![• Mandell, Douglas and Bennett`s Infectious Diseases Essentials, [edited by ]
J.E.Bennett, R.Dolin, M.J.Blaser. -Elseiver, 2017. – 520 p.
• Practice Guidelines for the Diagnosis and Management of Skin and Soft
Tissue Infections: 2014 Update by the Infectious Diseases Society of
America/ Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen
Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann,
Sheldon L. Kaplan, Jose G. Montoya, and James C.Wade/CID (2014):59 (15
July)
https://academic.oup.com/cid/article/59/2/e10/2895845
• Skin and Soft Tissue Infections (SSTI) Antibiotic Guidelines (Adult) Group
arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute
Hospitals NHS Trust (PAT) Issue Date: 29/08/2019
• Sartelli, M., Guirao, X., Hardcastle, T.C. et al. 2018 WSES/SIS-E consensus
conference: recommendations for the management of skin and soft-tissue
infections. World J Emerg Surg 13, 58 (2018).
https://doi.org/10.1186/s13017-018-0219-9](https://image.slidesharecdn.com/lecture3-230206162136-282d3aaa/85/lecture-3-ppt-22-320.jpg)
lecture 3.ppt
- 1. Wound and soft tissue infections. The main pathogens. Features of laboratory diagnostics, treatment. Vinnitsa National Pirogov Memorial Medical University/ Department of microbiology
- 2. Superficial cutaneous infection: Streptococci and Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA) Necrotizing infection: Mixed infection of facultative gram-negative bacilli, anaerobes, and gram-positive organisms S.pyogenes and other group A streptococci, Clostridium spp. Vibrio spp.
- 3. Impetigo Impetigo is a superficial crusting and at times bullous infection of the skin; localized progression into the dermis leads to ecthyma. • Mostly in children • Causes: β-hemolytic Streptococcus spp. and/or S. aureus.
- 4. Folliculitis, furuncle, carbuncle Folliculitis is a localized infection of hair follicles, which can extend into subcutaneous tissue, resulting in furuncles. These, in turn, may coalesce, leading to carbuncle formation. Main causes: S.epidermidis, S.aureus, including MRSA
- 5. Erysipelas, cellulitis Erysipelas is a rapidly progressive infection of the superficial dermis, with sharp erythematous borders; Cellulitis reflects deeper dermal involvement. Pathogens: Streptococcus spp., usually Streptococcus pyogenes, S.equi. S. aureus rarely causes erysipelas. Most facial infections are attributed to group A Streptococcus (GAS), with an increasing percentage of lower extremity infections being caused by non-GAS.
- 6. Abscess A cutaneous abscess is an infection characterized by a collection of pus underneath a portion of the skin. Pathogens reflect flora of the involved area (eg, S. aureus and streptococci in the trunk, axilla, head, and neck), but methicillin-resistant S. aureus (MRSA) has become more common.
- 7. Necrotizing fasciitis Necrotizing fasciitis affects the soft tissue and fascia. Necrotizing infections are polymicrobial with involvement of enteric flora including non-sporeforming anaerobs; clostridial infections are very severe, sometimes fatal (gas gangrene), other pathogens may also participate (Vibrio spp., Streptococcus pyogenes)
- 8. • NO DELAY! • Local surgical treatment (operative debridement) plus antiseptics irrigation • Recommended antibiotics are used parenterally (IV): main regimen: Vancomycin plus clindamycin plus meropenem • The initial empirical antibiotic regimen should comprise broad- spectrum drugs including anti-MRSA and anti-Gram-negative coverage. • Daptomycin or linezolid are drugs of choice for empirical anti-MRSA coverage. Alternatively, ceftaroline, telavancin, tedizolid, and dalbavacin can be used . The choice of anti-Gram-negative treatment should be based on local prevalence of ESBL-producing Enterobacateriaceae and multidrug-resistant organisms (MDROs) non-fermenters. • Adjuvant hyperbaric oxygen therapy in patients with NSTI after prompt debridement • Intravenous immunoglobulin therapy at clostridial infection
- 9. SSIs are defined as infections of skin or underlying soft tissues at the surgical site, occurring within 30 days following National Healthcare Safety Network (NHSN) operative procedure in which an incision was closed primarily.
