Community-acquired skin and soft-tissue infections in people who inject drugs

PURPOSE OF REVIEW

The aim of this review is to discuss the latest evidence of the epidemiology, microbiology, risk factors, diagnosis and management of community-acquired skin and soft tissue infections (SSTIs) in people who inject drug (PWID).

RECENT FINDINGS

SSTIs are common complications in PWID and a major cause of morbidity and mortality. Infections can range from uncomplicated cellulitis, to abscesses, deep tissue necrosis and necrotizing fasciitis. They are predominantly caused by Gram-positive pathogens in particular Staphylococcus aureus and Streptococcus species; however, toxin-producing organisms such as Clostridium botulism or Clostridium tetani should be considered. The pathogenesis of SSTI in the setting of intravenous drug use (IDU) is different from non-IDU related SSTI, and management often requires surgical interventions in addition to adjunctive antibiotics. Harm reduction strategies and education about safe practices should be implemented to prevent morbidity and mortality as well as healthcare burden of SSTI in PWID.

SUMMARY

Prompt diagnosis and proper medical and surgical management of SSTI will improve outcomes in PWID.

Under the Skin: The Relationship Between Subcutaneous Injection and Skin Infections Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are at increased risk for numerous negative health outcomes. Subcutaneous injections (aka skin popping) can result in greater risk of skin and soft tissue infections (SSTIs), but less is known about PWID who choose this route of administration. This study compares subcutaneous injectors to intravenous injectors, characterizes those who inject subcutaneously, and examines whether subcutaneous injection is associated with SSTIs in the past year.

METHODS

A cohort of hospitalized PWID (n = 252) were interviewed regarding injection-related behaviors, history of SSTI, and knowledge of subcutaneous injection risk. We examined differences between those who do and do not inject subcutaneously and used a negative binomial regression model to estimate adjusted odds associating subcutaneous injection and SSTI.

RESULTS

Participants averaged 38 years, with 58.3% male, 59.5% White, 20.6% Black, and 15.9% Latinx. PWID who performed subcutaneous injection were not demographically different from other PWID; however, the mean rate of past year SSTIs was higher for persons injecting subcutaneously than for those who did not (1.98 vs 0.96, P < 0.001). Persons injecting subcutaneously did not differ from those who injected intravenously in terms of their knowledge of subcutaneous injection risk (P = 0.112) and knowledge score was not associated with SSTIs (P = 0.457).

CONCLUSIONS

PWID who perform subcutaneous injections are demographically similar to other PWID but had higher rates of past year SSTIs. Knowledge of subcutaneous injection risk was not associated with SSTI risk.

National Public Health Burden Estimates of Endocarditis and Skin and Soft-Tissue Infections Related to Injection Drug Use: A Review

BACKGROUND

Despite concerns about the burden of the bacterial and fungal infection syndromes related to injection drug use (IDU), robust estimates of the public health burden of these conditions are lacking. The current article reviews and compares data sources and national burden estimates for infective endocarditis (IE) and skin and soft-tissue infections related to IDU in the United States.

METHODS

A literature review was conducted for estimates of skin and soft-tissue infection and endocarditis disease burden with related IDU or substance use disorder terms since 2011. A range of the burden is presented, based on different methods of obtaining national projections from available data sources or published data.

RESULTS

Estimates using available data suggest the number of hospital admissions for IE related to IDU ranged from 2900 admissions in 2013 to more than 20 000 in 2017. The only source of data available to estimate the annual number of hospitalizations and emergency department visits for skin and soft-tissue infections related to IDU yielded a crude estimate of 98 000 such visits. Including people who are not hospitalized, a crude calculation suggests that 155 000-540 000 skin infections related to IDU occur annually.

DISCUSSION

These estimates carry significant limitations. However, regardless of the source or method, the burden of disease appears substantial, with estimates of thousands of episodes of IE among persons with IDU and at least 100 000 persons who inject drugs (PWID) with skin and soft-tissue infections annually in the United States. Given the importance of these types of infections, more robust and reliable estimates are needed to better quantitate the occurrence and understand the impact of interventions.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur together in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective in preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess effects of skin care interventions, such as emollients, for primary prevention of eczema and food allergy in infants Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We searched the following databases up to July 2020: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two trials registers and checked reference lists of included studies and relevant systematic reviews for further references to relevant randomised controlled trials (RCTs). We contacted field experts to identify planned trials and to seek information about unpublished or incomplete trials.

SELECTION CRITERIA

RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (0 to 12 months) without pre-existing diagnosis of eczema, food allergy, or other skin condition were included. Comparison was standard care in the locality or no treatment. Types of skin care interventions included moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured by the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

This review identified 33 RCTs, comprising 25,827 participants. A total of 17 studies, randomising 5823 participants, reported information on one or more outcomes specified in this review. Eleven studies randomising 5217 participants, with 10 of these studies providing IPD, were included in one or more meta-analysis (range 2 to 9 studies per individual meta-analysis). Most studies were conducted at children's hospitals. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported our outcomes, 13 assessed emollients. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to two years. We assessed most of this review's evidence as low certainty or had some concerns of risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. Evidence for the primary food allergy outcome was rated as high risk of bias due to inclusion of only one trial where findings varied when different assumptions were made about missing data. Skin care interventions during infancy probably do not change risk of eczema by one to two years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; moderate-certainty evidence; 3075 participants, 7 trials) nor time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). It is unclear whether skin care interventions during infancy change risk of IgE-mediated food allergy by one to two years of age (RR 2.53, 95% CI 0.99 to 6.47; 996 participants, 1 trial) or allergic sensitisation to a food allergen at age one to two years (RR 0.86, 95% CI 0.28 to 2.69; 1055 participants, 2 trials) due to very low-certainty evidence for these outcomes. Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial). However, this was only seen for cow's milk, and may be unreliable due to significant over-reporting of cow's milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.34, 95% CI 1.02 to 1.77; moderate-certainty evidence; 2728 participants, 6 trials) and may increase risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) or stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although confidence intervals for slippages and stinging/allergic reactions are wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses show that effects of interventions were not influenced by age, duration of intervention, hereditary risk, FLG mutation,  or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and risk of developing eczema or food allergy.

AUTHORS' CONCLUSIONS

Skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema, and probably increase risk of skin infection. Effects of skin care interventions on risk of food allergy are uncertain. Further work is needed to understand whether different approaches to infant skin care might promote or prevent eczema and to evaluate effects on food allergy based on robust outcome assessments.

Infectious diseases of the skin in contact sports

Although the benefits of practicing sports are unquestionable, it can contribute to the spread of skin diseases. Mechanical trauma, exposure to environmental and infectious agents, and contact with the skin of other athletes increase the chances of getting an infection. In contact sports, skin infections are responsible for up to 20% of lost training and competition time. In the USA, skin infections, with an incidence of 8.5-20.9%, are the 2nd cause (following upper respiratory infections) of all medical consultations among young wrestlers. The high morbidity of skin diseases poses a great challenge for the diagnosis and treatment of skin infections in athletes practicing contact sports, for whom recommendations may differ from those in the general population. In this review paper, we summarize and discuss the management of infectious diseases of the skin in contact sports. The review shows that the most frequent among athletes are bacterial infections, including folliculitis, erysipelas, furuncles and inflammation of the subcutaneous tissue; viral infections caused by herpes simplex virus, human papilloma virus and molluscum contagiosum virus; fungal infections such as tinea; and infestations, including pediculosis and scabies. Preventing the spread of the infection is the 2nd most important aspect of treatment, following pharmacotherapy. This includes avoiding contact with other athletes, protection or removal of lesions, disinfection of common sports equipment, not sharing towels or other personal equipment. We conclude that protecting against infection and transmission of pathogens in sports teams is crucial in avoiding unnecessary morbidity and minimizing disruption to the training and competition schedule.

