Bioinspired Multifunctional Cellulose Nanofibril-Based In Situ Liquid Wound Dressing for Multiple Synergistic Therapy of the Postoperative Infected Wound.

A smart in situ-formed wound dressing with excellent antibacterial ability against drug-resistance bacterial, antitumor, and biofilm-eliminating activities to promote effective wound closure is highly desirable in therapeutic and clinical applications. Herein, we designed and developed a multifunctional; shape-adaptable; and pH, temperature, and near-infrared radiation (NIR) multiple responsive cellulose nanofibril (CNF)-based in situ liquid wound dressing, using a pH-sensitive CNF grafted with terminated amino hyperbranched polyamines (HBP-NH2) as a substrate, along with poly(N-isopropylacrylamide) and indocyanine green (ICG) loaded as the temperature and NIR on/off switches, respectively. The 3D nanocage network structure of CNF and the nanocavities in the hyperbranched structure of HBP-NH2 endow the dressing with a high loading capacity for active drugs (doxorubicin and ICG) simultaneously. Moreover, the responsiveness of the dressing to multiple stimuli enables controllable and efficient drug release to the wound area. The bioinspired dressing demonstrates excellent antibacterial activity against common bacteria and methicillin-resistant Staphylococcus aureus, antitumor activity against A375 tumor cells, and biofilm-eliminating capability. In addition, the developed dressing synergistically combines multiple therapeutic strategies for effective wound healing, specifically photothermal therapy, photodynamic therapy, and chemotherapy. The design provides an ideal clinical intervention strategy for irregular tumor postoperative infected wounds.

Palpebral anthrax, a rare though important condition in villagers: A case report and literature review.

The aerobic Gram-positive rod Bacillus anthracis can cause potentially lethal diseases affecting different organs. Localized eyelid inflammation is a rare presentation of cutaneous anthrax. This case report involves two patients with palpebral anthrax admitted to the oculoplastic ward of Feiz Eye Hospital, Isfahan, Iran. The patients had a history of close contact with animals. Clinical presentation included palpebral swelling and necrosis of the eyelids in both cases. The patients first underwent an appropriate antibiotic regimen, and biopsy specimens were collected from their necrotic tissues. They were discharged after complete healing and followed up to manage possible complications. Cicatricial ectropion developed in both cases during healing. Reconstructive surgery was scheduled for both cases 6 months after their discharge.

The Heroin Epidemic in America: A Surgeon's Perspective.

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Cutaneous melioidosis: a review of the literature.

BACKGROUND: Melioidosis is mainly observed in South-East Asia, where Burkholderia pseudomallei is endemic. Cutaneous melioidosis (CM) has rarely been described and in contrast to systemic forms, there are no therapeutic recommendations to guide management. METHODS: We reviewed the literature published before January 2018, evaluating: dermatological presentation, natural history, diagnostic methods, and treatment options. We also distinguish between primary and secondary CM in which the infection first started in the skin or came from an extracutaneous localization, respectively, and chronic CM when duration exceeded 2 months. The recommended treatment for systemic forms included ceftazidime or meropenem, followed by oral maintenance therapy with cotrimoxazole or amoxicillin - clavulanic acid. RESULTS: Forty-three cases were published in 38 articles. Twenty-nine patients (67.4%) were travelers, including 13 (44.8%) returning from Thailand. Thirty-eight patients (88%) had primary CM, including nine (29.9%) with chronic infection. All cases of secondary CM first presented with acute infection. The median incubation time was 3 weeks. The most common presentation was cutaneous abscesses (58%). The recommended treatment was administered in 62.7% cases with 37.2% for maintenance therapy. Sixteen patients (37.2%) underwent surgery. Death was reported in less than 5%. CONCLUSION: CM should be considered in travelers returning from or residents of endemic countries, particularly Thailand, presenting with cutaneous abscesses, cellulitis, or ulcerations. Surgery may be necessary in a substantial proportion of patients and follow-up of at least 1 year is essential. Therapeutic recommendations need to be established.

Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection.

INTRODUCTION: Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS: Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS: A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION: The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE: Prognostic, level IV.

Cervicofacial Primary Cutaneous Actinomycosis: Surgical Treatment for Complete Remission of the Disease.

Actinomycosis, an infectious bacterial disease caused by Actinomyces species, is very rare and is characterized by contiguous spreading, subacute to chronic granulomatous inflammation and the formation of multiple abscesses and sinus tracts that may discharge sulfur granules. Actinomycosis that presents on the skin without endogenous origin is called primary cutaneous actinomycosis, and the occurrence and treatment of primary cutaneous actinomycosis is rarely reported. This report describes the treatment of primary cervicofacial actinomycosis with a literature review, and emphasizes the importance of surgical option for complete remission of the disease.

