Trends in US hospital admissions for skin and soft tissue infections

Improving Empiric Antibiotic Selection for Patients Hospitalized With Skin and Soft Tissue Infection: The INSPIRE 3 Skin and Soft Tissue Randomized Clinical Trial

Importance

Empiric extended-spectrum antibiotics are routinely prescribed for patients hospitalized with skin and soft tissue infections (SSTIs) despite low likelihoods of infection with multidrug-resistant organisms (MDROs).

Objective

To evaluate whether computerized provider order entry (CPOE) prompts presenting patient-specific and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for noncritically ill patients admitted with SSTI.

Design, Setting, and Participants

This cluster randomized clinical trial included 92 hospitals and assessed the effect of an antibiotic stewardship bundle that included CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults hospitalized with SSTI. The trial population included adults 18 years and older treated with empiric antibiotics for SSTI in non-intensive care unit (ICU) settings. Data were collected from January 2019 to December 2023.

Interventions

CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period when absolute risk of MDRO SSTI was estimated to be less than 10%, coupled with feedback and education.

Main Outcomes and Measures

The primary outcome was empiric extended-spectrum antibiotic days of therapy (summed number of different extended-spectrum antibiotics targeting Pseudomonas and/or MDR gram-negative bacteria received per patient each calendar day). The secondary outcome was antipseudomonal days of therapy. Safety outcomes included days to ICU transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies.

Results

Among 118 562 patients admitted with SSTI at 92 hospitals, 67 033 (56.7%) were male and the mean (SD) age was 58.0 (17.5) years. A total of 57 837 patients were included in the baseline period and 60 725 in the intervention period. Receipt of any empiric extended-spectrum antibiotic during the baseline and intervention periods was 57.0% (16 855 of 29 595) and 56.0% (17 534 of 31 337), respectively, for the routine stewardship group compared with 55.4% (15 650 of 28 242) and 43.0% (12 647 of 29 388), respectively, for the CPOE group. Empiric extended-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens was 511.5 during the baseline period and 488.7 during the intervention period in the routine stewardship group and was 496.2 and 359.1, respectively, in the CPOE bundle group (rate ratio, 0.72; 95% CI, 0.67-0.79; P < .001). There was no evidence of inferiority in the CPOE bundle group for mean (SD) hospital length of stay (routine stewardship, 6.5 [3.8] days; CPOE bundle, 6.4 [3.8] days) and days to ICU transfer (routine stewardship, 6.3 [3.2] days; CPOE bundle, 6.3 [3.1] days).

Conclusions and Relevance

In this randomized clinical trial, CPOE prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI coupled with education and feedback significantly reduced use of extended-spectrum antibiotics without increasing admissions to ICUs or hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT05423756.

Community-acquired methicillin-resistant Staphylococcus aureus : is it still a significant pathogen for skin and soft tissue infections? A 30-year overview

PURPOSE OF REVIEW

The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin and soft tissue infections (SSTI) has significantly changed in recent decades. We conducted a literature review to determine whether this microorganism, which became increasingly common as a cause of SSTI in the 2000s, still plays a significant role in these infections today.

RECENT FINDINGS

Over the past 30 years, there has been a pattern of increase and then decrease in these infections. The highest frequency was observed in the United States, to the extent that guidelines recommended empirical antibiotic treatment for this pathogen in SSTI. Clone USA300 is the primary causative agent in the United States. In Europe, SSTI are much less common than in the United States, and the presence of this clone has been significantly lower. A decrease in the frequency of SSTI and CA-MRSA has been observed in developed countries. However, the spread of specific clones in Latin America, Asia and Africa highlights the need for rigorous global surveillance.

SUMMARY

In recent years, the prevalence of CA-MRSA SSTI has decreased in developed countries. However, globalisation, immigration and intercontinental travel have favoured the spread of some clones with epidemic potential. It remains to be seen whether the current lower frequency will be maintained or whether these clones will give rise to a new wave.

Omadacycline for the treatment of skin and soft tissue infections

PURPOSE OF REVIEW

To evaluate the current evidence on the use of omadacycline for the treatment of skin and soft tissue infections (SSTIs).

RECENT FINDINGS

This narrative review examines the available data on the pharmacology, clinical efficacy, safety profile, and comparative effectiveness of omadacycline in treating SSTIs, with a focus on its potential role in everyday clinical practice.

SUMMARY

Omadacycline is a viable option for outpatient therapy and early discharge in patients with SSTIs, particularly in frail populations and those undergoing chronic polypharmacotherapy. Emerging real-world evidence highlights its potential utility beyond approved indications, particularly for infections caused by multidrug-resistant microorganisms where treatment options are limited. However, further studies are needed to confirm its role in contexts beyond its current approvals.

Factors Associated With Observation Unit Admission in Emergency Department Patients With Skin and Soft Tissue Infections

Objectives

Skin and soft tissue infections (SSTIs) constitute a significant portion of emergency department (ED) cases, with some requiring admission into the observation unit (OU) for ongoing care. Identifying factors linked to OU admission is essential for optimizing patient disposition decisions.

Methods

A retrospective cohort study identified patients with the International Classification of Diseases 10th Revision (ICD-10) codes indicating SSTI at an urban, tertiary care ED over 3 years (2017-2019) who were ultimately discharged. Patients admitted at index visit were excluded. Medical charts were reviewed for demographic and clinical data. Simple logistic regression models explored bivariate associations with OU admission, while a multiple logistic regression model adjusted for demographics, clinical characteristics, vital signs, and pre-index visit and in-ED management.

Results

Among 1675 patients (42.9% female; mean age, 45.5 ± 15.4 years; 56.4% identifying as Black), 20.7% (n = 346) were admitted to the OU. Unadjusted analysis showed associations between OU admission and factors, including age, history of intravenous drug use (IVDU), lower extremity SSTI, subjective systemic illness, fever at index visit, ED surgical consultation, and pre-index visit antimicrobial choice. After adjustment, age (odds ratio [OR], 1.16; 95% CI, 1.04-1.30), immunocompromised status (OR, 1.83; 95% CI, 1.07-3.13), extremity cellulitis (lower: OR, 2.51; 95% CI, 1.55-4.14; upper: OR, 2.35; 95% CI, 1.36-4.12), surgical consultation (OR, 2.64; 95% CI, 1.79-3.91), and prehospital methicillin-resistant Staphylococcus aureus (MRSA) antibiotic prescription (OR, 2.76; 95% CI, 1.69-4.54; P = .0001) remained statistically significant.

Conclusion

Identifying factors associated with OU admission provides insights into clinician decision making, potentially identifying patients who might benefit from OU admission through future work, which should focus on predictors of hospital admission, OU failure, and antimicrobial selection to reduce OU failure rates.

Infection prevention-how can we prevent transmission of community-onset methicillin-resistant Staphylococcus aureus?

