Practice guidelines for the diagnosis and management of skin and soft-tissue infections

Measuring the Direct Medical Costs of Hospital-Onset Infections Using an Analogy Costing Framework

BACKGROUND

The majority of recent estimates on the direct medical cost attributable to hospital-onset infections (HOIs) has focused on device- or procedure-associated HOIs. The attributable costs of HOIs that are not associated with device use or procedures have not been extensively studied.

OBJECTIVE

We developed simulation models of attributable cost for 16 HOIs and estimated the total direct medical cost, including nondevice-related HOIs in the USA for 2011 and 2015.

DATA AND METHODS

We used total discharge costs associated with HOI-related hospitalization from the National Inpatient Sample and applied an analogy costing methodology to develop simulation models of the costs attributable to HOIs. The mean attributable cost estimate from the simulation analysis was then multiplied by previously published estimates of the number of HOIs for 2011 and 2015 to generate national estimates of direct medical costs.

RESULTS

After adjusting all estimates to 2017 US dollars, attributable cost estimates for select nondevice-related infections attributable cost estimates ranged from $7661 for ear, eye, nose, throat, and mouth (EENTM) infections to $27,709 for cardiovascular system infections in 2011; and from $8394 for EENTM to $26,445 for central nervous system infections in 2016 (based on 2015 incidence data). The national direct medical costs for all HOIs were $14.6 billion in 2011 and $12.1 billion in 2016. Nondevice- and nonprocedure-associated HOIs comprise approximately 26-28% of total HOI costs.

CONCLUSION

Results suggest that nondevice- and nonprocedure-related HOIs result in considerable costs to the healthcare system.

No role for standard imaging workup of patients with clinically evident necrotizing soft tissue infections: a national retrospective multicenter cohort study

PURPOSE

To assess the diagnostic contribution of different imaging studies to diagnose necrotizing soft tissue infections (NSTIs) and the time to surgery in relation to imaging with the hypothesis that imaging studies may lead to significant delays without being able to sufficiently dismiss or confirm the diagnosis since a NSTI is a surgical diagnosis.

METHODS

A retrospective multicenter cohort study of all NSTI patients between 2010 and 2020 was conducted. The primary outcome was the number of cases in which imaging contributed to or led to change in treatment. The secondary outcomes were time to treatment determined by the time from presentation to surgery and patient outcomes (amputation, intensive care unit (ICU) admission, length of ICU stay, hospital stay, and mortality).

RESULTS

A total of 181 eligible NSTI patients were included. The overall mortality was 21% (n = 38). Ninety-eight patients (53%) received imaging in the diagnostic workup. In patients with a clinical suspicion of a NSTI, 81% (n = 85) went directly to the operating room and 19% (n = 20) underwent imaging before surgery; imaging was contributing in only 15% (n = 3) by ruling out or determining underlying causes. In patients without a clinical suspicion of a NSTI, the diagnosis of NSTI was considered in 35% and only after imaging was obtained.

CONCLUSION

In patients with clinically evident NSTIs, there is no role for standard imaging workup unless it is used to examine underlying diseases (e.g., diverticulitis, pancreatitis). In atypical presenting NSTIs, CT or MRI scans provided the most useful information. To prevent unnecessary imaging and radiation and not delay treatment, the decision to perform imaging studies in patients with a clinical suspicion of a NSTI must be made extremely careful.

Severe Bullous Erysipelas/Cellulitis, Atypically Caused by Escherichia coli, in Kidney Transplant Recipient - Case Report and Review of Literature

Erysipelas/cellulitis are severe skin infections that are especially dangerous for immunocompromised patients. The most common cause of these diseases is streptococcal infection, but sometimes they may be caused by other Gram-positive or negative bacteria or other factors. Proper diagnosis and treatment should be implemented accurately to prevent dangerous complications. We present a case of severe bullous erysipelas caused by Escherichia coli and discuss the diagnosis, differential diagnosis, and treatment of cellulitis in kidney transplant patients.

The diagnostic accuracy of Gram stain on formalin-fixed paraffin-embedded sections of skin tissue in the diagnosis of bacterial skin infection

BACKGROUND AND OBJECTIVE

To evaluate the sensitivity, specificity, and likelihood ratios of Gram stain on formalin-fixed, paraffin-embedded (GS-FFPE) sections of skin in diagnosing bacterial skin infection.

METHODS

We reviewed a retrospective series of skin specimens reported at our institution wherein histopathological assessment included Gram stain and fresh tissue was concurrently submitted for microscopy and culture. The clinicopathological correlation was the reference standard, whereby the presence of infection was deduced from the final diagnosis in each patient's case notes.

RESULTS

Our sample included 168 cases (105 positive for infection). GS-FFPE showed a sensitivity of 0.43 (95% confidence interval 0.29, 0.57), a specificity of 0.98 (0.95, 1.01), a positive likelihood ratio of 21.50 (19.76, 23.24), and a negative likelihood ratio of 0.58 (0.41, 0.75).

CONCLUSIONS

GS-FFPE has poor sensitivity, and a negative result should not be used as evidence to exclude infection. In contrast, it has excellent specificity and, unless the pretest probability of infection is very low, a positive result would make infection much more likely. The value of the GS-FFPE lies in cases where sterile tissue was not submitted for microbiological studies, or sterile tissue culture was negative, and there is at least a low-to-moderate pretest probability of infection.

Impact of Subarachnoid Hemorrhage in Ventriculostomy-Related Infections Prospective Comparison of Two Neurosurgical Injury Contexts

BACKGROUND

Long thought to be immune privileged, the central nervous system is far from being devoid of local immunity. Subarachnoid hemorrhage (SAH) and traumatic brain injury represent 2 distinct central nervous system injury situations which, while both exposed to external ventricular drains, present different incidences of ventriculostomy-related infection (VRI). We sought to compare VRI incidence and initial cerebrospinal fluid (CSF) inflammatory profiles in these 2 clinical situations.

METHODS

From 2015 to 2020, 227 patients treated for SAH (193) or traumatic brain injury (34) with an external ventricular drain were prospectively included. CSF samples were sent daily for microbiological examination, cell count, and biochemical analysis. VRI was defined as a positive CSF culture associated with CSF profile modifications and clinical signs. Ventriculostomy-related colonization was defined as positive catheter culture at removal. Positive events were defined as VRI and/or ventriculostomy-related colonization.

RESULTS

Eleven patients suffered from VRI, with an incidence of 3.6 VRI per 1000 catheter-days. All VRIs occurred among SAH patients without a significant difference. Median duration of drainage was 12 (7-18) days, there were no significant differences for known VRI risk factors. Positive events were significantly higher in SAH patients (20.7% vs. 2.9%, P = 0.013). Inflammatory CSF markers and serum white blood cells were higher in SAH patients.

CONCLUSIONS

Local inflammatory markers were markedly higher in SAH than in traumatic brain injury. However, positive events were more frequent in SAH. Furthermore, SAH may be a risk factor for VRI. Hypothesis that a primary injury to the subarachnoid space could impair central nervous system immune functions should be explored.

