Protecting the skin-implant interface with transcutaneous silver-coated skin-and-bone-integrated pylon in pig and rabbit dorsum models.

Implant-associated soft tissue infections at the skin-implant interface represent the most frequent complications in reconstructive surgery and lead to implant failures and revisions. Titanium implants with deep porosity, called skin-and-bone-integrated-pylons (SBIP), allow for skin ingrowth in the morphologically natural direction, thus restoring a reliable dermal barrier and reducing the risk of infection. Silver coating of the SBIP implant surface using physical vapor deposition technique offers the possibility of preventing biofilm formation and exerting a direct antimicrobial effect during the wound healing phase. In vivo studies employing pig and rabbit dorsum models for assessment of skin ingrowth into the pores of the pylon demonstrated the safety of transcutaneous implantation of the SBIP system. No postoperative complications were reported at the end of the follow-up period of 6 months. Histological analysis proved skin ingrowth in the minipig model without signs of silver toxicity. Analysis of silver release (using energy dispersive X-ray spectroscopy) in the model of intramedullary-inserted silver-coated SBIP in New Zealand rabbits demonstrated trace amounts of silver after 3 months of in-bone implantation. In conclusion, selected temporary silver coating of the SBIP implant surface is powerful at preventing the periprosthetic infections without imparing skin ingrowth and can be considered for clinical application.

Pin tract infection prophylaxis and treatment.

Pin tract infection in external fixation (ExFix) is a frequent finding which can eventually lead to loosening, osteomyelitis and loss of fixation. Its diagnosis is based on high empiricism and low validity, although it is possible to distinguish between minor and major infection. The first is limited to soft tissues, whereas the latter includes bone involvement. The rate of infection after conversion of external fixation to intramedullary nailing (IMN) is not well known. Unfortunately, papers referring to infection after the conversion of ExFix to intramedullary nailing (IMN) are of evidence level IV or V. It is suggested that conversion of ExFix to IMN should be carried out in a 2 step regimen. The time interval of 2 step regimen is uncertain although some authors have recommended to occur within 9 days. There is no consensus as to which prophylaxis protocol should be applied prior to conversion. In order to throw more light into this important issue, registries capturing important related parameters to the development of infection should be established.

Protection against Staphylococcus aureus Colonization and Infection by B- and T-Cell-Mediated Mechanisms.

Staphylococcus aureus is a major cause of morbidity and mortality worldwide. S. aureus colonizes 20 to 80% of humans at any one time and causes a variety of illnesses. Strains that are resistant to common antibiotics further complicate management. S. aureus vaccine development has been unsuccessful so far, largely due to the incomplete understanding of the mechanisms of protection against this pathogen. Here, we studied the role of different aspects of adaptive immunity induced by an S. aureus vaccine in protection against S. aureus bacteremia, dermonecrosis, skin abscess, and gastrointestinal (GI) colonization. We show that, depending on the challenge model, the contributions of vaccine-induced S. aureus-specific antibody and Th1 and Th17 responses to protection are different: antibodies play a major role in reducing mortality during S. aureus bacteremia, whereas Th1 or Th17 responses are essential for prevention of S. aureus skin abscesses and the clearance of bacteria from the GI tract. Both antibody- and T-cell-mediated mechanisms contribute to prevention of S. aureus dermonecrosis. Engagement of all three immune pathways results in the most robust protection under each pathological condition. Therefore, our results suggest that eliciting multipronged humoral and cellular responses to S. aureus antigens may be critical to achieve effective and comprehensive immune defense against this pathogen.IMPORTANCES. aureus is a leading cause of healthcare- and community-associated bacterial infections. S. aureus causes various illnesses, including bacteremia, meningitis, endocarditis, pneumonia, osteomyelitis, sepsis, and skin and soft tissue infections. S. aureus colonizes between 20 and 80% of humans; carriers are at increased risk for infection and transmission to others. The spread of multidrug-resistant strains limits antibiotic treatment options. Vaccine development against S. aureus has been unsuccessful to date, likely due to an inadequate understanding about the mechanisms of immune defense against this pathogen. The significance of our work is in illustrating the necessity of generating multipronged B-cell, Th1-, and Th17-mediated responses to S. aureus antigens in conferring enhanced and broad protection against S. aureus invasive infection, skin and soft tissue infection, and mucosal colonization. Our work thus, provides important insights for future vaccine development against this pathogen.

Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less.

BACKGROUND: To evaluate the role of initial prophylactic antibiotics on facial fractures, outcomes were compared between a short course (≤24 hours) of antibiotics to those who received an extended course (>24 hours). METHODS: Adults admitted (2010-2015) to a Level I trauma center intensive care unit with at least one facial bone fracture and major injuries isolated to the head and neck were included. Our primary analysis compared infectious complications of the head or neck (H/N infection) between patients given short or extended courses of antibiotic prophylaxis. Multivariate logistic regression and analysis of propensity score matched pairs were performed. RESULTS: A total of 403 patients were included, 85.6% had blunt injuries and 72.7% had their facial fracture managed nonoperatively. The H/N infection rate was 11.2%. Two hundred eighty patients received a short course of antibiotics and 123 patients received an extended course. Median Injury Severity Score was 14 in both groups (p = 0.78). Patients receiving an extended course of antibiotics had higher rates of H/N infection (20.3% vs. 7.1%, p < 0.001). Factors associated with development of H/N infection included younger age, penetrating injury, open fracture, upper face or mandible fracture, fractures in multiple facial thirds, vascular injury, hypertension, and extended antibiotic course. Multivariate logistic regression identified younger age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-1.00; p = 0.02), multiple facial third fractures (OR, 4.9; 95% CI, 2.4-10.2; p < 0.001), and penetrating mechanism (OR, 3.1; 95% CI, 1.5-6.4; p = 0.003) as independent predictors of H/N infection, but not antibiotic duration. Propensity score-matched analysis found no differences in H/N infection between short and extended antibiotic courses (11.4% vs. 12.5%; p = 1.0). Subgroup analyses demonstrated no differences in H/N infection between short or extended antibiotic courses by injury pattern, mechanism, or treatment (operative or nonoperative). CONCLUSION: These results lead us to believe that we should limit antibiotics to 24 hours or less upon admission for facial fractures. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Prospective observational study to assess the need for postoperative antibiotics following surgical incision and drainage of skin and soft tissue abscess in pediatric patients.

BACKGROUND: Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (I&D). We propose that antibiotics are unnecessary following I&D. METHODS: Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring I&D were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence). RESULTS: A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p<0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04). CONCLUSIONS: Post-operative management excluding antibiotics should be considered for patients who undergo I&D for SSTI. LEVEL OF EVIDENCE: Level II (prospective cohort study with <80% follow-up).

Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries.

BACKGROUND: We examined combat-related open extremity fracture infections as a function of whether posttrauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. METHODS: Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of ≥7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, and/or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. RESULTS: The study population included 1,044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p < 0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% vs. 22%; p = 0.029), whereas osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at 2 and 4 weeks postinjury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operating room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% vs. 40%; p < 0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (hazard ratio: 1.41; 95% confidence interval: 1.09-1.83). DISCUSSION: Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis, and there seems to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend the use of cefazolin or clindamycin with open fractures. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level II; Therapy, level IV.

Early local delivery of vancomycin suppresses ectopic bone formation in a rat model of trauma-induced heterotopic ossification.

