Impact of traditional cutaneous scarification on anthrax lesions: A series of cases from Cubal, Angola.

OBJECTIVES: Bacillus anthracis infection is a worldwide zoonosis that affects the most vulnerable population and has a high mortality rate without treatment, especially in non-cutaneous presentations. Cutaneous scarification is still common in some regions of the world for the treatment of certain diseases as part of traditional medicine. We describe a series of cutaneus anthrax from a rural setting in Angola where cutaneus scarification is common. CASE PRESENTATION: This is a retrospective observational study describing a series of cutaneous anthrax cases from Cubal (Angola), many of whom were treated with skin scarification before admission. A total of 26 cases were diagnosed from January 2010 to December 2018. None of the cases were confirmed and eight (30.8%) were probable cases according to the Centers for the Disease Control and Prevention anthrax case definition. The median age was 11 (4.7-30.5) years, 17 (65.4%) had lesions on the head, face, or neck and 15 (57.7%) were treated with cutaneous scarification. Nine (34.6%) patients died. Traditional cutaneous scarification was significantly associated with cutaneous superinfection, respiratory, systemic involvement, and death. CONCLUSION: Our case series points to increased complications and worse outcome of cutaneous anthrax disease if treated with skin scarification.

Current treatment options for Mycobacterium marinum cutaneous infections.

INTRODUCTION: Mycobacterium marinum is a slowly growing photochromogenic nontuberculous mycobacterium that has special growth characteristics. It causes a uniquely human disease, a cutaneous syndrome named fish tank granuloma or swimming pool granuloma because of the strong epidemiological links with water. The treatment of this disease involves the use of different antimicrobials alone and in combination, depending on the severity of the disease. The antibiotics most frequently used are macrolides, tetracyclines, cotrimoxazole, quinolones, aminoglycosides, rifamycins, and ethambutol. Other approaches include the use of surgery in some cases. New treatment options, like new antibiotics, phage therapy, phototherapy, and others are currently being developed with good in vitro experimental results. In any case, the disease is usually a mild one, and the outcome is good in most of the treated patients. AREAS COVERED: We have searched the literature for treatment schemes and drugs used for treatment of M. marinum disease, as well as other therapeutic options. EXPERT OPINION: Medical treatment is the most recommended approach option, as M. marinum is usually susceptible to tetracyclines, quinolones, macrolides, cotrimoxazole, and some tuberculostatic drugs, usually used in a combined therapeutic scheme. Surgical treatment is an option that can be curative and diagnostic in small lesions.

Cutaneous Infections Due to Nontuberculosis Mycobacterium: Recognition and Management.

Nontuberculous mycobacteria (NTM) are a diverse group of organisms that are ubiquitous in the environment, and the incidence of cutaneous infections due to NTM has been steadily increasing. Cutaneous infections due to NTM can be difficult to diagnose, due to their wide spectrum of clinical presentations and histopathological findings that are often nonspecific. A variety of modalities including tissue culture and polymerase chain reaction (PCR) assays may be necessary to identify the organism. Treatment can also be challenging, as it can depend on multiple factors, including the causative organism, the patient's immunological status, and the extent of disease involvement. In this review, we discuss the common presentations of cutaneous NTM infections, diagnostic tools, and treatment recommendations. A multi-disciplinary approach that involves good communication between the clinician, the histopathologist, the microbiologist, and infectious disease specialists can help lead to successful diagnosis and management.

Antimicrobial treatment decision for non-purulent skin and soft tissue infections in the emergency department.

OBJECTIVES: We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics. METHODS: We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method. RESULTS: The survey response rate was 36.9% (n=391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10. CONCLUSIONS: The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.

Staphylococcus lugdunensis infections, filling in the gaps: a 3-year retrospective review from a comprehensive cancer center.

OBJECTIVE: Staphylococcus lugdunensis is considered to be more aggressive than other coagulase-negative staphylococci (CoNS). There are gaps in knowledge regarding the importance of isolating S. lugdunensis from different sources and in different patient subsets. Our objective was to describe the spectrum, clinical manifestations, and outcomes of infections caused by S. lugdunensis in patients with cancer. METHODS: A retrospective review of all cancer patients from whom S. lugdunensis was isolated in a pure culture from clinically significant sites. RESULTS: Between 2011 and 2014, 2263 CoNS were isolated, of them 45 S. lugdunensis were isolated in a pure culture and were included in this analysis. Only three patients were neutropenic. Skin and skin structure infections (SSSIs) occurred most often (36 cases) followed by five blood stream infections, one of which had destructive endocarditis and four infections at other sites. Of the 36 SSSIs, 29 were related to surgical or invasive procedures, and six of these involved an implanted medical device. All isolates were susceptible to vancomycin, 98% to levofloxacin and 89% to oxacillin. All patients responded to the therapy. CONCLUSIONS: Cancer patients including those with neutropenia do not appear to have an increased frequency of infections caused by S. lugdunensis. SSSIs are predominant and are often associated with surgical procedures and/or implanted medical devices. Blood stream infections caused by S. lugdunensis are uncommon but may have an increased rate of serious complications such as endocarditis. Nevertheless, these organisms are generally susceptible to multiple classes of antimicrobial agents, and the overall response to therapy is high.

