Sarcopenia Is Associated With Increased Mortality in Patients With Necrotizing Soft Tissue Infections

INTRODUCTION

Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI.

METHODS

This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality.

RESULTS

There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8).

CONCLUSIONS

Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.

A dose response model for Staphylococcus aureus

Dose-response models (DRMs) are used to predict the probability of microbial infection when a person is exposed to a given number of pathogens. In this study, we propose a new DRM for Staphylococcus aureus (SA), which causes skin and soft-tissue infections. The current approach to SA dose-response is only partially mechanistic and assumes that individual bacteria do not interact with each other. Our proposed two-compartment (2C) model assumes that bacteria that have not adjusted to the host environment decay. After adjusting to the host, they exhibit logistic/cooperative growth, eventually causing disease. The transition between the adjusted and un-adjusted states is a stochastic process, which the 2C DRM explicitly models to predict response probabilities. By fitting the 2C model to SA pathogenesis data, we show that cooperation between individual SA bacteria is sufficient (and, within the scope of the 2C model, necessary) to characterize the dose-response. This is a departure from the classical single-hit theory of dose-response, where complete independence is assumed between individual pathogens. From a quantitative microbial risk assessment standpoint, the mechanistic basis of the 2C DRM enables transparent modeling of dose-response of antibiotic-resistant SA that has not been possible before. It also enables the modeling of scenarios having multiple/non-instantaneous exposures, with minimal assumptions.

Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study

BACKGROUND

Necrotizing soft tissue infection (NSTI) of the upper extremities is a rare, but potentially life-threatening infection in patients with type 2 diabetes mellitus (T2DM). We analyzed the clinical characteristics and the outcome of NSTI of upper extremities in these patients.

METHODS

This was a retrospective study analyzing the clinical characteristics and the outcomes of 33 T2DM patients with NSTI of upper extremities, who were treated in the department of hand surgery between January 2011 and December 2017.

RESULTS

Predisposing factors for NSTI were recognized in 16 (48.5%) patients. Eleven (33.3)% patients had septic shock while ten (30.3%) had acute renal insufficiency at the time of presentation, of which six required dialysis. The mean glycosylated hemoglobin was 9.6(±2.6)% and the random plasma glucose at admission was 271(±96) mg/dl. Monomicrobial infection was seen in 16(49%) patients and polymicrobial infection in 9(27%) patients. Gram-positive causation was found in 25(66%) patients. Twelve (36.4%) patients required amputation, six (18.2%) of which were major. Death occurred in more than one-fifth (21.2%) of the patients during treatment.

CONCLUSION

Necrotizing soft tissue infection of the upper extremities in T2DM is associated with increased risk of severe infection, amputation and mortality.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking.

METHODS

Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05.

RESULTS

1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location.

CONCLUSIONS

In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Association of Negative Pressure Wound Therapy and Dermatotraction for Management of Necrotizing Soft Tissue Infections: A Case Series

INTRODUCTION

Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs.

OBJECTIVE

The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs.

MATERIALS AND METHODS

The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently.

RESULTS

The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half.

CONCLUSIONS

Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.

An unexpected host in a soft-tissue lesion of thigh

Rhinosporidiosis is an enigmatic entity and poses a major health problem in the developing countries of South-East Asia. A soft friable polypoid nasal mass is the most common presentation, while sparse literature is available on extranasal involvement. We describe the case of a 35-year-old female patient who presented with a slow-growing soft-tissue swelling with ulceration over the thigh. On clinical and radiological examination, a provisional diagnosis of soft-tissue neoplasm was made. After resection, histopathological sections showed a closely packed cyst with innumerable endospores. The present case report documents the rare occurrence of an incidentally detected cutaneous rhinosporidiosis causing diagnostic difficulty.

Panton-Valentine leukocidin-positive Staphylococcus aureus in skin and soft tissue infections from primary care patients

OBJECTIVES

To characterize deep skin and soft tissue infections (dSSTI) caused by Panton-Valentine leukocidin (PVL)-positive versus PVL-negative Staphylococcus aureus isolates.

METHODS

We performed a retrospective analysis of patients' records including S. aureus isolates from outpatients with dSSTI. Samples had been submitted by primary care physicians, i.e. general practitioners, surgeons, dermatologists and paediatricians, located in Berlin, Germany, in 2007-2017. Bacterial isolates were identified and tested for antimicrobial susceptibility by VITEK 2; PVL was detected by PCR.

RESULTS

In total, 1199 S. aureus isolates from 1074 patients with dSSTI were identified, and 613 (51.1%) of 1199 samples were PVL⁺. The median age of patients with PVL⁺S. aureus was lower than in patients with PVL- S. aureus (34 years, range 0-88 years, vs. 44 years, range 0-98 years; p < 0.0001). PVL was associated with repeated/multiple samples compared to single sample submission (69/92, 75% vs. 448/982, 45.6%, p < 0.0001; odds ratio (OR), 3.6; 95% confidence interval (CI), 2.2-5.8). Interestingly, the highest PVL positivity rate was found in isolates from gluteal (82/108, 75.9%; OR, 3.6; 95% CI, 2-5) or axillary (76/123, 61.8%; OR, 2; 95% CI, 1.1-3.3) localizations compared to isolates from the arm. The PVL positivity rate did not increase over time. Yet we noticed an increase in the trimethoprim/sulfamethoxazole (SXT) resistance rate in PVL⁺ isolates, mainly methicillin-sensitive S. aureus, when considering SXT resistance rates of 2007-2012 versus 2013-2017 (35/226, 15.5% vs. 74/289, 25.6%; p 0.01).