Heterotopic ossification (HO) is a debilitating sequela of high-energy injuries. It frequently requires surgical excision once symptomatic and there is no practical prophylaxis for combat-injured patients. In this study, we examined the effect of local vancomycin powder on HO formation in a small animal model of blast-related, post-traumatic HO. Male Sprague-Dawley rats were subjected to a polytraumatic extremity injury and amputation with or without methicillin-resistant Staphylococcus aureus infection. Animals were randomized to receive a single local application of vancomycin (20 mg/kg) at the time of injury (POD-0, n = 34) or on postoperative day-3 (POD-3, n = 11). Quantitative volumetric measurement of ectopic bone was calculated at 12-weeks post-injury by micro-CT. Bone marrow and muscle tissues were also collected to determine the bacterial burden. Blood for serum cytokine analysis was collected at baseline and post-injury. Vancomycin treatment on POD-0 suppressed HO formation by 86% and prevented bone marrow and soft tissue infections. We concurrently observed a marked reduction histologically in nonviable tissue, chronic inflammatory cell infiltrates, bone infection, fibrous tissue, and areas of bone necrosis within this same cohort. Delayed treatment was significantly less efficacious. Neither treatment had a marked effect on the production of pro-inflammatory cytokines. Our study demonstrates that local vancomycin treatment at the time of injury significantly reduces HO formation in both the presence and absence of infection, with decreased efficacy if not given early. These findings further support the concept that the therapeutic window for prophylaxis is narrow, highlighting the need to develop early treatment strategies for clinical management. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2397-2406, 2017.

Treatment of open fractures of the hand in the emergency department.

Current guidelines suggest early surgical treatment of open fractures. This rule in open hand fractures is not well supported and may be unpractical. Furthermore, desirable debridement and washout can be obtained in the emergency department (ED). The purpose of this study was to evaluate the relationship between the level of contamination, quality of washout in the emergency room, and the development of infection. Sixty-one patients with open fractures of the hand were retrospectively reviewed for demographic and fracture characteristics, and other complications. The infection rate was 14.8%. Contamination was present in 43 patients (70.5%). One thousand milliliters or more were used to obtain a grossly clean wound in 43 patients (70.5%). No significant relationship was found between fracture type, finger involved, hand dominance, comorbidities, and development of infection. The amount of fluid used for washout was significantly related to infection (P = 0.047), whereas wound contamination was not (P = 0.259). Type of oral antibiotic was significantly related to infection (P = 0.039). The level of contamination was not a significant factor in predicting infection, whereas the amount of fluid used for washout and the oral antibiotic type were significant factors in preventing infection. Since administration of intravenous antibiotics and thorough wound cleansing can be performed on open hand fractures in the ED under adequate anesthesia, most open fractures in the hand do not need to be treated early in the operating theater.

Obesity and skin and soft tissue infections: how to optimize antimicrobial usage for prevention and treatment?

PURPOSE OF REVIEW: Skin and soft tissue infections (SSTIs) are prevalent in the obese population, with rising trend expected. Although numerous antibiotics are available for the prevention and treatment of SSTIs, their characterization in obese patients is not a regulatory mandate. Consequently, information that carries importance for optimizing the dosing regimen in the obese population may not be readily available. This review focuses on the most recent pharmacokinetic and pharmacodynamic data on this topic with attention to cefazolin for surgical prophylaxis as well as antibiotics that are active against methicillin-resistant Staphylococcus aureus (MRSA). Moreover, the implications for optimizing SSTIs prevention and treatment in the obese population will also be discussed. RECENT FINDINGS: On the basis of pharmacokinetic/pharmacodynamic considerations, most studies found a perioperative prophylactic cefazolin regimen of 2 g to be reasonable in the case of obese patients undergoing cesarean delivery or bariatric surgery. There is general paucity of data regarding the pharmacokinetic/pharmacodynamic characteristics of antimicrobials active against MRSA in obese patients, especially for the target tissue. Therapeutic drug monitoring has been correlated with pharmacokinetic/pharmacodynamic optimization for vancomycin and teicoplanin, and should be used in these cases. There is more supportive evidence for the use of oxazolidinones (linezolid and tedizolid), daptomycin and lipoglycopeptides (telavancin, dalbavancin and oritavancin) in the management of SSTIs in this population. SUMMARY: The pharmacokinetic/pharmacodynamic approach, which can be used as a basis or supplement to clinical trials, provides valuable data and decision-making tools for optimizing regimens used for both prevention and treatment of SSTIs in the obese population. Important pharmacokinetic/pharmacodynamic characteristics of antibiotics, such as the penetration into the subcutaneous tissue and the probability of reaching the pharmacodynamic, target dictate efficacy, and thus should be taken into account and further investigated.

