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Montravers P, Soussan R, Tanaka S. Identifying patients with difficult-to-treat acute bacterial skin infections. Curr Opin Infect Dis 2024; 37:87-94. [PMID: 38037891 DOI: 10.1097/qco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs. RECENT FINDINGS Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection. SUMMARY Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.
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Affiliation(s)
- Philippe Montravers
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris
| | - Romy Soussan
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
| | - Sébastien Tanaka
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- DéTROI, Institute of Health and Medical Research (INSERM) U1188, Saint-Pierre, Reunion Island, France
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Blanes Hernández R, Rodríguez Pérez M, Fernández Navarro J, Salavert Lletí M. Current approach to skin and soft tissue infections. Thinking about continuity of care. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2023; 36 Suppl 1:37-45. [PMID: 37997870 PMCID: PMC10793549 DOI: 10.37201/req/s01.10.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Skin and soft tissue infections are a common reason for patients seeking inpatient and outpatient medical care. Surgery is an essential part of managing in many episodes. Careful evaluation of antibiotic therapy could help clinicians in early identification to patients with treatment failure and to consider an alternative approach or a new surgical revision in "focus control". With the arrival of new drugs, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life (long-acting lipoglycopeptides such as dalbavancin or oritavancin), which allows weekly administration (or even greater), can reduce hospital admission and length of stay with fewer healthcare resources through outpatient management (home hospitalization or day hospitals). New anionic fluoroquinolones (e.g. delafloxacin), highly active in an acidic medium and with the possibility of switch from the intravenous to the oral route, will also make it possible to achieve these new healthcare goals and promote continuity of care. Therefore, management should rely on a collaborative multidisciplinary group with experience in this infectious syndrome.
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Affiliation(s)
| | | | | | - M Salavert Lletí
- Miguel Salavert Lletí. Unidad de Enfermedades Infecciosas (Infectious Diseases Unit). Área Clínica Médica. Hospital Universitario y Politécnico La Fe, Valencia. Av. Fernando Abril Martorell, nº 106; 46026-Valencia. (Spain). /
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Taniguchi T, Tsuha S, Shiiki S, Narita M, Teruya M, Hachiman T, Kogachi N. High yield of blood cultures in the etiologic diagnosis of cellulitis, erysipelas, and cutaneous abscess in elderly patients. Open Forum Infect Dis 2022; 9:ofac317. [PMID: 35899281 PMCID: PMC9310324 DOI: 10.1093/ofid/ofac317] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/23/2022] [Indexed: 12/05/2022] Open
Abstract
Background Cellulitis is a common disease in the elderly, and detecting etiologic organisms with blood cultures is difficult because of the low positive rate and occasional skin contamination. Therefore, routine blood cultures are not recommended for uncomplicated cellulitis. However, it is unclear whether blood culture collection for the diagnosis of cellulitis in elderly patients is useful. Methods This single hospital–based observational study was performed between April 2012 and March 2015 in Okinawa, Japan. All enrolled patients were aged 15 years or older and admitted to the Division of Infectious Diseases with suspected cellulitis, erysipelas, and cutaneous abscess. Two routine sets of blood cultures were obtained. Results Two hundred and twenty-one patients were enrolled. The median age was 77 years. The proportion of bacteremia was 21.7% for all patients (48/221), 8.5% (4/47) for those <65 years, and 25.3% (44/174) for those ≥65 years old (P = .013). The skin contamination rate was 0.9% (2/221). The most common pathogen was Streptococcus dysgalactiae (62.5%). Gram-negative bacteremia not susceptible to cefazolin was detected in 8.3%. Cefazolin and ampicillin were the first- and second-most commonly used therapies. Anti–methicillin-resistant Staphylococcus aureus therapy was required in 3.6% of patients. In addition to age and severe infection, shaking chills and white blood count ≥13 000 cells/µL were independent risk factors of bacteremia. Conclusions Two routine sets of blood cultures are recommended for the precise diagnosis and appropriate treatment of cellulitis in elderly patients, especially in patients with shaking chills or leukocytosis.