CONCLUSIONS

In outpatients, gluteal and axillary dSSTI are indicative of PVL⁺S. aureus. Providing SXT as a complementary treatment for dSSTI should be based on susceptibility testing.

Diagnostic Value of Laboratory Parameters for Distinguishing Between Herpes Zoster and Bacterial Superficial Skin and Soft Tissue Infections

Clinical differentiation between herpes zoster and bacterial superficial skin and soft tissue infections of the face can be difficult. In addition, diagnosis can be complicated by bacterial superinfection of lesional herpes zoster. The aim of this study was to determine whether inflammatory parameters, such as C-reactive protein (CRP) and blood counts, might be reliable biomarkers to distinguish between skin and soft tissue infections and herpes zoster when the face is infected. The study data (multivariate analysis and area under the curve) identified CRP (0.880) and leukocytes (0.730) together as the parameters that best discriminate between skin and soft tissue infections and herpes zoster. A CRP threshold ≥ 2.05 mg/dl indicated a diagnosis of skin and soft tissue infection with a sensitivity of 80% and specificity of 83.8%. For leukocytes ≥ 7.3×109/l, diagnosis of skin and soft tissue infection had a sensitivity of 75% and specificity of 67.6%. Thus, when differential diagnosis is difficult, CRP and leukocytes should be determined, while parameters such as neutrophils or immature granulocytes do not add diagnostic value.

Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection

Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.

Necrotizing Myositis: A Rare Necrotizing Soft Tissue Infection Involving Muscle

INTRODUCTION

Necrotizing myositis (NM) is an extremely rare necrotizing soft tissue infection involving muscle. Unlike similar infections (eg, necrotizing fasciitis, clostridial myonecrosis) that can be more readily diagnosed, NM can have a benign presentation then rapidly progress into a life-threatening condition with a mortality rate of 100% without surgical intervention.

CASE REPORT

A 74-year-old man with a history of prostate cancer with radiation therapy, seed implants, and 2 transurethral resection procedures presented to the emergency department after a fall. He was initially diagnosed and treated for urosepsis. Sixteen hours after presentation, he complained of pain and swelling of his right groin. Computed tomography of the abdomen and pelvis showed gas findings suspicious for necrotizing infection of the bilateral thighs. Surgical exploration revealed NM. Separate cultures from the left thigh and bladder grew Streptococcus intermedius, Clostridium clostridioforme, and Peptostreptococcus, suggesting a possible common source of infection from the prostate gland or the osteomyelitic pubic symphysis, which subsequently spread to the bilateral thighs.

CONCLUSIONS

To the best of the authors' knowledge, this is the first reported case of S intermedius and C clostridioforme causing NM. A high index of suspicion is required for extremely rare conditions like NM, because early diagnosis and surgical intervention significantly reduce mortality.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Mycobacterial skin and soft tissue infections: TB or not TB?

Non-tuberculous mycobacteria are a known cause of skin and soft tissue infections. However, only too often it takes inordinately long to arrive at the appropriate diagnosis and start treatment. Actively searching for predilection factors, exposure risks and specific clinical clues may speed up the diagnostic process. Deep tissue biopsy cultures are indispensable to determine the species and strain of mycobacterium, with important consequences for treatment. Less well known as a causative agent of prolonged tenosynovitis is Mycobacterium tuberculosis. We present a case series and performed a literature search concerning mycobacterial tenosynovitis.

Surveillance of Extrapulmonary Nontuberculous Mycobacteria Infections, Oregon, USA, 2007-2012

Limited data are available describing extrapulmonary nontuberculous mycobacteria (NTM) infections in the general population. We describe results from statewide population-based laboratory surveillance in Oregon, USA, during 2007–2012. We defined a case of extrapulmonary NTM infection as >1 isolate from skin/soft tissue, disseminated sites, lymph node, joint, or other sites. The annual incidence of extrapulmonary NTM infection (other than Mycobacterium gordonae) was stable, averaging 1.5 cases/100,000 population. Median age of the 334 patients was 51 years, and 53% of patients were female. Half of cases were caused by M. avium complex, but rapid-growing NTM species accounted for one third of cases. Most extrapulmonary NTM infections are skin/soft tissue. Compared with pulmonary NTM infection, more extrapulmonary infections are caused by rapid-growing NTM species. the designation of NTM as a reportable disease in Oregon in 2014 will result in better detection of changes in the incidence and patterns of disease in the future.

