Randomized clinical study to compare negative pressure wound therapy with simultaneous saline irrigation and traditional negative pressure wound therapy for complex foot infections.

The aim of this study was to compare the efficacy of different negative pressure wound therapy (NPWT) devices and NPWT with and without simultaneous irrigation in patients admitted to hospital with moderate and severe foot infections. Ninety patients were randomized in a 12-week prospective, randomized noninferiority trial to compare wound healing in patients with moderate and severe infected foot wounds treated with NPWT after surgery. Inclusion criteria included ABI > 0.5 or toe pressures >30 PVR/mmHg, >18 years of age and exclusion included active Charcot arthropathy, collagen vascular disease, HIV, and hypercoagulable state. We compared two different traditional devices, NPWT-K (KCI, VAC Ulta) and NPWT-C (Cardinal, PRO), and NPWT-I with saline irrigation (Cardinal, PRO). All patients had therapy delivered at 125 mmHg continuous pressure. In patients who received simultaneous saline irrigation (NPWT-I), the administration rate was 15 ml per hour. The primary outcome was the proportion of healed wounds in 12 weeks. Secondary outcomes included surgical wound closure, number of surgeries, length of stay, and time to wound healing. Continuous data was presented as mean ± standard deviation. Analysis of variance was used to compare continuous variables and chi-square to compare dichotomous variables with an alpha of 0.05. There were no differences in outcomes among NPWT-I, NPWT-C, and NPWT-K groups in proportion of healed wounds (63.3%, 50.0%, 46.7% p = 0.39), surgical wound closure (83.3%, 80.0%, 63.3%, p = 0.15), number of surgeries (2.0 ± 0.49, 2.4 ± 0.77, 2.4 ± 0.68, p = 0.06), length of stay (16.3 ± 15.7, 14.7 ± 7.4, 15.3 ± 10.5 days, p = 0.87), time to wound healing (46.2 ± 22.8, 40.9 ± 18.8, 45.9 ± 28.3 days, p = 0.78). We did not identify any significant differences in clinical outcomes or adverse events between patients treated with different NPWT devices or NPWT with and without irrigation.

Deep Infection Following Dry Needling in a Young Athlete: An Underreported Complication of an Increasingly Prevalent Modality: A Case Report.

CASE: Dry needling frequently is performed by a variety of practitioners for pain treatment. A 16-year-old boy had dry needling in the posterolateral aspect of the right thigh for treatment of pain after a knee injury. He developed an abscess on the posterolateral distal aspect of the right thigh deep to the site of the dry needling. Treatment included surgical drainage and intravenous antibiotics. CONCLUSION: Deep infection is a rare but serious complication of dry needling. Standardized guidelines for safety and sterile technique with dry needling are needed to minimize the risk of infection.

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.

[Dynamics of local expression of connexin-43 and basic fibroblast growth factor receptors in patients with skin and soft-tissue infections against the background of diabetes mellitus type II].

Clinical results of wound healing dynamics were studied in 60 patients with soft-tissue infection against the background of diabetes mellitus type II. At the same time the study considered indices of intercellular contacts protein tissue expression such as connexin 43 (Cx43) and basic fibroblast growth factor receptors (bFGFR). The basic therapy of biopsy material of wound borders was applied. The reduction of bFGFR expression and the minor growth of Cx43 expression were observed. The pain syndrome proceeded for a long time and there were signs of perifocal inflammation, retard wound healing with granulation tissue. The application of combined method of ozone therapy which included autohemotherapy with ozone and an external management of wound by ozone-oxygen mixture facilitated to considerable shortening of inflammatory phase and regeneration. It was associated with increased Cx43 expression (in 1.9 times) in comparison with initial level and bFGFR was enlarged in 1.7 times to eighth day of postoperative period.

[Necrotising soft-tissue infections: diagnostics and treatment]. / Necrotiserende wekedeleninfecties: diagnostiek en behandeling.