An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment.

PURPOSE: The purpose of this study was to provide an overview of infections associated with facial soft tissue fillers. MATERIALS AND METHODS: A literature review was performed which evaluated infections associated with facial soft tissue fillers. RESULTS: Infection rates with soft tissue fillers are low and are estimated at 0.04 to 0.2%. Most of these infections arise when skin contaminants infiltrate the injection site at the time of injection. These infections can occur early, up to several days after treatment, or delayed, occurring weeks to years after treatment. Reactions vary based on the filler absorbability and duration. Early recognition and treatment are important factors in managing our cosmetic surgery patients. CONCLUSION: Although facial fillers are safe and predictable, infections can still occur. Oral and maxillofacial surgeons need to be able to prevent, recognize, and properly manage infections related to these popular injections.

Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients.

BACKGROUND: Charcot neuropathic arthropathy (CN) is a chronic, progressive, destructive, non-infectious process that most frequently affects the bone architecture of the foot in patients with sensory neuropathy. We evaluated the outcome of protected weightbearing treatment of CN in unilaterally and bilaterally affected patients and secondarily compared outcomes in protected versus unprotected weightbearing treatment. METHODS: Patient records and radiographs from 2002 to 2012 were retrospectively analyzed. Patients with Type 1 or Type 2 diabetes with peripheral neuropathy were included. Exclusion criteria included immunosuppressive or osteoactive medication and the presence of bone tumors. Ninety patients (101 ft), mean age 60.7 ± 10.6 years at first diagnosis of CN, were identified. Protected weightbearing treatment was achieved by total contact cast or custom-made orthosis. Ulcer, infection, CN recurrence, and amputation rates were recorded. Mean follow-up was 48 (range 1-208) months. RESULTS: Per the Eichenholtz classification, 9 ft were prodromal, 61 in stage 1 (development), 21 in stage 2 (coalescence) and 10 in stage 3 (reconstruction). Duration of protected weightbearing was 20 ± 21 weeks and 22 ± 29 weeks in patients with unilateral and bilateral CN, respectively. In bilaterally affected patients, new ulcers developed in 9/22 (41%) feet. In unilaterally affected patients, new ulcers developed in 5/66 (8%) protected weightbearing feet and 4/13 (31%) unprotected, full weightbearing feet (p = 0.036). The ulceration rate was significantly higher in bilaterally versus unilaterally affected patients with a protected weightbearing regimen (p = 0.004). Soft tissue infection occurred in 1/13 (8%) unprotected weightbearing feet and 1/66 (2%) protected weightbearing feet in unilaterally affected patients, and in 1/22 (4%) protected weightbearing feet of bilaterally affected patients. Recurrence and amputation rates were similar across treatment modalities. CONCLUSIONS: Bilateral CN results in significantly more ulcers than unilateral CN and leads to slightly higher soft tissue infections. Protected weightbearing in an orthopedic device can reduce the risk for complications in acute CN of the foot and ankle.

[Burn child specificity]. / Les spécificités de la brûlure chez l'enfant.

Burn is still a frequent accident in children and particularly occurs in young children under 4years. The majority were caused by hot liquids (scalds) with mixed-dermal burns and is commonly treated conservatively with surgery performed at 10-15 days post-injury after healing of superficial burn. Patients with burns greater than 10% need early fluid resuscitation and adequate nutritional support to avoid deepening with infection, improve healing and survival. Hypovolemic shock could be very abrupt in children. Prophylactic prevention of infection and optimization of healing before 21 days improve quality of scar. Management with rehabilitation team is more important in children than in adults because hypertrophic scar and retraction can restrain growth and function particularly for palmar hand burns occurring at the beginning of walking. Follow-up is essential during the growth to assess scar tension requiring secondary surgery. Better knowledge of injury mechanisms should facilitate education and prevention programs and decrease the incidence.

Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

Facial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1-5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

Reference positions for transosseous elements in femur: A cadaveric study.

INTRODUCTION: During external fixator treatment, displacement of soft tissue at pin sites may cause infection and contracture. Due to surrounding soft tissue thickness, the femur is especially susceptible to severe complications. However, standard textbooks demonstrate only how major neurovascular bundles should be avoided. This study is the first cadaver study investigating which pin sites within safe zones exhibit minimal soft tissue displacement. METHODS: To identify the clear direction of any pin, the femoral shaft was divided into eight levels, from I to VIII. The transverse sections at each level were further divided into 12 radial positions analogous to a clock face, where the anterior direction was assigned twelve o'clock, the medial three, etc. Fifteen adult cadavers were used. Twelve wires were aligned radially on the examined ring, and were dyed at each point toward the soft tissue. Each soft tissue displacement was measured by marking the surface before and after three particular joint motions, namely hip flexion (0-90°), abduction (0-45), and knee flexion (0-90). The same procedures were performed in three layers of soft tissue: skin, fascia, and muscle. RESULTS: The average displacement was determined in 89 directions excluding the groin part, upon three joint motions. The three layers of skin, fascia, and muscle showed similar data curves. Greater displacements were seen at juxta-articular areas than at the mid-diaphyseal. The data curve exhibited a bimodal characteristic, with larger displacements at the extension and flexion directions. The amount of displacement at 6 o'clock was large at the levels near the hip joint, whereas at 12 o'clock, it was large near the knee joint. DISCUSSION: "Reference positions" for transosseous elements were defined within zones absent neurovascular bundles, indicating 30 sites with minimal tissue displacement. Three or four directions at each level were chosen: I.9-11, II.9-11, III.8-11, IV.8-11, V.7-10, VI.3, 7-9, VII.3, 4, 8, 9, and VIII.3, 4, 8, 9. The anterolateral aspect near the hip joint and the posterolateral aspect near the knee tended to be chosen. They may prove useful in perioperative practice.

Sequential therapy with "vacuum sealing drainage-artificial dermis implantation-thin partial thickness skin grafting" for deep and infected wound surfaces in children.

OBJECTIVE: To evaluate the efficacy of a "vacuum sealing drainage (VSD) - artificial dermis implantation (ADI) - thin partial thickness skin grafting (TSG)" sequential therapy for deep and infected wounds in children. MATERIALS AND METHODS: Fifty-three pediatric patients with deep and infected wounds were treated with sequential VSD-ADI-TSG therapy. The efficacy of this treatment was compared with that of the surgical debridement-change dressings-thin partial thickness skin grafting previously performed on 20 patients. Survival of tissue grafts, color and flexibility, subcutaneous fullness and scar formation of the graft site were examined and compared. RESULTS: The sequential therapy combined the advantages of the VSD treatment, in reducing tissue necrosis and infection on the wound surfaces and promoting the growth of granulation tissue, with the enhancement of grafting by artificial dermis. Compared with the 20 controls, skin grafted on the artificial dermis was more smooth and glossy, while the textures of the region were more elastic, and the scars were significantly lighter in Vancouver scale. CONCLUSION: The sequential VSD-ADI-TSG therapy is a simple and effective treatment for children with deep and infected wounds. LEVEL OF EVIDENCE: IV.

What's new in wound treatment: a critical appraisal.

With the growing demand for the specialized care of wounds, there is an ever expanding abundance of wound care modalities available. It is difficult to identify which products or devices enhance wound healing, and thus, a critical and continual look at new advances is necessary. The goal of any wound regimen should be to optimize wound healing by combining basic wound care modalities including debridement, off-loading, and infection control with the addition of advanced therapies when necessary. This review takes a closer look at current uses of negative pressure wound therapy, bioengineered alternative tissues, and amniotic membrane products. While robust literature may be lacking, current wound care advances are showing great promise in wound healing.

The use of trimethoprim and sulfamethoxazole (TMP-SMX) in dermatology.