A Fatal Case of Super-super Obesity (BMI >80) in a Patient with a Necrotic Soft Tissue Infection

A 35-year-old man (height, 169 cm; body weight, 240 kg; BMI, 84) visited the Department of Dermatology due to left leg pain and swelling. Focused enhanced computed tomography (CT) of the left leg ruled out complications of deep venous thrombosis. Surgical exploration of the left leg resulted in a diagnosis of necrotic soft tissue infection, but amputation was ruled out due to his weight. The patient ultimately died of multiple organ failure on the fourth day of hospitalization. A culture of the surgical material revealed Streptococcus dysgalactiae. The present case suggests that super-obese patients should be aggressively treated before lethal complications occur.

A Woman with a Necrotizing Soft-Tissue Infection

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Virulence Inhibitors from Brazilian Peppertree Block Quorum Sensing and Abate Dermonecrosis in Skin Infection Models

Widespread antibiotic resistance is on the rise and current therapies are becoming increasingly limited in both scope and efficacy. Methicillin-resistant Staphylococcus aureus (MRSA) represents a major contributor to this trend. Quorum sensing controlled virulence factors include secreted toxins responsible for extensive damage to host tissues and evasion of the immune system response; they are major contributors to morbidity and mortality. Investigation of botanical folk medicines for wounds and infections led us to study Schinus terebinthifolia (Brazilian Peppertree) as a potential source of virulence inhibitors. Here, we report the inhibitory activity of a flavone rich extract "430D-F5" against all S. aureus accessory gene regulator (agr) alleles in the absence of growth inhibition. Evidence for this activity is supported by its agr-quenching activity (IC50 2-32 μg mL-1) in transcriptional reporters, direct protein outputs (α-hemolysin and δ-toxin), and an in vivo skin challenge model. Importantly, 430D-F5 was well tolerated by human keratinocytes in cell culture and mouse skin in vivo; it also demonstrated significant reduction in dermonecrosis following skin challenge with a virulent strain of MRSA. This study provides an explanation for the anti-infective activity of peppertree remedies and yields insight into the potential utility of non-biocide virulence inhibitors in treating skin infections.

Association between cytokine response, the LRINEC score and outcome in patients with necrotising soft tissue infection: a multicentre, prospective study

Early assessment of necrotising soft tissue infection (NSTI) is challenging. Analysis of inflammatory markers could provide important information about disease severity and guide decision making. For this purpose, we investigated the association between cytokine levels and the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC)-score, disease severity and mortality in NSTI patients. In 159 patients, plasma was analysed for IL-1β, IL-6, IL-10 and TNF-α upon admission. The severity of NSTI was assessed by SAPS, SOFA score, septic shock, microbial aetiology, renal replacement therapy and amputation. We found no significant difference in cytokine levels according to a LRINEC- score above or below 6 (IL-1β: 3.0 vs. 1.3; IL-6: 607 vs. 289; IL-10: 38.4 vs. 38.8; TNF-α: 15.1 vs. 7.8 pg/mL, P > 0.05). Patients with β-haemolytic streptococcal infection had higher level of particularly IL-6. There was no difference in mortality between patients with a LRINEC-score above or below 6. In the adjusted analysis assessing 30-day mortality, the association was strongest for IL-1β (OR 3.86 [95% CI, 1.43-10.40], P = 0.008) and IL-10 (4.80 [1.67-13.78], P = 0.004). In conclusion, we found no significant association between the LRINEC-score and cytokine levels on admission. IL-6 was consistently associated with disease severity, whereas IL-1β had the strongest association with 30-day mortality.

In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis

OBJECTIVES

The primary objective of this systematic review was to determine the accuracy of point-of-care ultrasonography (POCUS) in diagnosing abscess in emergency department (ED) patients with skin and soft tissue infections (SSTI). The secondary objective was the accuracy of POCUS in the paediatric population subgroup.

SETTING

Prospective studies set in emergency departments.

PARTICIPANTS

Emergency department patients (adult and paediatric) presenting with SSTI and suspected abscess.

PRIMARY AND SECONDARY OUTCOME MEASURES

This systematic review was conducted according to Cochrane Handbook guidelines, and the following databases were searched: PubMed, MEDLINE, EMBASE and the Cochrane database of systematic reviews (1946-2015). We included prospective cohort and case-control studies investigating ED patients with SSTI and abscess or cellulitis, a defined POCUS protocol, a clearly defined gold standard for abscess and a contingency table describing sensitivity and specificity. Two reviewers independently ascertained all potentially relevant citations for methodologic quality according to QUADAS-2 criteria. The primary outcome measure was the sensitivity and specificity of POCUS for abscess. A preplanned subgroup (secondary) analysis examined the effects in paediatric populations, and changes in management were explored post hoc.

RESULTS

Of 3028 articles, 8 were identified meeting inclusion criteria; all were rated as good to excellent according to QUADAS-2 criteria. Combined test characteristics of POCUS on the ED diagnosis of abscess for patients with SSTI were as follows: sensitivity 96.2% (95% CI 91.1% to 98.4%), specificity 82.9% (95% CI 60.4% to 93.9%), positive likelihood ratio 5.63 (95% CI 2.2 to 14.6) and negative likelihood ratio 0.05 (95% CI 0.01 to 0.11).

