Dataset Information

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

ABSTRACT:

Purpose

To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis.

Methods

Guidelines, expert opinion, and local institutional policies were reviewed.

Results

Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described.

Conclusions

We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.

SUBMITTER: Burnham JP

PROVIDER: S-EPMC6276373 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Publications

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

Burnham Jason P JP Kirby John P JP Kollef Marin H MH

Intensive care medicine 20161003 12

<h4>Purpose</h4>To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis.<h4>Methods</h4>Guidelines, expert opinion, and local institutional policies were reviewed.<h4>Results</h4>Severe SSTIs are common and their management complex due to regional variation in pr ...[more]

PMID: 27699456

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Project description:ObjectivesSkin and soft tissue infections (SSTIs) constitute a significant portion of emergency department (ED) cases, with some requiring admission into the observation unit (OU) for ongoing care. Identifying factors linked to OU admission is essential for optimizing patient disposition decisions.MethodsA retrospective cohort study identified patients with the International Classification of Diseases 10th Revision (ICD-10) codes indicating SSTI at an urban, tertiary care ED over 3 years (2017-2019) who were ultimately discharged. Patients admitted at index visit were excluded. Medical charts were reviewed for demographic and clinical data. Simple logistic regression models explored bivariate associations with OU admission, while a multiple logistic regression model adjusted for demographics, clinical characteristics, vital signs, and pre-index visit and in-ED management.ResultsAmong 1675 patients (42.9% female; mean age, 45.5 ± 15.4 years; 56.4% identifying as Black), 20.7% (n = 346) were admitted to the OU. Unadjusted analysis showed associations between OU admission and factors, including age, history of intravenous drug use (IVDU), lower extremity SSTI, subjective systemic illness, fever at index visit, ED surgical consultation, and pre-index visit antimicrobial choice. After adjustment, age (odds ratio [OR], 1.16; 95% CI, 1.04-1.30), immunocompromised status (OR, 1.83; 95% CI, 1.07-3.13), extremity cellulitis (lower: OR, 2.51; 95% CI, 1.55-4.14; upper: OR, 2.35; 95% CI, 1.36-4.12), surgical consultation (OR, 2.64; 95% CI, 1.79-3.91), and prehospital methicillin-resistant Staphylococcus aureus (MRSA) antibiotic prescription (OR, 2.76; 95% CI, 1.69-4.54; P = .0001) remained statistically significant.ConclusionIdentifying factors associated with OU admission provides insights into clinician decision making, potentially identifying patients who might benefit from OU admission through future work, which should focus on predictors of hospital admission, OU failure, and antimicrobial selection to reduce OU failure rates.

Project description:BackgroundThe morbidity and treatment costs associated with skin and soft tissue infections (SSTIs) are high. Linezolid and vancomycin are antibiotics that are commonly used in treating skin and soft-tissue infections, specifically those infections due to methicillin-resistant Staphylococcus aureus (MRSA).ObjectivesTo compare the effects and safety of linezolid and vancomycin for treating people with SSTIs.Search methodsFor this first update of this review we conducted searches of the following databases: Cochrane Wounds Group Specialised Register (searched 24 March 2015; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also contacted manufacturers for details of unpublished and ongoing trials. We scrutinised citations within all obtained trials and major review articles to identify any additional trials.Selection criteriaWe included all randomised controlled trials (RCTs) comparing linezolid with vancomycin in the treatment of SSTIs.Data collection and analysisTwo review authors independently selected trials, assessed risk of bias and extracted data. The primary outcomes were clinical cure, microbiological cure, and SSTI-related and treatment-related mortality. We performed subgroup analyses according to age, and whether the infection was due to MRSA.Main resultsNo new trials were identified for this first update. We included nine RCTs (3144 participants). Linezolid was associated with a significantly better clinical (RR 1.09, 95% CI 1.03 to 1.16) and microbiological cure rate in adults (RR 1.08, 95% CI 1.01 to 1.16). For those infections due to MRSA, linezolid was significantly more effective than vancomycin in clinical (RR 1.09, 95% CI 1.03 to 1.17) and microbiological cure rates (RR 1.17, 95% CI 1.04 to 1.32). No RCT reported SSTI-related and treatment-related mortality. There was no significant difference in all-cause mortality between linezolid and vancomycin (RR 1.44, 95% CI 0.75 to 2.80). There were fewer incidents of red man syndrome (RR 0.04, 95% CI 0.01 to 0.29), pruritus (RR 0.36, 95% CI 0.17 to 0.75) and rash (RR 0.27, 95% CI 0.12 to 0.58) in the linezolid group compared with vancomycin, however, more people reported thrombocytopenia (RR 13.06, 95% CI 1.72 to 99.22), and nausea (RR 2.45, 95% CI 1.52 to 3.94) when treated with linezolid. It seems, from the available data, that length of stay in hospital was shorter for those in the linezolid group than the vancomycin group. The daily cost of outpatient therapy was less with oral linezolid than with intravenous vancomycin. Although inpatient treatment with linezolid cost more than inpatient treatment with vancomycin per day, the median length of hospital stay was three days shorter with linezolid. Thus, total hospital charges per patient were less with linezolid treatment than with vancomycin treatment.Authors' conclusionsLinezolid seems to be more effective than vancomycin for treating people with SSTIs, including SSTIs caused by MRSA. The available evidence is at high risk of bias and is based on studies that were supported by the pharmaceutical company that makes linezolid. Further well-designed, independently-funded, RCTs are needed to confirm the available evidence.

Project description:AimExploratory analyses evaluated patient characteristics and outcomes among patients with complicated skin and soft tissue infection (cSSTI) in the phase 3 COVERS study who were admitted to an intensive care unit (ICU).MethodsAdults with cSSTI (surface area ≥ 75 cm2) and evidence of systemic inflammation and/or underlying comorbidities were randomized 2:1 to intravenous ceftaroline fosamil (600 mg every 8 h [q8h]) or vancomycin (15 mg/kg every 12 h) plus aztreonam (1 g q8h) for 5-14 days. Clinical response and ICU length of stay (LOS) within first hospitalization were evaluated in the modified intent-to-treat (MITT) and clinically evaluable (CE) populations; a Cox proportional hazards model identified factors associated with increased hospital LOS.ResultsOverall, 42 of 761 randomized patients were admitted to the ICU (ceftaroline fosamil, n = 32; vancomycin plus aztreonam, n = 10) prior to, or at start of, study treatment. Baseline differences between the ICU and non-ICU populations were indicative of more severe disease in ICU patients; within this subset, there were also some notable imbalances between treatment groups. Clinical cure rates at test-of-cure (ceftaroline fosamil vs. vancomycin plus aztreonam) were generally similar in the non-ICU and ICU subsets (MITT population 79% vs. 79% and 69% vs. 90.0%, respectively; CE population 87% vs. 85% and 80% vs. 89%, respectively). Median ICU LOS was 8 vs. 13 days, respectively. ICU admission was a risk factor predicting increased hospital LOS (P < 0.001).ConclusionsClinical outcomes for patients admitted to the ICU were generally similar to non-ICU patients, despite more severe baseline disease, with shorter median treatment duration in the ceftaroline fosamil group. ICU admission was associated with longer hospital LOS. Given the small sample size and unbalanced patient and disease characteristics within the ICU subgroup, differences between treatment groups should be interpreted with caution.Trial registrationClinicalTrials.gov identifier, NCT01499277.

Dataset Information

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

Purpose

Methods

Results

Conclusions

Publications

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

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