We analyzed publications and articles in the PubMed database about the use of trimethoprim and sulfamethoxazole (TMP-SMX) in dermatology. Literature published in the English language, at least in the past two decades, was reviewed. Specific dermatologic indications for TMP-SMX are few but it is often used as the second- or third- line agent. TMP-SMX is used to treat cutaneous nocardiosis and Aeromonas infections. TMP-SMX is a treatment option for cat - scratch disease, granuloma inguinale, melioidosis and Mycobacterium marinum/fortuitum cutaneous infections. TMP-SMX is an alternate choice for treatment of pyodermas and lymphogranuloma venereum. TMP-SMX has been used to treat acne vulgaris in tetracycline and erythromycin - resistant patients. TMP-SMX is still the preferred empiric antibiotic for methicillin - resistant Staphylococcus aureus skin and soft tissue infection in HIV positive population. TMP-SMX is used in dermatology to treat various skin conditions and is one of the most commonly prescribed sulfonamide drugs. TMP-SMX as monotherapy is an effective treatment option in many diseases but due to drug resistance, a combination therapy-usually of two drugs-may be considered.

[Antibiotic prophylaxis in dermatologic and soft tissue surgery]. / Perioperative Antibiotikaprophylaxe bei Haut- und Weichteileingriffen.

In Germany, over half a million operations are done in dermatologic surgery in a hospital setting every year, as well as a less well quantified number of procedures in private offices. In spite of this large number, specific guidelines concerning the use of perioperative antibiotics in dermatologic surgery are sparse. In contrast to procedures in general, visceral or gynecological surgery, general guidelines on perioperative antibiotics issued by the Paul-Ehrlich Institutes and the AWMF do not specifically consider dermatologic operations. Several surveys indicate that familiarity with current recommendations on perioperative antibiotics is suboptimal and resulted in a considerable overuse of perioperative antibiotics in dermatologic surgery. Given the increasing antimicrobial resistance among important pathogens and the inherent risks of antibiotic administration, the decision for the use of prophylactic antibiotics should be based on the individual risk profile of the patient and of the surgical procedure. In the following, we will critically discuss the evidence for perioperative antibiotics in dermatologic surgery.

Staphylococcus aureus activation of caspase 1/calpain signaling mediates invasion through human keratinocytes.

The USA300 strains of Staphylococcus aureus are the major cause of skin and soft tissue infection in the United States. Invasive USA300 infection has been attributed to several virulence factors, including protein A and the α-hemolysin (Hla), which cause pathology by activating host signaling cascades. Here we show that S. aureus exploits the proinflammatory bias of human keratinocytes to activate pyroptosis, a caspase 1-dependent form of inflammatory cell death, which was required for staphylococci to penetrate across a keratinocyte barrier. Keratinocyte necrosis was mediated by calpains, Ca(2+)-dependent intracellular proteases whose endogenous inhibitor, calpastatin, is targeted by Hla-induced caspase 1. Neither Panton-Valentine leukocidin nor protein A expression was essential, but inhibition of either calpain or caspase 1 activity was sufficient to prevent staphylococcal invasion across the keratinocytes. These studies suggest that pharmacological interruption of specific keratinocyte signaling cascades as well as targeting the Hla might prevent invasive skin infection by staphylococci.

Update on the prevention and control of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA).

The rapid dissemination of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA) since the early 2000s and the appearance of new successful lineages is a matter of concern. The burden of these infections varies widely between different groups of individuals and in different regions of the world. Estimating the total burden of disease is therefore problematic. Skin and soft-tissue infections, often in otherwise healthy young individuals, are the most common clinical manifestation of these infections. The antibiotic susceptibilities of these strains also vary, although they are often more susceptible to 'traditional' antibiotics than related hospital-acquired strains. Preventing the dissemination of these organisms throughout the general population requires a multifaceted approach, including screening and decolonisation, general hygiene and cleaning measures, antibiotic stewardship programmes and, in the future, vaccination. The current evidence on the prevention and control of CA-MRSA is appraised and summarised in this review.