Bacterial Skin and Soft Tissue Infections in Older Adults

This article focuses on bacterial infections that commonly affect geriatric patients. The elderly population is at a higher risk of contracting bacterial infections due to weakened immune systems and comorbidities. The article explores the cause, pathogenesis, clinical manifestations, and treatment options of these infections. Additionally, antibiotic resistance is a growing concern in the treatment of bacterial infections. The article highlights the importance of preventing these infections through proper hygiene and wound care. This article aims to provide an understanding of bacterial infections in geriatric patients and inform health-care providers on the most effective ways to manage and prevent these infections.

Transferosomes stabilized hydrogel incorporated rhodomyrtone-rich extract from Rhodomyrtus tomentosa leaf fortified with phosphatidylcholine for the management of skin and soft-tissue infections

Rhodomyrtus tomentosa leaf (RT)-incorporated transferosomes were developed with lecithin and cholesterol blends with edge activators at different ratios. RT-transferosomes were characterized and employed in transferosomal gel formulations for the management of skin and soft-tissue infections. The optimized formulation entrapped up to 81.90 ± 0.31% of RT with spherical vesicles (405.3 ± 2.0 nm), polydispersity index value of 0.16 ± 0.08, and zeta potential of - 61.62 ± 0.86 mV. Total phenolic and flavonoid contents of RT-transferosomes were 15.65 ± 0.04 μg GAE/g extract and 43.13 ± 0.91 μg QE/g extract, respectively. RT-transferosomes demonstrated minimum inhibitory and minimum bactericidal concentrations at 8-256 and 64-1024 μg/mL, respectively. Free radical scavenging assay showed RT-transferosomes with high scavenging activity against DPPH and ABTS radicals. Moreover, RT-transferosomes demonstrated moderate activity against mushroom tyrosinase, with IC50 values of 245.32 ± 1.32 μg/mL. The biocompatibility results against L929 fibroblast and Vero cells demonstrated IC50 at 7.05 ± 0.17 and 4.73 ± 0.13 μg/mL, respectively. In addition, nitric oxide production significantly decreased by 6.78-88.25% following the treatment with 31.2-500 ng/mL RT-transferosomes (p < 0.001). Furthermore, the freeze-thaw stability study displayed no significant change in stability in the sedimentation and pH of gel fortified with RT-transferosomes. The results suggested that RT-transferosome formulation can be effectively employed as natural biomedicines for scar prevention and the management of skin soft-tissue infections.

Musculoskeletal infections through direct inoculation

Musculoskeletal infections consist of different clinical conditions that are commonly encountered in daily clinical settings. As clinical findings and even laboratory tests cannot always be specific, imaging plays a crucial role in the diagnosis and treatment of these cases. Musculoskeletal infections most commonly occur secondary to direct inoculation into the skin involuntarily affected by trauma, microorganism, foreign bodies, or in diabetic ulcers; direct infections can also occur from voluntary causes due to surgery, vaccinations, or other iatrogenic procedures. Hematogenous spread of infection from a remote focus can also be a cause for musculoskeletal infections. Risk factors for soft tissue and bone infections include immunosuppression, old age, corticosteroid use, systemic illnesses, malnutrition, obesity, and burns. Most literature discusses musculoskeletal infections according to the diagnostic tools or forms of infection seen in different soft tissue anatomical planes or bones. This review article aims to evaluate musculoskeletal infections that occur due to direct inoculation to the musculoskeletal tissues, by focusing on the traumatic mechanism with emphasis on the radiological findings.

Assessment of antibiotic release and antibacterial efficacy from pendant glutathione hydrogels using ex vivo porcine skin

Acute bacterial skin and skin structure infections (ABSSSIs) confer a substantial burden on the healthcare system. Local antibiotic delivery systems can provide controlled drug release directly to the site of infection to maximize efficacy and minimize systemic toxicity. The purpose of this study was to examine the antibacterial activity of antibiotic-loaded glutathione-conjugated poly(ethylene glycol) hydrogels (GSH-PEG) against ABSSSIs utilizing an ex vivo porcine dermal explant model. Vancomycin- or meropenem-loaded GSH-PEG hydrogels at 3 different dose levels were loaded over 1 h. Drug release was monitored in vitro under submerged conditions, by the Franz cell diffusion method, and ex vivo utilizing a porcine dermis model. Antibacterial activity was assessed ex vivo on porcine dermis explants inoculated with Staphylococcus aureus or Pseudomonas aeruginosa isolates treated with vancomycin- or meropenem-loaded GSH-PEG hydrogels, respectively. Histological assessment of the explants was conducted to evaluate tissue integrity and viability in the context of the experimental conditions. A dose-dependent release was observed from vancomycin and meropenem hydrogels, with in vitro Franz cell diffusion data closely representing ex vivo vancomycin release, but not high dose meropenem release. High dose vancomycin-loaded hydrogels resulted in a >3 log10 clearance against all S. aureus isolates at 48 h. High dose meropenem-loaded hydrogels achieved 6.5, 4, and 2 log10 reductions in CFU/ml against susceptible, intermediate, and resistant P. aeruginosa isolates, respectively. Our findings demonstrate the potential application of GSH-PEG hydrogels for flexible, local antibiotic delivery against bacterial skin infections.

Investigating Photoactive Antimicrobials as Alternatives (or Adjuncts) to Traditional Therapy

Photodynamic therapy (PDT) is an established therapy used for the treatment of cutaneous skin cancers and other non-infective ailments. There has been recent interest in the opportunity to use aPDT (antimicrobial PDT) to treat skin and soft tissue infections. PDT utilizes photosensitizers that infiltrate all cells and "sensitize" them to a given wavelength of light. The photosensitizer is simply highly absorbent to a given wavelength of light and when excited will produce, in the presence of oxygen, damaging oxygen radicals and singlet oxygen. Bacterial cells are comparatively poor at combatting oxidative stress when compared with human cells therefore a degree of selective toxicity can be achieved with aPDT.In this chapter, we outline methodologies for testing aPDT in vitro using standard lab equipment.

Imaging of MSK infections in the ER

Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.

Factors influencing patient experience during incision and drainage procedures in hidradenitis suppurativa: an analysis of patient-reported outcomes

Patients with hidradenitis suppurativa who undergo incision and drainage experience higher levels of dread and lower levels of benefit due to poor anaesthesia and wound packing practices, and lower levels of provider compassion. Higher levels of dread were associated with increased pain during incision (coefficient 0.3, 95% CI 0.19–0.42) and wound packing or drain vs. simple bandaging (coefficient 2.25, 95% CI 0.61–3.90). Higher perceived benefits over drawbacks were associated with higher physician compassion (coefficient 0.21, 95% CI 0.06–0.36) and decreased pain during incision (coefficient 0.14, 95% CI 0.03–0.27).

Risk Factors for Predicting Mortality and Amputation of Patients with Necrotizing Soft-Tissue Infections: Retrospective Analysis of 111 Cases from a Single Medical Center

Objective

Necrotizing soft-tissue infections (NSTIs) are rare clinical infections with surgical emergencies having a high mortality rate. This study aimed to investigate risk factors for mortality and amputation of patients with NSTI.