- 10. Classification SSIs are classified as: 1. Superficial incisional infection, 2. Deep incisional infection, 3. Organ space infection. Superficial incisional infections are the most common type of SSIs. Deep incisional and organ/space are the types of SSIs that cause the most morbidity. Organ space infections are not genuine soft-tissue infections.
- 11. Risk factors for SSIs Patients factor • Diabetes mellitus/perioperative hyperglycemia • Concurrent tobacco use • Remote infection at time of surgery • Obesity • Low preoperative serum albumin • Malnutrition • Concurrent steroid use • Prolonged preoperative stay • Prior site irradiation • Colonization with Staphylococcus aureus (MSSA, MRSA) Proceduralist factors Surgical technique (poor hemostasis, tissue trauma) Lapses in sterile technique and asepsis Glove micropenetrations Procedural factors • Shaving of site the night before procedure • Use of razor for hair removal • Improper preoperative skin preparation/use of non–alcohol- based skin preparation • Improper antimicrobial prophylaxis (wrong drug, wrong dose, wrong time of administration) • Failure to timely redose antibiotics in prolonged procedures • Perioperative hypothermia • Perioperative hypoxia
- 12. • Avoid preoperative antibiotic use (excluding surgical prophylaxis) • Minimize preoperative hospitalization • Treat remote sites of infection before surgery • Avoid shaving or razor use at operative site • Delay hair removal at operative site until time of surgery and remove hair (only if necessary) with electric clippers or depilatories • Ensure timely administration (including appropriate dose) of prophylactic antibiotics • Consider elimination of Staphylococcus aureus nasal carriage via decolonization techniques
- 13. Class I: No signs of systemic toxicity No uncontrolled comorbidities Can usually be managed with oral antimicrobials on an outpatient basis Class II: Systemically ill or Systemically well but with a co- morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection. Class III: Infection in a patient with evidence of systemic inflammatory response syndrome. Class IV: Septic shock (Sepsis plus hypotension) or signs of organ dysfunction.
- 14. Class First line Allergy to penicillin MRSA suspected Class I Flucloxacillin 1g orally clarithromycin 500mg orally doxycycline 100mg orally Class II Flucloxacillin 1g parenterally clarithromycin 500mg parenterally Vancomycin Class III Flucloxacillin 2g parenterally For immunocompromised: Piperacillin-tazobactam IV 4.5g Vancomycin parenterally Add oral ciprofloxacin 500mg for immunocompromised Vancomycin parenterally Add oral ciprofloxacin 500mg for immunocompromised Class IV Piperacillin-tazobactam parenterally 4.5g plus Vancomycin parenterally Vancomycin plus oral ciprofloxacin 500mg plus oral metronidazole 400mg TDS As first line
- 15. Swab collection Collect swab specimens before antimicrobial therapy where possible. Specimens should be transported and processed as soon as possible. The volume of the specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer. The recovery of anaerobes is compromised if the transport time exceeds 3 hr. If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48hr are undesirable for best result outcome Pus swabs; When using swabs, please sample the deepest part of the wound, or a representative part of the lesion. If specimens are taken from ulcers, the debris on the ulcer should be removed and the ulcer should be cleaned with saline. Swabs should be placed in bacterial transport media. If a delay in transporting to the laboratory is anticipated, please store at 4o c A biopsy or, preferably, a needle aspiration of the edge of the wound should then be taken. A less invasive irrigation-aspiration method may be preferred. Blood cultures should be taken for a line infection and for any Class III or IV infections
- 16. Bite wounds Bite wounds are common injuries caused by a wide variety of domestic and wild animals, as well as humans Mammalian bites are typically colonised by pathogens found in the oral cavities of the offending animal. These are a mixture of aerobic and anaerobic micro-organisms including; Streptococci, Staphylococci, Moraxella, Neisseria. Fusobacterium, Bacteroides, Porphyromonas, and Prevotella spp. Pasteurella multocida is a Gram-negative pathogen particularly prevalent in dog (57%) and cat (75%) bites. In cases of human bite wounds and clenched fist wounds, where HIV and Hepatitis B status is unknown, please treat patients in line with the Trust’s PEP policy.
