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PubMed2002

[Significance of antibiotic resistance in treatment of soft tissue infections].

Soft tissue infections are common. The clinical spectrum includes infections of skin, subcutaneous tissue, and of deeper structures such as fascia and muscles. The pathogenesis of these infections is quite variable. Introduction of microorganisms through skin breaks or through trauma of other soft tissue is usually at the origin of such infections. Staphylococci, especially S. aureus, as well as streptococci, mainly group A streptococci cause most soft tissue infections. In immunocompromised patients or in particuluar circumstances gram-negative bacteria may also be found to cause such infections. Occasionally, infections are polymicrobial. Given the predominance of gram-positive cocci, betalactam antibiotics with good antistaphylococcal activity are the drugs of choice for empiric treatment. Penicillins or cephalosporins that are stable against penicillinase should be chosen, since many staphylococci produce penicillinase. Over the course of the last 40 years staphylococci first became resistant against penicillin, and later developed resistance against methicillin. Methicillin-resistant S. aureus (MRSA) is now a significant problem worldwide. There continue to be major differences in the prevalence of MRSA between geographic regions. In areas with a high prevalence of methicillin resistance among S. aureus, empiric treatment of life-threatening soft tissue infections should include treatment with a glycopeptide (i.e. vancomycin or teicoplanin). New antibiotics such as oxazolidinones (i.e. linezolid) or quinupristin/dalfopristin are interesting alternatives to the glycopeptides in the treatment of soft tissue infections.

Anti-Bacterial Agents↗
PubMed2001

[Harmless or life threatening? Properly assessing soft tissue infections].

Soft tissue infections are highly diverse in presentation, and their severity is readily underestimated. Classifications in the literature are not uniform. Clinically, a recommended classification is based on the spread of the infection into deeper regions: superficial and deep soft tissue infections. Superficial infections, that is, those confined to the cutis and subcutis, include furuncles, erysipelas and phlegmons (acute suppurative inflammation). The second group--infection affecting fascia and muscle--include both classical gas gangrene and necrotizing fasciitis which, despite aggressive treatment, are associated with a high mortality rate. The present review shows the classification and differential diagnosis of these infections.

Diagnosis, Differential↗
PubMed1998

Soft tissue infections.

Soft tissue infections vary widely in their nature and severity, and their nomenclature is confusing. A clear approach to management must allow rapid identification and treatment of the diffuse necrotizing infections because they are life-threatening. This review classifies soft tissue infections by their degree of localization and the presence of tissue necrosis. Most focal nonnecrotizing infections start in the skin or adnexae and are easily recognized and readily treated by local measures. Patients with cellulitis, the commonest diffuse nonnecrotizing infection, should be stratified from mild to severe and complicated and then treated with oral or systemic antibiotics. Focal necrotizing infections are relatively uncommon, but they are readily diagnosed on sight and effectively managed by local debridement and systemic antibiotics. In contrast, diffuse necrotizing infections may masquerade in many forms, delaying diagnosis and treatment. Edema out of proportion to erythema, subcutaneous gas, and skin vesicles are important markers. Aggressive sequential debridement and broad-spectrum intravenous antibiotics revised after 48 hours provide the best strategy for management.

Anti-Bacterial Agents↗
PubMed2000

Soft tissue infections.

Soft tissue infections are almost routinely the product of direct microbe inoculation through a bridged protective skin. Day of onset and clinical presentation reflect the causative pathogen(s) and course that should be taken in treatment. Exclusive of chronic states, only in the most fulminating cases are culture and antimicrobial drugs of any real value.

Bacterial Infections↗
PubMed1990

[Etiology, diagnosis and therapy of soft tissue infections].

Soft tissue infections are caused by a multitude of bacteria. Their pathogenicity depends on the ability to adhere to surfaces, certain characteristics of the cell wall, exoenzymes or exotoxins, and endotoxins. Because etiologic classification of soft tissue infections is not satisfactory, we propose a clinical classification. 1. Abscesses are caused by staphylococci (carbuncle or suppurative hydroadenitis) or by polymicrobial infections (most subcutaneous abscesses). They are treated by incision and drainage and primary closure of the skin after drainage and curettage is often successful. Only in special cases are antibiotics indicated. 2. Cellulitis mostly caused by streptococci responds well to antibiotic therapy without surgery. 3. Ulcerative lesions i.e. pseudomonal gangrene and Meleney's gangrene need specific antibiotic therapy and complete excision with delayed grafting.