BACKGROUND

Staphylococcus aureus is a versatile organism, capable of existing as a commensal organism while also possessing pathogenic potential. The emergence of clinically and genetically distinct strains of methicillin-resistant S. aureus (MRSA), termed community-onset MRSA (CO-MRSA), resulted in an epidemic of invasive and skin and soft tissue infections (SSTI) in otherwise healthy individuals without traditional risk factors. Colonization with S. aureus is a risk factor for developing infection and also a source of transmission to close contacts. Outbreaks of S. aureus SSTI have been described in crowded settings and within households. Thus, preventive strategies are essential to interrupt recurrent infections.

OBJECTIVES

The objective of this narrative review is to provide a comprehensive, evidence-based approach to prevent transmission of CO-MRSA. We highlight key clinical trials that emphasize the importance of household and environmental S. aureus colonization in propagating household transmission. Finally, we highlight research priorities to prevent S. aureus infection.

SOURCES

We cite primary literature from peer-reviewed publications as sources for this review.

CONTENT

Our recommended approach to the management of individuals presenting with skin abscesses includes optimal treatment of the initial infection and hygiene education. Decolonization measures should be recommended for individuals with recurrent SSTIs or whose household members have SSTIs. Targeted decolonization with topical antimicrobials should be prescribed to all affected individuals within the household.

IMPLICATIONS

S. aureus infections result in substantial mortality and morbidity because of the high incidence of recurrent skin infections. Although current decolonization strategies are beneficial, interventions are often costly to families and effectiveness wanes over time. Results from a recently completed trial evaluating integrated periodic decolonization and household environmental hygiene will further add to our understanding of what constitutes a sustainable decolonization approach. In addition, novel preventive strategies are being developed such as S. aureus vaccines, lytic agents, probiotics, microbiota transplants, and phage therapy.

Pre- and Post-admission Care for Children Hospitalized With Skin and Soft Tissue Infections

BACKGROUND AND OBJECTIVES

Although skin and soft tissue infections (SSTIs) are among the most common indications for pediatric hospitalization, little is known about outpatient care received for SSTI before and after hospitalization. We assessed peri-hospitalization care for SSTI, including antibiotic exposures and their impact on hospital length of stay (LOS).

METHODS

This is a retrospective cohort study of 1229 SSTI hospitalizations in 2019 from children aged 1-to-18 years enrolled in Medicaid from 10 US states included in the Merative Marketscan Medicaid database. We characterized health service utilization (outpatient visits, laboratory and diagnostic tests, antibiotic exposures) 14 days before and 30 days after hospitalization and evaluated the effects of pre-hospitalization care on hospital LOS with linear regression.

RESULTS

Only 43.1% of children hospitalized with SSTI had a preceding outpatient visit with a SSTI diagnosis, 69.8% of which also filled prescription for an antibiotic. Median LOS for SSTI admission was 2 days (interquartile range 1-3). Pre-hospitalization visits with a diagnosis of SSTI were associated with a 0.7 day reduction (95% confidence interval: 0.6-0.81) in LOS (P < .001), but pre-hospital antibiotic exposure alone had no effect on LOS. Most children (81.7%) filled antibiotic prescriptions after hospital discharge and 74.5% had post-discharge ambulatory visits.

CONCLUSIONS

Although most children did not receive pre-admission care for SSTI, those that did had a shorter hospitalization. Further investigation is necessary on how to optimize access and use of outpatient care for SSTI.

Efficacy and Safety of Antibiotics in the Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections: A Systematic Review and Network Meta-Analysis

BACKGROUND

Vancomycin is a first-line drug for the treatment of MRSA infection. However, overuse of vancomycin can cause bacteria to become resistant, forming resistant strains and making infections more difficult to treat. This study aimed to evaluate the efficacy and safety of different antibiotics in the treatment of MRSA infections and to compare them, mainly with vancomycin, to find better vancomycin alternatives.

METHODS

All studies were obtained from the PubMed and Embase databases from inception to 13 April 2023. The three comprehensive indicators of clinical cure success rate, clinical microbiological success rate, and adverse reactions were evaluated, and the clinical cure success rates of three disease types, complex skin and skin structure infections (cSSSIs), complex skin and soft tissue infections (cSSTIs), and pneumonia, were analyzed in subgroups. All statistical analyses were performed using R and STATA 14.0 software for network meta-analysis.

RESULTS

A total of 38 trials with 6281 patients were included, and 13 drug treatments were evaluated. For MRSA infections, the results of network meta-analysis showed that the clinical success rates of linezolid, the combination of vancomycin and rifampin, and the combination of minocycline and rifampin were better than that of vancomycin (RR 1.71; 95%-CI 1.45-2.02), (RR 2.46; 95%-CI 1.10-5.49) (RR, 2.77; 95%-CI 1.06-7.21). The success rate of clinical microbiological treatment with vancomycin was inferior to that with telavancin (RR 0.74; 95%-CI 0.55-0.99). Linezolid had a higher rate of adverse reactions than teicoplanin (RR 5.35; 95%-CI 1.10-25.98). Subgroup analysis showed that vancomycin had a lower clinical success rate than linezolid in the treatment of MRSA-induced cSSSIs, cSSTIs, and pneumonia (RR 0.59; 95%-CI 0.44-0.80) (RR 0.55; 95%-CI 0.35-0.89) (RR 0.55; 95%-CI 0.32-0.93).

CONCLUSIONS

This systematic review and NMA provide a new comparison framework for the clinical treatment of MRSA infection. The NMA suggests that linezolid may be the antibiotic of choice for the treatment of MRSA infections, with the ability to improve clinical and microbiological success rates despite its disadvantage in terms of adverse effects. At the same time, the combination of minocycline and rifampicin may be the most effective drug to treat MRSA-induced cSSSIs, tedizolid may be the best drug to treat MRSA-induced cSSTIs, and the combination of vancomycin and rifampicin may be the most effective treatment for MRSA-induced pneumonia. More high-quality studies are still needed in the future to further identify alternatives to vancomycin.

TRIAL REGISTRATION

PROSPERO registration number CRD42023416788.

In-label, off-label prescription, efficacy and tolerability of dalbavancin: report from a National Registry

PURPOSE

Although dalbavancin is currently approved for the treatment of ABSSIs, several studies suggest its efficacy and tolerance as long-term therapy for other off-label indications requiring prolonged intravenous antibiotic administration.

METHODS

We conducted a prospective nationwide study of dalbavancin use in real-life settings for both approved and off-label indications analysing for each case the clinical and microbiological characteristics of infection the efficacy and safety of treatments.

RESULTS

During the study period (from December 2018 to July 2021), the ID specialists from 14 different centres enrolled 223 patients treated with dalbavancin [141 males (63%) and 82 females (37%); male/female ratio 1.72; mean age 59 (SD 17.2) years, (range 15-96). Most patients in the study population (136/223; 61.0%) came from community rather than health care facilities and most of them were visited in Infectious Diseases wards (93/223; 41.7%) and clinics (55/223; 24.7%) even though some patients were cured in other settings, such as surgery wards (18/223; 8.1%), orthopaedic wards (11/223; 4.9%), Emergency Rooms (7/223; 3.1%) and non-surgical other than ID wards (6/223; 2.7%). The most common ID diagnoses were osteomyelitis (44 cases/223; 19.7%; of which 29 acute and 15 chronic osteomyelitis), cellulitis (28/223; 12.5%), cutaneous abscess (23/223; 10.3%), orthopaedic prosthesis-associated infection (22/223; 9.9%), surgical site infection (20/223; 9.0%) and septic arthritis (15/223; 6.7%).