CONCLUSIONS

A total of 8 studies of good-to-excellent quality were included in this review. The use of POCUS helps differentiate abscess from cellulitis in ED patients with SSTI.

TRIAL REGISTRATION NUMBER

CRD42015017115.

[COMPARATIVE ESTIMATION OF THE APPLICATION EFFICACY FOR THE COMPOSITION, BASING ON NANODISPERSE SILICA, OWING ANTIMICROBIAL PROPERTIES FOR LOCAL TREATMENT OF PURULENT-INFLAMMATORY PROCESSES]

Comparative estimation of the local treatment results for purulent-inflammatory diseases of soft tissues, using standard methods and composition, owing sorption and antimicrobial properties and basing on a nanodispersedsilica, was conducted. The composition application in complex of treatment have promoted more rapid clearance from necrotized tissues and microorganisms, rapid appearance of granulations, the intoxication severity reduction, the phase I of the wound process duration shortening, what have permitted to put secondary sutures on the wound on the 6 – 7th postoperative day, and total duration of the patients’ stationary treatment have reduced by 3.7 days.

[IMPACT OF THE TISSUES OEDEMA ON THE RESULT OF SURGICAL TREATMENT OF INFLAMMATION]

Significance of the tissues oedema and its elimination in the course of inflammation and the wound healing was investigated. There were analyzed the results of treatment of 68 patients, suffering inflammatory and necrotic affection of soft tissues, including 65 – a lower one, 3 – an upper. In 47 observations the affection course was an acute, while in 18 – chronic. In 36 patients (control group) a local and systemic antibacterial therapy were conducted, and in accordance to indications – surgical interventions; in 32 (main group) this treatment was added with tight bandaging of the extremity, using elastic bandage. Tight squeezing of tissues with the oedema elimination on background of an adequate antibacterial therapy and surgical sanation of purulent-necrotic focus is accompanied by arrest of infiltrative and exudative stages of an acute inflammation, promotes an active course of the inflammation proliferative stage. While treatment of chronic cutaneous defect, the application of tight squeezing have promoted the granulating shaft resolution, the granulation growth in the wound and its boundary epithelization.

[APPLICATION OF VACUUM-THERAPY ON STAGES OF SURGICAL TREATMENT OF THE DIABETIC FOOT SYNDROME]

Vacuum therapy of an acute and chronic wounds was used in a complex of surgical treatment of 228 patients, suffering diabetic foot syndrome. There was established a positive local and systemic action of this method for the treatment of the wound defect. Vacuum therapy of the wounds guarantees the wound process clinical course stabilization, improvement of microcirculation, reduction of their microbial soiling, stimulation of regenerative processes, elimination of endogenous intoxication.

Unusual sites of hydatid cysts in India

Hydatid disease usually affects liver and lungs, but may affect any organ, posing a diagnostic and therapeutic dilemma. We analysed 110 patients with hydatid cyst over 21 years in our general surgical unit, which included 24 cases in unusual sites. The spleen was the most common, followed by skin and soft tissues.

[DYNAMICS OF BACTERIOLOGICAL AND PLANIMETRIC INDICES OF THE WOUND UNDER THE ACTION OF THE SILVER NANOPARTICLES, STABILIZED BY MEXIDOL AND POLYVINYLPYRROLIDONE]

Changes in bacteriological indices through the square of the wound of chemical origin under local impact of the silver nanoparticles (NP), stabilized by 2-ethyl-6-methyl-3-hydroxypyridine succinate (mexidol) and polyvinylpyrrolidone were studied. The wounds of submandibular region were simulated in white rats, using injection of 10% solution of calcium chloride with further opening of necrotic foci and open management of the wound. Beginning from the fifth day, every day the wound was irrigated with liquid, which have contented the stabilized NP of the silver, 0.05% water solution of chlorhexidine or isotonic solution of the the sodium chloride (control). There was established, that the silver NP impact antiseptically and regenerative while the wound treatment, and reduce during 10 days microbial contamination of exudate in 24 times, the wound square--in three times in comparison with original indices. These changes were identical to those while application of chlorhexidine.

Type I Interferon Signaling Prevents IL-1β-Driven Lethal Systemic Hyperinflammation during Invasive Bacterial Infection of Soft Tissue

Type I interferons (IFN-Is) are fundamental for antiviral immunity, but their role in bacterial infections is contradictory and incompletely described. Streptococcus pyogenes activates IFN-I production in innate immune cells, and IFN-I receptor 1 (Ifnar1)-deficient mice are highly susceptible to S. pyogenes infection. Here we report that IFN-I signaling protects the host against invasive S. pyogenes infection by restricting inflammation-driven damage in distant tissues. Lethality following infection in Ifnar1-deficient mice is caused by systemically exacerbated levels of the proinflammatory cytokine IL-1β. Critical cellular effectors of IFN-I in vivo are LysM+ and CD11c+ myeloid cells, which exhibit suppression of Il1b transcription upon Ifnar1 engagement. These cells are also the major source of IFN-β, which is significantly induced by S. pyogenes 23S rRNA in an Irf5-dependent manner. Our study establishes IL-1β and IFN-I levels as key homeostatic variables of protective, yet tuned, immune responses against severe invasive bacterial infection.