Abscess↗
PubMed1990

Impact of the antibiotic dosage schedule on efficacy in experimental soft tissue infections.

Soft tissue infection models have been used to study both the postantibiotic effect (PAE) and the effect of dosage intervals on antimicrobial efficacy. In vitro findings were mostly confirmed. For drug-organism combinations which showed a predominantly time-dependent killing pattern and absence of a PAE (beta-lactams vs Gram-negative organisms), frequent drug dosing was most efficacious. In contrast, a fast, predominantly concentration-dependent bactericidal effect followed by a PAE in vitro (e.g. aminoglycosides vs Gram-negative bacteria) correlated (though inconsistently) with superiority of bolus dosing over more continuous drug administration in vivo. Thus, the ratio of peak serum concentrations to MICs of target pathogens is possibly a valid predictor of efficacy for the aminoglycosides but not so for the activity of beta-lactam antibiotics where the duration of coverage at supra-MIC levels was clearly more important than the magnitude by which initial peaks exceeded the MIC of the target organism. It is not clear to what extent the results obtained in experimental soft tissue infections may hold true in man. Thus far, only a limited number of drug-organism combinations have been studied in well defined experimental settings using mostly small, granulocytopenic animals which differ pharmacokinetically from man. In addition, results are probably affected by the density of bacteria, their growth rate and metabolic activity, but also by the extent of inflammation at the site of infection.

Animals↗
PubMed2006

[Epidemiological characteristics and mortality risk factors in patients admitted in hospitals with soft tissue infections. A multicentric STIMG (Soft Tissue Infections Malacitan Group) study results].

OBJECTIVES: To describe the characteristics of patients admitted in hospitals with soft tissue infections, and analyse the variables whose died, in order to define risk groups. METHOD: retrospective analysis of medical reports of all patient admitted during 2002 year for soft tissue infections in public malacitans hospitals. We excluded the patient with soft tissue infections associated with burns, surgery, pressure ulcers, and orbit cellulitis. We analysed clinical, biochemical variables and indications for yields and imaging tests, so the empiric antibiotic treatment established and its correlations with practice guidelines. RESULTS: We analysed 391 admissions of 374 patients. Cellulitis was the most frequent diagnosis (69.3%). We did imaging tests in 51.6%. In 94.3% of cases were treated with empirics antibiotics. The most prescribed drug was amoxiciline plus clavulanate (39%). 27 patients died, 40.7% of them for septic cause. All deceased patients had chronic diseases. The only biochemical parameters associated with mortality were serum proteins and albumina (55 +/- 9 g/L vs. 63 +/- 8 g/L; p = 0.0231) and (22 +/- 7 g/L vs. 29 +/- 7 g/L; p = 0.0125) respectively. CONCLUSIONS: Cellullitis are the most frequent soft tissue infections that requires admissions in hospitals. We overuse imaging test and don t follow the practice guidelines recommendations in antibiotic therapy. Primary soft issue infection s mortality is low and it s restricted to people with chronic illness, deep infections and bad nutritional status.

Adolescent↗
PubMed1993

[Necrotizing soft tissue infections].

Necrotizing soft tissue infections are a group of life- and limb-threatening infections. They are caused by aerobic and anaerobic bacteria occasionally in a synergistic polymicrobial combination. The literature describing necrotizing soft tissue infections is controversial and often contradictory. Depending on their clinical appearance, tissue level and microbiological findings, necrotizing soft tissue infections are classified into two major groups, infections within the subcutaneous/fascia niveau and within the muscle level. Necrotizing infections of the subcutaneous level are further differentiated in hemolytic streptococcal gangrene, necrotizing fasciitis, clostridium fasciitis, and anaerobic nonclostridium fasciitis. In particular, necrotizing fasciitis is a rapidly progressing process, which is characterized by suppurative fasciitis, following by vascular thrombosis and cutaneous gangrene and is often accompanied by severe systemic toxicity, seen as septic-toxic shock and progressive (multi-) organ failure. Nineteen cases of necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich, between 1989 and 1992. These infections originated from "neglected trauma" in 9 (9/19), drug injections in 4 (4/19), acute infections in 3 (3/19), operative wounds in 2 (2/19) and perforation of the intestine in 1 case (1/19). Most of the patients (13/19) suffered from chronic debilitating diseases and were compromised by a suppressed immune system. We treated two groups of patients, one with septic-toxic clinical course and the other without. Eleven patients (11/19) belonged to group one and four of them, showing necrotizing fasciitis of the trunk, died as a result of multiorgan failure (MOF). Furthermore, three patients in this group had a limb amputated. In the other group without septic-toxic signs, no one died or lost a limb. The two groups differed also in length of hospital stay, an average of 60 days in group one (23 days intensive care) and 25 days in group two. Our results suggest that prompt recognition and treatment of necrotizing soft tissue infections are essential for the patient's survival. Often the full extent of the infections is underestimated initially, resulting in delayed surgical therapy. To control the rapidly spreading necrosis, early diagnosis and radical debridement of the affected tissue are essential and should be done without compromise, even if the affected limb must be amputated.

