis. Here, we report the preliminary results of our study, referring to a 12-month period (October 2016-September 2017). During this period, the study population included 254 adult patients and a total of 291 SSTI diagnoses were posed, with 36 patients presenting more than one SSTIs. The type of infection diagnosed, the aetiological micro-organisms involved and some notes on their antimicrobial susceptibilities were collected and are reported herein. The enrichment of our registry is ongoing, but these preliminary results suggest that further analysis could soon provide useful information to better understand the national epidemiologic data and the current clinical management of SSTIs in Italy.

Dalbavancin in the treatment of different gram-positive infections: a real-life experience

Dalbavancin is a lipoglycopeptide with a very prolonged half-life enabling treatment with a single intravenous administration that has been approved to treat complicated skin and soft-tissue infections. Information on the efficacy and safety of dalbavancin in other situations is very scarce. This retrospective study included adult patients who received at least one dose of dalbavancin between 2016 and 2017 in 29 institutions in Spain. The primary objective was to report the use of dalbavancin in clinical practice, including its efficacy and tolerability. The potential impact of dalbavancin on reducing the length of hospital stay and hospital costs was also evaluated. A total of 69 patients received dalbavancin during the study period (58.0% male; median age 63.5 years). Dalbavancin was used to treat prosthetic joint infection (29.0%), acute bacterial skin and skin-structure infection (21.7%), osteomyelitis (17.4%) and catheter-related bacteraemia (11.6%). These infections were mainly caused by Staphylococcus aureus (27 isolates), coagulase-negative staphylococci (24 isolates) and Enterococcus spp. (11 isolates). All but two patients received previous antibiotics for a median of 18 days. Dalbavancin was administered for a median of 21 days (range 7-168 days), and concomitant antimicrobial therapy was prescribed to 25 patients (36.2%). The overall clinical success rate of dalbavancin was 84.1%. Adverse events, mainly mild in intensity, were reported in nine patients. Overall, dalbavancin was estimated to reduce hospitalisation by 1160 days, with an estimated overall cost reduction of €211 481 (€3064 per patient). Dalbavancin appears to be an effective therapy for many serious Gram-positive infections.

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.