Skin and soft tissue infections SSTIs are common, and complicated SSTIs cSSTIs are the more extreme end of this Can e coli penetrate the skin 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. A range of new agents for the treatment of methicillin-resistant S.
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.
Skin and soft tissue infections SSTIs are ubiquitous and the most common of infections, suffered by everyone at some point to a lesser or greater degree and encountered by all doctors. SSTIs reflect inflammatory microbial invasion of the epidermis, dermis and subcutaneous tissues.
Indeed, the classical signs of inflammation were described in SSTI by Celsus in the first century as calor, rubor, tumor and dolor heat, redness, swelling and pain. To these four signs is often added a fifth—fluor discharge.
The skin is the largest organ of the body and, with the underlying soft tissue, which includes the fat layers, fascia and muscle, represents the majority of the tissue in the body. It acts as a tough, flexible, structural barrier to invasion. The skin is colonized with an indigenous microbial flora, which typically consists of a variety of species of staphylococci, corynebacteria, propionibacteria and yeasts, in numbers that may vary from a few hundred to many thousands per square centimetre in the moister areas such as the groin and axillae.
Breaks in the skin, such as leg ulcers, burns and surgical or traumatic wounds, allow colonization with a broader range of bacteria. Can e coli penetrate the skin of ulcers does not usually result in inflammation, but occasionally infection of the surrounding tissues may result from lateral spread of the colonizing organisms.
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Clinically, it is important to distinguish between colonization, which does not require antibiotic treatment, and infection, which might. Microbial disease of the skin may also occur by haematogenous Can e coli penetrate the skin of bacteria e.
Alternatively, they may be classified according to their microbial aetiology or by severity. By contrast, Eron et al. Classification of SSTI according to the severity of local and systemic signs, and associated management 7. It is a very mixed clinical group with even greater variation in the aetiology. In the USA, the Food and Drug Administration FDA issues guidance to the pharmaceutical industry with regard to developing the protocols for trials in this clinical area, 8 and it is largely through clinical trials that the concept of cSSTI has evolved.
Licensing of most new antibiotics follows the successful demonstration in clinical trials of their efficacy for treatment of cSSTIs. The FDA guidance regards infections that can be treated by surgical incision alone, such as cases of isolated meaning one solitary area of infection furunculosis or folliculitis, as uncomplicated infections that should not be included in clinical trials. In contrast, the complicated category includes infections either involving deeper soft tissue or Can e coli penetrate the skin requiring significant surgical intervention, such as infected ulcers, burns and major abscesses or a significant underlying disease state that complicates the response to Can e coli penetrate the skin.
Superficial infections or abscesses in an anatomical site such as the rectal area, where the risk of anaerobic or Gram-negative pathogen involvement is higher, should be considered complicated infections. Initial investigations should include blood cultures, full blood count and measurement of C-reactive protein, creatinine, bicarbonate and creatine phosphokinase levels. Soft tissue cultures should be done where possible.
If there is evidence of rapid spread of infection an early surgical review is essential to assess the requirement for debridement and drainage. The broad range of bacterial species reflects the fact that this group of patients is hospitalized and that it is a laboratory-based survey without direct clinical assessment of the relevance of the isolate to the clinical condition. As a result some of the isolates reported may not necessarily have been the causative pathogens.
Gram-negative and anaerobic bacteria are more common in association with surgical site infections of the abdominal wall or infections of the soft tissue in the anal and perineal region. Polymicrobial infections involving both Gram-positive and Gram-negative organisms occur particularly where tissue vascular perfusion is compromised, such as diabetic foot infection or infection of ischaemic or venous ulcers.
Chronic infections, especially in patients previously treated with antibiotics, are likely to be polymicrobial with Gram-negative and obligate anaerobic pathogens found alongside Gram-positive organisms.
Such infections with Gram-positive and Gram-negative microbes clearly require broad-spectrum antibiotic treatment. Int J Antimicrob Agents ; 34 Suppl 1: Antibiotics and surgical drainage are the basis of treatment for staphylococcal infections, but the emergence of strains with resistance to multiple agents has complicated the choice of empirical therapy.
It is therefore important that a local knowledge of the epidemiology and susceptibility of pathogens guides the development of antibiotic guidelines for empirical treatment. Methicillin resistance was first detected in S.
Having recurrent infections, being a child, a member of the armed forces, an athlete or an injecting drug user are recognized risk factors for infection with CA-MRSA in the USA; 21 similar risk factors are apparent in Europe as well. Should this change, which is likely, European infection doctors believe that empirical therapy for community SSTI would have to be changed.
Although a number of criteria have been proposed to predict the likelihood of infection with CA-MRSA, 1617 epidemiological and clinical criteria are rarely sufficient to distinguish accurately Can e coli penetrate the skin MRSA and methicillin-susceptible S. However, staphylococcal resistance to glycopeptides remains rare, 30 although rising MICs of glycopeptides may affect the efficacy of these agents.
The evolution of strains causing SSTI and serious infection is rarely static and strains of apparently susceptible at least phenotypically susceptible but mecA gene-positive S.
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With most community-acquired SSTIs being caused by staphylococci and streptococci it is easy to ignore more unusual causes. Of particular importance is the presence of underlying disease, Can e coli penetrate the skin hospital admissions, animal contact and bite history, injecting drug use and travel.
For example, a history of travel with water contact may hint at a diagnosis of an infection with a Vibrio spp. A drug user with an abscess at an injection site is most likely to have a staphylococcal infection, but Can e coli penetrate the skin bacteria such as Clostridium botulinum or Bacillus anthracis may also be involved.
