Frequent bacterial skin and soft tissue infections: diagnostic signs and treatment

Formulation and characterization of antibiotic drug loaded aquasome for the topical application

Aim: This study aimed to develop a topical antibiotic drug delivery system using aquasomes for enhanced treatment of skin and soft tissue infections (SSTIs). Materials & methods: Cephalothin was loaded into aquasomes using a multi-step process and optimized using design of experiment. The aquasomes were characterized for FT-IR, SEM and zeta potential analysis. Entrapment efficacy, In vitro drug release studies, antibacterial assays and stability study was performed to evaluate the efficacy of the formulated aquasomes. Results & conclusion: The formulated cephalothin-loaded aquasomes exhibited stable properties, controlled drug release and significant antibacterial activity against bacteria. This proves that the developed aquasome-based delivery system has the potential for sustained treatment of SSTIs.

Occlusive cutaneous vasculopathies as cause of chronic ulcers

The term occluding vasculopathies covers a large number of different conditions. These often manifest as skin ulcers. Occluding vasculopathies should be considered in the differential diagnosis of leg ulcers. The term "occlusive vasculopathies" encompasses pathophysiologically related entities that share structural or thrombotic obliteration of small cutaneous vessels. In this article, we will focus on livedoid vasculopathy with and without antiphospholipid syndrome and calciphylaxis with differentiation from hypertonic leg ulcer as the most relevant differential diagnoses of leg ulcer. The term also includes vascular occlusion, for example due to oxalate or cholesterol embolism, and septic vasculopathy. This often leads to acral ulceration and is therefore not a differential diagnosis with classic leg ulcers. It will not be discussed in this article. Occlusive vasculopathy may be suspected in the presence of the typical livedo racemosa or (non-inflammatory) retiform purpura as a sign of reduced cutaneous perfusion in the wound area. Inflammatory dermatoses, especially vasculitides, must be differentiated. This is achieved by histopathological evaluation of a tissue sample of sufficient size and depth taken at the appropriate time. In addition, specific laboratory parameters, particularly coagulation parameters, can support the diagnosis.

Okkludierende kutane Vaskulopathien als Ursachen chronischer Unterschenkelulzerationen

Unter den Begriff der okkludierenden Vaskulopathien fällt eine Reihe unterschiedlicher Krankheitsbilder. Diese manifestieren sich an der Haut häufig mit Ulzerationen. Gerade bei Ulzerationen der Unterschenkel sollten okkludierende Vaskulopathien in die differenzialdiagnostischen Überlegungen einbezogen werden. Der Begriff „okkludierende Vaskulopathien“ umfasst pathophysiologisch verwandte Entitäten, die eine strukturelle oder thrombotische Obliteration von kleinsten Hautgefäßen gemein haben. In diesem Artikel wird vor allem auf die Livedovaskulopathie mit und ohne Antiphospholipidsyndrom sowie die Calciphylaxie mit Abgrenzung zum Ulcus cruris hypertonicum als die relevantesten Differenzialdiagnosen von Unterschenkelulzerationen eingegangen. Der Begriff umfasst auch Gefäßverschlüsse, beispielsweise durch Oxalat oder Cholesterinembolie, sowie die septische Vaskulopathie. Diese führt häufig zu akralen Ulzerationen und stellt somit keine Differenzialdiagnose zum klassischen Ulcus cruris dar. Sie wird daher in diesem Artikel nicht behandelt.

Der Verdacht einer okkludierenden Vaskulopathie kann über die typische Livedo racemosa beziehungsweise die (nichtinflammatorische) retiforme Purpura als Zeichen der kutanen Minderdurchblutung in der Wundumgebung gestellt werden. Entzündliche Dermatosen, insbesondere Vaskulitiden, müssen differenzialdiagnostisch abgegrenzt werden. Dies geschieht zum Teil klinisch und durch die histopathologische Beurteilung einer Gewebeprobe, die in ausreichender Größe und Tiefe sowie zum richtigen Zeitpunkt entnommen werden muss. Ergänzend können spezifische Laborparameter, insbesondere die Gerinnungsdiagnostik, die Diagnosestellung unterstützen.

