A prospective, multicenter, observational study of complicated skin and soft tissue infections in hospitalized patients: clinical characteristics, medical treatment, and outcomes

Complicated skin and skin structure infections in alcoholics, a retrospective cohort study

BACKGROUND

Alcoholism increases the risk of skin and skin structure infections (SSSIs). Furthermore, in complicated SSSIs (cSSSIs) alcoholism is associated with delayed treatment response and a higher risk of blood culture positivity, suggesting poor outcomes. In pneumonia and bacteremia alcoholism is linked with higher mortality, longer hospital treatment and more ICU treatment.

METHODS

We conducted a population-based retrospective cohort study including all cases of complicated skin and skin structure infections (n = 460) treated in Gothenburg, Sweden and Helsinki, Finland from 2008 - 2011. Patients were stratified as alcoholics (9%) and non-alcoholics (91%) and patient and disease factors, treatment, and outcomes were compared.

RESULTS

Alcoholics were comparatively younger and more often male, with more liver diseases. We observed higher rates of bacteraemia, intensive care unit admission, surgical intervention, and clinical failure in alcoholics. Alcoholism was associated with longer length of stay and more interdepartmental transfers. We did not observe differences in infection type or time from symptom onset to diagnosis. Mortality was low and equivalent in alcoholics and non-alcoholics.

CONCLUSIONS

Alcoholism is associated with increased cSSSI disease severity and resource utilisation.

Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review

Aim

To generate a landscape of the current knowledge in the interventional management and outcomes of purulent skin and soft tissue infections.

Design

This study is a scoping review.

Methods

Electronic searches were undertaken using CINAHL, Medline, Cochrane Library, British Nursing Index, Science Direct, the National Health Service knowledge and library hub, ClinicalTrials.gov, and MedNar. The population, concept, context framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were utilised, supporting a rigorous appraisal and synthesis of literature. Data Sources. The initial search and synthesis of literature were completed in January 2022 with repeat searches completed in March 2022 and July 2023. There were no imposed chronological parameters placed on the returned literature.

Results

Nineteen papers were reviewed. Incision and drainage with primary closure, needle aspiration, loop drainage, catheter drainage, and suction drainage are viable adjuncts or alternatives to the traditional surgical management of skin and soft tissue abscesses.

Conclusion

Despite the empirically favourable alternatives to the incision and drainage technique demonstrated, this does not appear to be driving a change in clinical practice. Future research must now look to mixed and qualitative evidence to understand the causative mechanisms of incision and drainage and its ritualistic practice. Implications. Ritual surgical practices must be challenged if nurses are to improve the treatment and management of this patient group. This will lead to further practice innovation. Impact: This study explored the challenges posed to patients, clinicians, nurses, and stakeholders, resulting from the ritualistic practice of the incision and drainage technique in purulent skin or soft tissue abscesses. Empirically and holistically viable alternatives were identified, impacting all identified entities and recommending a wider holistic study. Reporting Method. Adherence to EQUATOR guidance was achieved through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

A Review of CRISPR-Based Advances in Dermatological Diseases

Clustered regularly interspaced short palindromic repeat (CRISPR) has revolutionized biomedical research by offering novel approaches to genetic and epigenetic manipulation. In dermatology, it has significantly promoted our understanding of complex diseases, and shown great potential in therapeutic applications. In this review, we introduce the adoption of CRISPR technology as a tool to study different types of skin disorders, including monogenic genodermatoses, inflammatory disorders, and cutaneous infections. We highlight the promising preclinical results of CRISPR-mediated treatment and important mechanic discoveries in investigative studies. Future opportunities and remaining challenges are also discussed. We predict that CRISPR will be more extensively used for dermatological research and even be accessible to patients in the future.

Tackling Extended Hospital Stays in Patients with Acute Bacterial Skin and Skin Structure Infections

Hospitalisation rates for acute bacterial skin and skin structure infection (ABSSSI) are rising and represent a large pharmacoeconomic burden as treatment may involve an extended number of days of antibiotic therapy. This article first aims to provide a review of treatment challenges associated with ABSSSIs in both hospital and outpatient settings, and shows that while more traditionally treatment has been conducted in a hospital setting, for a number of patients, a variety of considerations, including pharmacoeconomics, infection control, and patient preference, has led to the development of recommendations to assess the eligibility of patients for early discharge from hospital to complete their antibiotic regimen in the outpatient setting. However, such patients require monitoring for drug adherence to oral regimens or complications associated with daily intravenous administration, such as injection site reactions and infection. This review also focuses on one of a number of new antibiotics for ABSSSI, dalbavancin, as the long-acting glycopeptide with the most clinical experience to date. This antibiotic has been shown to be as effective as a daily/twice daily regimen with similar safety profiles. Health economic analysis of dalbavancin is also presented. It has shown that in some, though not all, clinical settings a reduction in the overall treatment cost is evident as, despite a higher medication cost, the lower hospitalisation time can lead to greater cost savings. In conclusion, while the burden of ABSSSI is rising, new treatment options provide additional therapeutic choice, although pharmacoeconomic considerations might limit use in some cases.

