[Pediatric necrotizing soft-tissue infections]. / Infections cutanées nécrosantes de l'enfant.

PEDIATRIC NECROTIZING SOFT-TISSUE INFECTIONS. Necrotizing soft-tissue infections (NSTI) include necrotizing forms of fasciitis, myositis, and cellulitis. In children, these are extremely rare conditions with an estimated annual incidence of less than 0.1/100,000 patients aged 0-18 years in France. Nevertheless, the evolution can be very serious (6% mortality, higher than the mortality observed in paediatric intensive care units [PICU]), whereas the initial local symptoms are poor and can be falsely reassuring. The monitoring of a skin infection must be close in order not to ignore the evolution towards a NSTI. In this case, prompt transfer to a PICU with all the necessary technical facilities and used to the management of these rare conditions must be done. Early initiation of antibiotic treatment and aggressive haemodynamic resuscitation according to the latest Surviving Sepsis Campaign guidelines should be a priority. The paediatric surgeon should be called upon as soon as clinical suspicion arises and participate in the frequent clinical reassessment to determine the optimal time to perform the surgical treatment.

INFECTIONS CUTANÉES NÉCROSANTES DE L'ENFANT. Les infections cutanées nécrosantes comprennent les dermo- hypodermites bactériennes nécrosantes (DHBN) et les fasciites nécrosantes (FN). Chez l'enfant, ce sont des pathologies extrêmement rares, avec une incidence annuelle en France estimée inférieure à 0,1/100 000 patients âgés de 0 à 18 ans. Néanmoins, leur évolution peut être gravissime (mortalité de 6 %, supérieure à la mortalité observée habituellement dans les unités de réanimation pédiatrique [URP]) alors que la symptomatologie locale initiale est pauvre et peut faussement rassurer. La surveillance d'une infection cutanée doit être rapprochée afin de ne pas méconnaître l'évolution vers une DHBN-FN. Dans ce cas, une orientation vers une URP disposant de l'ensemble du plateau technique nécessaire, et surtout habituée à gérer ces situations cliniques, est justifié. L'initiation précoce du traitement antibiotique et la prise en charge hémodynamique agressive en suivant les dernières recommandations de la Surviving Sepsis Campaign doivent être une priorité. Le chirurgien pédiatrique doit être appelé dès la suspicion clinique et participer à la réévaluation pluriquotidienne afin de déterminer le moment optimal pour réaliser le traitement chirurgical.

Cellulitis and bacteremia caused by the fish pathogen,Streptococcus iniae, in an immunocompromised patient: Case report and mini-review of zoonotic disease, lab identification, and antimicrobial susceptibility.

Streptococcus iniae is a fish pathogen that can also infect mammals including dolphins and humans. Its prevalence in farmed fish, particularly tilapia, provides potential for zoonotic infections, as documented by multiple case reports. Systematic clinical data beyond cellulitis for S. iniae infection in humans, including antimicrobial susceptibility data, are unfortunately rare. Here, we present a case of cellulitis progressing to bacteremia caused by Streptococcus iniae in a functionally immunocompromised patient based on CDK4/CDK6 inhibitor and endocrine therapy, and we discuss risk factors, identification, and antimicrobial susceptibility of this rare pathogen.

Orbital abscess with white eye in patients treated with oral antibiotics for orbital cellulitis.

PURPOSE: To report a case series of seven patients with late presentation of orbital/subperiosteal abscess following oral treatment of orbital cellulitis. METHODS: A retrospective case series of all patients presented with orbital abscess following oral treatment of orbital cellulitis from two tertiary-care eye centres in Riyadh, Saudi Arabia, was conducted. Demographic profiles, risk factors, initial clinical presentation, management regimens, and final outcome were analysed. RESULTS: Patients presented mainly with proptosis and limitation of extraocular motility without external ophthalmic inflammatory signs. Most patients needed surgical evacuation despite the appropriate initiation of intravenous antibiotics following presentation to our hospitals. CONCLUSION: Treating orbital cellulitis with oral antibiotics may lead to delayed presentation of orbital abscess without external ophthalmic inflammatory signs.