Recurrent Methicillin-Resistant Staphylococcus aureus Cutaneous Abscesses and Selection of Reduced Chlorhexidine Susceptibility during Chlorhexidine Use.

We describe the selection of reduced chlorhexidine susceptibility during chlorhexidine use in a patient with two episodes of cutaneous USA300 methicillin-resistant Staphylococcus aureus abscess. The second clinical isolate harbors a novel plasmid that encodes the QacA efflux pump. Greater use of chlorhexidine for disease prevention warrants surveillance for resistance.

Mycobacterium fortuitum skin infections after subcutaneous injections with Vietnamese traditional medicine: a case report.

BACKGROUND: Iatrogenic skin and soft tissue infections by rapidly growing mycobacteria are described with increasing frequency, especially among immunocompromised patients. CASE PRESENTATION: Here, we present an immunocompetent patient with extensive Mycobacterium fortuitum skin and soft tissue infections after subcutaneous injections to relieve joint pains by a Vietnamese traditional medicine practitioner. Moreover, we present dilemmas faced in less resourceful settings, influencing patient management. CONCLUSION: This case illustrates the pathogenic potential of rapid growing mycobacteria in medical or non-medical skin penetrating procedures, their world-wide distribution and demonstrates the dilemmas faced in settings with fewer resources.

Skin and soft tissue infections caused by nontuberculous mycobacteria.

PURPOSE OF REVIEW: Skin and soft tissues infections (SSTIs) caused by nontuberculous mycobacteria (NTM) are underrecognized and difficult to treat. Controversies exist for optimal medical management and the role of surgery. Defining the epidemiology in the environment, in animals and in healthcare aids disease prevention. This review focuses on recent advances in epidemiology, risk factors, diagnostics and therapy. RECENT FINDINGS: The increasing consumer appetite for cosmetic and body-modifying procedures (e.g. tattooing, mesotherapy, liposuction) has been associated with rises in sporadic cases and outbreaks of NTM SSTIs. In mainstream healthcare, recent epidemiological studies have helped to quantify the increased risk of NTM infection related to anti-tumour necrosis factor-α monoclonal antibody therapy. Cervicofacial lymphadenitis in children poses management dilemmas, but recent studies and resultant algorithms have simplified decision-making. Molecular studies have led to a better understanding of the epidemiology, therapy and course of Mycobacterium ulcerans infection (Buruli ulcer) that remains prevalent in many areas including sub-Saharan Africa and southeastern Australia. Apart from molecular methods, the widespread adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry by routine laboratories has potential to simplify and expedite the laboratory identification of NTMs. SUMMARY: An improved understanding of the epidemiology of NTM SSTIs indicates a need to apply effective infection control and ensure regulation of cosmetic and related procedures associated with nonsterile fluids. Broader access to newer diagnostic methods will continue to improve recognition of NTM disease. Along with a paucity of therapeutic agents, there is need for more reliable methods to assess susceptibility and selection of effective combination therapy.

Mycobacterium chelonae infections associated with bee venom acupuncture.

We report 3 cases of Mycobacterium chelonae infections after bee venom acupuncture. All were treated with antibiotics and surgery. Mycobacterium chelonae infections should be included in the differential diagnosis of chronic skin and soft tissue infections following bee venom acupuncture.

[A severe cutaneous anthrax case complicated with sepsis in Bursa, Turkey]. / Bursa'da sepsis klinik tablosu ile seyreden agir deri sarbonu olgusu.