Kimyrsa, An Oritavancin-Containing Product: Clinical Study and Review of Properties

Background

There is a need for improved antibiotic formulations for the treatment of acute bacterial skin and soft structure infection (ABSSSI), especially with the rise of antimicrobial resistance among Gram-positive bacteria. A new formulation of oritavancin was developed to reduce intravenous infusion volume (from 1000 mL to 250 mL), shorten infusion time (from 3 hours to 1 hour), and provide pharmacies with flexibility in oritavancin preparation (from 5% dextrose in sterile water to either normal saline or 5% dextrose in sterile water) compared with the current formulation.

Methods

A total of 102 adult patients with a diagnosis of ABSSSI suspected or confirmed to be caused by a Gram-positive pathogen were randomized 1:1 to receive either the new formulation of oritavancin or the current formulation. After a single 1200-mg intravenous infusion of oritavancin, the relative area-under-the-curve exposure of the new formulation and current formulation groups were compared. Safety and tolerability of the new formulation were assessed for treatment-emergent adverse events, serious adverse events, and changes to laboratory parameters.

Results

The area under the curve for 0 hour to 72 hours postdose was very similar in the new formulation group compared with the current formulation group. No differences in treatment-emergent adverse events were observed between the current and new formulation groups, and all treatment-emergent adverse events were consistent with the known safety profile of the current formulation.

Conclusions

The new formulation of oritavancin with reduced volume and duration of intravenous infusion demonstrates a safety profile and pharmacokinetics similar to that of the original formulation.

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis

AIM

Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery.

METHODS

Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO.

RESULTS

Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar.

CONCLUSIONS

Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.

Hospital admissions for skin and soft tissue infections in a population with endemic scabies: A prospective study in Fiji, 2018-2019

Scabies is an important predisposing factor for impetigo but its role in more serious skin and soft tissue infections (SSTIs) is not well understood. Information is limited on incidence of SSTIs in the presence of endemic scabies. We conducted a prospective study of hospital admissions for SSTIs in the Northern Division of Fiji (population: 131,914). Prospective surveillance for admissions with impetigo, abscess, cellulitis, wound infection, pyomyositis, necrotizing fasciitis, infected scabies, and crusted scabies was conducted at the Division’s referral hospital between 2018 to 2019. Information was collected on demographic characteristics, clinical features, microbiology, treatment and outcomes. Over the study period, 788 SSTI admissions were recorded corresponding to a population incidence 647 per 100,000 person-years (95%CI 571–660). Incidence was highest at the extremes of age with peak incidence in children aged <5 years (908 per 100,000) and those aged ≥65 years (1127 per 100,000). Incidence was 1.7 times higher among the Indigenous Fijian population (753 per 100,000) compared to other ethnicities (442 per 100,000). Overall case fatality rate was 3.3%, and 10.8% for those aged ≥65 years. Scabies was diagnosed concurrently in 7.6% of all patients and in 24.6% of admitted children <5 years. There is a very high burden of hospital admissions for SSTIs in Fiji compared to high-income settings especially among the youngest, oldest and indigenous population which is concordant with scabies and impetigo distribution in this population. Our findings highlight the need for strategies to reduce the burden of SSTIs in Fiji and similar settings.

Scabies is causally linked to impetigo in endemic populations. In turn, impetigo can progress to more serious skin and soft tissue infections (SSTI). However, there are few data on the epidemiology of SSTIs in settings where scabies is endemic. We conducted a prospective study of the incidence of hospitalizations for SSTIs in 2018 and 2019 at the referral centre for the Northern Division of Fiji (population of 131,914) where community scabies prevalence is very high. We measured the incidence of admissions for abscesses, cellulitis, impetigo, wound infections, pyomyositis, necrotizing fasciitis and crusted scabies. We observed a high incidence of SSTI admissions (647 cases per 100,000 person-years) with high associated morbidity and case fatality in this population. We found a very high incidence in young children, the elderly and iTaukei (Indigenous Fijian) population which is concordant with the distribution of scabies and impetigo in the community. These findings highlight SSTIs as an important public health concern and provide further impetus to advance research into strategies that will alleviate this burden.