CONCLUSION

In conclusion, by virtue of its PK/PD properties, dalbavancin represents a valuable option to daily in-hospital intravenous or outpatient antimicrobial regimens also for off-label indications requiring a long-term treatment of Gram-positive infections.

Real-World Use and Treatment Outcomes of Ceftaroline Fosamil in Patients with Complicated Skin and Soft Tissue Infection: A Multinational Retrospective Study

Background

Ceftaroline fosamil is approved for the treatment of complicated skin and soft tissue infections (cSSTI) and community-acquired pneumonia (CAP); however, data on its real-world use and effectiveness in Europe and Latin America are currently limited. This retrospective observational study assessed ceftaroline fosamil use and treatment outcomes in adults hospitalized with cSSTI or CAP treated with ceftaroline fosamil in a usual care setting in Europe and Latin America. Results for patients with cSSTI are reported.

Methods

Data from patients with cSSTI who received ≥4 consecutive intravenous ceftaroline fosamil doses up to May 31, 2019, were collected from sites in Brazil, Colombia, France, Greece, Italy, and Spain. Patient characteristics, clinical management, hospitalization information, microbiological diagnosis, and clinical responses were summarized descriptively. Healthcare resource use variables were evaluated by clinical response to ceftaroline fosamil.

Results

Data for 132 patients were included (58.3% male; mean age 58.5 years). Most common lesions were cellulitis/fasciitis (62.1%), abscess (34.1%), and post-surgical wounds (19.7%). Pathogens most frequently identified were methicillin-resistant (18.2%) and methicillin-susceptible Staphylococcus aureus (17.4%). Median (range) ceftaroline fosamil treatment duration was 8 (2-60) days (daily doses of 1200 [400-2400] mg); 78 patients (59.1%) received monotherapy. In total, 75 (56.8%) patients had additional antibiotics after ceftaroline fosamil. Clinical response occurred in 118 (89.4%) patients. All-cause 30-day readmission occurred in 13 (9.8%) patients, and all-cause 30-day mortality in 7 (5.3%). Clinical response to ceftaroline was associated with >25% shorter length of hospital and intensive care stay, and with ~40% lower hospital costs, versus non-responders.

Conclusion

Ceftaroline fosamil was effective in treating adults with cSSTI and clinical response to ceftaroline fosamil was associated with reductions in healthcare resource use compared with non-responders, in Europe and Latin America.

Clinicaltrialsgov Identifier

NCT04198571.

The Incidence of Skin and Soft Tissue Infections in the United States and Associated Healthcare Utilization Between 2010 and 2020

Background

The number of patients with skin and soft tissue infections (SSTIs) in the United States appeared to be increasing well into the 21st century. However, no recent data have confirmed this trend.

Methods

This retrospective, observational cohort study used claims data over 11 years (2010-2020) from Optum's de-identified Clinformatics Data Mart Database. SSTI episodes, complications, and comorbidities were identified using International Classification of Diseases codes. Annual SSTI incidence rates, proportions of recurrent SSTI, SSTI-associated deaths, and total costs were estimated.

Results

During the study period, 5.4 million patients experienced 9.1 million SSTI episodes, with an incidence of 77.5 (95% confidence interval, 77.4-77.5) per 1000 person-years of observation (PYO). Annual incidence did not change significantly over time. Overall incidence (per 1000 PYO) of SSTI episodes in patients without comorbidities was 32.1 (highest incidence was for previous SSTI [113.5]) versus much higher rates if comorbidities were present. Incidence rates (per 1000 PYO) of chronic ulcers increased over time from 11.3 to 18.2 (P < .0001) and complicated disease from 3.5 to 6.3 (P < .0001). Deaths occurring within 30 days post-SSTI hospitalization rose from 2.6% to 4.6% in 2020. Recurrences occurred in 26.3% of index cases. The mean cost of an SSTI episode was US$3334 (median US$190) and was highest for surgical site infections and chronic ulcers.

Conclusions

The epidemiology of SSTI in the United States is changing and the disease burden is increasing despite stabilization in overall incidence. These data can inform identification of priority populations who could benefit from targeted interventions.

Staphylococcus aureus Infections and Human Intestinal Microbiota

Staphylococcus aureus (S. aureus) is a common pathogen that can cause many human diseases, such as skin infection, food poisoning, endocarditis, and sepsis. These diseases can be minor infections or life-threatening, requiring complex medical management resulting in substantial healthcare costs. Meanwhile, as the critically ignored "organ," the intestinal microbiome greatly impacts physiological health, not only in gastrointestinal diseases but also in disorders beyond the gut. However, the correlation between S. aureus infection and intestinal microbial homeostasis is largely unknown. Here, we summarized the recent progress in understanding S. aureus infections and their interactions with the microbiome in the intestine. These summarizations will help us understand the mechanisms behind these infections and crosstalk and the challenges we are facing now, which could contribute to preventing S. aureus infections, effective treatment investigation, and vaccine development.

Nanosecond pulsed electric fields increase antibiotic susceptibility in methicillin-resistant Staphylococcus aureus

IMPORTANCE

We have found that treatment with short electric pulses potentiates the effects of multiple antibiotics against methicillin-resistant Staphylococcus aureus. By reducing the dose of antibiotic necessary to be effective, co-treatment with electric pulses could amplify the effects of standard antibiotic dosing to treat S. aureus infections such as skin and soft-tissue infections (SSTIs). SSTIs are accessible to physical intervention and are good candidates for electric pulse co-treatment, which could be adopted as a step-in wound and abscess debridement.

Current approach to skin and soft tissue infections. Thinking about continuity of care

Skin and soft tissue infections are a common reason for patients seeking inpatient and outpatient medical care. Surgery is an essential part of managing in many episodes. Careful evaluation of antibiotic therapy could help clinicians in early identification to patients with treatment failure and to consider an alternative approach or a new surgical revision in "focus control". With the arrival of new drugs, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life (long-acting lipoglycopeptides such as dalbavancin or oritavancin), which allows weekly administration (or even greater), can reduce hospital admission and length of stay with fewer healthcare resources through outpatient management (home hospitalization or day hospitals). New anionic fluoroquinolones (e.g. delafloxacin), highly active in an acidic medium and with the possibility of switch from the intravenous to the oral route, will also make it possible to achieve these new healthcare goals and promote continuity of care. Therefore, management should rely on a collaborative multidisciplinary group with experience in this infectious syndrome.