Mycobacterium marinum.

Mycobacterium marinum is a well-known pathogenic mycobacterium for skin and soft tissue infections and is associated with fishes and water. Among nontuberculous mycobacteria (NTM), it is the leading cause of extrarespiratory human infections worldwide. In addition, there is a specific scientific interest in M. marinum because of its genetic relatedness to Mycobacterium tuberculosis and because experimental infection of M. marinum in fishes mimics tuberculosis pathogenesis. Microbiological characteristics include the fact that it grows in 7 to 14 days with photochromogenic colonies and is difficult to differentiate from Mycobacterium ulcerans and other mycolactone-producing NTM on a molecular basis. The diagnosis is highly suspected by the mode of infection, which is related to the hobby of fishkeeping, professional handling of marine shells, or swimming in nonchlorinated pools. Clinics distinguished skin and soft tissue lesions (typically sporotrichoid or subacute hand nodules) and lesions disseminated to joint and bone, often related with the local use of corticosteroids. In clinical microbiology, microscopy and culture are often negative because growth requires low temperature (30°C) and several weeks to succeed in primary cultivation. The treatment is not standardized, and no randomized control trials have been done. Therapy is a combination of surgery and antimicrobial agents such as cyclines and rifampin, with successful outcome in most of the skin diseases but less frequently in deep tissue infections. Prevention can be useful with hand protection recommendations for professionals and all persons manipulating fishes or fish tank water and use of alcohol disinfection after contact.

A serious case of anthrax associated with compartment syndrome.

Compartment syndrome linked to skin anthrax is a rare complication that may develop and it should be noted that the disease may progress in spite of medical drug treatment. Our case was a farmer who was exposed after slaughtering a dead animal, a time delay for treatment hided this history and then developed compartment syndrome. In anthrax cases with delayed treatment and aggressive progression, circulation in the extremities should be carefully noted. We believe that the cases with compartment syndrome progressing in spite of medical drug treatment may be assessed for fasciotomy as a treatment approach.

Packing versus non-packing outcomes for abscesses after incision and drainage.

CLINICAL QUESTION: In non-diabetic, non-immunocompromised individuals with skin abscesses, does packing after incision and drainage (I&D) reduce the risk of recurrence or reintervention compared with not packing? ANSWER: No. If the abscess is less than 5 cm, packing does not affect outcomes. LEVEL OF EVIDENCE FOR THE ANSWER: B. DATE SEARCH WAS CONDUCTED: November 2014. INCLUSION CRITERIA: Published RCTs and meta-analysis studies. EXCLUSION CRITERIA: Abscess greater than 5 cm, abscess in diabetics, abscess in immunocompromised.

The role of adjunctive antibiotics in the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis.

OBJECTIVE: To perform a review and meta-analysis on the effect of antibiotics on treatment of skin and soft tissue abscesses (SSTAs) after incision and drainage. METHODS: We searched MEDLINE, EMBASE, Web of Knowledge, and Google Scholar databases to identify randomized controlled trials (RCTs) and observational studies. For RCTs, we included studies comparing any antibiotic (treatment) to placebo (control). For observational studies, treatment was the use of appropriate antibiotics effective against bacterial isolate, and control was the use of inappropriate (ineffective) or no antibiotics. Outcome was treatment success during follow-up. Two investigators reviewed records, assessed quality (according to Cochrane and Newcastle-Ottawa tools), and extracted treatment success rates. Primary analysis was the effect of treatment among RCTs. Secondary analyses included the effect of treatment in 1) observational studies of confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection (MRSA-only) and 2) all studies after 1998 (MRSA-era). We used random effects modelling, except when no heterogeneity was present when we used fixed effects. RESULTS: We screened 1,968 records. Twelve were included (five RCTs, seven observational studies), representing 1,969 subjects. Seven enrolled from emergency departments, two from surgical clinics, and three from ambulatory clinics. Three enrolled children only. Pooled relative risk (RR) of treatment success among RCTs was 1.03 (95% confidence interval [CI] 0.97-1.08). Pooled RR in the secondary analyses was 1.05 (95% CI 0.96-1.15) in MRSA-only and 0.99 (95% CI 0.98-1.01) in MRSA-era. CONCLUSION: Despite limitations in pooling available data, there is no clear evidence to support antibiotic use in treating uncomplicated SSTAs.