Diagnostic Value of Erythrocyte Sedimentation Rate and C Reactive Protein in detecting Diabetic Foot Osteomyelitis; a Cross-sectional Study

INTRODUCTION

Osteomyelitis is one of the complications of diabetic foot infection. The present study aimed to evaluate the diagnostic value of erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) in detection of osteomyelitis in patients with diabetic foot.

METHODS

In this cross-sectional study, serum levels of ESR and CRP were measured for patients with diabetic foot referring to emergency department or endocrinology clinic and the screening performance characteristics of these markers in detection of osteomyelitis were calculated. The diagnosis of osteomyelitis was based on clinical examination and positive probe-to-bone test, which was confirmed by plain x-rays or MRI.

RESULTS

142 diabetic patients with an average age of 61.2 ± 11.8 years were evaluated (66.2 % male). The area under the ROC curve of ESR in detection of osteomyelitis in diabetic foot cases was 0.70 (95% CI: 0.62-0.79). The best ESR cut-off point in this regard was 49 mm/hour. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of ESR in 49 mm/Hour cut-point were 74.6% (95% CI: 62.9-83.9), 57.7% (95% CI: 45.5-69.2), 63.9% (95% CI: 52.5-73.9), 69.5 % (95% CI: 56.0-80.0), 1.8 (95% CI: 1.3-2.4) and 0.4 (95% CI: 0.3-0.7), respectively. The area under the ROC curve of CRP in detection of osteomyelitis was 0.67 (95% CI: 0.58-0.76). The best cut-off point for CRP in this regard was 35 mg/liter with sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of 76% (95% CI: 64.2-85), 54.9% (95% CI: 42.7-66.6), 62.8% (95% CI: 51.6-72.8), 69.6% (95% CI: 51.7-80.8), 1.7 (95% CI, 1.3-2.2), and 0.4 (95% CI: 0.3-0.7), respectively.

CONCLUSION

Based on the findings of ROC curve analysis, ESR and CRP had fair and poor accuracy, respectively, in detecting the diabetic foot cases with osteomyelitis.

Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment

OBJECTIVES

Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children.

METHODS

We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response.

PROSPERO

CRD42018100602.

RESULTS

We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I²=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I² = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse.

CONCLUSIONS

The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.

Ceftobiprole Activity against Bacteria from Skin and Skin Structure Infections in the United States from 2016 through 2018

Ceftobiprole medocaril is an advanced-generation cephalosporin prodrug that has qualified infectious disease product status granted by the US FDA and is currently being evaluated in phase 3 clinical trials in patients with acute bacterial skin and skin structure infections (ABSSSIs) and in patients with Staphylococcus aureus bacteremia. In this study, the activity of ceftobiprole and comparators was evaluated against more than 7,300 clinical isolates collected in the United States from 2016 through 2018 from patients with skin and skin structure infections. The major species/pathogen groups were S. aureus (53%), Enterobacterales (23%), Pseudomonas aeruginosa (7%), beta-hemolytic streptococci (6%), Enterococcus spp. (4%), and coagulase-negative staphylococci (2%). Ceftobiprole was highly active against S. aureus (MIC_50/90, 0.5/1 mg/liter; 99.7% susceptible by EUCAST criteria; 42% methicillin-resistant S. aureus [MRSA]). Ceftobiprole also exhibited potent activity against other Gram-positive cocci. The overall susceptibility of Enterobacterales to ceftobiprole was 84.8% (>99.0% susceptible for isolate subsets that exhibited a non-extended-spectrum β-lactamase [ESBL] phenotype). A total of 74.4% of P. aeruginosa, 100% of beta-hemolytic streptococci and coagulase-negative staphylococci, and 99.6% of Enterococcus faecalis isolates were inhibited by ceftobiprole at ≤4 mg/liter. As expected, ceftobiprole was largely inactive against Enterobacterales that contained ESBL genes and Enterococcus faecium Overall, ceftobiprole was highly active against most clinical isolates from the major Gram-positive and Gram-negative skin and skin structure pathogen groups collected at U.S. medical centers participating in the SENTRY Antimicrobial Surveillance Program during 2016 to 2018. The broad-spectrum activity of ceftobiprole, including potent activity against MRSA, supports its further evaluation for a potential ABSSSI indication.

Risk factors associated with methicillin-resistant Staphylococcus aureus skin and soft tissue infections in hospitalized patients in Colombia

OBJECTIVES

Methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs) represent a major clinical problem in Colombia. The aim of this study was to evaluate the risk factors associated with MRSA SSTI in Colombia.