Perioperative Antibiotikaprophylaxe in der Dermatochirurgie - Positionspapier der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie (DGDC), Teil 2: Spezielle Indikationen und Situationen

Neben der Vermeidung postoperativer Wundinfektionen nach dermatochirurgischen Eingriffen hat die perioperative Antibiotikaprophylaxe (PAP) das Ziel, das Auftreten weiterer postoperativer Infektionskomplikationen, insbesondere der bakteriellen Endokarditis oder hämatogener Gelenkprotheseninfektionen, zu verhindern. In der vorliegenden Arbeit werden spezielle Situationen dargestellt, in denen eine PAP notwendig werden kann. So benötigen Patienten nach Herzklappenersatz jeglicher Art, einschließlich Transkatheter‐Klappenersatz oder bei Verwendung von Prothesenmaterial zur Herzklappenkorrektur, oder Patienten nach einer durchgemachten bakteriellen Endokarditis bei zweizeitigen dermatochirurgischen Eingriffen, Eingriffen an der Schleimhaut oder ulzerierten Tumoren eine PAP.

Auch die Anwendung einer PAP in speziellen Situationen wie bei sekundärer Wundheilung, septischen dermatochirurgischen Eingriffen oder Ulcus cruris‐Chirurgie werden in dieser Arbeit anhand der aktuellen wissenschaftlichen Literatur ausführlich dargestellt und diskutiert. Die vorliegende Arbeit ist der 2. Teil des Positionspapiers der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie und formuliert evidenzbasierte Empfehlungen für die Verabreichung einer PAP bei dermatochirurgischen Eingriffen bei speziellen Indikationen und Situationen. Dies ist von besonderer Wichtigkeit, da bei dermatochirurgischen Eingriffen, wie im ersten Teil dargelegt, im Regelfall auf eine PAP verzichtet werden kann und sollte.

Perioperative antibiotic prophylaxis in skin surgery - Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 2: Special indications and situations

In addition to prevention of surgical site infections after skin surgery, perioperative antibiotic prophylaxis (PAP) aims to prevent the occurrence of other postoperative infectious complications, especially bacterial endocarditis and hematogenous joint prosthesis infections. This article discusses specific indications for the use of PAP. For example, patients who have undergone any type of heart valve replacement, including transcatheter valve replacement or use of prosthetic material to correct the heart valve, or patients who have experienced bacterial endocarditis, require PAP during skin surgery on mucosal membranes or ulcerated tumors. The use of PAP in special situations such as secondary wound healing, septic dermatosurgery or ulcer surgery is also presented and discussed in detail in this paper based on the current scientific literature. This paper represents the second part of the position paper of the Antibiotic Stewardship Working Group of the German Society for Dermatologic Surgery (DGDC) and summarizes evidence-based recommendations for the administration of PAP during skin surgery for special indications and situations. This is particularly important because, as detailed in Part 1 of this position paper, PAP can and usually should be avoided in skin surgery.

Perioperative Antibiotikaprophylaxe in der Dermatochirurgie - Positionspapier der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie (DGDC), Teil 1: Eingriffs- und patientenbezogene Risikofaktoren

Die perioperative Antibiotikaprophylaxe (PAP) hat das Ziel, postoperative Wundinfektionen und Infektionskomplikationen (insbesondere bakterielle Endokarditis oder septische Arthritis) bei chirurgischen Eingriffen zu vermeiden. Die PAP hat sich besonders bei Eingriffen bewährt, bei denen die Infektionsraten auch ohne Berücksichtigung der patientenbezogenen Risikofaktoren insgesamt hoch sind (wie für orthopädische Eingriffe oder die Versorgung von Frakturen). Auch Operationen mit Eröffnung der Atemwege, des Verdauungs‐, Genital‐ oder Harntrakts gelten als mit Infektionsrisiko behaftet und können eine PAP erfordern. In der Dermatochirurgie sind Infektionskomplikationen insgesamt verhältnismäßig selten und variieren in Abhängigkeit von der Lokalisation, Komplexität des Eingriffes und der Patientenkohorte zwischen 1% und 11%. Daher spiegeln die allgemeinchirurgischen Empfehlungen bezüglich der PAP die Bedürfnisse der Dermatochirurgie nur begrenzt wider. Im Gegensatz zu den USA, wo eine entsprechende Empfehlung vorliegt, existiert in Deutschland zurzeit keine speziell für dermatochirurgische Eingriffe konzipierte Leitlinie zur Anwendung von PAP. In Abwesenheit evidenzbasierter Empfehlungen wird die PAP durch die Erfahrung der einzelnen Operateure geprägt, was zu einer heterogenen Anwendung antimikrobieller Substanzen führt. In der vorliegenden Arbeit wird die aktuelle wissenschaftliche Literatur zu dem Thema zusammengefasst und die daraus resultierende Empfehlung zur Anwendung der PAP in Abhängigkeit von eingriffs‐ und patientenbezogenen Risikofaktoren formuliert.

