In the present review, authors take into consideration the classification and the epidemiology of the skin and soft tissue infections (SSTIs), a set of commonly observed pathologies, which can present different features, relatively to site and localization, clinical characteristics, and aetiological agent, their severity being related to the depth of the interested sites. Given the variable presentation of SSTIs, an assessment of their incidence and prevalence is difficult. In general, the incidence of SSTIs has increased due to the ageing of the general population, the increased number of critically ill patients, the increased number of immunocompromised patients (HIV, cancer and organ transplant patients) and the recent emergence of multi-drug resistant pathogens.

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Skin and soft tissue infections (SSTI) are common and, generally, uncomplicated at the time of initial presentation. However, these infections can worsen quickly when there are delays in diagnosis and treatment. The clinical presentation of most SSTI is the culmination of a microbial three-step process as follow: i) bacterial adherence to host cells; ii) invasion of tissue with evasion of host defences, and iii) elaboration of toxins. Even if the microbiology of wounds has been actively investigated in recent years, there is still much to be learned about the microbial mechanisms that induce infection and prevent wound healing. There are also several means by which bacteria penetrate the skin barrier. The most common route is through a break in the barrier (lacerations, bite wounds, scratches, instrumentations, pre-existing skin conditions, wounds or ulcers, burns and surgery); other routes of penetration include contiguous spread from adjacent infections (e.g. osteomyelitis), entry of water into the skin pores, and, rarely, haematogenous seeding (i.e septic emboli). From what it was said, many microrganisms, above all from the normal skin microbiota, can be involved in these often polymicrobial infections, with Gram-positives such as Staphylococcus aureus, Streptococcus pyogenes, Staphylococcus epidermidis, Corynebacterium spp being predominant. Many other aerobic and anaerobic species, including Gram-negative bacilli, can also be involved. Even if the diagnosis of most SSTI is based on clinical examination, laboratory investigations, guided by clinical information, can help to confirm the diagnosis and elucidate the characteristics of specific pathogens. These microbiological investigations may include blood cultures, tissue swabs with culture, and needle aspiration. In rapidly progressing infections, empirical therapy is essential, although microbiological data are important in confirming subsequently that the chosen regimen is appropriate. Furthermore, the number of microrganisms becoming resistant to many usual drugs and the changing microbial epidemiology of these infections, such as the emergence of CA-MRSA, required a constant cooperation between the microbiology lab and the clinician in order to address microbiological aspects that can be critical to the successful management of SSTI.

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Skin and soft tissue infections represent a heterogeneous group of clinical entities that require to be accurately identified for an appropriate and immediate management. Clinicians are challenged by the need to rapidly select those patients requiring hospitalization and medical therapy only and those to be immediately submitted to surgery. Erysipelas and several forms of cellulitis, involving the superficial structures of epidermis and dermis, are medical conditions; some cutaneous abscess may require surgical drainage, and all the necrotizing infections, involving the subcutaneous tissue (necrotizing fasciitis) or muscles (myonecrosis) are surgical conditions. Among the clinical clues useful for the diagnosis are the presence of severe pain disproportionate to the clinical evidence of the lesion (necrotizing fasciitis), the presence of crepitus (gas gangrene) and signs of systemic toxicity (high fever, hypotension, tachycardia, shock and multiple organ failure).

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The pharmacodynamic and pharmacokinetic characteristics of antimicrobial agents are the two fundamental pharmacological components which provide a rational for the choice of therapy for skin and skin structure infections, and especially serious infections. The most important PK-PD parameters are well known which can potentiate therapeutic efficacy. Antimicrobial agents ca be subdivided into categories based on whether their activity is dependent on concentration or exposure time. Therefore, a correct dosing regimen for the time-dependent molecules (i.e. beta-lactams, linezolid, tigecycline) should prolong the maximum exposure time to maintain serum levels over the minimum inhibitory concentration (MIC). The concentration-dependent molecules, on the other hand, which include aminoglycosides and fluoroquinolones, should be given in order to reach maximum concentrations, since they are bactericidal in direct proportion to their concentrations and possess a prolonged post-antibiotic effect.