METHODS

A multicenter cohort study with nested case-control design was performed. Patients with an SSTI with at least 48h of inpatient care were included. Patients with an MRSA SSTI were considered the case group and patients with either a non-MRSA SSTI or with an Methicillin-susceptible S. aureus (MSSA) SSTI were the control groups. A multivariate logistic regression approach was used to evaluate risk factors associated with MRSA SSTI with two different statistical models.

RESULTS

A total 1134 patients were included. Cultures were positive for 498 patients, of which 52% (n=259) were Staphylococcus aureus. MRSA was confirmed in 68.3% of the S. aureus cultures. In the first model, independent risk factors for MRSA SSTI were identified as the presence of abscess (P<0.0001), cellulitis (P=0.0007), age 18-44 years (P=0.001), and previous outpatient treatment in the previous index visit (P=0.003); surgical site infection was a protective factor (P=0.008). In the second model, the main risk factor found was previous outpatient treatment in the previous index visit (P=0.013).

CONCLUSIONS

Community-acquired SSTIs in Colombia are commonly caused by MRSA. Therefore, clinicians should consider MRSA when designing the initial empirical treatment for purulent SSTI in Colombia, although there seems to be low awareness of this fact.

Modeling operational quality metrics and costs of long-acting antibiotics for acute bacterial skin and skin structure infection treatment in the emergency department

Aims: To model implementation of a new treatment pathway leveraging long-acting antibiotics (LAs) for treatment of acute bacterial skin and skin structure infections (ABSSSIs) in a hospital emergency department (ED) with an observation unit, and to quantify health resource utilization and economic outcomes versus standard care (intravenous vancomycin). Materials and methods: Discrete-event simulation was used to model implementation of the LA treatment pathway in the ED versus standard care from the US Medicare perspective. Model inputs were derived from published sources to simulate a real-world hospital ED with an observation unit. Outcomes included key ED metrics such as patient throughput rate and length of stay (LOS) and cost (estimated through reimbursed amounts in 2017 USD). Results: Implementation of an LA pathway in the ED improved ABSSSI patient throughput rate by 350% (+5.8 dispositions/ED and observation unit day) and reduced LOS by 68% (-7.2 h/patient). These improvements in patient outcomes are driven by the reduced infusion time required for LA antibiotics and are greater for dalbavancin than oritavancin owing to the shorter infusion duration (30 min vs. 3 h). Limitations: External validity of the model was not assessed. The model was limited to care received in EDs; therefore, certain clinical variables outside the ED were not captured for this analysis. Conclusions: LA pathway implementation for ABSSSI treatment in the ED supported improved efficiency, which may translate to economic value. As EDs continue to focus on improving key metrics such as throughput rate and LOS, LA pathway implementation should be considered as a potential approach for abbreviated ABSSSI treatment in the ED.

Analysis of Pooled Phase III Efficacy Data for Delafloxacin in Acute Bacterial Skin and Skin Structure Infections

BACKGROUND

Delafloxacin is an oral or intravenous (IV) antibiotic indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI), including both gram-positive (including methicillin-resistant Staphylococcus aureus [MRSA]) and gram-negative organisms. Chemically distinct from other quinolones, delafloxacin exhibits enhanced potency, particularly against gram-positive pathogens. The integration of efficacy data across the Phase III ABSSSI studies is presented here and allows for additional examination of results across subgroups.

METHODS

Results of 2 multicenter, randomized, double-blind trials of 1510 adults with ABSSSI were pooled for this analysis. Subjects in the vancomycin arm received 15 mg/kg, plus 1-2 g of aztreonam every 12 hours. Delafloxacin was dosed at 300 mg IV every 12 hours in Study 302; dosing in Study 303 was 300 mg IV every 12 hours for 3 days, with a mandatory, blinded switch to delafloxacin at 450 mg orally every 12 hours. The primary endpoint was objective response (OR), defined as a ≥20% reduction of lesion spread of erythema area at the primary infection site at 48 to 72 hours (±2 hours), in the absence of clinical failure. Investigator-assessed response, based on the resolution of signs and symptoms at follow-up (FU; Day 14 ± 1) and late follow-up (LFU; Day 21- 28), were secondary endpoints.

RESULTS

In the intent-to-treat analysis set, the OR was 81.3% in the delafloxacin arm and 80.7% in the comparator arm (mean treatment difference 0.8%, 95% confidence interval -3.2% to 4.7). Results for OR in the defined subgroups showed delafloxacin to be comparable to vancomycin/aztreonam. Investigator-assessed success was similar at FU (84.7% versus 84.1%) and LFU (82.0% versus 81.7%). Delafloxacin was comparable to vancomycin/aztreonam in the eradication of MRSA, at 98.1% versus 98.0%, respectively, at FU. The frequencies of treatment-emergent adverse events between the groups were similar.