Necrotising soft-tissue infections occur in the soft tissue compartment consisting of the dermis, subcutaneous tissue, superficial fascia (fascia of Scarpa), deep fascia and muscle. Although this severe and acutely life-threatening infection has a low incidence, both GPs and specialists will see a necrotizing soft-tissue infection more than once during their career. The mortality related to necrotising soft-tissue infections has been halved during the past 15 years from nearly 40 to 20% due to adequate treatment. Laboratory examination and X-ray findings could be of added value, but the gold standard remains biopsy of the fascia and Gram staining. Treatment consists of prompt volume resuscitation in case of sepsis, administration of broad spectrum antibiotics and surgical debridement; this debridement should be as skin-sparing as possible. The use of hyperbaric oxygen therapy has remained a controversial issue, unless a patient has gas gangrene, caused by Clostridium species. A multidisciplinary treatment and admission to a tertiary intensive care unit are indispensable for the treatment of a septic patient with necrotizing soft-tissue infection.

Secondary prevention of diabetic foot infections in a Caribbean nation: a call for improved patient education.

Most countries have instituted measures to limit the complications of diabetes. We evaluate secondary prevention strategies for diabetic foot infections in a Caribbean country. We performed a prospective questionnaire study evaluating all patients admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. Primary study end points were the number of patient-detected injuries and the time interval between injury and presentation. Secondary end points included the practice of regular foot inspection (≥2 foot examinations per week) for early detection and the use of self-directed nonmedical therapies to treat foot infections. There were 446 patients admitted with diabetic foot infections at an average age of 56.9 ± 12.4 years. Three hundred and fifty-six (80%) were previously hospitalized with foot infections and 226 (51%) had already sustained end organ injury from diabetes. There were 163 (36.6%) patients walking barefoot at the time of injury and 189 (42.4%) had footwear-related injuries. In 257 (57.6%) cases, patients identified their foot injury shortly after the event. Despite early detection, they presented to hospital after a mean interval of 6.2 ± 5.03 days, with 78 (30.4%) having tried some form of home therapy first. Overall, 190 (42.6%) patients did not practice regular foot examinations. There is room for improvement in secondary preventative measures for diabetic foot infections in this setting. Educational campaigns may be beneficial to educate diabetics on the dangers of walking barefoot, the importance of appropriate footwear, regular foot inspection, and the importance of seeking immediate medical attention instead of experimenting with home remedies.

Superimposed infection in mandibular osteoradionecrosis: diagnosis and outcomes.

BACKGROUND: Radiation therapy can result in osteoradionecrosis (ORN) and mucosal ulceration predisposing to infection. METHODS: Fourteen patients presenting with infectious sequelae related to mandibular ORN were retrospectively reviewed. RESULTS: In most patients, infection followed diagnosis of ORN; but in 4 patients, ORN was not diagnosed until after the time of infection and imaging. An early imaging finding of ORN was lingual cortical defects near the last molar. Pain followed by erythema, purulent drainage, and subperiosteal abscess by imaging were the most common signs of infection. In most patients, conservative management eventually failed and segmental mandibulectomies were required. CONCLUSIONS: Soft tissue infection with characteristic bone findings such as subperiosteal abscess and cortical bone erosions helps to distinguish infected ORN from recurrent tumor or sterile ORN. In patients previously treated with radiation who present with infection, pain or an avid PET scan with bone involvement, the mandible should be scrutinized.

High prevalence of abscesses and self-treatment among injection drug users in Tijuana, Mexico.

BACKGROUND: Soft tissue infections are common among injection drug users (IDUs), but information on correlates and treatment in this highly marginalized population is lacking. METHODS: Six hundred twenty-three community-recruited IDUs in Tijuana, Mexico, completed a detailed interview on abscess history and treatment. Univariate and multiple logistic regressions were used to identify factors independently associated with having an abscess in the prior 6 months. RESULTS: Overall, 46% had ever had an abscess and 20% had had an abscess in the past 6 months. Only 12% had sought medical care for their most recent abscess; 60% treated the abscess themselves. The most common self-treatment method was to apply heated (24%) or unheated (23%) Aloe vera leaf. Other methods included draining the wound with a syringe (19%) or knife (11%). Factors independently associated with recent abscess were having income from sex work (adjusted odds ratio (aOR) 4.56, 95% confidence interval (CI) 2.08-10.00), smoking methamphetamine (aOR 1.65, 95% CI 1.05-2.62), seeking someone to help with injection (aOR 2.06, 95% CI 1.18-3.61), and reporting that police affected where they used drugs (aOR 2.14, 95% CI 1.15-3.96). CONCLUSIONS: Abscesses are common among IDUs in this setting, but appropriate treatment is rare. Interventions to reduce barriers to medical care in this population are needed. Research on the effectiveness of Aloe vera application in this setting is also needed, as are interventions to provide IDU sex workers, methamphetamine smokers, and those who assist with injection with the information and equipment necessary to reduce abscess risk.

