Diagnosis and treatment of surgical skin and soft tissue infections - current status.

Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.

[Rubor, calor, dolor, tumor†: skin and soft tissue infections]. / Rubor, calor, dolor, tumor†: infections de la peau et des tissus mous.

Skin infections are a frequent cause of consultation, yet the diagnosis can be challenging for physicians. Microbiological documentation is rare, and empiric antibiotic regimens should cover the most commonly identified bacteria, i.e. streptococci Staphylococcus aureus. Other pathogens should be considered in case of immunosuppression or certain exposures. Necrotizing fasciitis (NF) is a severe but rare infection. Early surgical management in parallel with antibiotics is the cornerstone of treatment. Despite the high incidence of these infections, little progress has been made in their management and some areas of uncertainty exist, especially regarding the optimal duration of treatment, the prevention of recurrences and the use of polyclonal immunoglobulins for NF. This article reviews the main aspects of diagnosis and treatment of these infections.

Les infections de la peau sont fréquentes mais leur diagnostic peut représenter un défi pour le clinicien. La documentation de l'étiologie microbiologique est rare et le traitement empirique doit couvrir les germes fréquents, notamment Streptococcus spp. et Staphylococcus aureus. Des bactéries inhabituelles peuvent être retrouvées lors d'immunosuppression ou exposition spéciale. La fasciite nécrosante (FN) est une infection sévère mais rare, dont le traitement repose sur la chirurgie rapide et l'antibiothérapie. Malgré leur fréquence, peu de progrès ont été réalisés dans la prise en charge de ces infections et des incertitudes persistent par rapport à la durée optimale de traitement, la prophylaxie pour les récurrences ou l'utilité des immunoglobulines polyclonales intraveineuses pour la FN. Cet article aborde les aspects diagnostiques et thérapeutiques de ces infections.

Factors influencing drainage setting and cost for cutaneous abscesses among pediatric patients.

OBJECTIVE: To evaluate the clinical and microbiological factors associated with skin and soft tissue infections drained in the emergency department (ED) vs operative drainage (OD) in a tertiary care children's hospital. METHODS: This was a cross-sectional study among children aged 2 months to 17 years who required incision and drainage (I&D). Demographic information, signs and symptoms, abscess size and location, and wound culture/susceptibility were recorded. Patient-specific charges were collected from the billing database. Multivariate regression analysis was used to determine factors determining setting for I&D and the effect of abscess drainage location on cost. RESULTS: Of 335 abscesses, 241 (71.9%) were drained in the ED. OD for abscesses was favored in children with prior history of abscess (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.36-7.44; P = .01) and labial location (OR, 37.81; 95% CI, 8.12-176.03; P < .001). For every 1-cm increase in size, there was approximately a 26% increase in the odds of having OD (OR, 1.26; 95% CI, 1.11-1.44, P < .001). Methicillin-resistant Staphylococcus aureus was identified in 72% of the 300 abscesses cultured and 12.3% were clindamycin resistant. OD was more expensive than I&D in the ED. Per abscess that underwent I&D, OD is $3804.29 more expensive than I&D in the ED while controlling for length of stay. DISCUSSION: Clinical factors associated with OD rather than I&D in the ED included history of abscess, increased abscess length, and labial location. Microbiological factors did not differ based on I&D setting. For smaller, nonlabial abscesses, ED drainage may result in significant cost savings.

Elderly patients are at increased risk for treatment failure in outpatient management of purulent skin infections.