Fabrication of Novel Omeprazole-Based Chitosan Coated Nanoemulgel Formulation for Potential Anti-Microbia; In Vitro and Ex Vivo Characterizations

Infectious diseases remain inevitable factors for high mortality and morbidity rate in the modern world to date. Repurposing is a novel approach to drug development has become an intriguing research topic in the literature. Omeprazole is one of the top ten proton pump inhibitors prescribed in the USA. The literature suggests that no reports based on omeprazole anti-microbial actions have been discovered to date. This study entails the potential of omeprazole to treat skin and soft tissue infections based on the literature's evident anti-microbial effects. To get a skin-friendly formulation, a chitosan-coated omeprazole-loaded nanoemulgel formulation was fabricated using olive oil, carbopol 940, Tween 80, Span 80, and triethanolamine by high-speed homogenization technique. The optimized formulation was physicochemically characterized for zeta potential, size distribution, pH, drug content, entrapment efficiency, viscosity, spreadability, extrudability, in-vitro drug release, ex-vivo permeation analysis, and minimum inhibitory concentration determination. The FTIR analysis indicated that there was no incompatibility between the drug and formulation excipients. The optimized formulation exhibited particle size, PDI, zeta potential, drug content, and entrapment efficiency of 369.7 ± 8.77 nm, 0.316, -15.3 ± 6.7 mV, 90.92 ± 1.37% and 78.23 ± 3.76%, respectively. In-vitro release and ex-vivo permeation data of optimized formulation showed 82.16% and 72.21 ± 1.71 μg/cm², respectively. The results of minimum inhibitory concentration (1.25 mg/mL) against selected bacterial strains were satisfactory, suggesting a successful treatment approach for the topical application of omeprazole to treat microbial infections. Furthermore, chitosan coating synergistically increases the antibacterial activity of the drug.

Bactericidal Activity of Sodium Bituminosulfonate against Staphylococcus aureus

Antibiotic resistance is increasing worldwide making it necessary to search for alternative antimicrobials. Sodium bituminosulfonate is a long-known substance, whose antimicrobial inhibitory activity has recently been re-evaluated. However, to the best of our knowledge, the bactericidal mode of action of this substance has not been systematically characterized. The aim of this study was to investigate the in vitro bactericidal activity of sodium bituminosulfonate by determining the minimal bactericidal concentrations (MBC), as well as the rapidity of bactericidal effect by time-kill curves. Clinical isolates of methicillin-susceptible (MSSA, n = 20) and methicillin-resistant (mecA/mecC-MRSA, n = 20) Staphylococcus aureus were used to determine MBC by a broth microdilution method. Sodium bituminosulfonate (Ichthyol^® light) was tested in double-dilution concentration steps ranging from 0.03 g/L to 256 g/L. For time-kill analysis, two reference and two clinical S. aureus strains were tested with different concentrations of sodium bituminosulfonate (1× minimal inhibitory concentration (MIC), 2× MIC, 4× MIC, 16× MIC and 256× MIC). For MSSA isolates, MBC₅₀, MBC₉₀ and the MBC range were 0.5 g/L, 1.0 g/L and 0.125–1.0 g/L; (MBC/MIC ratio)₅₀, (MBC/MIC ratio)₉₀ and the range of the MBC/MIC ratio were 4, 4 and 1–8, respectively. Among MRSA isolates, MBC₅₀, MBC₉₀ and the MBC range amounted to 0.5 g/L, 1.0 g/L and 0.06–1.0 g/L; (MBC/MIC ratio)₅₀, (MBC/MIC ratio)₉₀ and the range of the MBC/MIC ratio were 2, 4 and 1–8, respectively. Time-kill kinetics revealed a bactericidal effect after 30 min for sodium bituminosulfonate concentrations of 16× MIC and 256× MIC. The bactericidal activity against MSSA and MRSA was demonstrated for sodium bituminosulfonate. The killing was very rapid with the initial population reduced by 99.9% after only short incubation with concentrations of 16× MIC and higher.