Cutaneous Manifestations of COVID-19: An Evidence-Based Review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has affected 18 million people and killed over 690,000 patients. Although this virus primarily causes respiratory symptoms, an increasing number of cutaneous manifestations associated with this disease have been reported.

OBJECTIVE

The aim of this review was to collate and categorize the dermatologic findings reported in patients with COVID-19 and identify specific lesions that may facilitate diagnosis and prognostication.

METHODS

An evidence-based review of the PubMed database was conducted on 14 May, 2020 using the search terms "Covid-19 skin," "Covid-19 rash," "Covid-19 exanthem," and "Covid-19 chilblains." Peer-reviewed publications containing original COVID-19 patient cases and a discussion of the associated cutaneous findings were included in the analysis.

RESULTS

The literature search identified 115 records, of which 34 publications describing 996 patients with dermatologic conditions were included. Case reports (n = 15), case series (n = 13), and observational prospective studies (n = 4) were the most common publication types. Acral lesions resembling pseudo-chilblains were the most frequent lesion identified (40.4% of cases), appearing in young adults (mean age, 23.2 years) after the onset of extracutaneous COVID-19 symptoms (55/100 patients). Erythematous maculopapular rashes affected 21.3% of patients, most frequently impacting middle-aged adults (mean age, 53.2 years) and occurring at the same time as non-cutaneous symptoms (110/187 patients). Vesicular rashes affected 13.0% of patients, appearing in middle-aged adults (mean age, 48.3 years) after the onset of other symptoms (52/84 patients). Urticarial rashes affected 10.9% of patients, appearing in adults (mean age, 38.3 years) and occurring at the same time as non-cutaneous symptoms (46/78 patients). Vascular rashes resembling livedo or purpura were uncommon (4% of cases), appearing in elderly patients (mean age, 77.5 years) and occurring at the same time as non-cutaneous COVID-19 symptoms (18/29 patients). Erythema multiforme-like eruptions, although infrequent (3.7% of cases), affected mostly children (mean age, 12.2 years).

CONCLUSIONS

Vesicular rashes may suggest an initial diagnosis of COVID-19, acral lesions may be most appropriate for epidemiological uses, and vascular rashes may be a useful prognostic marker for severe disease. As a potential correlate to disease severity, prognosis, or infectibility, it is critical that all healthcare professionals be well versed in these increasingly common cutaneous manifestations of COVID-19.

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK

BACKGROUND

Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.

METHODS

We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.

RESULTS

We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.

CONCLUSIONS

Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.

Diabetes and the Risk of Infection: A National Cohort Study

BACKGROUND

Several studies have shown that people with diabetes are vulnerable to infection. This study compared the risk of infection-related hospitalizations, intensive care unit (ICU) admission, and deaths between the person with diabetes and the general population in South Korea.

METHODS

We conducted a cohort study of 66,426 diabetes and 132,852 age-sex-region-matched non-diabetes controls from the general population using a sample of data from the National Health Insurance Service-National Sample Cohort. The cohort was followed up for 9 years. Infections were classified into 17 separate categories. We used Poisson regression, with adjustment for household income and other comorbidities, to estimate incidence rate ratios (IRRs) in order to compare of infection-related hospitalizations, ICU admissions, and deaths.

RESULTS

Compared to non-diabetes controls, diabetes group had a greater risk of almost all the types of infections considered, with the adjusted IRRs (aIRRs) for infection-related hospitalizations being the highest for hepatic abscess (aIRR, 10.17; 95% confidence interval [CI], 7.04 to 14.67), central nervous system (CNS) infections (aIRR, 8.72; 95% CI, 6.64 to 11.45), and skin and soft tissue infections other than cellulitis (SSTIs) (aIRR, 3.52; 95% CI, 3.20 to 3.88). Diabetes group also had a greater risk of ICU admission and death due to SSTIs (aIRR, 11.75; 95% CI, 7.32 to 18.86), CNS infections (aIRR, 5.25; 95% CI, 3.53 to 7.79), and bone and joint infections (aIRR, 4.78; 95% CI, 3.09 to 7.39).

CONCLUSION

In South Korea, people with diabetes has a considerably higher incidence of infection-related hospitalizations and deaths than the general population.

Predictors of hospital readmission in United States adults with psoriasis

BACKGROUND

Previous studies showed a large inpatient burden of psoriasis in the United States. Less is known about the hospital readmission for psoriasis.

OBJECTIVES

To determine the patterns and predictors of hospital readmission rates for psoriasis.

METHODS

We analyzed data from the 2012-2014 Nationwide Readmissions Database, a representative sample of hospital readmissions in the United States.

RESULTS

Among 2606 admissions for psoriasis, 216 had ≥1 readmissions for psoriasis (prevalence [95% confidence interval]: 8.3% [6.6%-10.0%]) and 918 for all-causes (35.2% [32.2%-38.3%]). The mean annual cost of first readmission for any reason was $3,500,141, with $8,357,961 for subsequent readmissions. In multivariable regression models, readmission for psoriasis was associated with ≥6 day-long index hospitalization (adjusted hazard ratio [95% confidence interval]: 1.82 [1.06-3.12]), teaching hospital (1.93 [1.13-3.31]), comorbid skin infection (2.13 [1.11-4.08]), and hospitalization in the autumn (4.51 [2.54-8.00]), but inversely associated with other infections (0.49 [0.26-0.92]). Readmissions for psoriasis increased from 2012 to 2014 (1.93 [1.26-2.93]).

LIMITATIONS

No data on psoriasis characteristics.

CONCLUSION

Inpatients with psoriasis had high rates of readmission overall but low rates of readmission for psoriasis per se. A subset of psoriasis patients was hospitalized repeatedly and responsible for most inpatients costs. Future interventions are needed to lower readmission rates among psoriasis patients.

Infections in patients with burn injuries receiving extracorporeal membrane oxygenation

INTRODUCTION

Extracorporeal Membrane Oxygenation (ECMO) has only recently been described in patients with burn injuries. We report the incidence and type of infections in critically ill burn and non-burn patients receiving ECMO.

METHODS

A retrospective chart review was performed on all patients at Brooke Army Medical Center who received ECMO between September 2012 and May 2018.

RESULTS

78 patients underwent ECMO. Approximately half were men with a median age of 34 years with a median time on ECMO of 237 h (IQR 121-391). Compared to patients without burns (n = 58), patients with burns (n = 20) had no difference in time on ECMO, but had more overall infections (86 vs. 31 per 1000 days, p = 0.0002), respiratory infections (40 vs. 15 per 1000 days, p = 0.01), skin and soft tissue infections (21 vs. 5 per 1000 days, p = 0.02) and fungal infections (35% vs 10%, p = 0.02). Twenty percent of bacterial burn infections were due to drug resistant organisms.