[Follow-up on an outbreak in Venezuela of soft-tissue infection due to Mycobacterium abscessus associated with Mesotherapy]. / Seguimiento de un brote de infección en tejido blando causado por Mycobacterium abscessus posterior a la mesoterapia en Venezuela.

INTRODUCTION: Skin and soft tissue infections caused by nontuberculous mycobacteria (NMT) are reported to be associated with injections, liposuction, plastic surgery, and acupuncture. Herein, we describe an outbreak of soft tissue infection due to NMT following mesotherapy, a cosmetic procedure involving injection of poorly defined mixtures alleged to reduce local adiposity. METHODS: Patients with skin lesions and a history of mesotherapy treatment, who visited the dermatology department of the public hospital in Barinas, Venezuela, from November 2004 to February 2005 were interviewed. Clinical and environmental samples were taken for mycobacteria isolation. RESULTS: The interviews revealed that 68 patients who had been treated for cosmetic purposes at the same clinic by the same therapist had received injections with the same product and were infected with NMT. Clinical specimens from 5 patients grew Mycobacterium abscessus. No mesotherapy solution was available for analysis but M. abscessus was isolated from an environmental sample in the clinic. PCR-based strain typing techniques (ERIC-PCR, BOXA1R and RAPD) showed that the patient's isolates were undistinguishable from each other but different from the environmental isolate. CONCLUSIONS: This outbreak was likely caused by a contaminated injectable mesotherapy product and not by mycobacteria from the clinic environment. We emphasize the importance of better microbiological control of these products. To our knowledge, this outbreak, which affected at least 68 patients, appears to be the largest ever associated with mesotherapy and described in the literature.

An outbreak of skin and soft tissue infection caused by Mycobacterium abscessus following acupuncture.

Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue infections following acupuncture among the patients who visited an oriental medical clinic. Active surveillance of patients who had visited the clinic was conducted to define the extent of the outbreak. Environmental cultures and a case-control study were performed to elucidate the source of infection and mode of transmission. From 1002 patients interviewed, 109 patients were identified as having suffered M. abscessus skin and soft tissue infections at acupuncture sites. A single strain of M. abscessus was isolated from the wounds of 31 patients and nine environmental samples, including a diluted glutaraldehyde solution. The case-control study revealed that a higher numbers of visits to the clinic for acupuncture (adjusted OR (aOR) 20.12; 95% CI 4.34-93.35) and the use of interferential current therapy or low-frequency therapy (aOR 36.12; 95% CI 5.54-235.44) were associated with the development of M. abscessus infection. The contaminated diluted glutaraldehyde solution that was used to disinfect the physical therapy devices may have been the source of the outbreak of M. abscessus infection in the 109 patients who underwent acupuncture.

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.

[Soft-tissue infections due to non-tuberculous mycobacteria following mesotherapy. What is the price of beauty]. / Infecciones en tejidos blandos por micobacterias no tuberculosas secundarias a mesoterapia. 'Cuánto vale la belleza?