Fabrication and characterisation of poly(sulfonated) and poly(sulfonic acid) dissolving microneedles for delivery of antibiotic and antifungal agents

Skin and soft tissue infections (SSTIs) arise from microbial ingress into the skin. In this study, poly(2-acrylamido-2-methyl-1-propanesulfonic acid) (polyAMPS), which has been reported to exhibit antimicrobial properties was synthesised for the manufacture of microarray patches (MAPs). The free acid and sodium salt of polyAMPS with controlled molar masses and narrow dispersity were synthesised via reversible addition - fragmentation chain-transfer (RAFT) polymerisation reaction with a monomer conversion of over 99%, as determined by 1H NMR. The polymers were shown to be biocompatible when evaluated using a fibroblast dermal cell line while agar plating assay using cultures of C. albican demonstrated that the acid form of polyAMPS exhibited antimicrobial inhibition, which is potentiated in the presence of antimicrobial agents. The synthesised polymers were then used to fabricate dissolving MAPs, which were loaded with either ITRA or levofloxacin (LEV). The MAPs displayed acceptable mechanical resistance and punctured ex vivo skin to a depth of 600 µm. Skin deposition studies revealed that the MAPs were able to administer up to ∼ 1.9 mg of LEV (delivery efficiency: 94.7%) and ∼ 0.2 mg of ITRA (delivery efficiency: 45.9%), respectively. Collectively, the synthesis and development of this novel pharmaceutical system may offer a strategy to manage SSTIs.

Skin Popping for the Hand Surgeon: A Case Report and Review

INTRODUCTION

Subcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery.

METHODS

A case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria.

RESULTS

In this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described.

CONCLUSIONS

Skin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of "skin popping" sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.

How to manage skin and soft-tissue infections in the emergency department

PURPOSE OF REVIEW

Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures.

RECENT FINDINGS

Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods.

SUMMARY

The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.

Cost analysis of dalbavancin versus standard of care for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) in two Italian hospitals

Objectives

Thanks to its long half-life, dalbavancin qualifies as an optimal drug for saving costs. We aimed to assess the cost and effectiveness of dalbavancin versus the standard of care (SoC).

Patients and methods

We conducted a multicentre retrospective study, including all hospitalized or outpatients diagnosed with ABSSSIs at Padua University Hospital, Padua and San Paolo Hospital, Milan (1 January 2016 to 31 July 2020). We compared patients according to antibiotic treatment (dalbavancin versus SoC), the number of lines of dalbavancin treatment, and monotherapy or combination (dalbavancin in association with other antibiotics). Primary endpoints were direct medical costs and length of hospital stay (LOS) associated with ABSSSI management; Student's t-test, chi-squared test and one-way ANOVA were used.

Results

One hundred and twenty-six of 228 (55.3%) patients received SoC, while 102/228 (44.7%) received dalbavancin. Twenty-seven of the 102 (26.5%) patients received dalbavancin as first-line treatment, 46 (45.1%) as second-line, and 29 (28.4%) as third- or higher-line treatment. Most patients received dalbavancin as monotherapy (62/102; 60.8%). Compared with SoC, dalbavancin was associated with a significant reduction of LOS (5 ± 7.47 days for dalbavancin, 9.2 ± 5.59 days for SoC; P < 0.00001) and with lower mean direct medical costs (3470 ± 2768€ for dalbavancin; 3493 ± 1901€ for SoC; P = 0.9401). LOS was also reduced for first-line dalbavancin, in comparison with second-, third- or higher-line groups, and for dalbavancin monotherapy versus combination therapy. Mean direct medical costs were significantly lower in first-line dalbavancin compared with higher lines, but no cost difference was observed between monotherapy and combination therapy.

Conclusions

Monotherapy with first-line dalbavancin was confirmed as a promising strategy for ABSSSIs in real-life settings, thanks to its property in reducing LOS and saving direct medical costs.

Frequency and Impact of Infectious Disease Conditions Diagnosed During Decompensated Heart Failure Hospitalizations in the United States

There are limited data on the frequency of diagnosis of infectious disease and its impact on patients hospitalized with decompensated heart failure. We sought to evaluate the prevalence, types, trends, and outcomes of infectious disease diagnosis in patients admitted with decompensated heart failure. We performed a retrospective cohort study in patients admitted with a primary diagnosis of heart failure using the National Inpatient Sample database from 2009 to 2019. Patients with a length of stay ≥3 days were included. Patients with chronic dialysis, left ventricular assist devices, cardiogenic shock, or solid organ transplantation or who required mechanical ventilation or mechanical circulatory support were excluded. Patients were stratified according to the presence or absence of infectious disease diagnosis. Outcomes of interest were in-hospital mortality, length of stay, and resource utilization. Among the 7,228,521 admissions with a primary diagnosis of heart failure that met the inclusion and exclusion criteria, an infectious disease diagnosis was reported in 1,806,514 (24.9%). Infectious disease diagnosis was more frequent in patients who were female, older, and White, and who had higher baseline co-morbidity. Since 2014, there has been a steady decrease in infectious conditions in patients admitted with a primary diagnosis of heart failure (p for trend <0.01). After propensity match analysis was performed, patients with infectious disease diagnosis had a longer length of stay (6.9 vs 5.7 days, p <0.001) and higher cost ($14,305 vs $11,760, p <0.001), were less likely to be discharged home (35.3% vs 44.7%, p <0.001), and had higher in-hospital mortality (2.6% vs 1.6%, p <0.001). In conclusion, approximately 1 in 4 patients admitted with primary heart failure will be diagnosed with an infectious condition. The presence of an infectious disease diagnosis is associated with increased morbidity and mortality.

Clinical Impact of Staphylococcus aureus Skin and Soft Tissue Infections

The pathogenic bacterium Staphylococcus aureus is the most common pathogen isolated in skin-and-soft-tissue infections (SSTIs) in the United States. Most S. aureus SSTIs are caused by the epidemic clone USA300 in the USA. These infections can be serious; in 2019, SSTIs with S. aureus were associated with an all-cause, age-standardized mortality rate of 0.5 globally. Clinical presentations of S. aureus SSTIs vary from superficial infections with local symptoms to monomicrobial necrotizing fasciitis, which can cause systemic manifestations and may lead to serious complications or death. In order to cause skin infections, S. aureus employs a host of virulence factors including cytolytic proteins, superantigenic factors, cell wall-anchored proteins, and molecules used for immune evasion. The immune response to S. aureus SSTIs involves initial responders such as keratinocytes and neutrophils, which are supported by dendritic cells and T-lymphocytes later during infection. Treatment for S. aureus SSTIs is usually oral therapy, with parenteral therapy reserved for severe presentations; it ranges from cephalosporins and penicillin agents such as oxacillin, which is generally used for methicillin-sensitive S. aureus (MSSA), to vancomycin for methicillin-resistant S. aureus (MRSA). Treatment challenges include adverse effects, risk for Clostridioides difficile infection, and potential for antibiotic resistance.

Hospital Admissions Related to Infections and Disorders of the Skin and Subcutaneous Tissue in England and Wales

OBJECTIVES

To investigate hospital admissions in England and Wales due to infections and diseases of the skin and subcutaneous tissue.