Clinical diagnosis and outcome of cervicofacial cellulitis in pyrexic rabbits: six cases (2014-2021).

OBJECTIVES: To assess the signalment, history, exam findings, diagnostics, treatment and outcome of rabbits diagnosed with pyrexia and concurrent cervicofacial cellulitis. MATERIALS AND METHODS: Retrospective evaluation of medical records of rabbits diagnosed with cervicofacial cellulitis and pyrexia based on physical exam, contrast-enhanced CT, clinicopathology and microbiology findings. RESULTS: Six out of 1588 rabbits met the study inclusion criteria. Rabbits presented with a median age of 6 years (range, 8 months to 8 years) with a presenting complaint of anorexia or hyporexia. All rabbits had a rectal temperature >40.2°C (104.4°F). Physical exam and contrast-enhanced CT revealed unilateral submandibular and ipsilateral cervical diffuse soft tissue swelling in five of six rabbits. No antemortem evidence of periodontal or dental disease was found on physical exam or CT. Leucopenia was present in five of six rabbits. A left shift with marked toxic changes was present in all four rabbits, for which blood smears were reviewed. Bacterial cultures of the aspirated subcutaneous soft tissue swelling cultured Escherichia coli, Pasteurella multocida, Granulicatella adiacens, Streptococcus species, Haemophilus species and Bacteroides species. Treatment was pursued in five rabbits, where all rabbits received supportive care and four of five rabbits received systemic antibiotics. One rabbit was euthanased following a diagnosis of cervicofacial cellulitis. Three out of five rabbits continued to decline clinically despite medical management, and thus, euthanasia was pursued within 24 hours of starting treatment. Two rabbits responded to initial treatment and developed subsequent multi-focal abscessation. One rabbit was euthanased due to client cost constraints, and one rabbit died shortly after achieving clinical resolution of cervicofacial cellulitis. CLINICAL SIGNIFICANCE: Cervicofacial cellulitis should be considered a differential diagnosis in pyrexic rabbits with facial or cervical swelling with medical and surgical management pursued for therapy.

Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single-centre audit of cellulitis outcomes.

BACKGROUND: Cellulitis is a common acute skin and soft tissue infection that causes substantial morbidity and healthcare costs. AIMS: To audit the impact on cellulitis management, regimen tolerability and outcomes of switching from outpatient parenteral antimicrobial therapy (OPAT) using intravenous (i.v.) cefazolin once daily plus probenecid to oral beta-lactam therapy (OBLT) using oral flucloxacillin plus probenecid. METHODS: We undertook a retrospective audit on cellulitis management, regimen tolerability and outcomes at the Dunedin Public Hospital Emergency Department (ED) before and after a change of the local outpatient cellulitis treatment pathway from OPAT using i.v. cefazolin once daily plus probenecid to OBLT using oral flucloxacillin plus probenecid. RESULTS: OPAT was used in 97/123 (78.9%) patients with cellulitis before compared to 1/70 (1.4%) after the pathway change (odds ratio (OR), 0.04, P < 0.01). OBLT was used in 26/123 (21.1%) patients with cellulitis before and 69/70 (98.6%) after (OR, 218.8, P < 0.01). Antimicrobial change due to intolerance occurred in 4/123 (3.2%) patients with cellulitis before and 4/70 (5.7%) after (OR, 1.8, P, not significant (NS)) the pathway change. Inpatient admission within 28 days occurred in 15/123 (12.2%) cellulitis patients before and 9/70 (12.9%) after (OR, 1.1, P, NS) the pathway change. CONCLUSIONS: Implementation of a change in outpatient cellulitis treatment pathway resulted in a significant change in prescribing practice. Our findings suggest that OBLT was both tolerable and had similar outcomes to OPAT.