OBJECTIVE: Current Infectious Disease Society of America (IDSA) guidelines for the management of purulent skin or soft tissue infections do not account for patient age in treatment recommendations. The study objective was to determine if age was associated with outpatient treatment failure for purulent skin infection after adjusting for IDSA treatment guidelines. METHODS: We conducted a multicenter retrospective study of adult patients treated for a purulent skin infection and discharged home from four emergency departments between April and September 2014. Patients were followed for one month to assess for treatment failure (defined as need for a change in antibiotics, surgical intervention, or hospitalization). We used multivariable logistic regression to examine the role of patient age on treatment failure adjusting for demographic variables (gender, race), comorbidities and severity of infection. RESULTS: A total of 467 patients met inclusion criteria (mean age 37.9years [SD 14.0], 48.2% of whom were women). Overall, 12.4% failed initial therapy. Patients 65years and older (n=35) were almost 4 times more likely to fail initial ED therapy in follow-up compared with younger patients (adjusted Odds Ratio (OR) 3.87, 95% Confidence Interval (CI) 1.24-12.10). After adjustment, for every 10years of advancing age there was a 43% increased odds of failing initial treatment (OR 1.43 95% CI 1.09-1.88). CONCLUSION: Elderly patients with purulent skin infections, whose providers followed the 2014 IDSA guidelines, were more likely to fail initial treatment than younger patients. This study suggests that there is a need to re-evaluate treatment guidelines in elderly patients.

The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED.

OBJECTIVE: This study assesses outcome in pediatric patients with skin abscess using the LOOP compared to the standard incision and drainage (I&D) with packing method. METHODS: This retrospective study used ICD-9 codes to identify pediatric patients aged 0 to 17 years with a skin abscess presenting to a level I pediatric trauma emergency department (ED). Patients requiring surgical debridement were excluded; as were patients with abscesses on the face, scalp, hands or feet. The primary outcome was failure rate, defined as those requiring admission, intravenous antibiotics, or repeat drainage. RESULTS: Over a 1-year period there were 233 pediatric abscesses identified: 79 cases (34%) treated with the LOOP technique and 154 cases with standard I&D (66%). The overall mean age of patients was 6.2 yrs: children in the LOOP group were younger than those in the standard group, 4.4 vs 7.1 years respectively (P=.001). Abscess location also differed between the two groups; however they had a similar gender distribution and mean temperature. Of the cases identified by chart review, clinical outcome could be assessed in 143 patients (61%): 52 (36%) patients with LOOP vs 91 (64%) with I&D. Failure rate was 1.4% in the LOOP group and 10.5% in the standard I&D (P<.030). CONCLUSION: There was a significant difference in failure rate between the LOOP and the standard I&D groups. A prospective randomized trial is needed to confirm these results, but this novel technique shows promise as an alternative to I&D with packing in the management of skin abscesses in pediatric ED patients.

[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.

Population-based study of the increased incidence of skin and soft tissue infections and associated antimicrobial use.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has spread rapidly throughout the world in the last decade. We sought to demonstrate the impact of the emergence of CA-MRSA in Western Canada on physician visits, incision-and-drainage procedures, and antibiotic prescribing for skin and soft tissue infections (SSTI). We used the provincial physician billing system to determine the rate of physician visits (per 1,000 population per year) of SSTI and incision-and-drainage procedures. A database capturing all outpatient prescriptions in the province was anonymously linked to associated physician billing codes to quantify prescriptions associated with SSTI. Antibiotic prescriptions (overall and class specific) were expressed as their defined daily dose (DDD) per 1,000 inhabitants per day. Between 1996 and 2008, the rate of visits for all SSTI increased by 15%, and the majority of visits did not include an incision-and-drainage procedure. The rate of antibiotic prescribing for SSTI increased by 49%. The majority of this increase was attributable to the higher rates of use of clindamycin (627%), trimethoprim-sulfamethoxazole (380%), cephalosporins (160%), and amoxicillin-clavulanate (627%). Health care utilization and antibiotic prescribing rates for SSTI, but not incision-and-drainage procedures, have increased in association with the CA-MRSA epidemic. While much of the increase in antibiotic use reflects an appropriate change to trimethoprim-sulfamethoxazole, there is room for education regarding the limitations of cephalosporins and clindamycin, given current susceptibility profiles.

Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department.