Methods

We retrospectively analyzed critical factors for outcomes of 111 patients with NSTI hospitalized in our department from 1 January 1999 to 31 December 2018. NSTI diagnosis was based on the patient's clinical characteristics, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, laboratory test data, and microbiological findings in blood and wound culture. The risk factors for mortality and amputation of NSTI were determined using univariate or multivariate logistic regression analysis, receiver operating characteristics (ROC), and the area under the ROC curve (AUC) at 90 days after admission.

Results

Diagnosis of 111 patients with NSTI was confirmed according to clinical features, LRINEC score, image data, laboratory findings, and microorganism culture in blood and wounds. The mortality rate was 9.91% (11/111) at day 90 follow-up. High white blood cell (WBC), low hematocrit (HCT), and multiple surgeries were identified to be critical risk factors for NSTI mortality in univariate and multivariate logistic analyses. AUCs, 95% confidence intervals (CI), and P values of risk factors were 0.699, 0.54-0.95, and P = 0.0117 for high WBC; 0.788, 0.63-0.97, and P = 0.0006 for low HCT; and 0.745, 0.59-0.90, and P = 0.0018 for multiple surgeries, respectively. These patients also had high LRINEC scores. Amputation occurred in 34.23% (38/111) of patients. Risk factors for amputation were higher age, low hemoglobin (Hb), and multiple wounds. AUCs, 95% confidence intervals (CI), and P values were 0.713, 0.11-0.32, and P < 0.0001 for higher age; 0.798, 0.08-0.29, and P=0.0007 for low Hb; and 0.757, 0.17-0.34, and P  < 0.0001 for multiple lesion sites, respectively.

Conclusions

High LRINEC scores, high WBC, low HCT, and multiple surgeries were relevant to increased mortality. Higher age, low Hb, and multiple wounds were associated with amputation risk. These clinical features must be paid attention to when patients are diagnosed with NSTI.

Animal Bite Injuries to the Face: A Retrospective Evaluation of 111 Cases

The treatment of bite wounds to the face is discussed controversially in relation to surgery and antibiotics. The aim of this study is a retrospective evaluation of 111 cases of animal bite injuries to the face that presented to our unit of oral and maxillofacial surgery over a 13-year period. Children under 10 years of age were predominantly involved. A total of 94.5% of the assessed injuries were caused by dogs. Wound infections occurred in 8.1%. Lackmann type II was the most common type of injury (36.9%). The perioral area was affected most frequently (40.5%). Primary wound closure was carried out in 74.8% of the cases. In 91.9% of the cases, antibiotic prophylaxis was prescribed. The most often administered type of antibiotic was amoxicillin with clavulanic acid (62.1%). Patients without antibiotics showed an increased infection rate without significance. Wound infections occurred significantly more frequently in wounds to the cheeks (p = 0.003) and when local flap reconstruction was necessary (p = 0.048). Compared to the other surgical treatment options, primary closure showed the lowest infection rates (4.8%, p = 0.029). We recommend antibiotic prophylaxis using amoxicillin with clavulanic acid and wound drains for wounds of Lackmann class II or higher. Primary closure seems to be the treatment of choice whenever possible.

Battle of the milky way: Lymphatic targeted drug delivery for pathogen eradication

Many viruses, bacteria, and parasites rely on the lymphatic system for survival, replication, and dissemination. While conventional anti-infectives can combat infection-causing agents in the bloodstream, they do not reach the lymphatic system to eradicate the pathogens harboured there. This can result in ineffective drug exposure and reduce treatment effectiveness. By developing effective lymphatic delivery strategies for antiviral, antibacterial, and antiparasitic drugs, their systemic pharmacokinetics may be improved, as would their ability to reach their target pathogens within the lymphatics, thereby improving clinical outcomes in a variety of acute and chronic infections with lymphatic involvement (e.g., acquired immunodeficiency syndrome, tuberculosis, and filariasis). Here, we discuss approaches to targeting anti-infective drugs to the intestinal and dermal lymphatics, aiming to eliminate pathogen reservoirs and interfere with their survival and reproduction inside the lymphatic system. These include optimized lipophilic prodrugs and drug delivery systems that promote lymphatic transport after oral and dermal drug intake. For intestinal lymphatic delivery via the chylomicron pathway, molecules should have logP values >5 and long-chain triglyceride solubilities >50 mg/g, and for dermal lymphatic delivery via interstitial lymphatic drainage, nanoparticle formulations with particle size between 10 and 100 nm are generally preferred. Insight from this review may promote new and improved therapeutic solutions for pathogen eradication and combating infective diseases, as lymphatic system involvement in pathogen dissemination and drug resistance has been neglected compared to other pathways leading to treatment failure.

Design and Characterization of Citronella Oil-Loaded Micro-Emulgel for the Treatment of Candida Albicans Infection

The purpose of the current study was to prepare and evaluate a citronella oil-loaded microemulsion-based micro-emulgel for the treatment of Candida albicans. The primary objective was to use the skin to transfer hydrophobic medications into the bloodstream. The formulation included cinnamon oil as an antifungal oil and citronella oil as an active pharmaceutical ingredient, respectively. Tween 80 and PEG 200 were used as the surfactant and co-surfactant, respectively, to create phase diagrams. Carbopol 940, one of the frequently used polymers, was investigated for its ability to prepare gel formulations. The optimized (F3) batch contained the highest percentage (87.05 ± 0.03%) of drug content and, according to the statistics provided, had the highest drug release rate of around 87.05% within 4 h. The Korsmeyer-Peppas model with n value of 0.82, which is in the range 0.5-1, had the highest r2 value, indicating that release following non-Fickian/anomalous diffusion provided a better dimension for all of the formulations. The optimized (F3) formulation had stronger antifungal activity in comparison to other formulations. This leads to the conclusion that citronella oil can be made into a micro-emulgel, which may improve its release in aqueous systems while maintaining a high level of drug release at the target site.

Severe skin infections

PURPOSE OF REVIEW

The incidence of necrotizing soft-tissue infections (NSTI) has increased during recent decades. These infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. This review will focus on practical approaches to management of NSTI focusing on antibiotic therapies and optimizing the management of group A streptococcus (GAS)-associated NSTIs.

RECENT FINDINGS

Antibiotic therapy for NSTI patients faces several challenges as the rapid progression of NSTIs mandates broad-spectrum agents with bactericidal action. Current recommendations support using clindamycin in combination with penicillin in case of GAS-documented NSTIs. Linezolide could be an alternative in case of clindamycin resistance.

SUMMARY

Reducing the time to diagnosis and first surgical debridement, initiating early broad-spectrum antibiotics and early referral to specialized centres are the key modifiable factors that may impact the prognosis of NSTIs. Causative organisms vary widely according to the topography of the infection, underlying conditions, and geographic location. Approximately one third of NSTIs are monomicrobial, involving mainly GAS or Staphylococcus aureus . Data for antibiotic treatment specifically for necrotizing soft-tissue infections are scarce, with guidelines mainly based on expert consensus.