- 17. Prophylaxis with antimicrobials of mammalian bites is indicated in the following circumstances: 1. all cat bites, animal bites to the hand, foot and face; 2. puncture wounds; 3. wounds requiring surgical debridement; 4. wounds involving joints, tendons, ligaments or suspected fracture 5. Clenched-fist wounds (wound inflicted from a punch coming in contact with teeth) Wounds that have undergone primary closure 6. People who are at risk of serious wound infection e.g. diabetic, cirrhotic, asplenic or immunocompromised patients 7. People with a prosthetic valve or prosthetic joint
- 18. • Irrigate wounds with copious amounts of normal saline. • Cautiously debride devitalized or necrotic tissue. • Primary wound closure is not usually advocated; delayed primary closure or allowing the wound to close by secondary intention is recommended. • Loose approximation of wound edges with adhesive strips or sutures may be necessary for selected, fresh, uninfected wounds. Closure of facial wounds may be considered if coupled with copious irrigation and antimicrobial preemptive therapy. • Provide antimicrobial therapy for (1) moderate-to-severe injuries less than 8 hours old, especially if edema or significant crush injury is present; (2) bone or joint space penetration; (3) deep hand wounds; (4) immunocompromised patients (including those with mastectomy, advanced liver disease, asplenia, or chronic steroid therapy); (5) wounds adjacent to a prosthetic joint; and (6) wounds in close proximity to the genital area. Early presenting (uninfected) wounds: • Infected wounds: Cover Pasteurella (Eikenella in human bites), Staphylococcus, Streptococcus, and anaerobes including Fusobacterium, Porphyromonas, Prevotella, and Bacteroides spp. The following antimicrobials can be considered for most terrestrial animal and human bites in adults:
- 19. The following antimicrobials can be considered for most terrestrial animal and human bites in adults: • First choice: Amoxicillin/clavulanic acid with food. • Penicillin allergy: For adults: • Clindamycin plus either ciprofloxacin or levofloxacin orally daily Alternative: Doxycycline or Moxifloxacin orally daily. • In cases where intravenous antibiotics are deemed necessary, single antimicrobial choices can include ampicillin/sulbactam, cefoxitin, ertapenem, or moxifloxacin. • Empirical regimens for marine- and freshwater-acquired infection should also cover Vibrio and Aeromonas species, respectively, with agents such as third-generation cephalosporins (e.g., cefotaxime) and fluoroquinolones. Others: TT is given intramuscularly if a person is not immune to tetanus Rabies vaccine is given to those who is suspected for being bitten with rabid or wild animal
- 20. Burn wounds • Burn wound infections usually are polymicrobial. They can be immediately colonized by Gram- positive bacteria (Staphylococcus spp., Streptococcus spp.) from the patient’s endogenous skin flora or the external environment. • However, they can also be rapidly colonized by Gram-negative bacteria (Acinetobacter spp.,Pseudomonas, enteric bacteria) usually within a week of the burn injury. • Bacterial cultures can aid in the selection of an appropriate antibiotic, especially in cases of bacterial drug resistance
- 21. SSTIs encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing infections. The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious diseases specialists, who have shared these clinical practice recommendations. Cited from: Sartelli, M., Guirao, X., Hardcastle, T.C. et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 13, 58 (2018). https://doi.org/10.1186/s13017-018-0219-9
- 22. • Mandell, Douglas and Bennett`s Infectious Diseases Essentials, [edited by ] J.E.Bennett, R.Dolin, M.J.Blaser. -Elseiver, 2017. – 520 p. • Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America/ Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Sheldon L. Kaplan, Jose G. Montoya, and James C.Wade/CID (2014):59 (15 July) https://academic.oup.com/cid/article/59/2/e10/2895845 • Skin and Soft Tissue Infections (SSTI) Antibiotic Guidelines (Adult) Group arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute Hospitals NHS Trust (PAT) Issue Date: 29/08/2019 • Sartelli, M., Guirao, X., Hardcastle, T.C. et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 13, 58 (2018). https://doi.org/10.1186/s13017-018-0219-9