METHODS

Data from the Patient Episode Database for Wales (PEDW) and the Hospital Episode Statistics (HES) database in England for the years between April 1999 and April 2020 were used in this study. Using all the relevant diagnosis codes (L00-L99), hospital admissions related to various skin infections and diseases of the subcutaneous tissue were identified.

RESULTS

Hospital admissions for all causes increased overall by 78.8%, from 276,464 in 1999 to 494,433 in 2020, representing an increase in hospital admission rate of 56.1% (from 530.23 (95% CI 528.26-532.20) in 1999 to 827.92 (95% CI 825.62-830.22) per 100,000 people in 2020, p ≤ 0.05). The most prevalent diagnoses were disorders of the skin's appendages, infections of the skin and subcutaneous tissue, and other disorders of the skin and subcutaneous tissue. Nearly half of all hospital admissions were for males and for patients between the ages of 15 and 59. In 2020, the hospital admission rate for males increased by 60.2%, from 540.16 (95% CI 537.32-543.01) per 100,000 people in 1999 to 865.10 (95% CI 861.76-868.44) in 2020. From 520.75 (95% CI 518.02-523.48) in 1999 to 791.03 (95% CI 787.86-794.19) in 2020, the hospital admission rate for females grew by 51.9%.

CONCLUSION

Hospital admission due to infections and disorders of the skin and subcutaneous tissue increased during the past two decades in England and Wales. Further studies are needed to explore the risk factors associated with infections and disorders of the skin and subcutaneous tissue complications, and its associated admissions.

Pillars for prevention and control of healthcare-associated infections: an Italian expert opinion statement

Healthcare-associated infections (HAIs) represent a relevant problem for all healthcare facilities, because they involve both the care aspect and the economic management of the hospital. Most HAIs are preventable through effective Infection Prevention and Control (IPC) measures. Implementation and improvement of IPC programs are critical to reducing the impact of these infections and the spread of multi-resistant microorganisms. The purpose of this Expert Opinion statement was to provide a practical guide for healthcare organizations, physicians, and nursing staff on the optimal implementation of the core components of Infection Prevention and Control, as recommended by a board of specialists after in-depth discussion of the available evidence in this field. According to their independent suggestions and clinical experiences, as well as evidence-based practices and literature review, this document provides a practical bundle of organizational, structural, and professional requirements necessary to promote, through multimodal strategies, the improvement of the quality and safety of care with respect to infectious risk in order to protect the patient, facilities, and healthcare providers.

Outpatient management of moderate cellulitis in children using high-dose oral cephalexin

Objectives

To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.

Methods

In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.

Results

A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).

Conclusions

With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.

Antibiotic treatment of acute bacterial skin and skin structure infections

PURPOSE OF REVIEW

Acute bacterial skin and skin structure infections (ABSSSI) are a leading cause of morbidity, with a considerable variety of clinical presentation and a wide range of etiological pathogens. Of importance, the spread of multidrug-resistant (MDR) strains (i.e. methicillin-resistant Staphylococcus aureus or Gram-negative bacteria) is increasingly reported in some regions. in this review, we summarize the current clinical approach to patients with ABSSSI.

RECENT FINDINGS

Accurate diagnosis and identification of risk factors for MDR pathogens are key determinants for administering appropriate therapy in patients with ABSSSI. In daily clinical practice, this can be critical as there are many features defining the 'high risk patient' including both disease and host-associated risk factors.

SUMMARY

Antibiotic therapy should be based according to the different clinical spectrum of disease belonging to the ABSSSI, on the pathogens most likely to be involved and local resistance. Careful evaluation of antibiotic therapy after 48-72 h of initial therapy could help clinicians to early identify patients with treatment failure and to consider an alternative approach. Close monitoring of patients with multiple comorbidities, drug-drug interaction or adverse host factors are also necessary.

New drugs for methicillin-resistant Staphylococcus aureus skin and soft tissue infections

PURPOSE OF REVIEW

Staphylococcus aureus is a pathogen incriminated in skin and soft tissue infections (SSTIs), with methicillin-resistant S. aureus (MRSA) becoming the predominant cause and representing a significant burden to the healthcare system. The last updated Infectious Diseases Society of America (IDSA) guidelines concerning MRSA infections and SSTIs management were published in 2011 and 2014, respectively. The UK updated guidelines for MRSA infection treatment were published in 2021. Older treatment options may be associated with toxicity and require frequent dosing. There is a paucity of recent reviews on the armamentarium of new agents for MRSA SSTIs treatment.

RECENT FINDINGS

Since 2005, several new antibiotics received a fast-track approval by the Food and Drug Administration (FDA) for SSTI treatment. These drugs include delafloxacin, omadacycline, tedizolid, ceftaroline, dalbavancin, oritavancin and telavancin. In this manuscript, we will review the data that led to these new drugs approval and discuss their advantages and disadvantages in MRSA SSTIs management.

SUMMARY

MRSA is a major cause of SSTIs. Several novel therapies covering MRSA were FDA-approved for SSTIs. However, the current IDSA guidelines for MRSA infection and SSTIs as well as the recently published UK guidelines on MRSA treatment only consider these drugs as alternative choices or do not mention them at all.

Management and Prevention of Staphylococcus aureus Infections in Children

Staphylococcus aureus is a common skin commensal with the potential to cause severe infections resulting in significant morbidity and mortality. Up to 30% of individuals are colonized with S aureus, though infection typically does not occur without skin barrier disruption. Infection management includes promptly addressing the source of infection, including sites of metastatic infection, and initiation of effective antibiotics, which should be selected based on local antibiotic susceptibility patterns. Given that S aureus colonization is a risk factor for infection, preventive strategies are aimed at optimizing hygiene measures and decolonization regimens for outpatients and critically ill children with prolonged hospitalizations.

Severe Skin and Soft-Tissue Infections

Skin and soft-tissue infections (SSTIs) are a common reason for hospital admission. Severe SSTIs, particularly necrotizing infections, often require intensive care. Source control (often with surgical debridement) and broad-spectrum antimicrobials are paramount for minimizing significant morbidity and mortality. Rapid diagnostic tests may help in selection and de-escalation of antimicrobials for SSTIs. Besides early source control and early effective antimicrobial therapy, other patient-level factors such as comorbidities and immune status play a role in clinical outcomes. Intravenous immunoglobulin continues to be studied for severe SSTI, though recruitment in trials continues to be an issue. Severe SSTIs are complex to manage, due in part to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. This review includes descriptions of source control, antimicrobial therapies, intravenous immunoglobulin, and hyperbaric oxygen therapy, as well as host factors in severe SSTIs.

Efficacy and Safety of Omadacycline Versus Linezolid in Acute Bacterial Skin and Skin Structure Infections in Persons Who Inject Drugs

Introduction

Acute bacterial skin and skin structure infections (ABSSSI) represent one of the most common reasons for emergency department visits, and are frequent complications of intravenous drug use in persons who inject drugs (PWID). This study examined the efficacy and safety of omadacycline, versus linezolid, in PWID and persons who do not inject drugs, in the Phase 3 Omadacycline in Acute Skin and Skin Structure Infection (OASIS-1, OASIS-2) studies.