Bugs Behind the Bulging Eyeball: Microbiology and Antibiotic Management in Orbital Cellulitis With or Without Subperiosteal Abscess.

The objective of this study is to describe causative pathogens and current antibiotic management among hospitalized children with orbital cellulitis. This retrospective study, performed at a tertiary care children's health system, included patients up to 18 years old who presented with radiographic evidence of orbital cellulitis from 2012 to 2019. Of the 298 patients included in the study, 103 had surgery and an intraoperative culture obtained. A pathogen was recovered in 86 cultures (83.5%). The most common pathogens were Streptococcus anginosus group (26.2%), Streptococcus pyogenes (11.7%), methicillin-susceptible Staphylococcus aureus (10.7%), and Streptococcus pneumoniae (9.7%). Only 8/194 (4.1%) blood cultures returned positive. Median duration of intravenous antibiotics was 4 days and median total duration was 17 days. The most common empiric regimen prescribed was ceftriaxone and clindamycin (64.1%). Despite low incidence of methicillin-resistant S aureus, empiric antibiotics often consisted of 2 antibiotics to ensure coverage for this bacterium.

Clinical outcomes in patients with complicated appendicitis.

BACKGROUND: Complicated appendicitis (appendicitis with abscess, perforation, or generalized peritonitis) poses a significant burden on healthcare systems, with incidence up to 28-29%. Current management options include antibiotic therapy and up-front surgery, antibiotic therapy and percutaneous drainage, or antibiotic therapy alone. There is no consensus on treatment guidelines in current literature. This study aims to better define treatment algorithms for patients presenting with acute complicated appendicitis by evaluating clinical outcomes in those treated with or without surgery. METHODS: We performed a single-institution, retrospective review of 220 adult patients (≥ 18 years old) treated for acute complicated appendicitis from January 2017 to June 2022. Demographic and clinicopathologic variables were collected and analyzed. We compared patients who were managed non-operatively versus operatively. Regression modeling was used to determine factors associated with non-operative management (NOM) and those predictive of failure of NOM. RESULTS: Our analysis showed 26.3% patients with acute complicated appendicitis underwent NOM (n = 58), versus 73.6% underwent operative management at index admission (n = 162). Within the NOM group, 55.1% patients were treated with antibiotics alone (n = 32) versus 44.8% with percutaneous drainage (n = 26). Within the operative cohort, 88.7% of patients underwent appendectomy (n = 142). Age, body mass index, comorbidities, vital signs and laboratory values on admission were similar between both groups. Clinical factors predictive of initial NOM were perforation (OR 7.9, 95% CI 3.7-16.5) and phlegmon (OR 6.3, 95% CI 2.8-14.1) at presentation. Clinical factors predictive of failure of NOM requiring surgery on index admission or within 30 days was larger abscess and/or phlegmon size (OR 1.76, 95% CI 1.0-3.0). CONCLUSION: There may be a role in identifying clinical factors in patients with complicated appendicitis that favor non operative versus operative management. Larger abscess and/or phlegmon size could be a predictor of failure of NOM.

Development and validation of the Baseline Recurrence Risk in Cellulitis (BRRISC) score.