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Skin and soft tissue infections (SSTIs) are a set of commonly observed pathologies which can present different features in terms of site and localization, clinical features, and the aetiological agent; their severity is related to the depth of the affected sites. The aim of this review is to summarize the recommendations of current guidelines concerning the management of SSTIs.

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Therapeutic strategies in the management of skin and soft tissue infections should take account of different variables: epidemiological trends (community or hospital acquired infections), pathogen or pathogens involved, virulence, seriousness of pathology (possible co-morbidities, knowledge of local epidemiology and antimicrobial susceptibility patterns of community and hospital strains. Therapy often should be started promptly, and on an empiric base, once microbiological analysis have been performed, waiting for culture and antimicrobial susceptibility testing. Surgical incision and drainage represent essential therapeutic procedures in the treatment of many complicated skin and soft tissue infections such as abscesses and fasciitis. Gram-positive bacteria and specifically Staphylococcus aureus, are the main cause of such kind of infections. Therefore antistaphylococcal beta-lactams represents a first choice in empirical antimicrobial chemotherapy. Considering high incidence of MRSA in Italian hospitals, treatment of hospital acquired skin and soft tissue infections should be based on glycopeptides combined with third generation cephalosporins, piperacillin-tazobactam, carbapenems or fluoroquinolones. Recently, new drugs (as linezolid, daptomycin, tigecycline) demonstrated good efficacy in the treatment of serious infections caused by multi-drug resistant micror- ganisms. Most recent guidelines for the diagnosis and treatment of skin and soft tissue infections were published in 2005 by Infectious Diseases Society of America (IDSA). In Italy, the multidisciplinary group of Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti (FADOI) published guidelines for the treatment of skin and soft tissue infections in Internal Medicine wards in 2005. General approach and methodology in writing test were based on analysis of data from available scientific literature and comparing them with actual Italian epidemiological trends and drug prescribing policy. Considering these guidelines, we updated the newest antimicrobial drugs suggested for the treatment of skin and soft tissue infections, such as daptomycin and tigecycline.

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Infection of diabetic foot represents one of the most serious complications of diabetes. Deep infections of the foot, due to the compartment structure of the foot, can cause severe infective compartment syndromes that pose the diabetic patient to very high risk of major amputation and sepsis. The treatment of choice of this severe infective condition is represented by an aggressive surgical debridement with the aim to drainage pus and to remove infective and non vital tissue. Surgical debridement has to be performed as soon as possible since any delay corresponds to an increase of the risk of major amputation and death for sepsis. In case of concomitant severe peripheral vascular disease any revascularisation procedures, surgical or endoluminal, have to be performer once the local and systemic infection has been controlled.

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Pressure ulcers in elderly individuals can cause significant morbidity and mortality and are a major economic burden to the health care system. Prevention should be the ultimate objective of pressure ulcer care, and it requires an understanding of the pathophysiology leading to pressure ulcers and the means of reducing both intrinsic and extrinsic risk factors. Clinical examination often underestimates the degree of deep-tissue involvement, and its findings are inadequate for the detection of associated osteomyelitis. Microbiological data, if obtained from deep-tissue biopsy, are useful for directing antimicrobial therapy, but they are insufficient as the sole criterion for the diagnosis of infection. Imaging studies, such as computed tomography and magnetic resonance imaging, are useful, but bone biopsy and histopathological evaluation remain the “gold standard” for the detection of osteomyelitis. The goals of treatment of pressure ulcers should be resolution of infection and promotion of wound healing. A combination of surgical debridement and medical interventions may be required. Systemic antimicrobial therapy should be used for patients with serious pressure ulcers infections, including those with spreading cellulitis, bacteremia or osteomyelitis.

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