[The pitfalls of necrotising soft tissue infection: a 'wake-up call' for surgeons]

Necrotising soft tissue infections require early consultation of an experienced surgeon, regardless of what time of day they occur. Delays in diagnosis and treatment should not occur. Necrotectomy should be skin-sparing when possible. A low threshold for consultation with a tertiary referral center is recommended.

Pitfalls in diagnosing diabetic foot infections

Although the diagnosis of a diabetic foot infection is made based on clinical symptoms and signs, we also use blood laboratory, microbiological and radiological studies to make treatment decisions. All of these diagnostic studies have pitfalls that can lead to a delay in diagnosis. Such delays will likely lead to further tissue damage and to a higher chance of amputation. One of these pitfalls is that some clinicians rely on microbiological, rather than clinical data, to diagnose infection. Though subjective by nature, clinical signs predict outcome of foot infections accurately. Another pitfall is that microbiological data can be misleading. All wounds harbour microorganisms; therefore, a positive wound culture does not mean that a wound is infected. Furthermore, the outcome of cultures of wound swabs does not correlate well with culture results of tissue biopsies. Therapy guidance by wound swab will likely lead to overtreatment of non-pathogenic organisms. Genotyping might have a role in identifying previously unrecognized (combinations of) pathogens in diabetic foot infection, bacteria in sessile phenotype and non-culturable pathogens, e.g. in cases where antibiotics have already been administered. One more pitfall is that the diagnosis of osteomyelitis remains difficult. Although the result of percutaneous bone biopsy is the reference standard for osteomyelitis, some other diagnostic modalities can aid in the diagnosis. A combination of several of these diagnostic tests is probably a good strategy to achieve a higher diagnostic accuracy. Relying on a single test will likely lead to misidentification of patients with osteomyelitis with associated overtreatment and undertreatment.

[PROGNOSIS OF INFECTIVE COMPLICATIONS OF THE GUN-SHOT WOUNDS OF SOFT TISSUES]

The method of prognostication of infectious complications in a gun-shot wound was elaborated, using the methods of logistic regression analysis.

Development of a Novel Model for the Assessment of Dead-Space Management in Soft Tissue

Following extensive surgical debridement in the treatment of infection, a “dead space” can result following surgical closure that can fill with hematoma, an environment conducive to bacterial growth. The eradication of dead space is essential in order to prevent recurrent infection. This study describes a novel small animal model to investigate dead-space management in muscle tissue. Two absorbable test materials were implanted in each animal; beads of calcium sulfate alone, and beads loaded with vancomycin and tobramycin. In-life blood samples and radiographs were taken from each animal following implantation. Animals were sacrificed at 1, 7, 21, 42, and 63 days post-operatively (n = 4), and implant sites were analysed by micro-computed tomography, histology and immunohistochemistry. Complete resorption was confirmed radiographically at 3 weeks post-implantation. Histologically, the host tissue response to both materials was identical, and subsequent healing at the implant sites was observed with no dead space remaining. Vancomycin was not detected in blood serum. However, peak tobramycin levels were detected in all animals at 6 hours post-implantation with no detectable levels in any animals at 72 hours post implantation. Serological inflammatory cytokine expression for IL-6, TNF-α and IL-1β indicated no unusual inflammatory response to the implanted materials or surgical procedure. The model was found to be convenient and effective for the assessment of implant materials for management of dead space in muscle tissue. The two materials tested were effective in resolving the surgically created dead space, and did not elicit any unexpected adverse host response.

Subcutaneous Injection of Percocet: A Case of Severe Soft Tissue Loss

Prescription drug abuse ranks as the second most common class of illicit drug use in the United States, and one mechanism of opiate abuse involves intravenous injection of enteral narcotics such as oxycodone or hydrocodone. The authors describe a patient who sustained significant soft tissue necrosis after intravenously injecting a solution made from crushed enteral narcotics, with a focus on the operative course that resulted due to a delay in initial definitive treatment. The patient's wounds encompassed 8% total body surface area and covered 247 cm2. A 55-year-old female was admitted to the burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) after she initially presented with infection and cellulitis to her bilateral upper extremities 3 weeks after intravenously injecting herself with crushed oxycodone/acetaminophen. She underwent numerous sequential operative repairs including initial debridement, placement of dermal replacement templates, and several split-thickness autografts and xenografts. Her total length of stay was 59 days, broken into an initial 47-day stay, and a subsequent 12-day readmission due to graft failure secondary to poor follow-up. As the number of prescription drug abusers rises, it is possible that an increase in attempts to intravenously abuse enteral narcotics may also rise. As such, burn centers should be prepared for the extent of potential limb necrosis and the operative treatment that may ensue.