[Soft tissue infections]

Acute skin and soft tissue infections are among the most frequent infections in medicine. There is a broad spectrum including simple local infections as well as severe and life-threatening diseases. Along with Staphylococcus aureus, group A Streptococci are mainly responsible for these illnesses. The therapeutic approach ranges from antiseptic local treatments to administering systemic antibiotics or emergency surgery. Treating physicians often face challenges when presented with soft tissue infections due to a great discrepancy between the first impression of the disease compared to a possibly quick progression as well as the wide range of sometimes confusing historic terms and definitions being used in the English and German language, for instance pyoderma, erysipelas or phlegmon. A recently more popular collective term emphasized by clinical trials is "acute bacterial skin and skin structure infections" (ABSSSI).

Diagnosis and treatment of the invasive extension of bacteria (cellulitis) from chronic wounds utilising point-of-care fluorescence imaging

Early diagnosis of wound‐related cellulitis is challenging as many classical signs and symptoms of infection (erythema, pain, tenderness, or fever) may be absent. In addition, other conditions (ie, chronic stasis dermatitis) may present with similar clinical findings. Point‐of‐care fluorescence imaging detects elevated bacterial burden in and around wounds with high sensitivity. This prospective observational study examined the impact of incorporating fluorescence imaging into standard care for diagnosis and management of wound‐related cellulitis. Two hundred thirty‐six patients visiting an outpatient wound care centre between January 2020 and April 2021 were included in this study. Patients underwent routine fluorescence scans for bacteria (range: 1‐48 scans/patient). Wound‐related cellulitis was diagnosed in 6.4% (15/236) of patients. In these patients, fluorescence scans showed an irregular pattern of red (bacterial) fluorescence extending beyond the wound bed and periwound that could not be removed through cleansing or debridement, indicating the invasive extension of bacteria (wound‐related cellulitis). Point‐of‐care identification facilitated rapid initiation of treatments (source control and antibiotics, when warranted) that resolved the fluorescence. No patients had worsening of cellulitis requiring intravenous antibiotics and/or hospitalisation. These findings demonstrate the utility of point‐of‐care fluorescence imaging for efficient detection and proactive, targeted management of wound‐related cellulitis.

Antimicrobial Peptides: A New Hope in Biomedical and Pharmaceutical Fields

Antibiotics are essential drugs used to treat pathogenic bacteria, but their prolonged use contributes to the development and spread of drug-resistant microorganisms. Antibiotic resistance is a serious challenge and has led to the need for new alternative molecules less prone to bacterial resistance. Antimicrobial peptides (AMPs) have aroused great interest as potential next-generation antibiotics, since they are bioactive small proteins, naturally produced by all living organisms, and representing the first line of defense against fungi, viruses and bacteria. AMPs are commonly classified according to their sources, which are represented by microorganisms, plants and animals, as well as to their secondary structure, their biosynthesis and their mechanism of action. They find application in different fields such as agriculture, food industry and medicine, on which we focused our attention in this review. Particularly, we examined AMP potential applicability in wound healing, skin infections and metabolic syndrome, considering their ability to act as potential Angiotensin-Converting Enzyme I and pancreatic lipase inhibitory peptides as well as antioxidant peptides. Moreover, we argued about the pharmacokinetic and pharmacodynamic approaches to develop new antibiotics, the drug development strategies and the formulation approaches which need to be taken into account in developing clinically suitable AMP applications.

Investigation of In-Vitro Adaptation toward Sodium Bituminosulfonate in Staphylococcus aureus

The global increase in antimicrobial resistance has revived the interest in “old” substances with antimicrobial activity such as sodium bituminosulfonate. However, for those “old” compounds, scientific studies are still sparse and the ones available do not mostly meet the current standards. Since this compound is used for topical applications, investigation of a potential increase in minimal inhibitory concentrations (MICs) is of particular importance. For selection of phenotypes with decreased susceptibility, a collection of 30 genetically diverse methicillin-susceptible (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) strains were cultured on bi-layered linear gradient agar plates containing sub-inhibitory concentrations of the active agents. The stability of phenotypes with increased MICs was determined by serial passage on agent-free medium. Within 10 passages, only slight and, in most cases, reversible increases in MSSA and MRSA MIC levels toward sodium bituminosulfonate were obtained. Fusidic acid, used as a control, showed exponential expansions in MIC based on mutations in the fusA gene (elongation factor G or EF-G) with no reduction during the recovery phase. The only marginal and largely reversible changes of S. aureus MICs after exposition to sodium bituminosulfonate indicate a low potential for resistance development.