OBJECTIVES: Cellulitis is often treated with antibiotics for longer than recommended by guidelines. Prolonged therapy may reduce recurrence in certain patients, but it is not known which patients are at greatest risk. Our objective was to develop and temporally validate a risk prediction score to identify patients attending hospital with cellulitis at highest risk of recurrence. METHODS: We included UK adult patients with cellulitis attending hospital in an electronic health records (EHR) study to identify demographic, comorbid, physiological, and laboratory factors predicting recurrence (before death) within 90 days, using multivariable logistic regression with backwards elimination in complete cases. A points-based risk score integerised model coefficients for selected predictors. Performance was assessed using the C-index in development and temporal validation samples. RESULTS: The final model included 4938 patients treated for median 8 days (IQR 6-11); 8.8% (n = 436) experienced hospitalisation-associated recurrence. A risk score using eight variables (age, heart rate, urea, platelets, albumin, previous cellulitis, venous insufficiency, and liver disease) ranged from 0-15, with C-index = 0.65 (95%CI: 0.63-0.68). Categorising as low (score 0-1), medium (2-5) and high (6-15) risk, recurrence increased fourfold; 3.2% (95%CI: 2.3-4.4%), 9.7% (8.7-10.8%), and 16.6% (13.3-20.4%). Performance was maintained in the validation sample (C-index = 0.63 (95%CI: 0.58-0.67)). Among patients at high risk, four distinct clinical phenotypes were identified using hierarchical clustering 1) young, acutely unwell with liver disease; 2) comorbid with previous cellulitis and venous insufficiency; 3) chronic renal disease with severe renal impairment; and 4) acute severe illness, with substantial inflammatory responses. CONCLUSIONS: Risk of cellulitis recurrence varies markedly according to individual patient factors captured in the Baseline Recurrence Risk in Cellulitis (BRRISC) score. Further work is needed to optimise the score, considering baseline and treatment response variables not captured in EHR data, and establish the utility of risk-based approaches to guide optimal antibiotic duration.

Cellulitis caused by Roseomonas mucosa in a child: a case report.

BACKGROUND: Roseomonas mucosa (R. mucosa) is a pink-pigmented, Gram-negative short rod bacterium. It is isolated from moist environments and skin, resistant to multiple drugs, including broad-spectrum cephalosporins, and a rare cause of infection with limited reports. R. mucosa mostly causes catheter-related bloodstream infections, with even fewer reports of skin and soft tissue infections. CASE PRESENTATION: A 10-year-old boy received topical steroid treatment for sebum-deficient eczema. A few days before the visit, he was bitten by an insect on the front of his right lower leg and scratched it due to itching. The day before the visit, redness, swelling, and mild pain in the same area were observed. Based on his symptoms, he was diagnosed with cellulitis. He was treated with sulfamethoxazole/trimethoprim, and his symptoms improved. Pus culture revealed R. mucosa. CONCLUSIONS: We report a rare case of cellulitis caused by R. mucosa. Infections caused by rare organisms that cause opportunistic infections, such as R. mucosa, should be considered in patients with compromised skin barrier function and regular topical steroid use. Gram stain detection of organisms other than Gram-positive cocci should be considered.

Pseudomonas otitidis bacteremia in an immunocompromised patient with cellulitis: case report and literature review.

BACKGROUND: Pseudomonas otitidis belongs to the genus Pseudomonas and causes various infections, including ear, skin, and soft tissue infections. P. otitidis has a unique susceptibility profile, being susceptible to penicillins and cephalosporins but resistant to carbapenems, due to the production of the metallo-ß-lactamase called POM-1. This revealed genetic similarities with Pseudomonas aeruginosa, which can sometimes lead to misidentification. CASE PRESENTATION: We report the case of a 70-year-old Japanese male who developed cellulitis and bacteremia during chemotherapy for multiple myeloma. He was initially treated with meropenem, but blood culture later revealed gram-negative bacilli identified as P. otitidis using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Carbapenem resistance was predicted from previous reports; therefore, we switched to dual therapy with levofloxacin and cefepime, and favorable treatment results were obtained. CONCLUSION: This is the first reported case of P. otitidis cellulitis and bacteremia in an immunocompromised patient. Carbapenems are typically used in immunocompromised patients and P. otitidis is often resistant to it. However, its biochemical properties are similar to those of Pseudomonas aeruginosa; therefore, its accurate identification is critical. In the present study, we rapidly identified P. otitidis using MALDI-TOF MS and switched from carbapenems to an appropriate antimicrobial therapy, resulting in a successful outcome.