CONCLUSION

This is the first study to describe the incidence of infection in burn injury patients who are undergoing ECMO. We observed an increase in infections in burn patients on ECMO compared to non-burn patients. ECMO remains a viable option for critically ill patients with burn injuries.

Prevalence of skin disorders and associated socio-economic factors among primary school children in the Eastern region of Saudi Arabia

OBJECTIVE

To identify the prevalent skin disorders among primary school children, awareness of its risk factors and to assess the socio-demographic determinants associated with their development.

METHODS

The cross-sectional observational study was conducted in September-December 2016 comprising children from six public and private schools in Wadi Al Dawaser region of Eastern Saudi Arabia. A self-generated self-administered questionnaire was sent through the children to be filled up by their parents. Details on sociodemographic and skin dermatoses conditions were collected. Data were analyzed using SPSS 16..

RESULTS

Of the 710 students approached, 499(70.2%) responded. Of them, 151(30.2%) were boys and 348(69.7%) were girls. The overall mean age was 10.3}1.4 years (range: 3-15 years). The overall prevalence of skin disorders was 118(23.6%). Allergic dermatoses 11(11.3%) and eczema 4(11.8%) were the commonest conditions. Lichen planus 6(5%), acne 9(7.6%), allergic rashes 4(3.3%), and psoriasis 3(2.5%) were also recorded. Sociodemographic and hygiene factors were significantly associated with the disease (p<0.05 each).

CONCLUSIONS

A high prevalence of skin disorders was encountered among primary school children in the region studied.

Infections in Dupilumab Clinical Trials in Atopic Dermatitis: A Comprehensive Pooled Analysis

BACKGROUND

Patients with moderate-to-severe atopic dermatitis (AD) have increased infection risk, including skin infections and systemic infections. Immunomodulators (e.g., anti-tumor necrosis factors, anti-interleukin [anti-IL]-23, anti-IL-17, Janus kinase inhibitors) increase risk of infections. Dupilumab (a monoclonal antibody blocking the shared receptor component for IL-4 and IL-13) is approved for inadequately controlled moderate-to-severe AD and for moderate-to-severe eosinophilic or oral corticosteroid-dependent asthma.

OBJECTIVE

The aim was to determine the impact of dupilumab on infection rates in patients with moderate-to-severe AD.

METHODS

This analysis pooled data from seven randomized, placebo-controlled dupilumab trials in adults with moderate-to-severe AD. Exposure-adjusted analyses assessed infection rates.

RESULTS

Of 2932 patients, 1091 received placebo, 1095 dupilumab 300 mg weekly, and 746 dupilumab 300 mg every 2 weeks. Treatment groups had similar infection rates overall per 100 patient-years (placebo, 155; dupilumab weekly, 150; dupilumab every 2 weeks, 156; dupilumab combined, 152), and similar non-skin infection rates. Serious/severe infections were reduced with dupilumab (risk ratio 0.43; p < 0.05), as were bacterial and other non-herpetic skin infections (risk ratio 0.44; p < 0.001). Although herpesviral infection rates overall were slightly higher with dupilumab than placebo, clinically important herpesviral infections (eczema herpeticum, herpes zoster) were less common with dupilumab (risk ratio 0.31; p < 0.01). Systemic anti-infective medication use was lower with dupilumab.

CONCLUSIONS

Dupilumab is associated with reduced risk of serious/severe infections and non-herpetic skin infections and does not increase overall infection rates versus placebo in patients with moderate-to-severe AD. CLINICALTRIALS.

GOV IDENTIFIERS

NCT01548404, NCT02210780, NCT01859988, NCT02277743, NCT02277769, NCT02260986, and NCT02755649.

Comparison of livestock-associated and community-associated Staphylococcus aureus pathogenicity in a mouse model of skin and soft tissue infection

Industrial hog operation (IHO) workers are at increased risk of carrying Staphylococcus aureus in their nares, particularly strains that are livestock-associated (LA) and multidrug-resistant. The pathogenicity of LA-S. aureus strains remains unclear, with some prior studies suggesting reduced transmission and virulence in humans compared to community-associated methicillin-resistant (CA-MRSA) S. aureus. The objective of this study was to determine the degree to which LA-S. aureus strains contracted by IHO workers cause disease relative to a representative CA-MRSA strain in a mouse model of skin and soft tissue infection (SSTI). Mice infected with CC398 LA-S. aureus strains (IHW398-1 and IHW398-2) developed larger lesion sizes with higher bacterial burden than mice infected with CA-MRSA (SF8300) (p < 0.05). The greatest lesion size and bacterial burden was seen with a CC398 strain that produced a recurrent SSTI in an IHO worker. The LA-S. aureus infected mice had decreased IL-1β protein levels compared with CA-MRSA-infected mice (p < 0.05), suggesting a suboptimal host response to LA-S. aureus SSTIs. WGSA revealed heterogeneity in virulence factor and antimicrobial resistance genes carried by LA-S. aureus and CA-MRSA strains. The observed pathogenicity suggest that more attention should be placed on preventing the spread of LA-S. aureus into human populations.

Streptococcus pyogenes infections with limited emm-type diversity in the homeless population of Brussels, 2016-2018

OBJECTIVES

The aim was to characterize the clinical features, outcomes, and strain diversity of laboratory-confirmed Streptococcus pyogenes (group A Streptococcus, GAS) infections among inpatients hospitalized at a tertiary level hospital in Brussels, Belgium, according to the patients' housing status (homeless vs. not homeless).

METHODS

Between August 2016 and January 2018, all patients hospitalized with a laboratory-confirmed GAS infection were prospectively enrolled and risk factors were recorded. GAS strains were characterized using emm-typing and emm-clustering in both inpatients and outpatients. Analyses were performed according to homelessness status.

RESULTS

During the study period, 48% (28/58) of adults hospitalized with a GAS infection at the tertiary hospital were homeless. The estimated incidence rate was 100 times higher for homeless persons. Skin abscesses were more frequent in the homeless group (21.4% vs. 3.3%) and mortality was high (10.7%). Limited emm-type diversity was found in this group, with four emm-types (64, 77, 83, and 101) accounting for 76.1% of the infections, and the majority of these emm-types belonged to the D4 emm-cluster. Pooled analyses of inpatient and outpatient strains indicated lower diversity in the homeless group.

CONCLUSIONS

The homeless are disproportionately affected by GAS and have a higher rate of abscesses and high mortality. The lower emm-type diversity and preferential infection with four emm-types likely reflects endemic circulation of GAS in this population. Preventive strategies are warranted in this fragile population.

Age-based health and economic burden of skin and soft tissue infections in the United States, 2000 and 2012

OBJECTIVE

The aim of this study was to compare the incidence of skin and soft tissue infections (SSTIs) across healthcare settings and analyze direct healthcare expenditures related to SSTIs in 2000 and 2012 in the United States.