Anthrax is a zoonotic infection caused by Bacillus anthracis. Although the incidence of disease has been decreasing in Turkey, it is still endemic in some regions of the country. The cutaneous form of disease is the most common clinical form, usually benign and rarely causes bacteriemia and sepsis. In this report, a case of cutaneous anthrax complicated with sepsis where B.anthracis was isolated from blood and wound cultures, was presented. A 53-years-old male living in Bursa province (northwestern Turkey), admitted to the emergency ward with high fever and a lesion on the right arm. His history indicated that he is dealing with livestock breeding and injured his arm during slaughtering of a sick lamb. The infection started as a black colored painless ulcer with 2 cm in diameter on his right elbow. The case was hospitalized and penicillin G therapy was started with the preliminary diagnosis of anthrax. Bullous lesions occurred around the wound, got necrosis and integrated with the first lesion. Gram stained slides from the bullous lesions revealed capsulated gram-positive bacilli under light microscope. Gram-positive bacilli were also isolated from bullous lesions and the blood cultures. The isolates were identified and confirmed as B.anthracis by conventional and molecular methods. Antibiotic susceptibility tests were performed by E-test method and the isolates were found to be susceptible to ampicillin, tetracyclin, tigecyclin, ciprofloxacin, levofloxacin, gentamycin, chloramphenicol, erythromycin, clarithromycin, vancomycin, linezolid, daptomycin and rifampicin. The lesion became surrounded by an extensive erythema and edema and expanded to the whole arm. Moxifloxacin was initiated due to the fact that clinical progress. During the second week of the therapy, a black colored scar was observed on the wound while hyperemia and edema regressed. The necrotic tissue debridated to accelerate healing and rest of the skin defect was planned for reconstruction. The patient who had septicaemia and disseminated cellulitis was discharged after his treatment continued for 14 days. Multiple-locus variable-number tandem repeat analysis method was used for molecular epidemiological investigation. The strains isolated from the patient were identified as genotype (GK) 43 classified in A3.a major cluster, and found to be identical to those strains isolated from animals in different provinces located at central and eastern Anatolia of Turkey. In conclusion, the risk of sepsis must be considered in patients with cutaneous anthrax with appropriate follow-up and treatment plan.

Successful treatment of skin and soft tissue infection due to carbapenem-resistant Acinetobacter baumannii by ampicillin-sulbactam and meropenem combination therapy.

In recent years, carbapenem-resistant Acinetobacter baumannii infections have been responsible for outbreaks in medical facilities. A 35-year-old Japanese woman developed a skin and soft tissue infection due to carbapenem-resistant A. baumannii. The isolate was resistant to antibiotics other than ampicillin-sulbactam and colistin, suggesting drug resistance due to carbapenemase production by OXA-23. We selected a combination therapy consisting of intravenous ampicillin-sulbactam and meropenem. No changes were observed in aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, or serum creatinine during therapy, and carbapenem-resistant A. baumannii was not detected in wound exudates 3 days after therapy initiation. In our patient's case, combination therapy with ampicillin-sulbactam and meropenem was successful. Thus, combination therapy with ampicillin-sulbactam and meropenem is effective against skin and soft tissue infection due to carbapenem-resistant A. baumannii. Combination therapy with intravenous ampicillin-sulbactam and meropenem may be an option for skin and soft tissue infections due to carbapenem-resistant A. baumannii.

Nontuberculous mycobacterial infection after fractionated CO(2) laser resurfacing.

Nontuberculous mycobacteria are increasingly associated with cutaneous infections after cosmetic procedures. Fractionated CO2 resurfacing, a widely used technique for photorejuvenation, has been associated with a more favorable side effect profile than alternative procedures. We describe 2 cases of nontuberculous mycobacterial infection after treatment with a fractionated CO2 laser at a private clinic. Densely distributed erythematous papules and pustules developed within the treated area within 2 weeks of the laser procedure. Diagnosis was confirmed by histologic analysis and culture. Both infections responded to a 4-month course of a multidrug regimen. An environmental investigation of the clinic was performed, but no source of infection was found. The case isolates differed from each other and from isolates obtained from the clinic, suggesting that the infection was acquired by postprocedure exposure. Papules and pustules after fractionated CO2 resurfacing should raise the suspicion of nontuberculous mycobacterial infection.

Recent outbreak of cutaneous anthrax in Bangladesh: clinico-demographic profile and treatment outcome of cases attended at Rajshahi Medical College Hospital.

BACKGROUND: Human cutaneous anthrax results from skin exposure to B. anthracis, primarily due to occupational exposure. Bangladesh has experienced a number of outbreaks of cutaneous anthrax in recent years. The last episode occurred from April to August, 2011 and created mass havoc due to its dreadful clinical outcome and socio-cultural consequences. We report here the clinico-demographic profile and treatment outcome of 15 cutaneous anthrax cases attended at the Dermatology Outpatient Department of Rajshahi Medical College Hospital, Bangladesh between April and August, 2011 with an aim to create awareness for early case detection and management. FINDINGS: Anthrax was suspected primarily based on cutaneous manifestations of typical non-tender ulcer with black eschar, with or without oedema, and a history of butchering, or dressing/washing of cattle/goat or their meat. Diagnosis was established by demonstration of large gram-positive rods, typically resembling B. anthracis under light microscope where possible and also by ascertaining therapeutic success. The mean age of cases was 21.4 years (ranging from 3 to 46 years), 7 (46.7%) being males and 8 (53.3%) females. The majority of cases were from lower middle socioeconomic status. Types of exposures included butchering (20%), contact with raw meat (46.7%), and live animals (33.3%). Malignant pustule was present in upper extremity, both extremities, face, and trunk at frequencies of 11 (73.3%), 2 (13.3%), 1 (6.7%) and 1 (6.7%) respectively. Eight (53.3%) patients presented with fever, 7 (46.7%) had localized oedema and 5 (33.3%) had regional lymphadenopathy. Anthrax was confirmed in 13 (86.7%) cases by demonstration of gram-positive rods. All cases were cured with 2 months oral ciprofloxacin combined with flucoxacillin for 2 weeks. CONCLUSIONS: We present the findings from this series of cases to reinforce the criteria for clinical diagnosis and to urge prompt therapeutic measures to treat cutaneous anthrax successfully to eliminate the unnecessary panic of anthrax.