Management of Children With Uncomplicated Cellulitis in Emergency and Hospital Settings.

OBJECTIVE: The aim of the study is to establish consensus recommendations on features used to determine the route of antibiotic administration and disposition for children with uncomplicated cellulitis. METHODS: Modified Delphi methodology was performed with 2 rounds of confidential surveys of Emergency medicine and hospital medicine (HM) providers at Lurie Children's Hospital to assess cellulitis management in children (ages 6 months-18 years) without signs of sepsis or abscess formation. Using a 9-point Likert scale, emergency medicine providers ranked features by perceived level of importance when deciding initial antibiotic route and HM providers ranked features on importance when transitioning to oral antibiotics. Responses were grouped as not important (1-3), neutral (4-6), and important (7-9) and re-evaluated in the second round to reach consensus, defined as ≥70% agreement. RESULTS: Emergency medicine providers (n = 17) reached consensus on 15 of 16 features (93.8%), 10 deemed important. Participants reached greatest consensus (100%) on fevers/chills, lymphangitis, and functional impairment as considerations for initiating intravenous antibiotics. HM providers (n = 15) reached consensus on 9 of 11 factors (81.8%), with 7 considered important when deciding on readiness for oral antibiotics. Providers indicated that stability, rather than reduction, of erythematous margins is sufficient to consider transition and de-escalation of therapy at less than 24 hours if all other clinical improvement criteria are met. CONCLUSIONS: This study achieved consensus on important features for treatment and disposition of children with uncomplicated cellulitis in both emergency and inpatient contexts. These features have the potential to aid in decision making and improve standardization of clinical practice.

ALA-PDT shortens the course of antibiotic therapy for skin infection caused by Mycobacterium marinum.

BACKGROUND: Recently, the number of cases of Mycobacterium marinum infection has increased. Due to the nonspecific clinical manifestations and lack of standardized treatment guidelines, these infections are often misdiagnosed and are challenging to treat. METHODS: In this study, four patients had M. marinum skin infections accompanied by a high-risk exposure history and were diagnosed by bacterial culture and gene chip. Two patients were treated with antibiotic therapy alone, and the other two patients were treated with 5-aminolevulinic acid photodynamic therapy (ALA-PDT) combined with antibiotics. RESULTS: All four patients enrolled in the study were cured with 100 % efficacy. Two patients were cured after receiving two active antibiotics for 4 months. The other two patients, having considered the drug resistance and intolerance described above, were cured after receiving two active antibiotics for 1-1.5 months along with combination therapy with ALA-PDT. CONCLUSION: Combination therapy with ALA-PDT and antibiotics was chosen to shorten the duration of antibiotic treatment and reduce the occurrence of adverse reactions.

Erysipelothrix rhusiopathiae cellulitis with associated bacteraemia following seafood preparation.

Erysipelothrix rhusiopathiae is a pleomorphic Gram-positive bacillus, zoonotic pathogen of mammals, birds and fish. Human disease caused by this organism most commonly occurs following occupational or recreational exposure to infected animals and typically presents as a localised cutaneous disease. Invasive infection resulting in bacteraemia, endocarditis or other distant sequelae is infrequently seen. Most commonly, invasive infection is seen in patients with predisposing risk factors including diabetes, immunocompromising conditions, alcohol use disorder or chronic kidney disease. The organism is highly susceptible to penicillin-class drugs which serve as first-line antimicrobial therapy with prolonged courses typically prescribed for invasive disease, given the predilection of this organism to cause endocarditis. In this report, we present an interesting case of a polymicrobial finger abscess with E. rhusiopathiae bacteraemia following laceration with a fish spine in an immunocompetent patient in Southern US state. This bacteraemic episode was successfully treated with a fluoroquinolone course owing to patient's penicillin allergy.

Two Cases of Herpes Gladiatorum Identified in a Korean Middle-School Wrestling Team: A Case Report.

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