INTRODUCTION: Mesotherapy is widely used In Latin America for cosmetic purposes, particularly in obese individuals. We describe the clinical and epidemiological characteristics, microbiological diagnosis, treatment and follow-up of patients from Caracas (Venezuela) with soft tissue infection caused by non-tuberculous mycobacteria following mesotherapy. METHODS: Between March 2002 and December 2003, we evaluated 49 cases of skin and soft tissue infection following mesotherapy. Specimens obtained from the lesions and 15 products used in the mesotherapy procedure were cultured for the presence of non-tuberculous mycobacteria. Isolated mycobacteria were identified by PCR restriction fragment length polymorphism analysis of the hsp65 gene. RESULTS: Infection by non-tuberculous mycobacteria was confirmed in 81.6% of the 49 cases. Mycobacterium abscessus and M. fortuitum were the most common species, but M. chelonae, M. peregrinum, M. simiae and a new species that was designated "M. cosmeticum" were also isolated. Patients were treated with species-specific antibiotic agents for 3 to 18 months. Investigation into the source of the infection revealed that 21 patients were clustered within 3 different outbreaks and two products were found to be contaminated with M. fortuitum and M. abscessus, respectively. CONCLUSIONS: Physicians should be alerted to the possibility of infection by non-tuberculous mycobacteria in patients with a history of mesotherapy who develop late-onset skin and soft tissue infection, particularly if they do not respond to conventional antibiotic treatment.

Infecciones en tejidos blandos por micobacterias no tuberculosas secundarias a mesoterapia. ¿Cuánto vale la belleza? / Soft tissue infections due to non-tuberculous mycobacteria following mesotherapy. What is the price of beauty?

Introducción. La mesoterapia se utiliza mucho en Latinoamérica con fines cosméticos, especialmente en pacientes con obesidad. En este estudio se describen las características clínicas y epidemiológicas, el diagnóstico microbiológico, el tratamiento y el seguimiento de infecciones por micobacterias no tuberculosas en un grupo de pacientes en Caracas (Venezuela) con antecedentes de mesoterapia. Metodología. Entre marzo de 2002 y diciembre de 2003 se evaluaron 49 pacientes con infección en la piel y tejidos blandos secundaria a mesoterapia. Se tomaron muestras de las lesiones para el aislamiento de micobacterias y se elaboró una ficha clínica. Además, se analizaron 15 productos utilizados en mesoterapia. Las micobacterias aisladas fueron identificadas a través del polimorfismo de fragmentos de restricción del gen hsp65. Resultados. De los 49 pacientes evaluados, en el 81,6% se confirmó una infección por micobacterias no tuberculosas. Las especies más comunes fueron Mycobacterium abscessus y M. fortuitum pero también se aislaron M. chelonae, M. peregrinum, M. simiae y una nueva especie que fue designada M. cosmeticum. Los pacientes recibieron tratamiento específico para cada especie durante un período de 3 hasta 18 meses. La investigación de la fuente de infección reveló que 21 pacientes estaban agrupados en tres brotes y se encontraron dos productos contaminados, uno con M. fortuitum y otro con M. abscessus. Conclusiones. Los médicos deben estar atentos ante aquellos pacientes con antecedentes de mesoterapia que desarrollen tardíamente lesiones en piel y tejidos blandos, que no respondan al tratamiento antimicrobiano convencional, ya que éstas podrían ser causadas por micobacterias no tuberculosas (AU)

Introduction. Mesotherapy is widely used In Latin America for cosmetic purposes, particularly in obese individuals. We describe the clinical and epidemiological characteristics, microbiological diagnosis, treatment and follow-up of patients from Caracas (Venezuela) with soft tissue infection caused by non-tuberculous mycobacteria following mesotherapy. Methods. Between March 2002 and December 2003, we evaluated 49 cases of skin and soft tissue infection following mesotherapy. Specimens obtained from the lesions and 15 products used in the mesotherapy procedure were cultured for the presence of non-tuberculous mycobacteria. Isolated mycobacteria were identified by PCR restriction fragment length polymorphism analysis of the hsp65 gene. Results. Infection by non-tuberculous mycobacteria was confirmed in 81.6% of the 49 cases. Mycobacterium abscessus and M. fortuitum were the most common species, but M. chelonae, M. peregrinum, M. simiae and a new species that was designated "M. cosmeticum" were also isolated. Patients were treated with species-specific antibiotic agents for 3 to 18 months. Investigation into the source of the infection revealed that 21 patients were clustered within 3 different outbreaks and two products were found to be contaminated with M. fortuitum and M. abscessus, respectively. Conclusions. Physicians should be alerted to the possibility of infection by non-tuberculous mycobacteria in patients with a history of mesotherapy who develop late-onset skin and soft tissue infection, particularly if they do not respond to conventional antibiotic treatment (AU)