Pediatric Long Bone Fractures After Dog Bites: A Case Series and Systematic Review

This study presents a case series and systematic review of pediatric patients who sustained long bone fractures following dog bites. A systematic review of the studies on "pediatric fracture dog bite" based on a search of PubMed and OVID Medline databases was performed by adhering to PRISMA guidelines. Articles in English describing pediatric long bone fractures due to dog bites were included. Studies not differentiating pediatric from adult patients and not describing long bone fractures due to dog bites were excluded. Study characteristics, fracture epidemiology, management decisions, and follow-up data were extracted. Additionally, a seven-year retrospective chart review of cases treated at our level one pediatric trauma center was performed. Data on fracture characteristics, surgical management, choice of antibiotic therapy, and follow-up were collected. Five studies that met our criteria were analyzed. Pediatric long bone fractures from dog bites were identified in 0.35% (11/3,156) of patients. Such fractures most commonly involved the upper extremity (9/11, 82%). None of the studies described the choice of antibiotics, surgical decision-making, or wound closure preference for an underlying fracture. Our chart review elicited three cases of long bone fractures due to dog bites. Pediatric long bone fractures after dog bites are a rare injury pattern in the United States. These injuries should be treated as contaminated open fractures, and urgent immunization, intravenous antibiotic administration, wound care, and fracture stabilization should be provided. We recommend meticulous surgical debridement in the operating room, as wounds often probe deep into the bone. Nevertheless, there is much that remains unclear about these injuries. Hence, further research with greater power is needed to improve treatment decisions.

Chronic Diarrhea Due to Aeromonas hydrophila in an Immunosuppressed Patient with a Pancreas-Kidney Transplant

The genus Aeromonas belongs to the Aeromonadaceae family. A patient with a pancreas-kidney transplant had multiple episodes of abdominal sepsis after surgery. Aeromonas hydrophila was isolated in the ascitic and biliary fluid drains. After discharge, the patient had several diarrhea episodes, and A. hydrophila was isolated in four stool samples. We decided to test whether the one strain that we initially isolated in ascitic fluid was the same that appeared in the successive stool samples. Five isolates of A. hydrophila were found in the patient. Identification was performed using the MALDI-TOF system and confirmed via multiplex PCR. The analysis of the REP-PCR fingerprint patterns showed one cluster and confirmed that all isolates were related. We also demonstrated the virulent character of this species associated with genes encoding different toxins (act, alt, ast, hlyA, and aerA). The virulence of this species is associated with the expression of genes that encode different toxins, structural proteins, and metal-associated proteins. This case report highlights the severity of this disease, especially in immunocompromised patients, and its adequate treatment.

Evaluation of Poly(vinyl alcohol)-Xanthan Gum Hydrogels Loaded with Neomycin Sulfate as Systems for Drug Delivery

In recent years, multidrug-resistant bacteria have developed the ability to resist multiple antibiotics, limiting the available options for effective treatment. Raising awareness and providing education on the appropriate use of antibiotics, as well as improving infection control measures in healthcare facilities, are crucial steps to address the healthcare crisis. Further, innovative approaches must be adopted to develop novel drug delivery systems using polymeric matrices as carriers and support to efficiently combat such multidrug-resistant bacteria and thus promote wound healing. In this context, the current work describes the use of two biocompatible and non-toxic polymers, poly(vinyl alcohol) (PVA) and xanthan gum (XG), to achieve hydrogel networks through cross-linking by oxalic acid following the freezing/thawing procedure. PVA/XG-80/20 hydrogels were loaded with different quantities of neomycin sulfate to create promising low-class topical antibacterial formulations with enhanced antimicrobial effects. The inclusion of neomycin sulfate in the hydrogels is intended to impart them with powerful antimicrobial properties, thereby facilitating the development of exceptionally efficient topical antibacterial formulations. Thus, incorporating higher quantities of neomycin sulfate in the PVA/XG-80/20-2 and PVA/XG-80/20-3 formulations yielded promising cycling characteristics. These formulations exhibited outstanding removal efficiency, exceeding 80% even after five cycles, indicating remarkable and consistent adsorption performance with repeated use. Furthermore, both PVA/XG-80/20-2 and PVA/XG-80/20-3 formulations outperformed the drug-free sample, PVA/XG-80/20, demonstrating a significant enhancement in maximum compressive stress.

Hacking the Immune Response to Solid Tumors: Harnessing the Anti-Cancer Capacities of Oncolytic Bacteria

Oncolytic bacteria are a classification of bacteria with a natural ability to specifically target solid tumors and, in the process, stimulate a potent immune response. Currently, these include species of Klebsiella, Listeria, Mycobacteria, Streptococcus/Serratia (Coley's Toxin), Proteus, Salmonella, and Clostridium. Advancements in techniques and methodology, including genetic engineering, create opportunities to "hijack" typical host-pathogen interactions and subsequently harness oncolytic capacities. Engineering, sometimes termed "domestication", of oncolytic bacterial species is especially beneficial when solid tumors are inaccessible or metastasize early in development. This review examines reported oncolytic bacteria-host immune interactions and details the known mechanisms of these interactions to the protein level. A synopsis of the presented membrane surface molecules that elicit particularly promising oncolytic capacities is paired with the stimulated localized and systemic immunogenic effects. In addition, oncolytic bacterial progression toward clinical translation through engineering efforts are discussed, with thorough attention given to strains that have accomplished Phase III clinical trial initiation. In addition to therapeutic mitigation after the tumor has formed, some bacterial species, referred to as "prophylactic", may even be able to prevent or "derail" tumor formation through anti-inflammatory capabilities. These promising species and their particularly favorable characteristics are summarized as well. A complete understanding of the bacteria-host interaction will likely be necessary to assess anti-cancer capacities and unlock the full cancer therapeutic potential of oncolytic bacteria.

The Identification and Treatment of Common Skin Infections

Skin conditions are a common problem addressed by medical providers. Up to 25% of individuals in the United States will seek attention for these conditions each year. The same problem occurs in the athletic training room, where athletes with infectious skin conditions can be seen. Most conditions are simple and can be treated without concern for spread to susceptible athletes. However, others can be quite serious and spread rapidly through a team and opponents during competition. Knowledge of the different types of skin infections is necessary to help treat these athletes and prevent spread to others. With proper diagnosis and treatment, certified athletic trainers can keep the athlete off the field of play for a minimum period and prevent transmission.

Neutrophil (dys)function due to altered immuno-metabolic axis in type 2 diabetes: implications in combating infections

Metabolic and inflammatory pathways are highly interdependent, and both systems are dysregulated in Type 2 diabetes (T2D). T2D is associated with pre-activated inflammatory signaling networks, aberrant cytokine production and increased acute phase reactants which leads to a pro-inflammatory 'feed forward loop'. Nutrient 'excess' conditions in T2D with hyperglycemia, elevated lipids and branched-chain amino acids significantly alter the functions of immune cells including neutrophils. Neutrophils are metabolically active cells and utilizes energy from glycolysis, stored glycogen and β-oxidation while depending on the pentose phosphate pathway for NADPH for performing effector functions such as chemotaxis, phagocytosis and forming extracellular traps. Metabolic changes in T2D result in constitutive activation and impeded acquisition of effector or regulatory activities of neutrophils and render T2D subjects for recurrent infections. Increased flux through the polyol and hexosamine pathways, elevated production of advanced glycation end products (AGEs), and activation of protein kinase C isoforms lead to (a) an enhancement in superoxide generation; (b) the stimulation of inflammatory pathways and subsequently to (c) abnormal host responses. Neutrophil dysfunction diminishes the effectiveness of wound healing, successful tissue regeneration and immune surveillance against offending pathogens. Hence, Metabolic reprogramming in neutrophils determines frequency, severity and duration of infections in T2D. The present review discusses the influence of the altered immuno-metabolic axis on neutrophil dysfunction along with challenges and therapeutic opportunities for clinical management of T2D-associated infections.