METHODS

We performed a retrospective, cross-sectional analysis of nationally representative data from the Medical Expenditure Panel Surveys. Population-based incidence rates were examined for all healthcare settings that include inpatient visits, emergency department visits and ambulatory visits for SSTIs. The direct costs of healthcare services utilization were reported. Population-based prescribing rates for each antimicrobial class during ambulatory visits were compared.

RESULTS

A total of 2.4 million patients experienced an SSTI in 2000 compared to 3.3 million in 2012 (40% increase). From 2000 to 2012, the incidence of patients with at least one hospital visit for SSTIs increased 22%, ambulatory care visits increased 30%, and emergency department visits increased 40%. The incidence of SSTIs in children and adolescents declined 50% (from 150 to 76 per 10,000 person; RR = 0.51, 95% CI: 0.38-0.67; p<0.001) whereas SSTIs in older adults (> 65 years of age) increased almost 2-fold (from 67 to 130 per 10,000 person; RR = 1.94, 95% CI: 1.44-2.61; p<0.001). The annual incidence of SSTI in adults did not change significantly from 2000 to 2012 (from 84 to 81 per 10,000 person; RR = 0.96, 95% CI: 0.71-1.31; p = 0.41). The total estimated direct healthcare costs of SSTIs increased 3-fold from $4.8 billion in 2000 to $15.0 billion in 2012, largely driven by an 8-fold increase in ambulatory expenditures for SSTIs. Total population-based antimicrobial prescription rates for SSTIs increased 4-fold from 2000 to 2012 (from 59.5 to 250.4 per 10,000 person).

CONCLUSIONS

The highest healthcare utilization for SSTI treatment occurred in the ambulatory care setting and also accounted for the largest increase in overall direct expenditures from 2000 to 2012.

Skin diseases associated with atopic dermatitis

Atopic dermatitis is a common chronic pruritic inflammatory skin disorder, characterized by an abnormal skin barrier, immune dysfunction, and an altered skin microbiome. Atopic dermatitis may be seen in conjunction with a variety of other skin disorders due to the complex pathogenesis of atopic dermatitis, involving genetic and environmental factors that are associated with immune dysfunction, barrier defects, and altered skin microbiomes. Skin disorders associated with atopic dermatitis include diseases sharing similar genetic origins like ichthyosis vulgaris, infectious diseases such as impetigo, and eczema herpeticum, in addition to the cutaneous autoimmune diseases, alopecia areata, and vitiligo. Atopic dermatitis is also often linked to such benign conditions as pityriasis alba and keratosis pilaris. This review discusses the cutaneous comorbidities of atopic dermatitis and their relationship via their occurrence in conjunction with atopic dermatitis.

Retrospective Analysis of Pediatric Dermatologic Hospital Admissions

Statistical data on the frequency of skin conditions in the Pomeranian region of Poland are limited in the field of pediatric dermatology, requiring a multidisciplinary approach to each patient. Dermatitis and skin allergies are the 10 most common pediatric conditions, with a prevalence of 20% among such chronic illnesses in developed countries. This analysis is limited to the recurrence of dermatologic diseases in the hospitalized pediatric population within the Pomeranian region for the purpose of future targeted education. Retrospective analysis included 282 participants over a 3-year period between 2013 and 2015, with admissions to the Department of Dermatology, Venereology, and Allergology at the Medical University of Gdansk. Diagnoses were obtained from the ward admission book and CliniNet database.

[DERMATOLOGICAL DISEASES IN ELDERLY HOSPITALIZED PATIENTS IN THE GALILEE MEDICAL CENTER - COMPARISON BETWEEN TWO AGE GROUPS]

INTRODUCTION

Although dermatologic conditions bring relatively few people to the Emergency Department, hospitalized patients, especially older people, often suffer from skin problems that contribute to their morbidity.

AIMS

We wanted to identify the frequency, clinical course, treatment and influence on hospitalization of dermatologic conditions in patients hospitalized in internal and geriatric departments in Galilee Medical Center. We concentrated on two groups of adults, aged 40-65 years (adult group) and above 65 years (elderly group), in order to understand differences in the cause of referral, type of diagnosis and mode of treatment.

METHODS

We performed a retrospective review of 82 hospitalized patients who were referred for dermatological consultation between May-September 2013. Of the 82 patients, 47.6% made up the 'adult' group and 52.4% the 'elderly' group; 62.2% of patients were independent, 18.3% partially independent and 19.5% needed nursing care.

RESULTS

Skin infections (38.3%), allergy (mostly drug induced) (23.5%) and trophic disorders (18.5%) were the most common diagnoses. 'Elderly' were less often referred to dermatological consultation than 'adults' (44.3% vs. 55.7%, respectively); skin infections were more common in the 'elderly' (44.8% vs. 55.7%). Nursing care patients (19.5%) were least referred to dermatological consultation, but severity of skin condition (the number of diagnoses and number of treatments per patient) was greater in nursing care patients.

CONCLUSIONS

The clinical course between the independent and nursing care patients varies in the number of requests, the different type of diagnoses, the severity of the conditions and the number of treatments provided.

DISCUSSION

Our study emphasizes the importance of skin examination by a dermatologist, considering the high number of referrals for dermatological consultations. On the other hand, there was a significant difference between the 'elderly' and 'adult' groups, with fewer referrals for dermatological consultations by the medical staff in the 'elderly' group. Our results resemble those in the literature, having identified the most common skin problems in two groups of hospitalized patients.

Association between glycaemic control and common infections in people with Type 2 diabetes: a cohort study

AIM

To investigate the impact of glycaemic control on infection incidence in people with Type 2 diabetes.

METHODS

We compared infection rates during 2014 in people with Type 2 diabetes and people without diabetes in a large primary care cohort in the UK (the Royal College of General Practitioners Research and Surveillance Centre database). We performed multilevel logistic regression to investigate the impact of Type 2 diabetes on presentation with infection, and the effect of glycaemic control on presentation with upper respiratory tract infections, bronchitis, influenza-like illness, pneumonia, intestinal infectious diseases, herpes simplex, skin and soft tissue infections, urinary tract infections, and genital and perineal infections. People with Type 2 diabetes were stratified by good [HbA_1c < 53 mmol/mol (< 7%)], moderate [HbA_1c 53-69 mmol/mol (7-8.5%)] and poor [HbA_1c > 69 mmol/mol (> 8.5%)] glycaemic control using their most recent HbA_1c concentration. Infection incidence was adjusted for important sociodemographic factors and patient comorbidities.

RESULTS

We identified 34 278 people with Type 2 diabetes and 613 052 people without diabetes for comparison. The incidence of infections was higher in people with Type 2 diabetes for all infections except herpes simplex. Worsening glycaemic control was associated with increased incidence of bronchitis, pneumonia, skin and soft tissue infections, urinary tract infections, and genital and perineal infections, but not with upper respiratory tract infections, influenza-like illness, intestinal infectious diseases or herpes simplex.

CONCLUSIONS

Almost all infections analysed were more common in people with Type 2 diabetes. Infections that are most commonly of bacterial, fungal or yeast origin were more frequent in people with worse glycaemic control.

