Complicated skin and soft tissue infection

JAC  NOV 2010 V.65 suppl 3

Matthew S. Dryden*

Department of Microbiology, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK

*Corresponding author. Tel: +44-196-282-4451; Fax: +44-196-282-5431; E-mail: matthew.dryden@wehct.nhs.uk

Abstract

Skin and soft tissue infections (SSTIs) are common, and complicated SSTIs (cSSTIs) are the more extreme end of this clinical spectrum, encompassing a range of clinical presentations such as deep-seated infection, a requirement for surgical intervention, the presence of systemic signs of sepsis, the presence of complicating co-morbidities, accompanying neutropenia, accompanying ischaemia, tissue necrosis, burns and bites. Staphylococcus aureus is the commonest cause of SSTI across all continents, although its epidemiology in terms of causative strains and antibiotic susceptibility can no longer be predicted with accuracy. The epidemiology of community-acquired and healthcare-acquired strains is constantly shifting and this presents challenges in the choice of empirical antibiotic therapy. Toxin production, particularly with Panton–Valentine leucocidin, may complicate the presentation still further. Polymicrobial infection with Gram-positive and Gram-negative organisms and anaerobes may occur in infections approximating the rectum or genital tract and in diabetic foot infections and burns.

Successful management of cSSTI involves prompt recognition, timely surgical debridement or drainage, resuscitation if required and appropriate antibiotic therapy. The mainstays of treatment are the penicillins, cephalosporins, clindamycin and co-trimoxazole. β-Lactam/β-lactamase inhibitor combinations are indicated for polymicrobial infection. A range of new agents for the treatment of methicillin-resistant S. aureus infections have compared favourably with the glycopeptides and some have distinct pharmacokinetic advantages. These include linezolid, daptomycin and tigecycline. The latter and fluoroquinolones with enhanced anti-Gram-positive activity such as moxifloxacin are better suited for polymicrobial infection.

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http://jac.oxfordjournals.org/content/65/suppl_3/iii35.full.pdf+html

The diagnosis and management of prosthetic joint infections

JAC  NOV 2010 V.65 suppl 3

E. Moran1,2,*, I. Byren1,2 and B. L. Atkins1,2

1Department of Microbiology and Infectious Disease, John Radcliffe Hospital, Oxford OX3 9DU, UK

2Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK

*Corresponding author. Tel: +44-1865-220886; E-mail: edward.moran@imm.ox.ac.uk

Abstract

A host of technical and operative improvements have seen the rates of infection associated with joint replacement reach historic lows. However, the increasing number of operations being performed means that the absolute number of such infections remains significant. Diagnosis may be challenging and delaying appropriate treatment can lead to reduced joint function and the need for more complex, perhaps multiple, procedures. Individual centres tend to see small numbers of such cases, and in the absence of large clinical trials management varies. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Such packages of care are best delivered by a multidisciplinary team composed of orthopaedic and plastic surgeons, microbiologists, infectious disease physicians, specialist nurses, physiotherapists and occupational therapists. Each treatment plan must be developed in consultation with the patient, taking into account their aims and realistic goals. This review provides an overview of current understanding regarding diagnosis and treatment of prosthetic joint infections and suggests a treatment algorithm.

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http://jac.oxfordjournals.org/content/65/suppl_3/iii45.full.pdf+html