Recent Advances in Pharmaceutical Approaches of Antimicrobial Agents for Selective Delivery in Various Administration Routes

Globally, the increase of pathogenic bacteria with antibiotic-resistant characteristics has become a critical challenge in medical treatment. The misuse of conventional antibiotics to treat an infectious disease often results in increased resistance and a scarcity of effective antimicrobials to be used in the future against the organisms. Here, we discuss the rise of antimicrobial resistance (AMR) and the need to combat it through the discovery of new synthetic or naturally occurring antibacterial compounds, as well as insights into the application of various drug delivery approaches delivered via various routes compared to conventional delivery systems. AMR-related infectious diseases are also discussed, as is the efficiency of various delivery systems. Future considerations in developing highly effective antimicrobial delivery devices to address antibiotic resistance are also presented here, especially on the smart delivery system of antibiotics.

How to manage skin and soft-tissue infections in the emergency department

PURPOSE OF REVIEW

Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures.

RECENT FINDINGS

Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods.

SUMMARY

The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.

The effect of duration of antimicrobial treatment for bacteremia in critically ill patients on in-hospital mortality - Retrospective double center analysis

PURPOSE

Excessive duration of antibiotic treatment is a major factor for inappropriate antibiotic consumption. Although in some instances shorter antibiotic courses are as efficient as longer ones, no specific recommendations as to the duration of antimicrobial treatment for bloodstream infections currently exist. In the present study, we investigated the effect of antibiotic treatment duration on in-hospital mortality using retrospective data from two cohorts that included patients with bacteremia at two Swiss tertiary Intensive Care Units (ICUs).

MATERIALS AND METHODS

Overall 8227 consecutive patients requiring ICU admission were screened for bacteremia between 01/2012-12/2013 in Lausanne and between 07/2016-05/2017 in Bern. Patients with an infection known to require prolonged treatment or having single positive blood culture with common contaminant pathogens were excluded. The primary outcome of interest was the time from start of antimicrobial treatment to in-hospital death or hospital discharge, whichever comes first. The predictor of interest was adequate antimicrobial treatment duration, further divided into shorter (≤10 days) and longer (>10 days) durations. A time-dependent Cox model and a cloning approach were used to address immortality bias. The secondary outcomes were the median duration of antimicrobial treatment for patients with bacteremia overall and stratified by underlying infectious syndrome and pathogens in the case of secondary bacteremia.

RESULTS

Out of the 707 patients with positive blood cultures, 382 were included into the primary analysis. Median duration of antibiotic therapy was 14 days (IQR, 7-20). Most bacteremia (84%) were monomicrobial; 18% of all episodes were primary bacteremia. Respiratory (28%), intra-abdominal (23%) and catheter infections (17%) were the most common sources of secondary bacteremia. Using methods to mitigate the risk of confounding associated with antibiotic treatment durations, shorter versus longer treatment groups showed no differences in in-hospital survival (time-dependent Cox-model: HR 1.5, 95% CI (0.8, 2.7), p = 0.20; Cloning approach: HR 1.0, 95% CI (0.7,1.5) p = 0.83). Sensitivity analyses showed that the interpretation did not change when using a 7 days cut-off.

CONCLUSIONS

In this restrospective study, we found no evidence for a survival benefit of longer (>10 days) versus shorter treatment course in ICU patients with bacteremia.

TRIAL REGISTRATION

The study was retrospectively registered on clinicatrials.gov (NCT05236283), 11 February 2022. The respective cantonal ethics commission (KEK Bern # 2021-02302) has approved the study.

Gas-Producing Infections in the Foot at a Large Academic Medical Center: A 10-Year Retrospective Review

Gas-producing infections, such as clostridial and nonclostridial gas gangrene, crepitant cellulitis, and necrotizing fasciitis, are characterized in the literature by a variety of initial presentations, microbial burdens and surgical outcomes-ranging from debridement to amputation to death. The primary aim of this study was to identify the organisms cultured in gas-producing infections of the foot in patients that presented to a large academic medical center over a 10-year period. Our secondary aims were to report the prevalence of sepsis in this population upon presentation, and patient outcomes upon discharge. After a retrospective chart review of 207,534 procedures, 70 surgical cases met inclusion criteria. The most common organisms that grew in operating room cultures were Staphylococcus aureus, Group B Beta Streptococcus, and Enterococcus species. Just over half of the population presented with sepsis. After an average of 2 or more operations, 64% of patients underwent amputation. One death occurred. Gas-producing infections, or "gas gangrene," are primarily polymicrobial infections, rarely due to Clostridium perfringens, that warrant surgical exploration for optimal outcomes.

Population Pharmacokinetic and Pharmacokinetic/Pharmacodynamic Target Attainment Analyses for Dalbavancin in Pediatric Patients

BACKGROUND

Dalbavancin, approved for the treatment of pediatric and adult patients with acute bacterial skin and skin structure infections, has a terminal half-life of >14 days allowing administration as a single-dose regimen.

METHODS

We developed a population pharmacokinetic (PK) model using 1124 dalbavancin concentrations from 211 pediatric patients, with allometric scaling of clearance and volume parameter exponents fixed at 0.75 and 1, respectively. Serum albumin was included as a covariate on all PK parameters; creatinine clearance or estimated glomerular filtration rate was a covariate on clearance. The final model, qualified by visual predictive checks and bootstrapping, was used to simulate 1000 PK profiles for a range of pediatric age groups. PK/pharmacodynamic target attainment (PTA) was calculated for targets associated with stasis, 1-log kill, and 2-log kill of Staphylococcus aureus (neutropenic murine thigh infection model).

RESULTS

Dalbavancin PK was well characterized by a three-compartment model. No additional significant covariates were identified. Simulations showed that single-dose (30-minute intravenous infusion) regimens of 22.5 mg/kg (patients <6 years) and 18 mg/kg (patients 6 years to <18 years) resulted in PTA ≥94% for minimal inhibitory concentrations ≤2 mg/L and ≤0.5 mg/L for the stasis and 2-log kill targets, respectively. PTA for pediatric patients was similar to adults with exposures within the range for adults administered 1500 mg dalbavancin.

CONCLUSION

Dalbavancin PK in pediatric patients was well characterized by a three-compartment model. Simulations with the final model demonstrated adequate PTA across the entire age range for the approved pediatric dalbavancin doses.

Marine biological injuries and their medical management: A narrative review

The marine environment can be extremely dangerous, and the harm caused by marine organisms when they contact the human body can be especially harmful, even deadly. Contact includes stings, bites, wounds, and consumption as food. In this article, the characteristics of the common marine biological injuries are summarized, the major marine organisms causing damage in China’s marine waters are described, and injury prevention and treatment methods are discussed.