Advances in the medical management of skin and soft tissue infections

Skin and soft tissue infections are some of the most common infectious disease diagnoses in both inpatient and outpatient settings. With bacterial resistance to antimicrobials growing, decision making on empiric antibiotics is becoming increasingly difficult. Additionally, the most recent guidance from a professional society on the treatment of skin and soft tissue infections was published in 2014 by the Infectious Diseases Society of America and is now two years old. New antimicrobial agents have been developed and approved for the treatment of skin and soft tissue infections since then, and more are in the pipeline. This review summarizes the evidence on treatments that are new or in development and the potential repurposing of old antimicrobials. The clinical utility of these treatments is also discussed.

Skin Lesions: Mirror Images of Oral Lesion Infections

Skin lesions can be the presenting signs for HIV disease and are among the most prevalent manifestations throughout the course of HIV disease. Correlation of skin diseases and HIV disease staging has long been recognized and used to guide medical management in resource-limited settings. The purpose of this paper is to give a review of common skin infections presented in HIV-infected patients. Common skin infections presenting in HIV-infected patients include viral, fungal, mycobacterial, and bacterial infections, along with skin infestation. Key diagnostic points correlate with certain HIV disease staging for many skin diseases. These can help facilitate appropriate diagnosis and referral by health care personnel when treating HIV-infected patients who have skin lesions. Knowledge of common skin manifestations found in HIV-infected patients is essential for all health care personnel who work in the HIV field. Most skin infections presenting in HIV-infected patients can be treated effectively if the correct diagnosis and appropriate referral are made promptly.

Intestinal infection associated with future onset of an anxiety disorder: Results of a nationally representative study

Recent research involving mice suggests a possible relationship between intestinal infection and future anxiety-like behavior. However, there has been little epidemiological research showing such a connection in humans. This study uses the Medical Expenditure Panel Survey (MEPS) to assess longitudinally the association between intestinal infection and later onset of an anxiety disorder, through a nationally representative sample. Six 2-year panel datasets, each comprised of 5 consecutive rounds, were pooled from 2007 to 2013 to gather records for all respondents 18years of age or older that did not have an anxiety disorder in Round 1 (n=63, 133 people). Within the study sample, there were 2577 individuals with an intestinal infection in Round 1 and 4239 individuals with an anxiety disorder that began in Round 2, 3, 4, or 5. Overall, intestinal infection in Round 1 was associated with a 1.34 (P<0.01) odds ratio of having an anxiety disorder that began in Round 2, 3, 4, or 5. Separate analyses were performed to determine whether the association applied to other infection types, including respiratory infection, urinary tract infection, hepatitis infection, and skin infection. Respiratory infection was associated with a 1.36 (P<0.01) odds ratio of having an anxiety disorder that began in Round 2, 3, 4, or 5; no other infection type showed a significant association. More research on human populations is needed to examine the apparent association and explore potential mechanisms by which gut pathogens might influence anxiety.

[Empirical therapeutic approach to infection by resistant gram positive (acute bacterial skin and skin structure infections and health care pneumonia). Value of risk factors]

Antibiotic treatment inadequacy is common in these sites of infection and may have implications for the patient's prognosis. In acute bacterial skin and skin structure infections, the document states that for the establishment of an adequate treatment it must be assessed the severity, the patient comorbidity and the risk factors for multidrug-resistant microorganism. The concept of health care-associated pneumonia is discussed and leads to errors in the etiologic diagnosis and therefore in the selection of antibiotic treatment. This paper discusses how to perform this approach to the possible etiology to guide empirical treatment.

Epidemiology of skin diseases in University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State

BACKGROUND

Several studies have been carried out to determine the patterns of skin diseases across Nigeria and results have shown changing patterns with the trend reflecting a higher tendency for allergic dermatoses in a majority of these studies. This study was carried out to evaluate the current clinical picture of patients presenting to our clinic.

MATERIALS AND METHODS

A prospective study of new patients seen in the skin clinic of University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, between November 2013 and August 2014 was carried out. A total of 387 patients' data was analysed. Data collected on patients' sociodemographic status and diagnosis were entered into SPSS Version 17 and analyzed. Diagnosis was based on clinical findings, laboratory diagnosis including biopsy and histopathology were requested when necessary to make a diagnosis.

RESULTS

There were more females 245 (63%) than males 142 (37%). Most of the patients (81.9%) were aged above 16years and the commonest skin disease was infections (29.5%) followed by allergic skin diseases (13.6%). There was a significant difference in levels of income of study participants across gender and females who were engaged in unskilled labour were more likely to earn lower than males.

CONCLUSION

Comparing the study findings with an earlier one from the same center, there is a change in pattern with infections being the most common skin disease. These are largely preventable; public enlightenment campaigns and policies to discourage over the counter purchase of prescription strength corticosteroid creams are highly desirable.

Skin disorders among school children in rural Tanzania and an assessment of therapeutic needs

Eight hundred and twenty primary school children were examined to assess the spectrum and prevalence of skin diseases in rural Tanzania. In all, 55% of the children had one or several skin disorders, but only 33% of all diagnoses in a cluster of 14% of the children required treatment. Tinea versicolor was found in 26.2%, pyoderma and dermatophytoses in less than 10%, while few children had scabies or eczematous lesions.

Changing modalities of outpatient parenteral antimicrobial therapy use over time in Italy: a comparison of two time periods

This study aimed to assess the extent and nature of recent changes in the management of outpatient parenteral antimicrobial therapy (OPAT) in Italy. We reviewed our previously reported data from 1999 to 2003 and compared them with data from patients who received OPAT from 2005 to 2010. Data for 1175 patients who received OPAT were analysed. Skin and soft tissue infections (SSTIs) were the most common infection treated with OPAT in both time periods, but an increase in patients with SSTIs receiving OPAT was observed. By contrast, a decline over time of OPAT use was found for patients affected by pneumonia. Furthermore, ceftriaxone use declined, whereas teicoplanin increased over time. In conclusion, OPAT use has significantly changed over time in Italy.

A practical overview of pediatric atopic dermatitis, part 3: differential diagnosis, comorbidities, and measurement of disease burden

Atopic dermatitis (AD) is a multisystem disorder that has wide-reaching comorbidities and may mimic a variety of skin conditions. In the third part of this series, the differential diagnosis of pediatric AD including possible clinical mimics is discussed as well as the many recently identified comorbidities of pediatric AD, including psychosocial and allergic diseases.

Body Mass Index and Risk of Infections Among Women in the Danish National Birth Cohort

We investigated the possible association between body mass index (BMI; weight (kg)/height (m)(2)) and hospitalization or treatment for acute infection in a prospective cohort study. We linked 75,001 women enrolled in the Danish National Birth Cohort from 1996 to 2002, who had information on BMI and a broad range of confounders, to data on infectious diseases and use of antimicrobial agents from the National Patient Register and the Danish Prescription Register. Associations were tested using Cox proportional hazards models. During 12 years of follow-up, we observed a U-shaped association between baseline BMI and later hospitalization for 1) any infectious disease and 2) infections of the respiratory tract, whereas a dose-response relationship was seen for skin infections. The most pronounced associations were seen for acute upper respiratory infections at multiple and unspecified sites (underweight (BMI <18.5): hazard ratio (HR) = 4.26, 95% confidence interval (CI): 1.69, 10.7; obesity (BMI ≥30): HR = 3.64, 95% CI: 1.62, 8.18), erysipelas (obesity: HR = 5.19, 95% CI: 3.38, 7.95), and fungal infections (underweight: HR = 3.19, 95% CI: 1.53, 6.66). Slightly greater use of antimicrobials was observed among overweight (BMI 25-<30; HR = 1.08, 95% CI: 1.06, 1.10) and obese (HR = 1.21, 95% CI: 1.17, 1.24) women. Among Danish women, underweight and obesity were associated with increased risk of community-acquired infectious diseases, especially infections of the upper respiratory tract and skin.