Diagnostic and therapeutic evaluation of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA) skin and soft tissue infections in the emergency department.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections commonly present as skin and soft-tissue infections (SSTIs). Treatment often includes incision and drainage with or without adjunctive antibiotics. Emergency department (ED) pharmacists wished to provide specific data to emergency physicians to better inform antibiotic choices for patients with SSTIs. STUDY OBJECTIVES: The objectives of this study were to describe local susceptibility trends of CA-MRSA isolates obtained from patients with SSTIs and describe diagnostic and empiric therapeutic management of CA-MRSA SSTIs among ED health care providers at University of Utah Hospitals and Clinics. METHODS: Susceptibility of all unique CA-MRSA SSTI isolates for 2008 were identified and compiled into an antibiogram. ED providers evaluated their diagnostic and treatment habits using a self-assessment questionnaire, which was verified against charted information documented in the electronic medical records for patients presenting to the ED with a CA-MRSA SSTI. RESULTS: The ED antibiogram indicated that 57/58 (98%) CA-MRSA SSTI isolates were susceptible to sulfamethoxazole/trimethoprim (SMX/TMP); 50/58 (86%) isolates were susceptible to tetracycline, and 47/58 (81%) isolates were susceptible to clindamycin. Incision and drainage were performed in 23/25 (92%) patient cases, which was consistent with providers' perceived habits (100%). SMX/TMP monotherapy was preferred among 23/35 (66%) providers, however, SMX/TMP combined with cephalexin was the antibiotic regimen prescribed in 9/22 (41%) patient cases. CONCLUSIONS: Cephalexin was often added to cover for potential cellulitis due to Streptococcus spp., however, the surrounding erythema may simply be an extension of the CA-MRSA infection. Department-specific antibiograms are useful in guiding empiric antibiotic selection and may help providers judiciously prescribe antibiotics only when necessary.

Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment.

Mycobacterium haemophilum is a slow-growing nontuberculous mycobacterium that can cause disease in both immunocompetent and immunocompromised patients. The most common clinical presentations of infection are the appearance of suppurative and ulcerated skin nodules. For the diagnosis, samples collected from suspected cases must be processed under the appropriate conditions, because M. haemophilum requires lower incubation temperatures and iron supplementation in order to grow in culture. In this case report, we describe the occurrence of skin lesions in a kidney transplant recipient, caused by M. haemophilum, associated with acupuncture treatment. The diagnosis was established by direct smear and culture of material aspirated from cutaneous lesions. Species identification was achieved by characterization of the growth requirements and by partial sequencing of the hsp65 gene. The patient was successfully treated with clarithromycin and ciprofloxacin for 12 months. Considering that the number of patients receiving acupuncture treatment is widely increasing, the implications of this potential complication should be recognized, particularly in immunosuppressed patients.

[Antibiotic therapy in the outpatient setting: update 2009]. / Antibiotikatherapie in der Praxis: Update 2009.

Rational outpatient therapy restricts antibiotics to infections where they are beneficial and selects substances based on local resistance patterns. Respiratory tract infections typically caused by viruses should not be treated with antibiotics (e.g., rhinitis, bronchitis, sinusitis). Many respiratory infections likely caused by bacteria can be treated with aminopenicillin, sometimes combined with a beta-lactamase inhibitor. Quinolones should be used only as exception for respiratory tract infections, since resistance is rising. For this reason uncomplicated urinary tract infections (cystitis) should be treated with trimethoprim-sulfa-methoxazole (TMP-SMX) instead of quinolones, even though approximately 20% of Escherichia coli are resistant to TMP-SMX. Skin and soft tissue infections are best treated with beta-lactam antibiotics, as long as the community acquired methicillin-resistant strains of S. aureus frequently seen in certain countries remain uncommon here.