Antimicrobial peptides - Advances in development of therapeutic applications

The severe infection is becoming a significant health problem which threaten the lives of patients and the safety and economy of society. In the way of finding new strategy, antimicrobial peptides (AMPs) - an important part of host defense family, emerged with tremendous potential. Up to date, huge numbers of AMPs has been investigated from both natural and synthetic sources showing not only the ability to kill microbial pathogens but also propose other benefits such as wound healing, anti-tumor, immune modulation. In this review, we describe the involvements of AMPs in biological systems and discuss the opportunity in developing AMPs for clinical applications. In the detail, their properties in antibacterial activity is followed by their application in some infection diseases and cancer. The key discussions are the approaches to improve biological activities of AMPs either by modifying chemical structure or incorporating into delivery systems. The new applications and perspectives for the future of AMPs would open the new era of their development.

Diagnostic value of laboratory parameters for the discrimination between erysipelas and limited cellulitis

BACKGROUND AND OBJECTIVES

Erysipelas, caused by beta-hemolytic streptococci, and limited cellulitis, frequently caused by Staphylococcus aureus or other bacteria, are skin and soft tissue infections characterized by typical clinical signs. However, despite the therapeutical relevance they are often not differentiated (e.g in clinical trials). Erysipelas are efficiently treated with penicillin, while limited cellulitis is treated with more wide-spectrum antibiotics. This study investigates whether parameters such as CRP, blood counts or novel parameters like immature granulocytes could serve as biomarkers to distinguish between these entities.

PATIENTS AND METHODS

For this retrospective analysis 163 patients were included. We compared laboratory markers in patients with erysipelas (n = 68) to those with limited cellulitis (n = 41) of the leg. Both erysipelas and limited cellulitis were defined clinically, with an additional aspect for erysipelas being a prompt response to penicillin.

RESULTS

Erysipelas were characterized by higher levels of inflammation. CRP and leukocyte counts are the best parameters to discriminate between both infections. A CRP value ≥ 3.27 mg/dl indicated the diagnosis of erysipelas with 75 % sensitivity and 73.2 % specificity.

CONCLUSIONS

Our results support the thesis that erysipelas and limited cellulitis are distinct infections as defined in the German guidelines and that an assessment of CRP and leukocytes is useful for differential diagnosis.

Contamination of wounds with fecal bacteria in immuno-suppressed mice

Immunocompromised patients are predisposed to chronically infected wounds. Especially ulcers in the dorsal region often experience secondary polymicrobial infections. However, current wound infection models mostly use single-strain bacteria. To mimic clinically occurring infections caused by fecal contamination in immunocompromised/immobile patients, which differ significantly from single-strain infections, the present study aimed at the establishment of a new mouse model using infection by fecal bacteria. Dorsal circular excision wounds in immunosuppressed mice were infected with fecal slurry solution in several dilutions up to 1:8,000. Impact of immunosuppressor, bacterial load and timing on development of wound infections was investigated. Wounds were analyzed by scoring, 3D imaging and swab analyses. Autofluorescence imaging was not successful. Dose-finding of cyclophosphamide-induced immunosuppression was necessary for establishment of bacterial wound infections. Infection with fecal slurry diluted 1:166 to 1:400 induced significantly delayed wound healing (p < 0.05) without systemic reactions. Swab analyses post-infection matched the initial polymicrobial suspension. The customized wound score confirmed significant differences between the groups (p < 0.05). Here we report the establishment of a simple, new mouse model for clinically occurring wound infections by fecal bacteria and the evaluation of appropriate wound analysis methods. In the future, this model will provide a suitable tool for the investigation of complex microbiological interactions and evaluation of new therapeutic approaches.