OBJECTIVE: The objective of this study was to investigate the impact of wound packing versus no wound packing on short-term failure rates and long-term recurrences after incision and drainage (I&D) of a simple cutaneous abscess. METHODS: In this randomized, single-blind, prospective study, subjects between the ages 1 and 25 years with skin abscesses needing an I&D were enrolled consecutively and randomized to be packed or not packed following the procedure. Treatment failure was assessed at a 48-hour follow-up visit by a masked observer who rated the need for a major intervention (repeat I&D or re-exploration) or minor intervention (antibiotics initiated or changed, need for packing, or repeat visit). Pain scores were assessed using color analog scales before and after the procedure and repeated at the 48-hour follow-up visit. Healing and abscess recurrence were assessed via telephone interview at 1 week and 1 month. RESULTS: Fifty-seven subjects were enrolled over a 15-month period. Overall failure rates were similar between the groups, with 19 (70%) of 27 subjects in the packed group needing an intervention by 48 hours compared with 13 (59%) of 22 subjects in the nonpacked group who needed an intervention (difference, 11%; 95% confidence interval, -15% to 36%). Major and minor intervention rates were also similar. Pain scores did not significantly differ between groups. CONCLUSIONS: Wound packing does not appear to significantly impact the failure or recurrence rates after simple I&D. Larger studies are needed to better validate the equivalency of these 2 strategies.

[New directions of hypertermic surgery in experiment].

Mechanisms of influence of thermal stream towards living biological tissues were studied. Bacteriological investigations of infected, purulent wounds before and after their thermostream processing were conducted. There was substantiated the possibility of the method usage for sanation of subfascial massively infected purulent wounds.

Refractory Human Cutaneous Protothecosis.

A 67-year-old Scottish woman presented to her general practitioner with a subcentimeter lump between her shoulder blades. The lump was suspected to be an epidermal cyst and was excised. The patient had a history of controlled diabetes. Most summers, she spent a month near a beach resort in Mexico. The lump reappeared after 6 months within the scar area and was re- excised. Both skin excisions were performed in the primary care setting without histologic assessment.

Recurrent sacrococcygeal pilonidal disease: the efficacy of minimal subcutaneous excision of the sinus and unroofing of pseudocystic cavity.

Patients undergoing surgery for recurrent pilonidal disease are at high risk of developing re-recurrence. The present prospective analysis was performed to evaluate the outcome for recurrent pilonidal disease treatment with a technique that provides a minimal subcutaneous excision of fistula and of the skin above the cyst, with secondary healing of wounds. METHODS: 48 consecutive patients with previous surgical excision and recurrent pilonidal disease underwent surgery from January 2009 to December 2016, under local anaesthesia. The age of the patients (42 males and 6 females) at the time of our observation was 28.5 ± 10.2 years, the BMI of 26.3 ± 6.8. The average number of interventions prior to our was 2.02 ± 1.14. RESULTS: The mean operative time was 18.2 ± 5.5 minutes. All patients were discharged 2 to 4 hours after surgery, with an average healing time of 22.8 ± 15.3 days. We recorded, in the follow-up period, only 4 relapses (8.32%), all retreated with the same surgical procedure and brought to complete healing. The results of the cosmetic questionnaire, which assessed patient satisfaction and contentment, showed that 96% of patients were completely satisfied and all patients recommended surgery to others. Kaplan-Meier analysis showed that in 7 years of follow-up, 85% of patients healed without recurrence. CONCLUSIONS: Our simple procedure appears to be safe and easily reproducible, allowing a high surgical success in the treatment of recurrent pilonidal disease. KEY EORDS: Excision, Healing, Recurrent sacrococcygeal pilonidal disease.

Septicemia secondary to Vibrio cholerae (non-O1/non-O139) in wound.