Management of dog bite wounds: Our protocol and experience with early surgical intervention

Dog bites injuries are a significant cause of morbidity and mortality. Conventionally, it was suggested to leave the wounds open due to probable increased risk of infections and occurrence of rabies with suturing.Recent publications indicate that primary closure does not necessarily affect the chances of infection but definitely helps in improving the quality of scar. We are presenting our experience and protocol for primary closure of all dog bite wounds. From March 2020 to February 2021, 10 consecutive patients of all ages coming to the emergency of our hospital with category 3 dog bite that penetrated the epidermis and dermis and presenting within 48 hours of injury were included. Every patient was administered first dose of anti rabies vaccine (ARV) (zero dose) for active immunisation and was also given injection tetanus intramuscularly. Mean age of patients in our study was 20.9 with range from 2 years to 90 years. Only 2/10 patients developed infections which were managed conservatively with drainage of abscess and antibiotics. Rest all patients recovered without complications. Primary closure of dog bite wounds when associated with debridement, sufficient irrigation, povidine iodine cleansing and antibiotic administration resulted in improved cosmetic appearance without increase in the rate of infection.

Mathematical model and stability analysis on the transmission dynamics of skin sores

In this study, a non-linear deterministic model for the transmission dynamics of skin sores (impetigo) disease is developed and analysed by the help of stability of differential equations. Some basic properties of the model including existence and positivity as well as boundedness of the solutions of the model are investigated. The disease-free and endemic equilibrium were investigated, as well as the basic reproduction number, R₀, also calculated using the next-generation matrix approach. When R₀ < 1, the model's stability analysis reveals that the system is asymptotically stable at disease-free critical point globally as well as locally. If R₀ > 1, the system is asymptotically stable at disease-endemic equilibrium both locally and globally. The long-term behaviour of the skin sores model's steady-state solution in a population is investigated using numerical simulations of the model.

Hanitsch L, Krüger R, K. Lindner A, S. Stegemann M, Nurjadi D. Skin Infections Due to Panton-Valentine Leukocidin-Producing S. Aureus

BACKGROUND

Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus (PVL-SA) strains are frequently associated with large, recurring abscesses in otherwise healthy young individuals. The typical clinical presentation and the recommended diagnostic evaluation and treatment are not widely known.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to international recommendations.

RESULTS

PVL-SA can cause leukocytolysis and dermatonecrosis through specific cell-wall pore formation. Unlike other types of pyoderma, such conditions caused by PVL-SA have no particular site of predilection. In Germany, the PVL gene can be detected in 61.3% (252/411) of skin and soft tissue infections with S. aureus. Skin and soft tissue infections with PVL-SA recur three times as frequently as those due to PVL-negative S. aureus. They are diagnosed by S. aureus culture from wound swabs and combined nasal/pharyngeal swabs, along with PCR for gene detection. The acute treatment of the skin abscesses consists of drainage, followed by antimicrobial therapy if needed. Important secondary preventive measures include topical cleansing with mupirocin nasal ointment and whole-body washing with chlorhexidine or octenidine. The limited evidence (level IIb) concerning PVL-SA is mainly derived from nonrandomized cohort studies and experimental analyses.

CONCLUSION

PVL-SA skin infections are easily distinguished from other skin diseases with targeted history-taking and diagnostic evaluation.

Canine Saliva as a Possible Source of Antimicrobial Resistance Genes

While the One Health issues of intensive animal farming are commonly discussed, keeping companion animals is less associated with the interspecies headway of antimicrobial resistance. With the constant advance in veterinary standards, antibiotics are regularly applied in companion animal medicine. Due to the close coexistence of dogs and humans, dog bites and other casual encounters with dog saliva (e.g., licking the owner) are common. According to our metagenome study, based on 26 new generation sequencing canine saliva datasets from 2020 and 2021 reposited in NCBI SRA by The 10,000 Dog Genome Consortium and the Broad Institute within Darwin’s Ark project, canine saliva is rich in bacteria with predictably transferable antimicrobial resistance genes (ARGs). In the genome of potentially pathogenic Bacteroides, Capnocytophaga, Corynebacterium, Fusobacterium, Pasteurella, Porphyromonas, Staphylococcus and Streptococcus species, which are some of the most relevant bacteria in dog bite infections, ARGs against aminoglycosides, carbapenems, cephalosporins, glycylcyclines, lincosamides, macrolides, oxazolidinone, penams, phenicols, pleuromutilins, streptogramins, sulfonamides and tetracyclines could be identified. Several ARGs, including ones against amoxicillin–clavulanate, the most commonly applied antimicrobial agent for dog bites, were predicted to be potentially transferable based on their association with mobile genetic elements (e.g., plasmids, prophages and integrated mobile genetic elements). According to our findings, canine saliva may be a source of transfer for ARG-rich bacteria that can either colonize the human body or transport ARGs to the host bacteriota, and thus can be considered as a risk in the spread of antimicrobial resistance.

Compartment syndrome as a novel complication of extended spectrum beta lactamase Escherichia coli necrotising soft tissue infection – A case report

Introduction and importance

Necrotising soft tissue infections (NSTI) encompass a group of destructive soft tissue disease processes which can involve skin, subcutaneous tissue, fascia and or muscle, associated with rapid spread along tissue planes and mortality. Clinical presentations include progressive pain, suppuration/necrosis and systemic toxicity with haemodynamic instability. While diagnosis is based on clinical findings it can be augmented with imaging. Treatment is typically in the form of resuscitation, immediate administration of broad spectrum intravenous antibiotics and urgent source control through radical surgical debridement.

Case presentation

An 82-year-old man presented with left forearm/hand pain and fevers in the context of immunocompromise. Examination found tense swelling of the left volar and dorsal forearm and hand, absent distal pulses with pain and paraesthesia over both surfaces. He underwent surgical debridement with fasciotomy and remained in intensive care with blood cultures revealing ESBL E. coli.

Clinical discussion

Compartment syndrome is a rare complication of NSTI and its clinical presentation can obscure early diagnosis. ESBL E. coli is an uncommon pathogen to cause monomicrobial infection and must be accounted for when considering broad spectrum empirical antibiotic cover.

Conclusion

Review of this case and the literature show a rare presentation of NSTI and highlights the importance of early diagnosis based on even a small index of suspicion. It also shows the key significance rationalisation of antibiotics as soon as practicable, given that even broad spectrum empirical cover can be inappropriate in the context of novel microorganisms, particularly in high risk patients.

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First recorded case of monomicrobial ESBL E. coli compartment syndrome

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ESBL E. coli NSTI is rare and not covered by many empirical antimicrobial guidelines.

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Compartment syndrome secondary to NSTI is uncommon and associated with streptococci.

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Early recognition and prompt management are essential to prognosis.