[Superinfected epidermal inclusion cyst of the thigh with development of squamous cell carcinoma--case report of a rare complication]. / Superinfektion einer epidermalen Inklusionszyste des Oberschenkels mit Ausbildung eines Plattenepithelkarzinoms--Fallbericht einer seltenen Komplikation.

Epidermal cysts (atheroma) are the most common benign tumours of the skin with ubiquitous localisation all over the body. However, rupture of the atheroma and formation of an inclusion cyst with additional superinfections are frequently seen. Malignant transformations have rarely been reported. Presented here is the unusual case of a 65-year-old woman with multiple atheromas and a distinctive tumour of the upper limb. Imaging diagnostics showed malignant deformation. Contrary to the imaging findings the histological/microbiological examination showed an enormous superinfected and ruptured epidermoid cyst with multiple abscess formation in the ventral upper limb. Radical surgical restoration with salvage of the limb was frustrated because of honey-combed anterior soft tissue and the changing bacterial spectrum. After resection of the complete ventral compartment, remission was realised approximately. In the follow-up there was a recurring infection with spontaneous fistula formation that histologically impressed as a squamous cell carcinoma. After proximal ablation of the upper limb, total rehabilitation of the infection as well as the malignoma could be achieved.

Tuberculous botryomycosis of the hand: case report.

We report a case of a 17-year-old boy who presented with botryoid lesions of both hands. These lesions resembled those of cutaneous botryomycosis. We treated him with surgical debridement and were unable to isolate infective agents initially. However, 3 months later Mycobacterium tuberculosis grew in the culture. One year of antituberculous drug therapy resulted in healing of the lesions.

Incidence of surgically drained cutaneous abscess in relation to climate in Mayotte, Comoros.

Although skin infections are common in tropical countries, there is scant data quantifying the relationship with climate conditions. The aim of this study was to assess the incidence and seasonality of skin abscess in Mayotte, Comoros. We collected data on patients with cutaneous abscesses requiring surgical drainage from January 2009 to December 2010. A total of 3423 abscesses were recorded. The overall annualized incidence was 785 cases per 100,000 population (95% confidence interval 754-814). The incidence rate peaked in children and abscesses were highest during the rainy season (964 cases per 100,000 population per 6 months). A greater frequency of insects bites, a lower level of sensitization and lack of access to adequate hygiene are potential explanations for these findings. A community-based intervention strategy should target vulnerable children in order to combat this disease.

Minimally invasive drainage of subcutaneous abscesses reduces hospital cost and length of stay.

OBJECTIVE: We compared outcomes among pediatric patients managed with minimally invasive (MI) packing techniques with those managed with traditional packing techniques for drainage of subcutaneous abscesses. METHODS: After institutional review board approval, medical records of children requiring drainage of subcutaneous abscesses between January 2010 and June 2011 were reviewed. Data were collected on patient demographics, abscess location, surgical procedure, microbiology cultures, and hospital length of stay (LOS). The hospital accounting system was queried for direct and indirect costs. We compared LOS and cost data among groups managed with MI versus traditional packing techniques. RESULTS: Incision and drainage was performed on 329 children (57.8% girls, 72% white, mean age of 43 months [range <1 to 218]). Of the total abscesses 198 (60.2%) were located in the groin/buttocks/perineum. Methicillin-resistant Staphylococcus aureus was identified in 74% of culture specimens. A total of 202 patients (61.4%) underwent packing and 127 (38.6%) underwent MI drainage. MI drainage ranged from 0% (0/110) in January to June 2010 to 34.6% (44/127) in the July to December 2010 transition period and reached 90.2% (83/92) in 2011 (P < 0.001). Median LOS decreased from 2 days (interquartile range 1-2) in the packing-only period to 1 day (interquartile range 1-2) in the predominantly MI period (P < 0.001). Hospital costs decreased with the transition to the MI technique (P < 0.001). MI drainage was associated with a $520 reduction in median direct costs and a $385 reduction in median indirect costs (P < 0.001). CONCLUSIONS: Soft tissue infections requiring incision and drainage are common in the pediatric population, with the majority caused by methicillin-resistant Staphylococcus aureus. Infections requiring drainage most frequently occurred in the diaper area of girls younger than 3 years old. Changing to an MI technique significantly decreased the hospital costs and LOS in our patient population.

Chronic dermatitis caused by Lactobacillus jensenii infection in a blue and gold macaw (Ara ararauna).