Calculated initial parenteral treatment of bacterial infections: Skin and soft tissue infections

This is the ninth chapter of the guideline "Calculated Parenteral Initial Therapy of Adult Bacterial Disorders - Update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter contains the first German S2k guidelines for bacterial skin and soft tissue infections. They encompass recommendations on diagnosis and treatment of the defined entities erysipelas (caused by beta-hämolytic streptococci), limited superficial cellulitis (S. aureus), severe cellulitis, abscess, complicated skin and soft tissue infections, infections of feet in diabetic patients ("diabetic foot"), necrotizing soft tissue infection and bite injuries.

In Vitro Activity of Sodium Bituminosulfonate: Susceptibility Data for the Revival of an Old Antimicrobial

Revival of old antibiotic compounds is a promising strategy to strengthen the antimicrobial armamentarium in the era of increasing resistance and limited development pipelines. To exploit their full potential, their reinvestigation using current standards is needed. We aimed to investigate the in vitro activity of the old antimicrobial agent sodium bituminosulfonate in accordance with the current recommendations for antimicrobial susceptibility testing (AST) and to generate susceptibility data reflecting the current epidemiological situation. The in vitro activity of sodium bituminosulfonate was tested on consecutive clinical isolates, including 12 methicillin-resistant Staphylococcus aureus (MRSA) and 12 methicillin-susceptible S. aureus (MSSA), 24 coagulase-negative staphylococci (CoNS), 60 streptococci, 12 Enterococcus faecalis, 12 Enterococcus faecium (including two vancomycin-resistant strains), 12 Enterobacterales, 12 nonfermenting Gram-negative bacilli, and 12 Cutibacterium [Propionibacterium] acnes. AST of sodium bituminosulfonate was performed using broth microdilution method for Gram-positive cocci and Gram-negative rods and by agar dilution method for C. acnes. Sodium bituminosulfonate demonstrated activity against Gram-positive pathogens with minimal inhibitory concentration 90 (MIC₉₀) values (g/L) for MRSA 0.25, MSSA 1, CoNS 16, Streptococcus pyogenes 0.03, Streptococcus agalactiae 0.125, Streptococcus dysgalactiae ≤0.015, Streptococcus pneumoniae ≤0.015, viridans streptococci 0.03, E. faecalis 0.25, E. faecium 0.5, and C. acnes 0.03 (without blood supplement). MIC values for Gram-negative bacteria were considerably higher. Blood-supplemented media proved to be unsuitable for activity testing of this agent. Sodium bituminosulfonate may represent an alternative to classical antibiotics for topical use. Although it has been clinically used for many decades, well-designed randomized trials are needed for the effective revival of this old antimicrobial.

S2k guidelines for skin and soft tissue infections Excerpts from the S2k guidelines for "calculated initial parenteral treatment of bacterial infections in adults - update 2018"

These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for "calculated initial parenteral treatment of bacterial infections" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for "complicated soft tissue infections", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.

Guía de práctica clínica para el diagnóstico y manejo de las infecciones de piel y tejidos blandos en Colombia

Las infecciones de piel y tejidos blandos (IPTB) representan la tercera causa de consulta por enfermedad infecciosas a los servicios médicos, después de las infecciones respiratorias y urinarias. Se presenta una guía de práctica clínica (GPC) con 38 recomendaciones basadas en la evidencia, graduadas bajo el sistema SIGN, para el diagnóstico y tratamiento de pacientes adultos con IPTB en el contexto colombiano, posterior a un proceso de adaptación de GPC publicadas y la búsqueda sistemática y síntesis de literatura para la actualización de la evidencia científica. Además, se realizó un consenso de expertos para la evaluación de las potenciales barreras para la implementación de las recomendaciones y la evaluación del grado de recomendación en el contexto local.

[Multiple well demarcated skin erosions and ulcers following exanthematous drug eruption after sultamicillin therapy]

This article presents the case of a patient with newly developed skin erosions and ulcerations following an exanthematous drug eruption due to sultamicillin therapy. The skin lesions were treated topically with clobetasol and prednicarbate and orally with methylprednisolone. A skin smear revealed massive growth of Escherichia coli bacteria. Blood cultures were negative. The cause for developing ecthyma gangrenosum in our patient were iatrogenic immunosuppression and transient bacteremia.