The combination of diethyldithiocarbamate and copper ions is active against Staphylococcus aureus and Staphylococcus epidermidis biofilms in vitro and in vivo

Staphylococcus aureus and Staphylococcus epidermidis are associated with life-threatening infections. Despite the best medical care, these infections frequently occur due to antibiotic resistance and the formation of biofilms of these two bacteria (i.e., clusters of bacteria embedded in a matrix). As a consequence, there is an urgent need for effective anti-biofilm treatments. Here, we describe the antibacterial properties of a combination treatment of diethyldithiocarbamate (DDC) and copper ions (Cu²⁺) and their low toxicity in vitro and in vivo. The antibacterial activity of DDC and Cu²⁺ was assessed in vitro against both planktonic and biofilm cultures of S. aureus and S. epidermidis using viability assays, microscopy, and attachment assays. Cytotoxicity of DDC and Cu²⁺ (DDC-Cu²⁺) was determined using a human fibroblast cell line. In vivo antimicrobial activity and toxicity were monitored in Galleria mellonella larvae. DDC-Cu²⁺ concentrations of 8 μg/ml DDC and 32 μg/ml Cu²⁺ resulted in over 80% MRSA and S. epidermidis biofilm killing, showed synergistic and additive effects in both planktonic and biofilm cultures of S. aureus and S. epidermidis, and synergized multiple antibiotics. DDC-Cu²⁺ inhibited MRSA and S. epidermidis attachment and biofilm formation in the xCELLigence and Bioflux systems. In vitro and in vivo toxicity of DDC, Cu²⁺ and DDC-Cu²⁺ resulted in > 70% fibroblast viability and > 90% G. mellonella survival. Treatment with DDC-Cu²⁺ significantly increased the survival of infected larvae (87% survival of infected, treated larvae vs. 47% survival of infected, untreated larvae, p < 0.001). Therefore, DDC-Cu²⁺ is a promising new antimicrobial with activity against planktonic and biofilm cultures of S. epidermidis and S. aureus and low cytotoxicity in vitro. This gives us high confidence to progress to mammalian animal studies, testing the antimicrobial efficacy and safety of DDC-Cu²⁺.

Etiology, clinical features, management, and outcomes of skin and soft tissue infections in hospitalized children: A 10-year review

PURPOSE

This study aimed to describe the etiology, clinical features, hospital course, and outcomes of hospitalized children with skin and soft tissue infections (SSTIs) and to test if clinical and laboratory variables at admission could differentiate between community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and community-acquired methicillin-sensitive S. aureus (CA-MSSA).

METHODS

We reviewed the clinical, laboratory, treatment, and outcome data for children hospitalized with SSTIs, aged 0-18 years at MacKay Children's Hospital between 2010 and 2019. Multivariable logistic regression was used to identify independent predictors of CA-MRSA and CA-MSSA SSTIs.

RESULTS

A total of 1631 patients were enrolled. Erysipelas/cellulitis (73.8%) was the most common pediatric SSTI type, followed by acute lymphadenitis (13.6%) and abscess/furuncle/carbuncle (8.6%). Among the 639 culture-positive isolates (purulent SSTIs), 142 (22.2%) were CA-MSSA and 363 (56.8%) were CA-MRSA. The age group 0-1 month (OR, 6.52; 95% CI 1.09-38.92; P = 0.04) and local lymph node reaction (OR, 2.47; 95% CI 1.004-6.08; P = 0.049) were independent factors for differentiating children with CA-MSSA from those with CA-MRSA SSTIs. MRSA isolates in our cohort were highly susceptible to glycopeptides (100%), linezolid (100%), daptomycin (100%), and sulfamethoxazole/trimethoprim (98.6%) but were significantly less susceptible to clindamycin compared with MSSA (34.2% vs. 78.2%, P < 0.001).

CONCLUSION

S. aureus is the leading pathogen of culture-proven SSTIs in hospitalized children with MRSA accounting for more than half. Determining the optimal empirical antibiotics in CA-SSTIs may rely on the patient's age, disease severity, and local epidemiologic data.

Antibiotics and Carbohydrate-Containing Drugs Targeting Bacterial Cell Envelopes: An Overview

Certain bacteria constitute a threat to humans due to their ability to escape host defenses as they easily develop drug resistance. Bacteria are classified into gram-positive and gram-negative according to the composition of the cell membrane structure. Gram-negative bacteria have an additional outer membrane (OM) that is not present in their gram-positive counterpart; the latter instead hold a thicker peptidoglycan (PG) layer. This review covers the main structural and functional properties of cell wall polysaccharides (CWPs) and PG. Drugs targeting CWPs are discussed, both noncarbohydrate-related (β-lactams, fosfomycin, and lipopeptides) and carbohydrate-related (glycopeptides and lipoglycopeptides). Bacterial resistance to these drugs continues to evolve, which calls for novel antibacterial approaches to be developed. The use of carbohydrate-based vaccines as a valid strategy to prevent bacterial infections is also addressed.

Effect of New 2-Thioxoimidazolidin-4-one Compounds against Staphylococcus aureus Clinical Strains and Immunological Markers’ Combinations

Although the structure-activity relationship indicates that the 4-thioxoimidazolidin ring is essential for antibacterial activities and pharmaceutical applications, there were no enough studies on the derivatives of this compound. Evaluating the new hydantoin compounds C5 (3-((2-bromobenzylidene) amino)-2- thioxoimidazolidin-4-one) and C6 (3-((4- methoxybenzylidene) amino)-2-thioxoimidazolidin-4-one) that were prepared against clinical Staphylococcus aureus isolates for antibacterial, antibiofilm, and antihemagglutination activities is the aim of this study. Therefore, the potential clinical resistance of the strains was evaluated by their ability to form biofilms, antibiotic resistance, and agglutinate erythrocytes macroscopically and microscopically; besides, the bacterial biofilm was screened for any association with the patient's serum immunoglobulin levels and complements. Despite the effective concentration for C5 and C6 compounds, which is ≤ 31.25 μg/ml, the reduction rate is not concentration-dependent; it depends on the molecular docking of the hydantoin compounds. Hence, the effect of the minimal inhibitory concentrations (MICs) is variable. In this study, the results for the compounds (with the concentration of 31.25–62.5 μg/mL for C5 and 62.5–125 μg/mL for C6) significantly manifest the antibacteria, antibiofilm, and antihemagglutination effects against the virulent strains of S. aureus due to the high percentage of biofilm inhibition that was caused by the new hydantoin compounds. Besides, time-kill kinetics studies showed that these compounds pose bactericidal action. Overall, this study revealed that the new hydantoin derivatives have an interesting potential as new antibacterial drugs through the inhibition of bacterial adhesion. The infections of these isolates activate the complement system through the lectin pathway. Nevertheless, these compounds can be improved in order to be used at even lower concentrations.

Clinical efficacy and safety of linezolid in intensive care unit patients

Background

To characterize the population of critically ill patients and infections treated with linezolid in the intensive care unit (ICU), and to evaluate the clinical efficacy and safety of linezolid therapy.

Methods

This multi-center, observational, real-world study was conducted across 52 hospitals between June 9, 2018, and December 28, 2019. Patients who met the following inclusion criteria were included: (1) admitted to the ICU, (2) of any age group, and (3) having a clinical or laboratory diagnosis of a Gram-positive bacterial infection. Clinical efficacy was categorized as success (cured or improved), failed, or non-evaluable. Adverse events and serious adverse events were recorded during treatment.