CASE DESCRIPTION: A 5-year-old sexually intact female blue and gold macaw (Ara ararauna) was evaluated because of a swelling on the right side of the face and irritated area on the ventral aspect of the keel. CLINICAL FINDINGS: Clinical findings were consistent with dermatitis (right facial lesion) and a coalescing subdermal granuloma (ventral keel lesion). Hematologic analysis revealed monocytosis and mild anemia. Histologic evaluation of the ventral keel lesion revealed evidence of chronic heterophilic dermatitis with multinucleated giant cells and bacterial rods and cocci. An unspeciated gram-positive rod-shaped bacterium was isolated via aerobic bacterial culture. Results of bacterial biochemical tests suggested the organism was a type of Actinomyces. A 16S rRNA gene sequence analysis was performed; results indicated the organism was Lactobacillus jensenii. TREATMENT AND OUTCOME: Extensive surgical debridement of the branching granuloma, which extended throughout the length of the keel, followed by long-term treatment with ciprofloxacin and clindamycin provided full resolution of clinical signs. No recrudescence of clinical signs was evident for up to 18 months after the initial evaluation. CLINICAL RELEVANCE: To the authors' knowledge, this is the first report of Lactobacillus-associated dermatitis or subdermal granuloma in the scientific literature and the second report of L jensenii in avian species. Use of 16S rRNA gene sequence analysis was instrumental in the identification of this fastidious organism, indicating the method's usefulness as a diagnostic tool.

Moxifloxacin in complicated skin and skin structure infections (cSSSIs): A prospective, international, non-interventional, observational study.

INTRODUCTION: ARTOS was an international, prospective, non-interventional, non-controlled observational study designed to determine the effectiveness, safety, and tolerability of moxifloxacin under daily-life conditions in patients with complicated skin and skin structure infections (cSSSIs) treated in Europe, the Middle East, and Asia-Pacific region. METHODS: Eligible patients included males and females who were hospitalized patients or outpatients requiring antibiotic therapy for cSSSIs and for whom the treating physician had elected to begin moxifloxacin therapy in accordance with its approved indications. Patients were assessed before therapy and then at one or two follow-up visits. Effectiveness was assessed with respect to improvement and resolution of signs and symptoms of cSSSIs and safety with respect to the nature and frequency of adverse events and adverse drug reactions. RESULTS: A total of 6,594 patients were enrolled of whom 5,444 had data available for analysis; 4,692 patients received sequential intravenous/oral (IV/PO) moxifloxacin and 752 exclusively IV therapy. A majority of patients were aged between 40 and 79 years and had one or more comorbid conditions. Post-surgical wound infection, skin abscess, and diabetic foot infection were the cSSSIs most frequently diagnosed and treated with moxifloxacin, with almost 90% of infections rated moderate or severe. Treating physicians chose sequential moxifloxacin 400 mg for most patients, switching from IV to PO after 3-4 days. On average, treatment was maintained for 10 days. Treatment with moxifloxacin was associated with rapid relief in symptoms, with 93.2% of patients experiencing either complete resolution of symptoms or improvement at follow-up. Moxifloxacin was well tolerated with adverse drug reactions occurring in only 2% of patients. CONCLUSIONS: This study, conducted in a 'real-world' setting, confirms the effectiveness and safety of moxifloxacin in the treatment of a wide spectrum of cSSSIs seen in routine clinical practice.

Antimicrobials as an adjunct to pilonidal disease surgery: a systematic review of the literature.

Surgical site infection (SSI) after pilonidal disease surgery can lead to serious complications. We systematically searched the PubMed, Scopus, and ClinicalTrials.gov databases for studies evaluating the use of antimicrobials as an adjunct to pilonidal disease surgery. We identified 12 eligible studies [nine randomized controlled trials (RCTs), three retrospective cohort studies], enrolling a total of 1,172 patients. No difference was observed when single-dose prophylaxis was compared to no prophylaxis or to a long course of antibiotics (seven studies, 690 patients). Similarly, gentamicin collagen sponges (GCS) did not appear to be beneficial when compared with no GCS (with primary or secondary closure; four studies, 402 patients). One study (80 patients) reported faster healing and lower SSI and recurrence rates with GCS than a 7-day course of antibiotics. The clinical heterogeneity precluded a formal meta-analysis. Although the generalization of our findings may be limited by the relative paucity and clinical heterogeneity of the existing studies, prophylactic antibiotics or GCS did not appear to be beneficial in promoting healing or reducing SSI or recurrence rates. Large, double-blind, placebo-controlled RCTs are warranted in order to further elucidate this issue.