Avaliação do efeito da oxigenoterapia hiperbárica no tratamento das infecções necrosantes pelviperineais / Evaluation of the effect of hyperbaric oxygen therapy in the treatment of pelviperineal necrotizing infections

As infecções necrosantes pelviperineais (INPPs) são infecções graves, pouco comum, com mortalidade aproximada em torno de 30 por cento de flora bacteriana mista e predomínio do sexo masculino. Objetivo: avaliar o efeito da oxigenoterapia hiperbárica (OHB) no tratamento das INPPs. Método: estudo clínico prospectivo randomizado realizado no Serviço de Cirurgia de Emergência do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo / The pelviperineal necrotizing infecctions are serious infections, relatively rare, with mortality approached around 30 por cent of mixed bacterial flora and prevalence of masculine sex. Objective: to evaluate the effect of hyperbaric oxygn (HBO) therapy in the treatment of pelviperineal necrotizing infections. Method: prospective randomized clinical study accomplished in the Service of Emergency Surgery at the Clinical Hospital of the School of Medicine at the University of São Paulo in the period from July 2000 to November 2002...

Eficacia de la monoterapia con piperacilina/tazobactám en infecciones de piel y partes blandas / Effectiveness of monotherapy with piperacillin/tazobactam in skin and soft tissue infections

Introducción. Se evaluaron la eficacia clínica por intención de tratar y la seguridad de piperacilina/tazobactám (monoterapia) en las infecciones de piel y partes blandas, así como los efectos secundarios ocasionados por dicho fármaco. Pacientes y métodos. Se realizó un estudio multicéntrico, prospectivo, observacional, en el que se incluyeron 160 pacientes con infección de piel y partes blandas, procedentes de los 15 centros participantes. Tras estandarizar los criterios diagnósticos, los pacientes fueron sometidos al protocolo de inclusión y se administró el fármaco indicado, por vía intravenosa, a dosis de 4/0,5 g cada 8 h. Se realizó control bacteriológico al inicio y al final del tratamiento. Resultados. La edad media de los pacientes fue de 57,3 años, con un porcentaje de varones afectados del 60,7 por ciento. La mayor parte de las infecciones fueron extrahospitalarias, y la diabetes fue el factor predisponente en más de la mitad de casos. El 43,8 por ciento de los procesos fue catalogado como grave. Se aisló el microorganismo responsable de la infección en el 59,3 por ciento de los casos, siendo la mayor parte monomicrobianas. Se suspendió el protocolo en 18 casos (11,2 por ciento) y aparecieron 8 casos de reacciones adversas relacionadas con el fármaco. La evaluación clínica indicó una respuesta favorable del 88,8 por ciento a la monoterapia con piperacilina/tazobactám, y la erradicación o presunta erradicación bacteriana alcanzó el 63,8 por ciento de pacientes. Conclusiones. En nuestra experiencia, la eficacia de piperacilina/tazobactám permite utilizar este antibiótico de forma empírica en monoterapia en infecciones graves de piel y partes blandas (AU)

Infecciones de tejidos blandos / Soft tissue infections

Se revisan 20 casos de infecciones de tejidos blandos hospitalizados en el Servicio de Cirugía del Hospital San Juan de Dios (1990-1998). De estos, 10 correspondieron a fasceítis, 9 a celulitis y 1 caso de erisipela. La etiología fue predominantemente polimicrobiana en la fasceítis necrotizante (80 por ciento) y monomicrobiana en la celulitis (55 por ciento). La evolución clínica fue favorable en el 100 por ciento de los casos de erisipela y celulitis, los cuales requirieron solamente tratamiento antimicrobiano. Falleció el 20 por ciento de los pacientes con fasceítis necrotizante y otro debió ser sometido a amputación. El tratamiento de estos casos es fundamentalmente quirúrgico, asociado a terapia antimicrobiana