CONCLUSIONS

Overall, IV/oral delafloxacin fixed-dose monotherapy was non-inferior to IV vancomycin/aztreonam combination therapy and was well tolerated in each Phase III study, as well as in the pooled analysis, regardless of endpoint or analysis population.

Factors associated with readmission and mortality in adult patients with skin and soft tissue infections

BACKGROUND

Skin and soft tissue infections (SSTIs) are a common cause of consultation, and complicated cases require hospitalization. We describe factors that are related to readmission and/or mortality of hospitalized patients diagnosed with SSTIs.

METHODS

Retrospective review of hospital-admitted patients with a diagnosis of cellulitis, abscess, hidradenitis, fasciitis, and Fournier's gangrene. Cases from January 2002 to October 2015 were extracted from the diagnostic codification database of the Archives and Clinical Documentation Department.

FINDINGS

We studied 1,482 episodes of hospitalized patients diagnosed with SSTIs. There were 187 (12.3%) readmissions, the most frequent diagnosis was cellulitis (72.7%), and the most commonly isolated microorganism was Staphylococcus aureus (25; 30.1%). Factors associated with readmissions were healthcare-related infections (P = 0.002), prior antibiotic therapy (P < 0.001), ischemic heart disease (P = 0.01), chronic liver disease (P = 0.001), and diabetes mellitus (DM) (P = 0.006). The number of patients who died as a result of an infection was 34 (2.2%) and, in these patients, the most common diagnosis was also cellulitis (79.4%), which in 52.9% (P = 0.001) was community acquired. DM (P = 0.01), heart failure (P = 0.001), and chronic liver disease (P = 0.003) were the most frequent comorbidities. This group presented more complications (P < 0.005) such as endocarditis (P < 0.005), amputation (P = 0.018), severe sepsis (P < 0.005), and septic shock (P < 0.001).

CONCLUSIONS

Readmitted patients had healthcare-related S. aureus infection, had received prior antibiotic therapy, and presented comorbid conditions such as ischemic heart disease, peripheral vascular disease, chronic liver disease, or DM. Comorbidities such as advanced age, DM, heart failure, and chronic liver disease were associated with complications and higher infection-related mortality.

Medical Imaging and Laboratory Analysis of Diagnostic Accuracy in 107 Consecutive Hospitalized Patients With Diabetic Foot Osteomyelitis and Partial Foot Amputations

The primary aim of our study was to compare the preoperative diagnostic accuracy of plain radiographic findings with the accuracy of magnetic resonance imaging (MRI) findings for diabetic foot osteomyelitis in hospitalized patients who underwent first-time partial foot amputations with confirmed histopathological specimens positive for osteomyelitis. Second, it was desired to determine whether certain variables within the initial clinical presentation and preoperative laboratory findings were associated with more accurate diagnosis of diabetic foot osteomyelitis in this study population. Finally, it was desired to determine the most common bacterial organisms found in bone and soft-tissue cultures taken intraoperatively and to determine how often the same organism was found in both. After applying the inclusion and exclusion criteria to the initial 329 patients identified through chart review, the final sample size for further analysis was n =107. In this study, after adjusting for the effects of covariates such as age, erythrocyte sedimentation rate (ESR) and C-reactive protein, plain radiographs seemed to have statistically more significant power than MRI in predicting and diagnosing diabetic foot osteomyelitis. In addition, higher ESR values were confirmed to predict a higher chance of positive diagnosis for diabetic foot osteomyelitis. Furthermore, the presence of positive bacterial identification from intraoperative bone cultures did not always indicate true osteomyelitis on histopathological examination.

LEVELS OF EVIDENCE

Level II: Diagnostic study.

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

BACKGROUND

Cellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code "other cellulitis and abscess" accounts for 1.4% of all admissions and $5.5 billion in annual costs. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis and to ascertain if the rate is comparable to the rate for low risk patients with community acquired pneumonia that are currently recommended for outpatient management.

METHODS

A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random effects model. Heterogeneity was estimated using the I² statistic.

RESULTS

Eighteen studies met inclusion criteria. The overall worldwide mortality rate was 1.1% (95% confidence interval (CI), 0.7-1.8). For studies from the USA, the rate was 0.5% (95% CI 0.3-0.9). The actual cause of death was generally poorly described, and only one third of deaths appeared to be due to infection.

DISCUSSION

The estimated mortality rate for patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that are recommended for outpatient management by the Pneumonia Severity Index and CURB65 prediction models and strongly endorsed by major infectious disease societies. Outpatient management of these patients could result in large cost savings and may be much preferred by patients.