Targeting Staphylococcus aureus α-toxin as a novel approach to reduce severity of recurrent skin and soft-tissue infections

Staphyococcus aureus frequently causes recurrent skin and soft-tissue infection (SSTI). In the pediatric population, elevated serum antibody targeting S. aureus α-toxin is correlated with a reduced incidence of recurrent SSTI. Using a novel model of recurrent SSTI, we demonstrated that expression of α-toxin during primary infection increases the severity of recurrent disease. Antagonism of α-toxin by either a dominant-negative toxin mutant or a small molecule inhibitor of the toxin receptor ADAM10 during primary infection reduces reinfection abscess severity. Early neutralization of α-toxin activity during S. aureus SSTI therefore offers a new therapeutic strategy to mitigate primary and recurrent disease.

A novel mouse model of soft-tissue infection using bioluminescence imaging allows noninvasive, real-time monitoring of bacterial growth

Musculoskeletal infections, including surgical-site and implant-associated infections, often cause progressive inflammation and destroy areas of the soft tissue. Treating infections, especially those caused by multi-antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) remains a challenge. Although there are a few animal models that enable the quantitative evaluation of infection in soft tissues, these models are not always reproducible or sustainable. Here, we successfully established a real-time, in vivo, quantitative mouse model of soft-tissue infection in the superficial gluteus muscle (SGM) using bioluminescence imaging. A bioluminescent strain of MRSA was inoculated into the SGM of BALB/c adult male mice, followed by sequential measurement of bacterial photon intensity and serological and histological analyses of the mice. The mean photon intensity in the mice peaked immediately after inoculation and remained stable until day 28. The serum levels of interleukin-6, interleukin-1 and C-reactive protein at 12 hours after inoculation were significantly higher than those prior to inoculation, and the C-reactive protein remained significantly elevated until day 21. Histological analyses showed marked neutrophil infiltration and abscesses containing necrotic and fibrous tissues in the SGM. With this SGM mouse model, we successfully visualized and quantified stable bacterial growth over an extended period of time with bioluminescence imaging, which allowed us to monitor the process of infection without euthanizing the experimental animals. This model is applicable to in vivo evaluations of the long-term efficacy of novel antibiotics or antibacterial implants.

[Frequency of diseases caused by group A streptococci among invasive infections of soft tissues and characteristics of the causative agent]

AIM

Determine frequency of diseases caused by group A streptococci (GAS) among invasive infections of soft tissues; identify emm-types of the isolated streptococci, determine the presence of bacteriophage integrases and toxin genes in their genomes.

MATERIALS AND METHODS

4750 case histories of patients with soft tissue infections of the purulent-surgical department of the 23rd City Clinical Hospital.of Moscow "Medsantrud" in 2008 - 2011 were analyzed. 46 strains of GAS isolated from patients with invasive streptococcus infection (ISI) were studied. GAS identification was carried out by latex-agglutination method. GAS emm-type was determined by molecular-genetic methods, as well as the presence of bacteriophage integrases int2, int3, int4, int5, int6, int7, int49, bacteriophage toxins speA, speI, sla, speC/J, speL, speH, speC, ssa and speB gene present on the chromosomal DNA.

RESULTS

132 cases (2.8%) were attributed to invasive infections. In 46 cases of invasive infections (35%) GAS were isolated. 22 different emm-types of invasive GAS strains were detected. Only speB gene among all the toxin genes (as well as the expression of the gene--SpeB toxin) was detected in all the strains, whereas sla and speI genes were not detected in any of the strains. Genes of the other toxins (ssa, speL, speC, speA, speH, speC/J) occurred in a number of strains. Genes of phage integrases were detected among all the strains however in varying combinations (from 1 to 4 genes).

CONCLUSION

Invasive infections caused by GAS are more frequently spread than had been previously assumed and a high degree of genetic heterogeneity of invasive GAS strains was detected.

[Expedience of application of a dietic therapy in treatment of purulent-septic diseases of soft tissues]

The results of investigation of the dietotherapy impact on the course of purulent-septic process in soft tissues were analyzed. There were operated 58 patients, to 38 of them a certain diet was prescribed. Immediate impact of the diet therapy on the wound process course was established, what was demonstrated by reduction of duration of the earning capacity loss in patients, who have followed a special diet, by 2.58 days.

Vacuum-assisted therapy accelerates wound healing in necrotizing soft tissue infections: our experience in two intravenous drug abuse patients

Negative pressure wound therapy using vacuum-assisted closure (VAC) devices is currently a well established technique for managing complicated wounds. Such wounds occur after aggressive surgical debridement for necrotizing soft tissue infections (NSTI). In this report we present our experience in two intravenous drug abusers managed with VAC for NSTIs. The patients were 25 and 34 years old, HCV positive and presented with oedema of the upper femoral compartments and concomitant severe sepsis. Ultrasonography and computed tomography revealed severe cellulitis, fluid collection and necrosis of the affected fasciae and muscles. After emergent and subsequent aggressive surgical debridement during the first 48h, the VAC device was applied. Both patients had an uncomplicated postoperative course and a fast recovery from their multiorgan dysfunction. Suture closure of the wounds was achieved at the 25th and 38th postoperative days respectively and patients were discharged without any motor deficit. Negative pressure wound therapy is a modern therapeutic modality for treating complicated infected wounds. Moreover, it accelerates wound healing and primary closure, facilitating patient ambulation and recovery. A dedicated medical and nursing team is an important prerequisite for a successful outcome.