[Infectious and other somatic comorbidity in problem drug users - results of a cross-sectional study with medical examination]

BACKGROUND

Problem drug use is associated with excess risk of infectious and other somatic diseases resulting mainly from injecting drug use.

MATERIAL AND METHODS

At the end of 2013, a complete medical history and physical examination was done in 40 problem drug users (30 males and 10 females), mean age 35.5 years (37.0 and 30.9, respectively), recruited in 4 low-threshold facilities in Prague. Of them, 37 were ex- or active injecting drug users, predominantly of methamphetamine (pervitin) and less often of buprenorphine.

RESULTS

The study physician rated the health status as -good or satisfactory in 35 participants and as unsatisfactory in five participants (12.5%). The most common pathologies were dental problems (36 participants, i.e. 90.0%) and skin conditions (15.0%). The most prevalent dental pathology was caries while dermatological disorders were mostly trophic skin lesions on the lower legs, including crural ulcers, and injection site infections. Gynaecological pathology was found in 2 of 10 females. The study subjects were most commonly diagnosed with chronic hepatitis C, status post hepatitis A and B, chronic caries, missing teeth, post-thrombotic swelling and trophic skin lesions on the lower legs, purulent skin lesions, and gastroduo-denal ulcer. A vast majority of the study participants were smokers. All were referred to various specialists for further examination or treatment, mostly to stomatology, hepatology, gastroenterology, and internal/general medicine departments. However, in reality the treatment participation rate is low among problem drug users due to the drug use-specific factors and needs that limit access to treatment.

CONCLUSION

The incidence of diverse somatic comorbidities requiring standard general medical care is significant among problem drug users. Infectious, dermatological, and dental pathologies are predominant. In areas with high prevalence of problem drug use, implementation of a special program should be considered to provide comprehensive medical care taking account of the special needs of this target group.

Global burden of skin disease in the elderly: a grand challenge to skin health

Skin diseases, as estimated in the global burden of disease study 2010, are a significant health problem in all global regions and many of those analyzed in this study show an increasing burden over recent years, extending into old age. Some of the conditions which have the highest impact on the elderly include non-melanoma skin cancer and skin ulceration, but bacterial skin infection, fungal disease or pruritus are all significant problems. With predicted changes in demography and a higher proportion of individuals above the age of 80 in the coming years concentrating new resources on gathering better data and devising preventative, therapeutic and palliative strategies is a priority.

The Effect of Online Hemodiafiltration on Infections: Results from the CONvective TRAnsport STudy

BACKGROUND

Hemodialysis (HD) patients have a high risk of infections. The uremic milieu has a negative impact on several immune responses. Online hemodiafiltration (HDF) may reduce the risk of infections by ameliorating the uremic milieu through enhanced clearance of middle molecules. Since there are few data on infectious outcomes in HDF, we compared the effects of HDF with low-flux HD on the incidence and type of infections.

PATIENTS AND METHODS

We used data of the 714 HD patients (age 64 ±14, 62% men, 25% Diabetes Mellitus, 7% catheters) participating in the CONvective TRAnsport STudy (CONTRAST), a randomized controlled trial evaluating the effect of HDF as compared to low-flux HD. The events were adjudicated by an independent event committee. The risk of infectious events was compared with Cox regression for repeated events and Cox proportional hazard models. The distributions of types of infection were compared between the groups.

RESULTS

Thirty one percent of the patients suffered from one or more infections leading to hospitalization during the study (median follow-up 1.96 years). The risk for infections during the entire follow-up did not differ significantly between treatment arms (HDF 198 and HD 169 infections in 800 and 798 person-years respectively, hazard ratio HDF vs. HD 1.09 (0.88-1.34), P = 0.42. No difference was found in the occurrence of the first infectious event (either fatal, non-fatal or type specific). Of all infections, respiratory infections (25% in HDF, 28% in HD) were most common, followed by skin/musculoskeletal infections (21% in HDF, 13% in HD).

CONCLUSIONS

HDF as compared to HD did not result in a reduced risk of infections, larger studies are needed to confirm our findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00205556.

Using Syndromic Surveillance to Investigate Tattoo-Related Skin Infections in New York City

In response to two isolated cases of Mycobacterium chelonae infections in tattoo recipients where tap water was used to dilute ink, the New York City (NYC) Department of Health and Mental Hygiene conducted an investigation using Emergency Department (ED) syndromic surveillance to assess whether an outbreak was occuring. ED visits with chief complaints containing the key word "tattoo" from November 1, 2012 to March 18, 2013 were selected for study. NYC laboratories were also contacted and asked to report skin or soft tissue cultures in tattoo recipients that were positive for non-tuberculosis mycobacterial infection (NTM). Thirty-one TREDV were identified and 14 (45%) were interviewed to determine if a NTM was the cause for the visit. One ED visit met the case definition and was referred to a dermatologist. This individual was negative for NTM. No tattoo-associated NTM cases were reported by NYC laboratories. ED syndromic surveillance was utilized to investigate a non-reportable condition for which no other data source existed. The results were reassuring that an outbreak of NTM in tattoo recipients was not occurring. In response to concerns about potential NTM infections, the department sent a letter to all licensed tattoo artists advising them not to dilute tattoo ink with tap water.

Interactions among urogenital, intestinal, skin, and oral infections in pregnant and lactating Panamanian Ngäbe women: a neglected public health challenge

Interrelationships among bacteria, protozoa, helminths, and ectoparasites were explored in a cross-sectional survey of 213 pregnant and 99 lactating indigenous women. Prevalences in pregnancy and lactation, respectively, were: vaginitis (89.2%; 46.8%), vaginal trichomoniasis (75.3%; 91.1%), bacterial vaginosis (BV; 60.6%; 63.3%), hookworm (56.6%; 47.8%), asymptomatic bacteriuria/urinary tract infection (AB/UTI; 56.2%; 36.2%), cervicitis (33.3%; 6.3%), vaginal yeast (24.9%; 11.4%), Ascaris (32.5%; 17.4%), vaginal diplococci (20.4%; 31.6%), caries (19.7%; 18.2%), scabies (17.4%; 8.1%), and Trichuris (12.5%; 8.7%). Multiple regressions revealed positive associations during pregnancy (trichomoniasis and AB/UTI; diplococci and Ascaris) and lactation (yeast and scabies). Negative associations were detected in pregnancy (BV and trichomoniasis; hookworm and diplococci) and lactation (BV and yeast). Vaginal Lactobacillus reduced odds of diplococci in pregnancy and lactation, but increased Ascaris eggs per gram (epg) and odds of trichomoniasis in pregnancy and yeast in lactation. These associations raised a concern that treatment of one condition may increase the risk of another.