Evaluation of Physician Prescribing Patterns For Antibiotics in the Treatment of Nonnecrotizing Skin and Soft Tissue Infections

PURPOSE

Skin and soft tissue infections (SSTIs) cause about 15 million cases of infection that result in more than 869,000 annual hospitalizations in the United States. Cellulitis accounted for 63% of all patients hospitalized with SSTIs between 2009 and 2011. The primary objective of this study was to evaluate physician adherence rates to evidence-based practice guidelines. Secondary objectives included evaluating antibiotic selection preferences and duration of therapy. The goal of the project was to generate data to inform the development of a hospital-based protocol for nonnecrotizing SSTI treatment.

METHODS

This study was a single-center, retrospective, electronic chart review of patients admitted to the hospital for nonnecrotizing SSTI. We reviewed charts of patients who were admitted with a diagnosis of cellulitis and abscess infection from August 2014 to August 2015.

RESULTS

Vancomycin, piperacillin/tazobactam, and clindamycin were the initial empiric antibiotics used most frequently. The adherence rates to guideline-recommended empiric antibiotic therapy and duration of treatment were about 40% and 70%, respectively. The median duration of antibiotic therapy was 12 days. Male gender and presence of purulent discharge as independent variables led to poor adherence to guideline-recommended empiric antibiotic therapy (male versus female gender, 35% versus 50.8%; P = 0.045; purulent discharge [yes versus no], 23.9% versus 60.4%; P < 0.0001).

CONCLUSIONS

The results showed substantial noncompliance with guideline recommendations on empiric antibiotic selection for the treatment of nonnecrotizing SSTIs. There is a substantial opportunity for clinical pharmacist intervention in ensuring the efficient utilization of hospital resources to improve guideline compliance; promote appropriate antibiotic selection; reduce unnecessary antibiotic exposure; and reduce cost of hospitalization.

Clinical Presentation of Soft-tissue Infections and its Management: A Study of 100 Cases

BACKGROUND

Soft-tissue infections vary widely in their nature and severity. A clear approach to the management must allow their rapid identification and treatment as they can be life-threatening.

OBJECTIVE

Clinical presentation of soft-tissue infections and its management.

MATERIALS AND METHODS

A prospective study based on 100 patients presenting with soft-tissue infections was done. All the cases of soft-tissue infections were considered irrespective of age, sex, etiological factors, or systemic disorders. The findings were evaluated regarding the pattern of soft-tissue infections in relation to age and sex, clinical presentation, complications, duration of hospital stay, management, and mortality.

RESULTS

The most commonly involved age group was in the range of 41-60 years with male predominance. Abscess formation (45%) was the most common clinical presentation. Type 2 diabetes mellitus was the most common associated comorbid condition. Staphylococcus aureus was the most common culture isolate obtained. The most common complication seen was renal failure. Patients with surgical site infections had maximum duration of stay in the hospital. About 94% of the cases of soft-tissue infections were managed surgically. Mortality was mostly encountered in the cases of complications of cellulitis.

CONCLUSION

Skin and soft-tissue infections are among the most common infections encountered by the emergency physicians. Ignorance, reluctance to treatment, economic constraints, and illiteracy delay the early detection and the initiation of proper treatment. Adequate and timely surgical intervention in most of the cases is of utmost importance to prevent the complications and reduce the mortality.

Clinical, diagnostic, and therapeutic features of patients admitted to acute care hospitals with trunk compared to lower limb cellulitis

The objective of this study is to report the clinical course and risk factors of trunk cellulitis, to identify diagnostic and therapeutic approaches, and compare them to patients with lower limb cellulitis. Medical records of adult patients with trunk cellulitis were reviewed and compared to an equal number of randomly selected patients with lower limb cellulitis. Demographic, clinical, and laboratory data were collected and analyzed using binary univariate and multivariate logistic regression analyses. Primary outcome was surgical drainage. Secondary outcomes were use of imaging studies, length of stay, readmission within 30 days, and 30-day mortality. During the study period, 74 patients were diagnosed with trunk cellulitis. Compared to patients with lower limb cellulitis, there are more women (57 vs. 39%, p = 0.032) and they are younger (mean age 59.7 vs. 68.4 years, p = 0.005). The only co-morbidity found as a significant risk factor for trunk cellulitis is malignancy (p = 0.017). These variables remain independent risk factors for trunk cellulitis after multivariate regression analysis. There is a trend toward more surgical interventions in the study group [6 (8%) patients vs. 1 (1%) with leg cellulitis, p = 0.116], and a longer hospital stay (5.8 days in the study group vs. 4.3 days in the control group, p = 0.025). Laboratory data are similar in both groups. There are risk factors for trunk cellulitis compared to lower limb cellulitis. However, diagnostic and therapeutic approaches are similar, except for a trend for more surgical interventions.