Acute focal bacterial nephritis due to methicillin-resistant Staphylococcus aureus in an immunocompetent adult

Acute focal bacterial nephritis (AFBN) is a rare, acute focal infection of the renal parenchyma without liquefaction. The pathogenesis is thought to be due to hematogenous infection or ascending infection from the lower urinary tract. Escherichia coli has been the major pathogen isolated in prior cases, but other Gram-negative enteric pathogens and Staphylococcus aureus have been reported as well. It is well described in children and adults with diabetes and organ transplantation, but has not been previously reported in healthy adults. We report a case of an immunocompetent adult female who presented with a methicillin-resistant Staphylococcus aureus bacteremia after a skin and soft tissue infection that resulted in AFBN.

Timing of redébridement after initial source control impacts survival in necrotizing soft tissue infection

Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate. There is a lack of literature examining outcomes in NSTI when surgical redébridements are performed in early versus delayed intervals. We hypothesized that early redébridement is associated with improved survival. Patients with NSTIs were prospectively enrolled between January 2006 and December 2011. Patient demographics, comorbidities, primary infection site, laboratory values, tissue cultures, time to surgery, and time between subsequent débridements were obtained. Two study groups with divergent redébridement protocols were observed: a short interval redébridement (SIRD) and an extended interval redébridement (EIRD). Univariate and multivariate statistics were performed. The primary outcome evaluated was in-hospital mortality. Sixty-four patients (46 SIRD, 18 EIRD) were included in the analysis. The two groups had comparable demographics. Polymicrobial NSTI was noted in 61 per cent of patients with Staphylococcus species being the predominant causative organism (59%). Multivariate analysis showed the EIRD protocol to be associated with a significantly increased incidence of acute kidney injury (adjusted odds ratio, 4.9 [1.1 to 22.5]; P = 0.04) and worse overall survival (hazard ratio, 10.6 [2.1 to 53.9]; P = 0.004). Delayed redébridement after initial source control in NSTIs results in worse survival and an increased incidence of acute kidney injury. Further studies to identify the optimal time interval for redébridement are warranted.

Necrotizing soft tissue infections (NSTIs): literary review and description of a Fournier syndrome case

A 62 y.o. male with tight fimosis, swelling, redness, pain on palpating and necrosis of the penis and scrotum was admitted in our clinic, (FGSI = 6) with periferic vasculopathy; and diabetes mellitus type II and he was in dialysis treatment before the hospitalization. The patient was HCV affected. In 24 hours he underwent radical surgical debridement with excision of all necrotic material from penis and scrotum up to the subdermal layer and tissue of doubtful viability for about 75% of the skin and circumcision. In third, fifth and seventh postoperative days he underwent to local infusion of autologous PLT growth factors. The patient was discharged in 9th postoperative day and FGSI was still 6; the skin and subdermal tissue was barely reskined, with low homogeneous granulation, edema was heavely reduced. In our case, deviation from homeostasis status at admission was the main worrying factor. We found that diabetes mellitus and renal dysfunction at admission was also important risk factor for FG. "E.Coli" was the most common organism isolated from patient wound cultures. The FGSI is an objective and easy to apply score method to quantify the metabolic status and can be used to evaluate therapeutic options and assess results.

[Treatment of patients with purulent wounds by using the original method of hydrodynamical drainage]

In this article the work of the Omsk State Medical Academy's department of general surgery is presented. The aim of study was to treat patients with purulent and necrotic wounds of soft tissue by using novel hydrodynamical drainaige. In this research 92 patients were taken part, who were inpatient treatment in the department of purulent surgery City Clinical Hospital No 1 named Kabanov A. N. 2010-2013 with purulent and necrotic wounds of soft tissue. Clinical, laboratory, cytological, bacteriological monitoring were conducted over the of wound process during the treatment. Assessment of the reliability of differences between the mean value of clinical indicators was with the calculation of the criterion t--Student, the method chi2 and Criterion Mann-Whitney U. The proposed method of treatment of purulent wound promotes fast the removal of necrotic tissue and pus in the first phase of the wound process that led to more rapid relief of symptoms of intoxication (fever, leukocytosis and common symptoms) at the patients of the basic group. Due to faster removal of necrotic tissue, reduction of common symptoms of intoxication at the patients of the basic group the transition from degenerative and inflammatory type of cystograms to regenerative occurred one or two days before than in the comparison group.

Magnetic resonance imaging of soft tissue infection with iron oxide labeled granulocytes in a rat model

OBJECT

We sought to detect an acute soft tissue infection in rats by magnetic resonance imaging (MRI) using granulocytes, previously labeled with superparamagnetic particles of iron oxide (SPIO).