Methods

Eligible participants were aged ≥ 18 years with qualifying skin infections: wound infection, cellulitis, erysipelas, or major abscess. The primary efficacy endpoint was early clinical response (ECR) in the modified intent-to-treat (mITT) population, defined as survival with ≥ 20% reduction in lesion size at 48–72 h after the first dose of omadacycline or linezolid. Key secondary endpoints included investigator-assessed clinical response at the post-treatment evaluation (PTE) in the mITT and clinical per-protocol populations, and clinical response at PTE in the micro-mITT population. Safety was assessed based on adverse events (AEs) and standard clinical laboratory tests. Efficacy endpoints of clinical response at ECR and PTE were analyzed for the mITT and clinically evaluable (CE) PTE populations.

Results

In total, 1380 patients (822 PWID, 558 non-PWID) were included in this secondary analysis. Wound infections were reported more frequently in the PWID subgroup (72.8%) at baseline; cellulitis or erysipelas (43.9%) and major abscess (37.4%) were the most frequently reported baseline infections in the non-PWID subgroup. Clinical success rates at ECR and PTE in the mITT population, and at PTE in the CE population, were high for patients receiving omadacycline or linezolid. Severe or serious treatment-emergent AEs (TEAEs), and TEAEs leading to discontinuation, were infrequent.

Conclusion

This subgroup analysis showed that omadacycline was effective and well tolerated, regardless of PWID status.

Outcomes and factors associated with occult septic shock in emergency department patients with soft tissue Infection

Introduction:

Patients who develop occult septic shock (OSS) are associated with worse outcomes than those with early septic shock (ESS). Patients with skin and soft tissue infection (SSTI) may have underlying organ dysfunction due to OSS, yet the prevalence and the outcomes of patients with SSTI and early versus occult shock have not been described. This study compared the clinical characteristics of SSTI patients and the prevalence of having no septic shock (NSS), ESS, or OSS.

Methods:

We retrospectively analyzed charts of adult patients who were transferred from any emergency department to our academic center between January 1, 2014, and December 31, 2016. Outcomes of interest were the development of OSS and acute kidney injury (AKI). We performed logistic regressions to measure the association between clinical factors with the outcomes and created probability plots to show the relationship between key clinical variables and outcomes of OSS or AKI.

Results:

Among 269 patients, 218 (81%) patients had NSS, 16 (6%) patients had ESS, and 35 (13%) patients had OSS. Patients with OSS had higher mean serum lactate concentrations than patients with NSS (3.5 vs. 2.1 mmol/L, P < 0.01). Higher sequential organ failure assessment (SOFA) score was associated with higher likelihood of developing OSS (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.23–1.62, P < 0.001). NSS was associated with very low odds of developing AKI (OR 0.16, 95% CI 0.08–0.33, P < 0.001).

Conclusions:

13% of the patients with SSTI developed OSS. Patients with OSS had elevated serum lactate concentration and higher SOFA score than those with NSS. Increased SOFA score is a predictor for the development of OSS.

Efficacy and safety of delafloxacin, ceftaroline, ceftobiprole, and tigecycline for the empiric treatment of acute bacterial skin and skin structure infections: A network meta-analysis of randomized controlled trials

Background

Method

Results

Conclusion

Clinical utility of negative methicillin-resistant Staphylococcus aureus (MRSA) nasal surveillance swabs in skin and skin structure infections

BACKGROUND

Negative methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs have a high negative predictive value of approximately 99% in respiratory infections. There is, however, a lack of data evaluating its use beyond respiratory infections.

METHODS

We conducted a retrospective analysis to determine the clinical utility of MRSA swabs for identifying MRSA-associated skin and skin structure infections (SSSIs) and the potential effects on antimicrobial stewardship efforts. Baseline characteristics, culture data, and antibiotic data were collected to determine the difference in duration of vancomycin therapy. Positive predictive value, negative predictive value, sensitivity, and specificity were secondary outcomes.

RESULTS

A total of 473 patients were included, of which 156 patients had a positive MRSA nasal swab and 317 patients had a negative swab. The median duration of vancomycin was 4 days in the positive group and 3 days in the negative group (P = .01). The positive predictive value and negative predictive value were 22.4% and 97.5%. The sensitivity and specificity were 81.4% and 71.9%.

CONCLUSION

Patients with a negative MRSA nasal swab received approximately 1 day less of vancomycin, which represented a decrease in drug administered. The negative predictive value for SSSIs is promising, showing potential for the role of MRSA nasal swabs in de-escalating therapy.

Sonographically Occult Abscesses of the Buttock and Perineum in Children

BACKGROUND

Ultrasound (US) is used to differentiate abscess from cellulitis. At our institution, we observed children who had purulent fluid obtained after a negative abscess US. We sought to determine the incidence of sonographically occult abscess (SOA) of the buttock and perineum, and identify associated clinical and demographic characteristics.

METHODS

Retrospective chart review including children younger than 18 years old presenting to pediatric emergency department with soft tissue infection of the buttock or perineum and diagnostic radiology US read as negative for abscess. We defined SOA as wound culture growing pathogenic organism obtained within 48 hours of the US. Clinical and demographic characteristics included age, sex, race, ethnicity, fever, history of spontaneous drainage, duration of symptoms, previous methicillin resistant Staphylococcus aureus (MRSA) infection, or previous abscess. We used univariate and multivariate logistic regression to assess correlation between these characteristics and SOA.

RESULTS

A total of 217 children were included. Sixty-one (28%) children had SOA; 33 of 61 (54%) had incision and drainage within 4 hours of the US. Of children with SOA, 49 (80%) grew MRSA and 12 (20%) grew methicillin-sensitive S. aureus. In univariate analysis, a history of MRSA, symptom duration 4 days or less, age of younger than 4 years, and Hispanic ethnicity increased the odds of having SOA. In multivariate analysis, history of MRSA and duration of 4 days or less were associated with SOA.

CONCLUSIONS

Twenty-eight percent of children in our institution with US of the buttock and perineum negative for abscess had clinical abscess within 48 hours, most within 4 hours. History of MRSA and shorter symptom duration increased the odds of SOA.

Anti-MRSA quinolones for acute bacterial skin and skin structure infection: a systematic review and meta-analysis of randomized controlled trials

OBJECTS

This study compared the clinical efficacy and safety of anti-methicillin-resistant Staphylococcus aureus (MRSA) quinolones for treating acute bacterial skin and skin structure infections (ABSSSIs).

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant articles from inception to 21 July 2021. RCTs comparing the clinical efficacy and safety of anti-MRSA quinolones with other antibiotics for treating adult patients with ABSSSIs were included.

RESULTS

Six RCTs were included. A total of 1,264 and 1,307 participants received the anti-MRSA quinolone-based study group and the control group. In the study group receiving anti-MRSA quinolone-based treatment, 935, 246, and 83 patients received delafloxacin, levonadifloxacin, and acorafloxacin, respectively. No significant difference was observed in the clinical cure rate at test of cure between the study and control groups (OR, 1.08; 95% CI, 0.91-1.29; I² = 0%). In patients with MRSA-associated ABSSSIs, the clinical cure rate (OR, 1.09; 95% CI, 0.71-1.65; I² = 0%) and microbiological response rate (OR, 1.24; 95% CI, 0.48-3.21; I² = 0%) of anti-MRSA quinolones were similar to those of other antibiotics.