Adult↗
PubMed1999

Necrotizing soft tissue infections.

Necrotizing soft tissue infections are a group of highly lethal infections that typically occur after trauma or surgery. Many individual infectious entities have been described, but they all have similar pathophysiologies, clinical features, and treatment approaches. The essentials of successful treatment include early diagnosis, aggressive surgical debridement, antibiotics, and supportive intensive treatment unit care. The two commonest pitfalls in management are failure of early diagnosis and inadequate surgical debridement. These life-threatening infections are often mistaken for cellulitis or innocent wound infections, and this is responsible for diagnostic delay. Tissue gas is not a universal finding in necrotizing soft tissue infections. This misconception also contributes to diagnostic errors. Incision and drainage is an inappropriate surgical strategy for necrotizing soft tissue infections; excisional debridement is needed. Hyperbaric oxygen therapy may be useful, but it is not as important as aggressive surgical therapy. Despite advances in antibiotic therapy and intensive treatment unit medicine, the mortality of necrotizing soft tissue infections is still high. This article emphasizes common treatment principles for all of these infections, and reviews some of the more important individual necrotizing soft tissue infectious entities.

Clostridium Infections↗
PubMed2006

[Strategies of management of necrotizing soft tissue infections].

Necrotizing soft tissue infections represent a group of rapidly progressive diseases requiring early and repeated debridement, associated with broad spectrum antibiotics. Delay in surgery or inadequate therapy are the main risk factors for death. Most patients need aggressive critical care management and intensive nutritional support. The management of these patients by experimented senior surgeons is mandatory. A plastic surgeon can help debridement in order to preserve possibilities of later myocutaneous or rotational skin flaps. Intravenous immunoglobulins are an efficacious adjunctive therapy for severe group A streptococcal infection.

Anti-Bacterial Agents↗
PubMed2005

ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections.

OBJECTIVES: Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses. METHODS: Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30-minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven-day follow-up was the criterion standard when I + D was not performed. RESULTS: Sixty-four of 107 patients had I + D-proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, chi(2) = 14.2, p = 0.0002). CONCLUSIONS: ED bedside US improves accuracy in detection of superficial abscesses.

Abscess↗
PubMed1988

Mead Johnson Critical Care Symposium for the Practising Surgeon. 5. The diagnosis and management of common soft-tissue infections.

Soft-tissue bacterial infections range from the superficial, relatively benign form, readily treated by oral administration of antibiotics, to the highly lethal variety which requires extensive surgical débridement, administration of broad-spectrum antibiotics and patient monitoring in the intensive care unit. The key to patient survival in the latter group is early diagnosis and treatment. Those at risk of serious infections include diabetic and cirrhotic patients and trauma victims who have been treated either surgically or medically. In addition to awareness of the possibility of serious infection, x-ray films of the soft tissue to show gas, aspiration of fluid collections for Gram's staining and local incision of the tissue to inspect fascia and muscle are all useful aids in diagnosis. This review attempts to classify soft-tissue infections and to recommend an approach to diagnosis and management.

Bacterial Infections↗
PubMed2003

Necrotizing Soft Tissue Infections.

Necrotizing soft tissue infections are characterized by necrosis of skin and associated structures. Despite advances in the diagnosis and treatment of these infections, the mortality remains high. There have been increasing reports of necrotizing fasciitis caused by group A Streptococcus over the past decade. Recent information supports the role of superantigens in the pathogenesis of this infection. The approach to management requires expeditious evaluation with early surgery and appropriate antimicrobial agents. Limited data suggest that surgical debridement may be delayed in selected patients until the patient is stable by the use of intravenous immunoglobulin, which can neutralize superantigens.

Journal Article↗
PubMed2006

Inappropriate antibiotic use in soft tissue infections.