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Affiliation(s)
- Tomohiro Taniguchi
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
- Division of General Internal Medicine and Infectious Diseases, Hiroshima Prefectural Hospital , 1-5-54 Ujinakanda, Minami-ku, Hiroshima 734-8530 , Japan
| | - Sanefumi Tsuha
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
- Division of General Internal Medicine and Infectious Diseases, Sakibana Hospital , 1-3-30 Nozomino, Izumi, Osaka 594-1105 , Japan
| | - Soichi Shiiki
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
| | - Masashi Narita
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
- Division of Infectious Diseases, Department of Medicine, Okinawa Nanbu Medical Center and Children's Medical Center, Arakawa 118-1, Haebaru-cho, Shimajiri-gun, Okinawa 901-1193 , Japan
| | - Mariko Teruya
- Microbiology Laboratory, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
| | - Teruyuki Hachiman
- Microbiology Laboratory, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
| | - Noriyasu Kogachi
- Microbiology Laboratory, Okinawa Chubu Hospital , 281 Miyazato, Uruma, Okinawa 904-2293 , Japan
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Xiao Y, Yan X, Shen L, Wang Q, Li F, Yang D, Wu W, Qian Y. Evaluation of qSOFA score, and conjugated bilirubin and creatinine levels for predicting 28‑day mortality in patients with sepsis. Exp Ther Med 2022; 24:447. [PMID: 35720627 PMCID: PMC9199080 DOI: 10.3892/etm.2022.11374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/03/2022] [Indexed: 11/06/2022] Open
Abstract
Sepsis is a dangerous disease that develops rapidly and has a high mortality rate. A timely and accurate assessment of the patient's condition is beneficial in improving prognosis and reducing mortality. Therefore, the present study was designed to investigate the potential association between quick sequential organ failure assessment (qSOFA) scores and biochemical indicators, such as conjugated bilirubin (CB) and creatinine levels, with the 28-day prognosis of patients with sepsis in a retrospective observational study. All cases were divided into survival and non-survival groups on the 28th day after diagnosis. The qSOFA scores, and CB and creatinine levels were significantly higher in the non-survival group than in the survival group (both P<0.01). Cox regression models identified CB [hazard ratio (HR), 1.006; P=0.002] and creatinine levels (HR, 1.002; P=0.024) as independent factors affecting 28-day mortality. The area under the curve (AUC) for CB and creatinine levels plus qSOFA score was 0.792 (95% confidence interval, 0.745-0.834), which was larger than the values for CB level, creatinine level and qSOFA score alone (all P<0.01) in the prognosis of 28-day mortality. The cut-off value of CB and creatinine levels plus qSOFA score for the 28-day mortality was 0.275 (-2.466 + 0.012 x CB + 0.002 x creatinine + 1.289 x qSOFA). Patients with lower combined predictor values had a better prognosis as demonstrated by Kaplan-Meier survival curves (log-rank test, 10.060; P=0.002). In both the septic shock and sepsis groups, the combined predictor value was higher in the non-survival group than in the survival group (P<0.001). Therefore, an increase in the combined predictor value of CB and creatinine levels plus qSOFA score may be an important predictor of disease progression and prognosis in patients with sepsis and septic shock.
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Affiliation(s)
- Yufei Xiao
- Department of Clinical Laboratory, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Xiaotian Yan
- Department of Clinical Laboratory, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Clinical Research Center for Oral Diseases of Zhejiang Province, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, Zhejiang 310006, P.R. China
| | - Lingwei Shen
- Department of Clinical Laboratory, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Qi Wang
- Department of Clinical Laboratory, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Fugang Li
- Shanghai Upper Biotech Pharma Co. Ltd., Shanghai 201201, P.R. China
| | - Dan Yang
- Department of Clinical Laboratory, The First People's Hospital of Fuyang District, Hangzhou, Zhejiang 311499, P.R. China
| | - Weiwei Wu
- School of Advanced Materials and Nanotechnology, Interdisciplinary Research Center of Smart Sensors, Xidian University, Xi'an, Shaanxi 710071, P.R. China
| | - Yun Qian
- Department of Clinical Laboratory, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Clinical Research Center for Oral Diseases of Zhejiang Province, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, Zhejiang 310006, P.R. China
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Boettler MA, Kaffenberger BH, Chung CG. Cellulitis: A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis. Am J Clin Dermatol 2022; 23:153-165. [PMID: 34902109 DOI: 10.1007/s40257-021-00659-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.