Antimicrobial Peptides and Their Therapeutic Potential for Bacterial Skin Infections and Wounds

Alarming data about increasing resistance to conventional antibiotics are reported, while at the same time the development of new antibiotics is stagnating. Skin and soft tissue infections (SSTIs) are mainly caused by the so called ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) which belong to the most recalcitrant bacteria and are resistant to almost all common antibiotics. S. aureus and P. aeruginosa are the most frequent pathogens isolated from chronic wounds and increasing resistance to topical antibiotics has become a major issue. Therefore, new treatment options are urgently needed. In recent years, research focused on the development of synthetic antimicrobial peptides (AMPs) with lower toxicity and improved activity compared to their endogenous counterparts. AMPs appear to be promising therapeutic options for the treatment of SSTIs and wounds as they show a broad spectrum of antimicrobial activity, low resistance rates and display pivotal immunomodulatory as well as wound healing promoting activities such as induction of cell migration and proliferation and angiogenesis. In this review, we evaluate the potential of AMPs for the treatment of bacterial SSTIs and wounds and provide an overview of the mechanisms of actions of AMPs that contribute to combat skin infections and to improve wound healing. Bacteria growing in biofilms are more resistant to conventional antibiotics than their planktonic counterparts due to limited biofilm penetration and distinct metabolic and physiological functions, and often result in chronification of infections and wounds. Thus, we further discuss the feasibility of AMPs as anti-biofilm agents. Finally, we highlight perspectives for future therapies and which issues remain to bring AMPs successfully to the market.

Complete penile skin necrosis

Superficial penile skin infections may be presented in different clinical situations that vary from simple infection to organ loss and serious morbidity and mortality. Antibiotic treatment and, if necessary, urgent debridement is required. A 46-year-old male patient with the complaints of urethral discharge and pain admitted to our outpatient clinic. He declared that there were midpenil tenderness and erythema 14 days ago which occurred after sexual intercourse. Complete penile skin necrosis with purulent discharge was detected in physical examination. After wound debridement and 14-days of intravenous antibiotic treatment, wound site culture was negative and then full-thickness skin grafting was performed. Urgent antibiotic treatment should be given, especially for the skin infections of the genital area. Despite the rapid spread of antibiotic treatment, clinical presentation may worsen within hours. It should be noted that especially in diabetics and elderly patients with poor hygiene, the infection may spread to anogenital region and may lead to fulminant necrotizing fasciitis which can present with severe morbidity and mortality. Reconstructive surgery is planned after the control of infection and according to the amount of tissue loss.

Cutaneous Manifestations of Diabetes Mellitus: A Review

Diabetes mellitus is a widespread endocrine disease with severe impact on health systems worldwide. Increased serum glucose causes damage to a wide range of cell types, including endothelial cells, neurons, and renal cells, but also keratinocytes and fibroblasts. Skin disorders can be found in about one third of all people with diabetes and frequently occur before the diagnosis, thus playing an important role in the initial recognition of underlying disease. Noninfectious as well as infectious diseases have been described as dermatologic manifestations of diabetes mellitus. Moreover, diabetic neuropathy and angiopathy may also affect the skin. Pruritus, necrobiosis lipoidica, scleredema adultorum of Buschke, and granuloma annulare are examples of frequent noninfectious skin diseases. Bacterial and fungal skin infections are more frequent in people with diabetes. Diabetic neuropathy and angiopathy are responsible for diabetic foot syndrome and diabetic dermopathy. Furthermore, antidiabetic therapies may provoke dermatologic adverse events. Treatment with insulin may evoke local reactions like lipohypertrophy, lipoatrophy and both instant and delayed type allergy. Erythema multiforme, leukocytoclastic vasculitis, drug eruptions, and photosensitivity have been described as adverse reactions to oral antidiabetics. The identification of lesions may be crucial for the first diagnosis and for proper therapy of diabetes.

Complicated Skin and Skin Structure Infection After Erysipelas

Erysipelas are common soft tissue infections responding to first-line antibiosis. Because of factors of related to responsible bacteria and host, complications can occur that need extensive surgery in addition to intensified drug therapy. We report on a 65-year-old woman with leg ulcer who developed an absceding and necrotizing panniculitis of the affected leg complicating erysipelas. Escherichia coli and Pseudomonas aeruginosa were identified. Debridement and surgical removal of inflamed subcutaneous adipose tissue was decisive to interrupt the process. Wound bed preparation was realized by vacuum-assisted closure. Final wound closure was done by split-skin mesh graft. Complicated skin and skin structure infections need a combined approach of intensified antibiosis and surgery to save life.