HYPOTHESIS: Many soft tissue infections treated with surgical drainage resolve even when treated with antibiotics not active against the organism isolated from the infection. DESIGN: Retrospective. SETTING: Integrated Soft Tissue Infection Services clinic. PATIENTS: All patients treated from July 19, 2000, to August 1, 2001, who underwent surgical drainage of a soft tissue infection and had microbiological culture results. MAIN OUTCOME MEASURES: Documented resolution of the infection with drainage of the abscess and antibiotic therapy alone was deemed a cure. An infection resulting in death or other surgical therapy was deemed a failure. Therapy was appropriate when the organism was sensitive to prescribed antibiotics and was inappropriate when the organism was insensitive. RESULTS: The study included 376 patients with 450 infections. Staphylococcus aureus as the primary organism was isolated from 441 of the cultures. Methicillin sodium-sensitive S aureus and methicillin-resistant S aureus were found in 157 and 284 of these isolates, respectively. Appropriate antibiotics were prescribed in 153 infections with methicillin-sensitive S aureus and in 25 with methicillin-resistant S aureus. Of 441 episodes, 408 were clinically evaluated for cure. Three patients failed treatment, 2 in the appropriately treated group (resulting in death and amputation) and 1 patient with osteomyelitis in the inappropriately treated group. The cure rate for infections treated appropriately or inappropriately was the same. CONCLUSIONS: Treatment of soft tissue infections after surgical drainage, even with inappropriate antibiotics, has a high cure rate. Further studies to evaluate the efficacy of treating these infections without antibiotics are needed.

Adult↗
PubMed2005

Rapidly progressive soft tissue infections.

Skin and soft tissue infections are among the most common reasons for people to seek medical advice. They also represent one of the most common indications for antimicrobial therapy and account for approximately 7-10% of hospitalisations in North America. Although non-limb and non-life threatening infections may be treated on an out-patient basis with oral antibiotics, patients with more serious acute skin and soft tissue infections may require admission to hospital for management; this decision is especially true if the infection is rapidly progressive. We provide a concise overview of the differential diagnosis and approach to management of community-acquired rapidly progressive skin and soft tissue infections.

Animals↗
PubMed2005

Predictors of mortality and limb loss in necrotizing soft tissue infections.

HYPOTHESIS: Necrotizing soft tissue infections are associated with a high mortality rate. We hypothesize that specific predictors of limb loss and mortality in patients with necrotizing soft tissue infection can be identified on hospital admission. DESIGN: A retrospective cohort study. SETTING: A tertiary care center. PATIENTS: Patients with a diagnosis of necrotizing soft tissue infection during a 5-year period (1996-2001) were included. Patients were identified with International Classification of Diseases, Ninth Revision hospital discharge diagnosis codes, and diagnosis was confirmed by medical record review. INTERVENTIONS: Standard current treatment including early and scheduled repeated debridement, broad-spectrum antibiotics, and physiologic and nutritional support was given to all patients. MAIN OUTCOME MEASURES: Limb loss and mortality. RESULTS: One hundred sixty-six patients were identified and included in the study. The overall mortality rate was 16.9%, and limb loss occurred in 26% of patients with extremity involvement. Independent predictors of mortality included white blood cell count greater than 30 000 x 10(3)/microL, creatinine level greater than 2 mg/dL (176.8 micromol/L), and heart disease at hospital admission. Independent predictors of limb loss included heart disease and shock (systolic blood pressure <90 mm Hg) at hospital admission. Clostridial infection was an independent predictor for both limb loss (odds ratio, 3.9 [95% confidence interval, 1.1-12.8]) and mortality (odds ratio, 4.1 [95% confidence interval, 1.3-12.3]) and was highly associated with intravenous drug use and a high rate of leukocytosis on hospital admission. The latter was found to be a good variable in estimating the probability of death. CONCLUSIONS: Clostridial infection is consistently associated with poor outcome. This together with the independent predictors mentioned earlier should aid in identifying patients on hospital admission who may benefit from more aggressive and novel therapeutic approaches.

Adult↗
PubMed1998

Outpatient parenteral anti-infective therapy for skin and soft-tissue infections.

Skin and soft tissue infections (SSIs) are one of the many infectious diseases that can be treated by outpatient parenteral anti-infective therapy (OPAT). Determining whether a patient with SSIs is treated topically, orally, or parenterally depends on the severity of infection and host factors. The decision to hospitalize, initiate, or transition to OPAT with SSIs depends on the medical assessment and consideration of available resources for OPAT. Anti-infective selection depends on the clinical presentation, likely organisms, pharmacodynamics, pharmacokinetics, and drug stability.

Anti-Bacterial Agents↗