CONCLUSIONS

The efficacy of anti-MRSA quinolone-based treatment is comparable to that of other anti-MRSA antibiotics for treating ABSSSIs.

Current and future options for treating complicated skin and soft tissue infections: focus on fluoroquinolones and long-acting lipoglycopeptide antibiotics

Bacterial skin and soft tissue infections are among the most common bacterial infections and constitute a major burden for patients and healthcare systems. Care is complicated by the variety of potential pathogens, some with resistance to previously effective antimicrobial agents, the wide spectrum of clinical presentations and the risk of progression to life-threatening forms. More-efficient care pathways are needed that can reduce hospital admissions and length of stay, while maintaining a high quality of care and adhering to antimicrobial stewardship principles. Several agents approved recently for treating acute bacterial skin and skin structure infections have characteristics that meet these requirements. We address the clinical and pharmacological characteristics of the fourth-generation fluoroquinolone delafloxacin, and the long-acting lipoglycopeptide agents dalbavancin and oritavancin.

Update on the epidemiology of healthcare-acquired bacterial infections: focus on complicated skin and skin structure infections

Healthcare-associated infections (HCAIs) are a threat to patient safety and cause substantial medical and economic burden in acute care and long-term care facilities. Risk factors for HCAIs include patient characteristics, the type of care and the setting. Local surveillance data and microbiological characterization are crucial tools for guiding antimicrobial treatment and informing efforts to reduce the incidence of HCAI. Skin and soft tissue infections, including superficial and deep incisional surgical site infections, are among the most frequent HCAIs. Other skin and soft tissue infections associated with healthcare settings include vascular access site infections, infected burns and traumas, and decubitus ulcer infections.

Clinical efficacy and safety of novel lipoglycopeptides in the treatment of acute bacterial skin and skin structure infections: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to investigate the clinical efficacy and safety of novel lipoglycopeptides in treating acute bacterial skin and skin structure infections (ABSSSIs).

RESEARCH DESIGN AND METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Turning Research into Practice, and ClinicalTrials.gov were searched from inception to 20 May 2021. Randomized controlled trials (RCTs) comparing the clinical efficacy and safety of lipoglycopeptides with other comparators in treating adult patients with ABSSSIs were included. The primary outcome was clinical response.

RESULTS

Eight RCTs (6416 patients; lipoglycopeptides: 3359, comparators: 3057) were enrolled. Clinical response rate was not significantly different between lipoglycopeptides and comparators at early-clinical-evaluation (odds ratio [95% confidence interval]: 1.01 [0.85-1.20], I² = 34%), end-of-treatment (0.94 [0.80-1.11], I² = 0%), and test-of-cure (1.05 [0.85-1.30], I² = 0%). Lipoglycopeptides showed a similar overall microbiological eradication rate (1.12 [0.90-1.38], I² = 21%) but a borderline higher microbiological eradication rate for methicillin-resistant Staphylococcus aureus (1.37 [1.00-1.86], I² = 0%) than the comparators. Lipoglycopeptides were not associated with a higher risk than comparators.

CONCLUSIONS

Lipoglycopeptides can achieve similar clinical and microbiological responses to other comparators in treating ABSSSIs. In addition, lipoglycopeptides are as tolerable as their comparators.

Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections

OBJECTIVES

Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single-dose, long-acting IV antibiotic.

METHODS

We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm² without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24-hour follow-up telephone call and had a 48- to 72-hour in-person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate.

RESULTS

Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm² and 289.0 (IQR = 161.3 to 555.0) cm² , respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP).

CONCLUSIONS

Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764.

Anti-MRSA Cephalosporin versus Vancomycin-Based Treatment for Acute Bacterial Skin and Skin Structure Infection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis of randomized controlled trials (RCTs) compared the clinical efficacy and safety of anti-MRSA cephalosporin and vancomycin-based treatment in treating acute bacterial skin and skin structure infections (ABSSSIs). PubMed, Embase, Cochrane Central Register of Controlled Trials, Turning Research into Practice, and ClinicalTrials.gov databases were searched for relevant articles from inception to 15 June 2020. RCTs comparing the clinical efficacy and safety of anti-MRSA cephalosporin with those of vancomycin-based regimens in treating adult patients with ABSSSIs were included. The primary and secondary outcomes were clinical response at the test-of-cure assessments and risk of adverse events (AEs), respectively. Eight RCTs were enrolled. The clinical response rate was not significantly different between anti-MRSA cephalosporin and vancomycin-based treatments (odds ratio [OR], 1.05; 95% CI, 0.90–1.23; I² = 0%). Except for major cutaneous abscesses in which anti-MRSA cephalosporin-based treatment was associated with a lower clinical response rate than vancomycin-based treatment (OR, 0.62; 95% CI, 0.40–0.97; I² = 0%), other subgroup analyses according to the type of cephalosporin (ceftaroline or ceftobiprole), type of infection, and different pathogens did not show significant differences in clinical response. Anti-MRSA cephalosporin-based treatment was only associated with a higher risk of nausea than vancomycin-based treatment (OR, 1.41; 95% CI, 1.07–1.85; I² = 0%). In treating ABSSSIs, the clinical efficacy of anti-MRSA cephalosporin is comparable to that of vancomycin-based treatment, except in major cutaneous abscesses. In addition to nausea, anti-MRSA cephalosporin was as tolerable as vancomycin-based treatment.

Knowledge, attitude, and practices associated with the diagnosis and management of skin and soft-tissue infections among medical students, residents, and attending physicians

Skin and soft-tissue infections (SSTIs) are commonly encountered by medical students, residents, and trainees. The Infectious Diseases Society of America (IDSA) has updated its recommendations regarding SSTI diagnosis and management in June 2014. We assessed knowledge, attitude, and practices toward diagnosis and management of SSTIs using an online survey. We disseminated the survey to medical students, residents, and attending physicians practicing in family and internal medicine department at a university-based hospital. A total of 103 surveys were completed out of 121 sent (85.1%) between July 2015 and March 2016. There were nine medical questions in the survey. The mean of correct answers was 4.5/9 ± 2.0. Medical knowledge correlated with the level of education (P < 0.001) but not with subspecialty (P = 0.97). Around 35% were familiar with the updated IDSA guidelines pertaining to SSTIs. The majority (85%) responded that the hospital staff would benefit from additional training and 75% agreed that more antibiotic stewardship education is needed. Our study shows that there are significant opportunities for development among students and physicians who encounter SSTIs.