Spectrum of outpatient illness in a school-based cohort in Haiti, with a focus on diarrheal pathogens

Currently, there are only limited data available on rates of major diagnostic categories of illnesses among Haitian children. We have established a cohort of 1,245 students attending schools run by the Christianville Foundation in the Gressier/Leogane region of Haiti, for whom our group provides primary medical care. Among 1,357 clinic visits during the 2012–2013 academic year, the main disease categories (with rates per 1,000 child years of observation) included acute respiratory infection (ARI) (385.6 cases/1,000 child years of observation), gastrointestinal complaints (277.8 cases/1,000 child years), febrile illness (235.0 cases/1,000 child years), and skin infections (151.7 cases/1,000 child years). The most common diarrheal pathogen was enteroaggregative Escherichia coli (present in 17% of children with diarrhea); Vibrio cholerae O1 and norovirus were the next most common. Our data highlight the importance of better defining etiologies for ARI and febrile illnesses and continuing problems of diarrheal illness in this region, including mild cases of cholera, which would not have been diagnosed without laboratory screening.

Diabetes mellitus and infection: an evaluation of hospital utilization and management costs in the United States

AIMS

The objective of this study is to evaluate the number of diabetics that seek medical treatment in emergency departments or require hospitalization for infection management in the United States. This study also assesses the socioeconomic impact of inpatient infection management among diabetics.

METHODS

We accessed the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample database and the Nationwide Inpatient Sample database to perform a retrospective analysis on diabetics presenting to the emergency department or hospitalized for infection management from 2006 to 2011.

RESULTS

Emergency Department: Since 2006, nearly 10 million diabetics were annually evaluated in the emergency department. Infection was the primary reason for presentation in 10% of these visits. Among those visits, urinary tract infection was the most common infection, accounting for over 30% of emergency department encounters for infections. Other common infections included sepsis, skin and soft tissue infections, and pneumonia. Diabetics were more than twice as likely to be hospitalized for infection management than patients without diabetes. Hospitalization: Since 2006, nearly 6 million diabetics were annually hospitalized. 8-12% of these patients were hospitalized for infection management. In 2011, the inpatient care provided to patients with DM, and infection was responsible for over $48 billion dollars in aggregate hospital charges.

CONCLUSIONS

Diabetics commonly present to the emergency department and require hospitalization for infection management. The care provided to diabetics for infection management has a large economic impact on the United States healthcare system. More efforts are needed to develop cost-effective strategies for the prevention of infection in patients with diabetes.

Nosocomial Infections Decade-Specific Risk

Although the elderly are thought to be at increased risk for acquiring nosocomial infections (NIs), the degree of risk has not been carefully quantified. We determined the decade-specific risks of NIs. The rate was constant at approximately 10 per 1,000 discharged patients from birth to 40 to 49 years. Thereafter the rate rose logarithmically and peaked at greater than 100 per 1,000 discharges after 70 years. Of all NIs, 64% occurred after 60 years of age. Yet, this elderly group made up only 23% of hospitalized patients. In conclusion, while the elderly comprise a small fraction of hospitalized patients, they account for the majority of nosocomial infections.

Socio-economic profile of patients with community-acquired skin and soft tissue infections in Delhi

AIM

To study the socio-demographic and clinical profile of patients with community-acquired skin and soft tissue infections (CA-SSTIs).

METHODS

This study was a cross sectional, observational study. Patients with CA-SSTIs (ICD-10 L00-L08) were enrolled from February to August 2013. Clinical and microbiological data of all patients were recorded. Socioeconomic status (SES) of each patient was calculated using the Modified Kuppuswamy Scale.

RESULTS

Seventy-three patients were studied, of whom 45 had SSTIs caused by Staphylococcus aureus. Of the 45, 11 (24%) were methicillin-resistant S. aureus (MRSA) and 34 (76%) were methicillin-sensitive S. aureus (MSSA). Patients with MRSA infections had significantly lower monthly income and lower educational status than those with MSSA infections. However, SES was not significantly different in the two groups.

CONCLUSION

S. aureus was the most common cause of CA-SSTIs, of which, MRSA was isolated in 24% of the cases. Patients with MRSA SSTIs had significantly lesser family income and lower education levels compared to patients with MSSA SSTIs.

[Dermatoses in the grocery industry]

Dermatological risks in supermarkets are largely comparable to those found in other workplaces such as food industry and trade in general Using two Pubmed search strings (one more specific, the other more sensitive) 11 papers were found (5 pertinent). The reasons for the little information may be the particular employment conditions that occur , in large-scale distribution. From this derives the difficulty in defining the epidemiology of skin diseases in the field and the need to refer to the literature on skin diseases in food handlers and cashiers. The most frequent dermatological disease in food handlers is irritant contact dermatitis, while the protein contact dermatitis seems to be more widespread than previously thought. Hand eczema together with nickel contact allergy is not rare in cashiers, but it can be difficult to assess if nickel allergy was occupationally acquired.

Characteristics of Sports-Related Dermatoses for Different Types of Sports: A Cross-Sectional Study

Skin lesions are common in athletes. Athletic activities may lead to new skin lesions or aggravate existing ones. We aimed to determine the effects of sport type and participation length on the occurrence of sports-related dermatoses and to identify the localization characteristics of these lesions. A total of 121 licensed athletes (42 swimmers, 23 handball players, 33 soccer players and 23 wrestlers) and 121 sedentary controls were included in the study. A consultant dermatologist examined all subjects. Lesion types, duration, and localization characteristics were noted. The lesions were categorized as viral, bacterial, traumatic, and non-traumatic. Traumatic lesions were frequently seen in soccer players and wrestlers; fungal infections were more commonly seen in swimmers and in soccer players. Lesion types and localizations varied by sport type. There were no significant relationships between sport type and the incidence of viral and bacterial lesions. The results suggest that athletic activity seems to be a predisposing factor, especially for fungal infections and acute or chronic traumatic lesions. Thus, regular dermatological screening of athletes is critical for rapid identification and treatment of dermatoses disrupting sport performance.

[Review of 1.250 episodes of skin and soft tissue infections attended at 49 hospital emergency departments]

OBJECTIVE

To review the prevalence, clinical characteristics, approach and outcome of patients with skin and soft tissue infections (SSTI) evaluated at the Emergency Departments (ED) in Spain.

METHODS

A descriptive multicenter cross-sectional analysis in 49 ED of patients with SSTI. Data were collected for age, gender, comorbid conditions, risk factors for multiresistant pathogens, STTI type, sepsis criteria, microbiology, antibiotic treatment, destination and ED mortality.

RESULTS

We documented 1,250 episodes (11% of all infections and 1.6% of all patients seen in ED), mean age 52 years (56% men) and the comorbidities and risk factors for major adverse outcomes were diabetes (15%), heart disease (12%), previous antibiotic therapy (10%) and solid malignancy (5%). 81% of STTI were nonnecrotizing, 3.3% had septic syndrome, in 65% of patients was not practised any microbiological study, and 16% had risk factors for infection for antibiotic-resistant gram-positive bacteria, with adequate empirical antibiotic therapy of 2.5%. 72% of patients were discharged home and 2 died. When comparing STTI discharged home respect those that were admitted, these latter were older patients with more comorbidities and risk factors for multidrug resistance, sepsis and there were more practised cultures (p < 0.05).