A potential benefit from infectious disease specialist and stationary ward in rational antibiotic therapy of complicated skin and skin structure infections

BACKGROUND

Management practices of complicated skin and skin structure infections (cSSSI) were compared between two areas with similar healthcare structure and low prevalence of antimicrobial resistance.

METHODS

The high affinity to public health-care in the Nordic countries enabled population-based approach used in this retrospective study. The study population (n = 460) consisted of all adult residents from Helsinki (Finland) and Gothenburg (Sweden) treated in hospital due to cSSSI during 2008-2011.

RESULTS

The majority of patients in Helsinki (57%) visited more than one ward during their hospital stay while in Gothenburg the majority of patients (85%) were treated in one ward only. Background and disease characteristics were largely similar in both cities but patients in Helsinki were younger [mean(SD) 59(18) versus 63(19) years, p = .0117], and greater proportions had diabetes (50% versus 32%, p < .0001) and polymicrobial infections (34% versus 13%, p < .0001). Patients in Helsinki received antimicrobials with Gram-negative coverage (in initial therapy 96%) more frequently than in Gothenburg (47%, p < .0001), had more treatment modifications (mean 4.3 versus 2.7 antibiotic agents used per patient, p < .0001), and longer median duration of antimicrobial therapy (29 versus 12 days, p < .0001) and median length of hospital stay (17 versus 11 days, p < .0001).

CONCLUSIONS

This real-life study revealed remarkable differences in the management of cSSSI between the two Nordic cities. Compared to mainly Infectious Disease Specialist guided treatment in Gothenburg, the more frequent transfer from one ward to another in Helsinki was linked to longer antimicrobial therapy and hospital stay and to more frequent changes in antimicrobial treatment.

Skin and Soft Tissue Infections

The skin is colonized by a diverse collection of microorganisms which, for the most part, peacefully coexist with their hosts. Skin and soft tissue infections (SSTIs) encompass a variety of conditions; in immunocompromised hosts, SSTIs can be caused by diverse microorganisms-most commonly bacteria, but also fungi, viruses, mycobacteria, and protozoa. The diagnosis of SSTIs is difficult because they may commonly masquerade as other clinical syndromes or can be a manifestation of systemic disease. In immunocompromised hosts, SSTI poses a major diagnostic challenge, and clinical dermatological assessment should be initially performed; to better identify the pathogen and to lead to appropriate treatment, etiology should include cultures of lesions and blood, biopsy with histology, specific microbiological analysis with special stains, molecular techniques, and antigen-detection methodologies. Here, we reviewed the epidemiology, pathophysiology, clinical presentation, and diagnostic techniques, including molecular biological techniques, used for SSTIs, with a focus on the immunocompromised host, such as patients with cellular immunodeficiency, HIV, and diabetic foot infection.

Methicillin-resistant Staphylococcus aureus infections: A review of the currently available treatment options

This review is the result of discussions that took place at the 5th MRSA Working Group Consensus Meeting and explores the possible treatment options available for different types of infections due to methicillin-resistant Staphylococcus aureus (MRSA), focusing on those antibiotics that could represent a valid alternative to vancomycin. In fact, whilst vancomycin remains a viable option, its therapy is moving towards individualised dosing. Other drugs, such as the new lipoglycopeptides (oritavancin, dalbavancin and telavancin) and fifth-generation cephalosporins (ceftaroline and ceftobiprole), are showing good in vitro potency and in vivo efficacy, especially for patients infected with micro-organisms with higher vancomycin minimum inhibitory concentrations (MICs). Tedizolid is an attractive agent for use both in hospital and community settings, but the post-marketing data will better clarify its potential. Daptomycin and linezolid have shown non-inferiority to vancomycin in the treatment of MRSA bacteraemia and non-inferiority/superiority to vancomycin in the treatment of hospital-acquired pneumonia. Thus, several options are available, but more data from clinical practice, especially for invasive infections, are needed to assign specific roles to each antibiotic and to definitely include them in the new antibacterial armamentarium.