Clinical efficacy and safety of ceftobiprole in the treatment of acute bacterial skin and skin structure infection: a systematic review and meta-analysis of randomized controlled trials

Objectives: To investigate the clinical efficacy and safety of ceftobiprole for acute bacterial skin and skin structure infections (ABSSSIs).Methods: PubMed, Web of Science, EBSO, Ovid Medline, ClinicalTrial.gov and Cochrane Library were searched until 25 December 2020. Only randomized controlled trials that compared the treatment efficacy of ceftobiprole with that of other antibiotics for adult patients with ABSSSIs were included in this meta-analysis.Results: The 3 RCTs involving 2291 adult patients with ABSSSIs were included. No significant difference in clinical success, as measured by the TOC, was observed between ceftobiprole and comparators among the intention-to-treat population (OR, 1.06; 95% CI, 0.85-1.33; I² = 0%) and clinical evaluable population (OR, 1.17; 95% CI, 0.76-1.79; I² = 17%). Ceftobiprole was associated with a similar risk of adverse events (AEs) to that of comparators.Conclusions: Ceftobiprole can achieve similar clinical and microbiological responses as alternative antibiotics in patients with ABSSSIs. In addition, ceftobiprole shares a similar safety profile to comparators.

New Antibiotics for Multidrug-Resistant Bacterial Strains: Latest Research Developments and Future Perspectives

The present work aims to examine the worrying problem of antibiotic resistance and the emergence of multidrug-resistant bacterial strains, which have now become really common in hospitals and risk hindering the global control of infectious diseases. After a careful examination of these phenomena and multiple mechanisms that make certain bacteria resistant to specific antibiotics that were originally effective in the treatment of infections caused by the same pathogens, possible strategies to stem antibiotic resistance are analyzed. This paper, therefore, focuses on the most promising new chemical compounds in the current pipeline active against multidrug-resistant organisms that are innovative compared to traditional antibiotics: Firstly, the main antibacterial agents in clinical development (Phase III) from 2017 to 2020 are listed (with special attention on the treatment of infections caused by the pathogens Neisseria gonorrhoeae, including multidrug-resistant isolates, and Clostridium difficile), and then the paper moves on to the new agents of pharmacological interest that have been approved during the same period. They include tetracycline derivatives (eravacycline), fourth generation fluoroquinolones (delafloxacin), new combinations between one β-lactam and one β-lactamase inhibitor (meropenem and vaborbactam), siderophore cephalosporins (cefiderocol), new aminoglycosides (plazomicin), and agents in development for treating drug-resistant TB (pretomanid). It concludes with the advantages that can result from the use of these compounds, also mentioning other approaches, still poorly developed, for combating antibiotic resistance: Nanoparticles delivery systems for antibiotics.

Ciprofloxacin-Resistant Staphylococcus aureus Displays Enhanced Resistance and Virulence in Iron-Restricted Conditions

The unreasonable misuse of antibiotics has led to the emergence of large-scale drug-resistant bacteria, seriously threatening human health. Compared with drug-sensitive bacteria, resistant bacteria are difficult to clear by host immunity. To fully explore the adaptive mechanism of resistant bacteria to the iron-restricted environment, we performed data-independent acquisition-based quantitative proteomics on ciprofloxacin (CIP)-resistant (CIP-R) Staphylococcus aureus in the presence or absence of iron. On bioinformatics analysis, CIP-R bacteria showed stronger amino acid synthesis and energy storage ability. Notably, CIP-R bacteria increased virulence by upregulating the expression of many virulence-related proteins and enhancing the synthesis of virulence-related amino acids under iron-restricted stress. This study will help us to further explain the adaptive mechanisms that lead to bacterial resistance to antibiotics depending on the host environment and provide insights into the development of novel drugs for the treatment of drug-resistant bacterial infections.

Skin and sepsis: contribution of dermatology to a rapid diagnosis

In patients who develop sepsis, whether due to primary, secondary or metastatic lesions, the skin is frequently affected. However, there are unresolved aspects regarding the general clinical manifestations in the skin or the prognosis and/or therapeutic implications. The main challenge in the approach to sepsis is its early diagnosis and management. In this review, we address the sepsis-skin relationship and the potential impact of early dermatological intervention on the septic patient through ten basic questions. We found little evidence of the participation of the dermatologist in sepsis alert programs. There are early skin changes that may alert clinicians on a possible sepsis, such as skin mottling or variations in acral skin temperature. In addition, the skin is an accessible and highly cost-effective tissue for etiological studies of some forms of sepsis (e.g., meningococcal purpura) and its involvement defines the prognosis of certain patients (e.g., infective endocarditis).

Approach to the Patient with a Skin and Soft Tissue Infection

The diagnosis of a skin and soft tissue infection (SSTI) requires careful attention to a patient's history, physical examination, and diagnostic test results. We review for many bacterial, viral, fungal, and parasitic pathogens that cause SSTIs the clues for reaching a diagnosis, including reported past medical history, hobbies and behaviors, travel, insect bites, exposure to other people and to animals, environmental exposures to water, soil, or sand, as well as the anatomic site of skin lesions, their morphology on examination, and their evolution over time. Laboratory and radiographic tests are discussed that may be used to confirm a specific diagnosis.

SOCS-1 inhibition of type I interferon restrains Staphylococcus aureus skin host defense

The skin innate immune response to methicillin-resistant Staphylococcus aureus (MRSA) culminates in the formation of an abscess to prevent bacterial spread and tissue damage. Pathogen recognition receptors (PRRs) dictate the balance between microbial control and injury. Therefore, intracellular brakes are of fundamental importance to tune the appropriate host defense while inducing resolution. The intracellular inhibitor suppressor of cytokine signaling 1 (SOCS-1), a known JAK/STAT inhibitor, prevents the expression and actions of PRR adaptors and downstream effectors. Whether SOCS-1 is a molecular component of skin host defense remains to be determined. We hypothesized that SOCS-1 decreases type I interferon production and IFNAR-mediated antimicrobial effector functions, limiting the inflammatory response during skin infection. Our data show that MRSA skin infection enhances SOCS-1 expression, and both SOCS-1 inhibitor peptide-treated and myeloid-specific SOCS-1 deficient mice display decreased lesion size, bacterial loads, and increased abscess thickness when compared to wild-type mice treated with the scrambled peptide control. SOCS-1 deletion/inhibition increases phagocytosis and bacterial killing, dependent on nitric oxide release. SOCS-1 inhibition also increases the levels of type I and type II interferon levels in vivo. IFNAR deletion and antibody blockage abolished the beneficial effects of SOCS-1 inhibition in vivo. Notably, we unveiled that hyperglycemia triggers aberrant SOCS-1 expression that correlates with decreased overall IFN signatures in the infected skin. SOCS-1 inhibition restores skin host defense in the highly susceptible hyperglycemic mice. Overall, these data demonstrate a role for SOCS-1-mediated type I interferon actions in host defense and inflammation during MRSA skin infection.

Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.

National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015

Nationally representative data from 2000-2015 demonstrated a rise in the incidence of outpatient visits for skin infections, peaking in 2010-2013, followed by a plateau. While cephalexin was the most frequently prescribed antibiotic at the beginning, trimethoprim-sulfamethoxazole was most frequently prescribed by the end of the study period.