CONCLUSIONS

The SSTI have a prevalence of 1.6%, representing 11% of visits to the ED for infection. 44% of patients have comorbidity and 16% have risk factors for infection for resistant gram-positive pathogens and they were not made an appropriate antibiotic coverage.

Clinicopathologic spectrum of cutaneous diseases in patients with hematologic malignancies with or without allogeneic bone marrow transplantation: an observational cohort study in 101 patients

AIM

Objective of the study was to determine the most common cutaneous lesions in patients with haematologic malignancies observed at dermatologic consultation and to identify the impact parameters related to the haematologic condition, like disease type/duration, remission, chemotherapy and transplantation, have on skin manifestations.

METHODS

A total of 101 consecutive patients with onco-haematological malignancies referred for dermatological consultation over a two-year period were included in this prospective single-centre observational cohort study.

RESULTS

The most common finding was infection (19.8%), followed by drug adverse reactions (16.8%) and malignant neoplasia (11.9%). Elderly patients and those with a longer disease duration had a higher frequency of cutaneous neoplasia. Squamous cell carcinoma was the most frequent cutaneous neoplasia; three cases of melanoma were diagnosed and had a high Breslow thickness. Cutaneous involvement due to the haematological malignancies was observed in 5 patients. Common chronic dermatoses (psoriasis and eczema) were found in 10% of patients. Transplant had no effect on the percentage of infections or tumours.

CONCLUSION

Patients with haematological malignancies have a higher incidence of adverse drug reactions with peculiar morphologic features and a lower incidence of common chronic dermatoses than patients referred for dermatological consultation by their general practitioner or other hospital services. Infectious dermatoses were less frequent than in solid organ transplanted patients. The complex variety of cutaneous lesions, the differential diagnostic pitfalls and the prognostic relevance of early skin tumour diagnosis, evidence the importance of a correct dermatological approach.

Pattern of dermatoses among inmates of Ilesha Prison, Nigeria

AIMS AND OBJECTIVES

Dermatoses are common health problems in prisons and environmental conditions influence their prevalence and pattern. Hot and humid environment as obtains in the tropics, stress, and overcrowding are conditions that facilitate development of. The aim of this study was to determine the prevalence and pattern of dermatoses in a prison located in a tropical environment.

MATERIALS AND METHODS

The study was done in May-July 2006 in a South-West Nigerian prison. Using a purpose designed questionnaire, information on sex, age, prison status, and number in rooms was obtained and inmates were clinically examined.

RESULTS

Inmates studied were 305 (296 males and 9 females). Dermatoses were found in 221 inmates with overall prevalence of 72.5% (221/305). Infectious disorders were seen in 67.9% (150/221) and non-infectious in 32.1% (71/221). The diseases occurred in 72.9% (167/229) of awaiting trial persons and 72.9% (51/70) convicted persons. Overcrowding was more in cells (average sleeping area was 9.5 sq feet). Skin diseases affected 80.3% (61/76) of inmates in cells and 69.9% (160/229) in dormitory rooms.. About 71.2% (94/132) of inmates affected stay in five highly overcrowded dormitory rooms with infectious disorders in 48.5% (64/132). Dermatophyte infections were 34.3% of 332 dermatoses seen, pityriasis versicolor 14.5%, acne vulgaris 12.3%, dandruff 10.5%, 28.4%. A significant relationship was found with overcrowding and place where dermatoses were first noticed.

CONCLUSION

Dermatoses are common health problem of prisoners, and prison conditions facilitate these problems.

Registered nurse assessment and treatment of skin sepsis in New Zealand schools: the development of protocols

BACKGROUND

Skin infection is the commonest medical cause of hospitalisation in school children. Disadvantaged children, usually Maori or Pacific, have high rates of preventable diseases.

AIM

To improve access to early treatment for skin infections using nurse-led school clinics in South Auckland, including provision of antibiotics under delegated standing orders.

METHOD

Evidence-based protocols for the recognition and treatment of skin sepsis were developed following a literature search. A training package was developed for health professionals involved and outcome data were collected from a pilot study in which the protocols were trialled.

RESULTS

An algorithm for diagnosis of skin infections was adapted from Steer et al (Bull World Health Organ. 2009;87:173-9). Fusidic acid ointment was recommended as first-line treatment for localised impetigo. Twice daily oral cephalexin was recommended for extensive impetigo and cellulitis, for palatability and simplicity of dosing. Fifty-six episodes of skin infection received treatment under standing orders in the first 15 weeks of the pilot study.

CONCLUSION

Robust evidence to determine optimal choice, dosage and duration of antibiotic therapy for skin sepsis in children is lacking. The algorithms described are consistent with available evidence and provide a pragmatic approach for use in registered nurse (RN)-led school clinics.

[Comparison of the prevalence frequency of infectious skin changes in dialyzed patients and after kidney transplantation]

Due to graft preserving immunosuppressive therapy, renal transplant recipients are predisposed to the development of a variety of skin infections and skin cancers. The aim of the study was to compare prevalence frequency of infective skin changes among patients after kidney transplantation and the dialyzed population. Clinical dermatological examination was performed in 486 patients after renal transplantation. The group consisted of 296 men (60.9%) and 190 women (30.1%), of mean age 46.1+/-13.1 (18-74 years) with median time after transplantation of 74.3+/-52.1 months. Most of the patients (80.7%) before transplantation were treated by maintenance hemodialysis. The most frequent immunosuppression regiments were combination of cyclosporine A (CsA) with mycofenolate mofetil (MMF) and steroids (GKS)-207 patients (42.5%); tacrolimus (TAC) with MMF and GKS-102 (20.9%) and CsA with azathiopine and GKS-53 patients (10.9%). The group of 112 dialyzed patients consisted of: 57 males (50.9%) and 55 females (49.1%), aged 57.4+/-15.4 years without history of immunosuppressive therapy and were on maintenance dialysis for 63.2+/-74.0 months. Most of this group (77.7%) was on maintenance hemodialysis, while the remaining 22.3% on peritoneal dialysis. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that infective skin changes were significantly more frequent in the group of patients after kidney transplantation as compared with the dialyzed population. They were observed in 53.9% and 9.8% of the studied populations, respectively (p<0.0001). In the studied group after kidney transplantation the most frequent were viral changes (38.9%). Fungal infection was observed in 25.9% of these patients, while bacterial in 1.2% of this study group. In the dialyzed population fungal infections were diagnosed in 8.9%, while viral in 3.6% of patients. No bacterial changes were observed in this group. Acne was observed in 16.5% of patients after kidney transplantation.

CONCLUSIONS

1. In the group of patients after kidney transplantation receiving immunosuppressive therapy viral, fungal and bacterial infective skin changes were significantly more frequent as compared with the dialyzed patients. 2. The most frequent skin changes observed in patients after kidney transplantation were viral warts.