MATERIALS AND METHODS

Parasternal infection was induced by subcutaneous inoculation of Staphylococcus aureus suspension in rats. Granulocytes isolated from isogenic donor rats were labeled with SPIO. Infected rats were imaged by MRI before, 6 and 12 hours after intravenous injection of SPIO-labeled or unlabeled granulocytes. MR findings were correlated with histological analysis by Prussian blue staining and with re-isolated SPIO-labeled granulocytes from the infectious area by magnetic cell separation.

RESULTS

Susceptibility effects were present in infected sites on post-contrast T2*-weighted MR images in all animals of the experimental group. Regions of decreased signal intensity (SI) in MRI were detected at 6 hours after granulocyte administration and were more pronounced at 12 hours. SPIO-labeled granulocytes were identified by Prussian blue staining in the infected tissue and could be successfully re-isolated from the infected area by magnetic cell separation.

CONCLUSION

The application of SPIO-labeled granulocytes in MRI offers new perspectives in diagnostic specificity and sensitifity to detect early infectious processes.

Necrotizing soft-tissue infections

NSTI is a life-threatening, surgical, and medical emergency. Clinical presentation, at least in the initial phase, can be misleading. Various studies have shown that delay in surgical debridement is associated with increased mortality. A high index of suspicion is important in early recognition and in instituting prompt therapy without delay. Early diagnosis, aggressive surgical debridement, aggressive supportive care, and optimal presumptive antibiotic therapy significantly improve morbidity and mortality associated with NSTIs.

ACTINOMYCOSIS INFECTION OF THE FINGER

Actinomycosis is a rare cause of infection in the hand. We report a case of actinomycosis infection involving proximal phalanx, with the clinical presentation mimicking that of a bony neoplasm.

Septic shock, pneumonia, and soft tissue infection due to Myroides odoratimimus: report of a case and review of Myroides infections

The genus Myroides comprises aerobic, yellow-pigmented, non-motile, non-fermenting gram-negative rods formerly classified as Flavobacterium odoratum. Members of the genus are widely distributed in the environment, especially in water, and usually behave as low-grade opportunistic pathogens, having been found to cause urinary tract infection, endocarditis, ventriculitis, and cutaneous infections in severely immunocompromised patients. We report a case of soft tissue infection, septic shock, and pneumonia due to M. odoratimimus in an immunocompetent male. To our knowledge, this is the first description of life-threatening infection caused by this organism in an immunocompetent host. We have also reviewed the medical literature on the genus Myroides.

[Experimental study of combination of ciprofloxacin and oxytocin on formation of biofilms by opportunistic bacteria]

AIM

To study in vitro and in vivo effect of oxytocin and ciprofloxacin combination on formation of biofilms by agents of surgical infections.

MATERIALS AND METHODS

Microorganisms of different species isolated by conventional methods from patients with purulent soft tissue infections were used in experiments. Ciprofloxacin manufactured by "Dr. Reddys" (India) and oxytocin manufactured by "Gedeon Richter" (Hungary) were used. For in vitro experiments one-half of minimal inhibitory concentrations of drugs were used. Oxytocin-placebo ("Gedeon Richter", Hungary) was used for control tests. Formation of biofilms was assessed using method proposed by G. O'Toole (2000). For in vivo experiments septic wounds in 1st phase of wound process were modeled according to method proposed by E.M. Danilova (1992). Wounds were infected with Staphylococcus aureus strain 104, which has strong ability to form biofilms. Efficacy of treatment was assessed on signs of inflammatory process and microscopy of touch smears for detection of bacterial biofilms.

RESULTS

In experiments in vivo addition of oxytocin to nutrient medium resulted in suppression of biofilm formation by studied microorganisms. Obtained data were confirmed by in vivo experiments which demonstrated higher efficacy of local application of ciprofloxacin and oxytocin combination for treatment of septic wounds compared to separate use of ciprofloxacin or oxytocin.

CONCLUSION

Studies performed in vitro and in vivo showed efficacy of oxytocin and ciprofloxacin combination, which is determined not only by enhancement of antimicrobial effect of the drug against pathogen but also by suppression of biofilm formation in the wound during infection.

The use of drotrecogin alpha for necrotizing soft tissue infections

The use of Drotrecogin alfa (DAA) (Xigris) in select patients with sepsis has had demonstrable improvement in survival, though its benefit in necrotizing soft tissue infections (NSTI) is unclear. A retrospective review of NSTI patients receiving DAA at our institution from 2006 to 2009 was performed. Our previously derived mortality prediction model, based on classification and regression tree analysis, was applied to patients and the predicted mortality was compared with the actual mortality rate. Ten patients with severe NSTI received DAA. The median admission values were: white blood cell count of 27,000/mm3, serum lactate of 4.0 mmol/L, and serum sodium of 128 mEq/L. Four (40%) patients had systemic complications, five (50%) patients required amputation, and one died (10%). Median time to DAA administration was 12 hours after debridement. There were no bleeding complications attributed to DAA use. Mortality in this series of severe NSTI was only 10 per cent, which compares favorably with the predicted mortality of 18 per cent based on classification and regression tree analysis (P = 0.2). A prospective, randomized study is warranted to determine if the use of DAA should be part of the standard therapy for NSTI patients with a predicted high mortality.