Results

A total of 366 ICU patients who met the inclusion criteria were evaluated. Linezolid was used as second- and first-line treatment in 232 (63.4%) and 134 (36.6%) patients, respectively. The most common isolated strain was Staphylococcus aureus (methicillin-resistant Staphylococcus aureus: n=37/119, 31.1%; methicillin-susceptible Staphylococcus aureus: n=15/119, 12.6%); this was followed by Enterococci (vancomycin-resistant Enterococci: n=8/119, 6.7%; vancomycin-susceptible Enterococci: n=11/119, 9.2%) and Streptococcus pneumoniae (multidrug-resistant: n=4/119, 3.4%; non-multidrug resistant: n=2/119, 1.7%). The main infection sites where pathogens were detected included the lung (n=216/366, 59.6%), skin and soft tissue (n=104/366, 28.4%), and blood (n=50/366, 13.7%). Clinical success was achieved in 301 (82.2%) patients; 34 (9.3%) were cured and 267 (73.0%) improved; treatment failure and non-evaluable outcomes were observed in 29 (7.9%) in 36 (9.8%) patients, respectively. Linezolid-related adverse events were reported in 8 (2.2%) patients. No treatment-related serious adverse events were reported.

Conclusions

Based on real-world results, linezolid was found to be effective and safe in the treatment of Gram-positive bacterial infections in critically ill patients.

Factors leading to dissemination of cutaneous anthrax: an international ID-IRI study

Background

Although anthrax is a rare zoonotic infection, it still causes significant mortality and morbidity. In this multicenter study, which is the largest anthrax case series ever reported, we aimed to describe the factors leading to dissemination of cutaneous anthrax.

Methods

Adult patients with cutaneous anthrax from 16 referral centers were pooled. The study had a retrospective design, and included patients treated between January 1, 1990 and December 1, 2019. Probable, and confirmed cases based upon CDC anthrax 2018 case definition were included in the study. A descriptive statistical analysis was performed for all variables.

Results

A total of 141 cutaneous anthrax patients were included. Of these, 105 (74%) patients had probable and 36 (26%) had confirmed diagnosis. Anthrax meningitis and bacteremia occurred in three and six patients, respectively. Sequelae were observed in three patients: cicatricial ectropion followed by ocular anthrax (n = 2) and movement restriction on the left hand after surgical intervention (n = 1). One patient had gastrointestinal anthrax. The parameters related to poor outcome (p < 0.05) were fever, anorexia, hypoxia, malaise/fatigue, cellulitis, fasciitis, lymphadenopathy, leukocytosis, high CRP and creatinine levels, longer duration of antimicrobial therapy, and combined therapy. The last two were seemingly the consequences of dissemination rather than being the reasons. The fatality rate was 1.4%.

Conclusions

Rapid identification of anthrax is crucial for prompt and effective treatment. Systemic symptoms, disseminated local infection, and high inflammatory markers should alert the treating physicians for the dissemination of the disease.

Potential of propolis antifungal activity for clinical applications

The high incidence of skin diseases of microbial origin along with the widespread increase of microbial resistance demand for therapeutic alternatives. Research on natural compounds has been opening new perspectives for the development of new therapies with health positive impacts. Propolis, a resinous mixture produced by honeybees from plant exudates, is widely used as a natural medicine since ancient times, mainly due to its antimicrobial properties. More recently, antioxidant, anti-tumor, anti-inflammatory, hepatoprotective and immunomodulatory activities were also reported for this natural product, highlighting its high potential pharmacological interest. In the present work, an extensive review of the main fungi causing skin diseases as well as the effects of natural compounds, particularly propolis, against such disease-causing microorganisms was organized and compiled in concise handy tables. This information allows to conclude that propolis is a highly effective antimicrobial agent suggesting that it could be used as an alternative skin treatment against pathogenic microorganisms and also as a cosmeceutic component or as a source of bioactive ingredients.

Risk Factors Associated with Surgical Site Infection following Cesarean Section in Tertiary Care Hospital, Nepal

Background

Cesarean section (CS) is one of the most performed surgeries in obstetrics. Surgical site infection is the major cause of morbidity and mortality causing an increase in the duration of hospitalization as well as the cost of admission for the patient.

Objective

To determine incidence of surgical site infection following cesarean section, classify them according to CDC criteria, and identify the different risk factors. Methodology. This is a case-control study conducted at the Department of Obstetrics and Gynecology at Tribhuvan University Teaching Hospital (TUTH), main campus of Institute of Medicine (IOM), Kathmandu, Nepal. Surgical site infections (SSI) in patients who underwent cesarean sections from February 2019 to August 2019 were taken as cases, while the patients who underwent cesarean section before or after the procedure and did not develop SSI comprised the controls. Visual inspection during ward rounds, reports from laboratory, and postprocedure follow-ups for up to 30 days formed the basis of identifying infections on the patients. Risk factors were identified by bivariate and multivariate logistic regression.

Results

Out of 1135 cases of cesarean sections, 97 of them developed SSI with incidence rate of 8.54%. Among them, 94.85% were superficial incisional and 5.15% were deep incisional type of SSI with no organ space type. Cases had higher mean age 26.88 ± 4.38 years compared to 24.81 ± 5.08 years in controls. Host-related risk factors which led to higher odds of developing surgical site infection (SSI) were obesity with adjusted odds ratio (AOR) 15.72 (confidence interval (CI): 4.60-53.67), diabetes/hypertension in pregnancy with AOR 4.75(CI 1.69-13.32), and other medical diseases with AOR 9.38 (CI 2.89-30.46). Duration of the rupture of membrane for more than 18 hours with AOR 8.38 (CI 1.48-47.35), more than five per vaginal (PV) examination with AOR 1.93 (95% CI 1.03-3.64), and in labor status with AOR 6.52 (CI 1.17-36.38) were some procedure-related factors resulting into higher odds of infection.

Conclusion

Multiple risk factors like age, obesity, medical complications during pregnancy, occurrence of labor status during cesarean section, prolonged duration of rupture of membrane for more than 18 hours, and more than five vaginal examinations before the procedure increases the chance of surgical site infection (SSI) following cesarean section.

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.

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema

Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.

Aligning Provider Prescribing With Guidelines for Soft Tissue Infections

OBJECTIVE

Despite evidence-based guidelines, antibiotics prescribed for uncomplicated skin and soft tissue infections can involve inappropriate microbial coverage. Our aim was to evaluate the appropriateness of antibiotic prescribing practices for mild nonpurulent cellulitis in a pediatric tertiary academic medical center over a 1-year period.

METHODS

Eligible patients treated in the emergency department or urgent care settings for mild nonpurulent cellulitis from January 2017 to December 2017 were identified by an International Classification of Diseases, Tenth Revision, code for cellulitis. The primary outcome was appropriateness of prescribed antibiotics as delineated by adherence with the Infectious Diseases Society of America guidelines. Secondary outcomes include reutilization rate as defined by revisit to the emergency department/urgent cares within 14 days of the initial encounter.

RESULTS

A total of 967 encounters were evaluated with 60.0% overall having guideline-adherent care. Common reasons for nonadherence included inappropriate coverage of MRSA with clindamycin (n = 217, 56.1%) and single-agent coverage with sulfamethoxazole-trimethoprim (n = 129, 33.3%). There were 29 revisits within 14 days of initial patient encounters or a reutilization rate of 3.0%, which was not significantly associated with the Infectious Diseases Society of America adherence.

CONCLUSIONS

Our data show antibiotic prescription for nonpurulent cellulitis as a potential area of standardization and optimization of care at our center.