A 63-year-old woman with a prior history of chronic lower extremity lymphedema came to the hospital for evaluation of new-onset left leg pain and swelling associated with haemorrhagic blisters and foul-smelling discharge. Relevant history included a recent trip to a Hudson River Valley beach in New York 1 week prior to hospitalisation. Laboratory evaluation revealed significant leukocytosis and lactic acidosis. She was found to have sepsis and bacteremia secondary to Vibrio cholerae (serotype non-O1, non-O139). During a prolonged intensive care unit course requiring intravenous pressor support and broad-spectrum antibiotics, she underwent debridement of her left foot eschar along with skin grafting. Once clinically stable and improved, she was discharged to a subacute rehabilitation centre with close follow-up for wound care. V. cholerae infection is rare and often benign but can be transmitted from contaminated seawater to individuals with underlying chronic illness and cause severe symptoms, including sepsis.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

[Current Concepts for the Treatment of Skin and Soft Tissue Infections in Orthopaedic and Trauma Surgery]. / Aktuelle Konzepte zur Behandlung von Haut- und Weichteilinfektionen in Orthopädie und Unfallchirurgie.

Skin and soft tissue infections include the skin as well as fascia, muscles, ligaments, tendons, synovial membranes, fat, blood vessels, nerves, and fibrous tissues. They range from superficial infections to deep infections with a necrotizing clinical course. These infections can promptly progress with severe systemic complications, requiring rapid management, and proper surgical and medical treatment. This manuscript provides recommendations based on current practice guidelines for diagnosis and treatment of surgically relevant skin and soft tissue infections in adults. Furthermore, it deals with a clinical guide of immediate identification of life threatening necrotizing clinical courses, detection of pathogens and the use of appropriate surgical, antimicrobial, and adjuvant treatment options.

Fournier gangrene.

Fournier gangrene is a necrotizing infection involving the soft tissues of the male genitalia. It was first described in 1764 by Baurienne and given its eponymous name after Jean-Alfred Fournier in 1883 presented a case of perineal gangrene in an otherwise healthy young man. While only 600 cases of Fournier gangrene have been reported in the world literature since 1996, it is a common and serious disease in Africa. In Maputo Central Hospital alone, between 12 and 16 cases are admitted every year and treated with a 20% mortality. The typical patient is an elderly male in his sixth or seventh decade with co-morbid diseases. While considered to affect males only, a similar condition may occasionally affect the female genitalia.

Variation in the use of procedural sedation for incision and drainage of skin and soft tissue infection in pediatric emergency departments.

OBJECTIVES: Little is known about procedural sedation use for anxiety and pain associated with skin and soft tissue infections (SSTIs) requiring incision and drainage (I&D). Our objectives were therefore (1) to characterize the use of procedural sedation use for SSTI I&D procedures in pediatric emergency departments (EDs), (2) to compare the frequency of procedural sedation for I&D across hospitals, and (3) to determine factors associated with use of procedural sedation for I&D. METHODS: We performed a retrospective cohort study of pediatric EDs contributing to the Pediatric Health Information Systems database in 2010. Cases were identified by primary International Classification of Diseases, 9th revision, Clinical Modification procedure codes for I&D. We used descriptive statistics to describe procedural sedation use across hospitals and logistic generalized linear mixed models to identify factors associated with use of procedural sedation. RESULTS: There were 6322 I&D procedures, and procedural sedation was used in 24% of cases. Hospital-level use of procedural sedation varied widely, with a range of 2% to 94% (median 17%). Procedural sedation use was positively associated with sensitive body site, female gender, and employer-based insurance, and negatively associated with African American race and increasing age. Estimates of hospital-level use of procedural sedation for a referent case eliminating demographic differences exhibit similar variability with a range of 5% to 97% (median 34%). CONCLUSIONS: Use of procedural sedation for SSTI I&D varies widely across pediatric EDs, and the majority of variation is independent of demographic differences. Additional work is needed to understand decision-making and to standardize delivery of procedural sedation in children requiring I&D.