Treatment of complicated skin and skin structure infections in areas with low incidence of antibiotic resistance-a retrospective population based study from Finland and Sweden

Complicated skin and skin-structure infections (cSSSI) are a common reason for hospitalization and practically all new antimicrobial agents against Gram-positive bacteria are studied in cSSSI. The aim of this population-based observational study was to assess the treatment of patients with cSSSI in areas with a low incidence of antibiotic resistance. The study population consisted of adult residents who were treated because of cSSSI during 2008-2011 from two Nordic cities, Helsinki and Gothenburg. In the final analysis population (460 patients; mean age 60.8 years; 60.9% male) 13.3% of patients had bacteraemia, 15.9% were admitted to an Intensive Care Unit and 51.5% underwent at least one surgical intervention. Treatment failure occurred in 28.2%, initial antibiotic treatment modification to another intravenous drug in 38.5% and streamlining in 5.0% of the cases. Gram-positive bacteria were predominantly isolated, with staphylococci (24.5%) and streptococci (16.0%) being the most common aetiologies. Median overall durations of hospital stay and antimicrobial treatment were 13 and 17 days, respectively, and on average 3.5 (SD 2.1) different antibiotics were used per patient. Oral antimicrobial treatment was continued in 64.3% of patients after discharge. The overall mortality rates in 30 days and in 12 months were 4.1% and 11.8%, respectively, and 16.4% of patients had a recurrence of SSSI within 12 months. In conclusion, in this population-based study antimicrobial treatment modifications were frequent and the treatment time was longer than recommended. However, bacteraemia, clinical failure and recurrences were more common than in previous non-population-based studies.

Indications and Types of Antibiotic Agents Used in 6 Acute Care Hospitals, 2009-2010: A Pragmatic Retrospective Observational Study

BACKGROUND To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. Infect. Control Hosp. Epidemiol. 2015;37(1):70-79.

Tedizolid for treatment of acute bacterial skin and skin structure infections

Tedizolid is a newly approved drug of the oxazolidinone class. It has high in vitro activity against Gram-positive bacteria, including multidrug-resistant strains. Peak plasma concentration of tedizolid is obtained within 3 h of oral dosing (PO), with high bioavailability. Tedizolid is mostly metabolized via the liver, and is excreted in feces in the form of a sulfate conjugate. Tedizolid 200 mg taken once daily demonstrated non-inferior efficacy and a good safety profile in patients with acute bacterial skin and skin structure infections. Results of two pivotal Phase III clinical trials showed that 6 days of 200 mg tedizolid PO or sequential intravenous (IV)/PO once-daily treatment was non-inferior to 10 days of 600 mg linezolid PO or sequential IV/PO twice-daily treatment at 48-72 h (primary end point) and at the test-of-cure in patients with acute bacterial skin and skin structure infections. The Phase II and Phase III trials also demonstrated that tedizolid was well tolerated.

Management of hospitalized patients with diabetic foot infections

Diabetic foot infections (DFIs), which present with a variety of clinical manifestations, are commonly encountered by clinicians. They are associated with a high morbidity, a high amputation rate, a high mortality, and increased health care costs. An effective management of DFIs requires a multidisciplinary approach with a strong collaboration among all involved health care providers as well as patient involvement. Diagnosing DFIs appropriately requires consideration of the clinical symptoms and signs of infection in addition to supplementary laboratory testing such as inflammatory markers and imaging studies. The comprehensive patient assessment should include the predisposing risk factors for infection; the type, severity, and extent of the infection; and the assessment of neurologic and vascular status, comorbid conditions, and psychosocial factors. The comprehensive management of DFIs include not only effective antibiotic therapy but also surgical debridement, pressure offloading, wound care and moisture, maintaining good vascular perfusion, control of edema and pain, correction of metabolic abnormalities such as hyperglycemia, and addressing psychosocial and nutritional issues. Discharge planning that addresses full medical and social needs along with suitable follow-up, patient education and counseling, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient management of hospitalized patients with DFIs.

Economic outcomes of inappropriate initial antibiotic treatment for complicated skin and soft tissue infections: a multicenter prospective observational study

This study examined economic outcomes associated with inappropriate initial antibiotic treatment (IIAT) in complicated skin and soft tissue infections using data from adults hospitalized and treated with intravenous antibiotic therapy. We specifically analyzed for the subsets of patients infected with methicillin-resistant Staphylococcus aureus (MRSA), with healthcare-associated (HCA) infections, or both. Data from 494 patients (HCA: 360; MRSA:175; MRSA + HCA: 129) showed the overall mean length of stay (LOS) was 7.4 days and 15.0% had the composite economic outcome of any subsequent hospital admissions, emergency department visits, or unscheduled visits related to the study infection. A total of 23.1% of patients had IIAT; after adjustments, these patients had longer LOS than patients without IIAT in the HCA cohort (marginal LOS = 1.39 days, P = 0.03) and the MRSA + HCA cohort (marginal LOS = 2.43 days, P = 0.01) and were significantly more likely to have the composite economic outcome in all study cohorts (odds ratio: overall = 1.79; HCA = 3.09; MRSA = 3.66; MRSA + HCA = 6.92; all P < 0.05).

The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis

Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 10(9)/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.