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Zhang J, Li X, Huang G, Wang A, Zhang F. Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department. Int J Gen Med 2021; 14:3511-3516. [PMID: 34295179 PMCID: PMC8290349 DOI: 10.2147/ijgm.s321662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background Musculoskeletal infection (MSKI) is a common reason to seek medical care in the emergency department (ED). We aimed to determine the clinical characteristics and etiology of patients with MSKI in our ED, the characteristics of MSKI with sepsis, and the predictors of death in sepsis patients. Methods The study retrospectively analyzed patients with MSKI from April 1, 2017, to March 31, 2021. The patients were divided into non-sepsis and sepsis groups. Clinical data of these patients including their basic information, laboratory results, diagnostic results, and outcomes were collected. Statistical analysis was carried out using GraphPad Prism 5. Results In all, 106 patients (70 male, 36 female) were enrolled in this study: 43 MSKI patients with sepsis and 63 MSKI patients without sepsis. Five patients with sepsis died. The patients’ age and sex ratio were no significantly different between the sepsis and non-sepsis groups. In the sepsis group, the ratio of rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis was significantly different than that in the non-sepsis group (all p<0.05). Fifty-six patients (54.37%) had positive etiology results. Staphylococcus, streptococcus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli were the most common bacteria found in both groups, but sepsis patients had more Candida albicans infections than non-sepsis patients (p=0.0331, p<0.05). The five patients who died in the sepsis group had higher serum levels of creatinine and procalcitonin (PCT). Multivariate logistic regression analyses showed that PCT (p=0.026; odds ratio, 1.038) was significantly related to mortality. Conclusion In MSKI patients, rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis are the risk factors for sepsis. Staphylococcus, streptococcus, K. pneumoniae, P. aeruginosa, and E. coli were the most common bacteria in MSKI patients, while MSKI patients with sepsis had more C. albicans infections. Elevated PCT was significantly related to death in sepsis patients.
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Affiliation(s)
- Juan Zhang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Xiangmin Li
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Guoqing Huang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Aimin Wang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Fangjie Zhang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
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Olszewski WL, Zaleska MT. Long-Term Benzathine Penicillin Prophylaxis Lasting for Years Effectively Prevents Recurrence of Dermato-Lymphangio-Adenitis (Cellulitis) in Limb Lymphedema. Lymphat Res Biol 2021; 19:545-552. [PMID: 33596117 DOI: 10.1089/lrb.2020.0051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The lymphedema-affected limbs are predisposed to acute and, subsequently, chronic dermato-lymphangio-adenitis (DLA) episodes in around 40%-50% of cases, irrespective of what the primary etiological factor is for the development of this condition. DLA is of bacterial etiology, and it needs antibiotic control and prevention of recurrence. Aim: To follow the effects of years-long continuous no-break administration of benzathine penicillin on the recurrence of acute DLA episodes. Methods and Results: Two hundred thirty-one patients were affected with lymphedema of lower and upper limbs. The mean duration of lymphedema was 10.2 ± 7.3 (range 2-30) years, and the number of DLA attacks/patient was 3.3 ± 3.2 (range 1-10). The total number of DLA episodes was 805. Benzathine penicillin injections 1,200,000 units were given i.m. at 14-21 days intervals (mean 18 ± 9 days) with short accidental breaks only. The period of therapy was 39.2 ± 38.7 (median 32) months. Recurrence occurred in 23 out of 231 (10%) (p < 0.01). There were 42 DLA incidents compared with 805 before introduction of therapy (5.2%) patients (hazard ratio 0.05, 95% confidence interval 0.034-0.079) (p < 0.01). Among patients with recurrence, there was a decrease of DLA episodes from 6.2% ± 3.6% to 1.7% ± 1.0%/patient. There were no differences in effectiveness of penicillin prophylaxis between etiological groups, depending on stages of lymphedema. Conclusions: Long-term years-long benzathine penicillin prophylaxis is extremely effective in prevention of DLA recurrence. It can be applied for years with no breaks, without clinical side-effects, and raising resistance to antibiotics. Microbial colonization and evoked inflammatory reaction of hosts should be controlled from the first symptoms of lymph stasis, irrespective of the etiology of lymphedema.
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Affiliation(s)
- Waldemar L Olszewski
- Department of Vascular Surgery, Central Clinical Hospital of Internal Affairs, Warsaw, Poland
- Department of Applied Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
| | - Marzanna T Zaleska
- Department of Vascular Surgery, Central Clinical Hospital of Internal Affairs, Warsaw, Poland
- Department of Applied Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
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