Although there is considerable debate over the value of microbiological culture in the management of SSTIs, there can be no doubt that the rise in multiply resistant bacteria and the possibility of unusual causes of SSTI increase the importance of diagnostic microbiology and antibiotic susceptibility testing for epidemiological purposes and the surveillance of antimicrobial resistance.
Whereas aspiration of the leading edge of cellulitis with a needle is often advocated in North America, this practice is rarely carried out in the UK and is generally deemed too invasive in enclosed cellulitis.
Blood cultures should be collected where there are signs of systemic sepsis, such as a raised temperature, tachycardia, hypotension or confusion. This medico-surgical emergency is a life-threatening, invasive, soft tissue infection caused by aggressive, usually gas-forming bacteria, which primarily involves the superficial fascia and extends rapidly along subcutaneous tissue planes with relative sparing of skin and underlying muscle.
Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to the clinical findings. Prompt surgical debridement, intravenous antibiotics, fluid and electrolyte management, and analgesia are the mainstays of therapy.
Adjuvant treatments such as hyperbaric oxygen therapy and intravenous immunoglobulins are sometimes advocated. In one recent study, 45 S. Virulence factors, including PVL, were detected and the isolates were assigned to clonal groups. Thirty isolates were positive for the gene encoding PVL.
The remaining methicillin-susceptible PVL-positive isolates belonged Can e coli penetrate the skin a variety of different multilocus sequence types. In a large, prospective study of patients with MRSA infection in North America, strains from community-acquired infections, which were most likely to be of the skin and soft tissues, were particularly likely to express exotoxins, especially PVL.
The use of antimicrobials effective against MRSA that also decrease exotoxin production, such as clindamycin and linezolid, is theoretically desirable.
This review will focus on a brief discussion of aggressive mammals, including humans, and the infections their bites cause. However, there are a good many non-vertebrates and indeed other vertebrates willing to cause trauma and transmit infection.
It might be imagined that the least of a victim's problems after a shark attack would be infection but this is not necessarily the case. Human bites can result in serious soft tissue infection.
It is important to seek a history of animal contact when Pasteurella is isolated. Infection usually follows a trivial bite in patients with asplenia or cirrhosis. Typically, Gram-negative bacilli are seen within polymorphs on peripheral blood films. Other considerations in animal bites and contact are rabies, tetanus and infections with unusual organisms of high pathogenicity, such as Francisella tularensis or Bacillus anthracis.
A history of travel is important in the assessment of SSTIs. Although the common causes of SSTI—streptococci and staphylococci—are also common in travellers, unusual microbial causes of infection may present in this group. Travel history should be sought and diagnostic microbiology performed. Unusual or non-bacterial Can e coli penetrate the skin may present a diagnostic challenge in travellers.
Can e coli penetrate the skin in travellers may be associated with a range of infections, such as primary Lyme disease erythema chronicum migrans caused by Borrelia burgdorferi ; serpiginous tracks caused by hookworm larvae cutaneous larva migrans ; and rickettsial infection, of which the most common presenting in UK travellers is African tick typhus Rickettsia conorii causing a widespread maculopapular rash associated with systemic symptoms.
Persistent ulcers may be caused by atypical mycobacteria or protozoa such as Leishmania spp. Enlarging, fluctuant and largely painless abscesses may be caused by arthropod maggot infestation, such as Cordylobia anthropophaga from tropical Africa or Dermatobia hominis from tropical America.
All of these infections or infestations may require specialist medical referral to make the diagnosis and initiate appropriate treatment. SSTIs in immunocompromised hosts can be challenging as they can be caused by unusual and diverse organisms. Surgical review and follow-up are often advisable. Establishing a diagnosis and performing susceptibility testing is crucial, 6 because many infections are hospital acquired and increasing resistance among both Gram-positive and Gram-negative bacteria makes empirical treatment regimens difficult, if not dangerous.
In addition, fungal infections such as cryptococcosis or histoplasmosis may present with cutaneous findings. The management of cSSTIs normally involves a combination of surgical debridement or drainage and empirical antibiotic therapy.
The antibiotic management of cSSTIs is well reviewed in the published guidelines.
In probable Gram-positive infection where MRSA is not suspected, penicillins, antistaphylococcal penicillins, cephalosporins, clindamycin or co-trimoxazole are indicated. The mainstay of treatment for serious MRSA infections has until recently been the glycopeptides vancomycin and teicoplanin.
However, concern about the gradual development of resistance and concerns about efficacy 3031 have turned attention to the development of new agents active against Gram-positive bacteria.
Those that have been licensed for treating cSSTI are linezolid, daptomycin and tigecycline. The range of oral antibiotics used to treat MRSA infections is very wide across Europe, 4 and the choice seems to depend on local susceptibility and personal experience, because there are no comparative trials to support the use of specific older agents. The only new oral agent is linezolid. There is, however, evidence to Can e coli penetrate the skin that agents such as co-trimoxazole and tetracycline, which are cheap and reasonably well tolerated, have good efficacy against MRSA 56 and the rate of therapeutic failure is low.
Newer antibiotics are finding a place in the treatment of cSSTI caused by more resistant strains and indeed many of the randomized clinical trials in cSSTI have been industry sponsored. All these trials have been designed specifically for licensing purposes and therefore have only been powered to show non-inferiority.
These efficacy data are supported by a meta-analysis suggesting that linezolid may indeed be superior to the glycopeptides. It is recommended for polymicrobial infection that may include MRSA and for necrotizing fasciitis. Daptomycin has rapid concentration-dependent bactericidal activity against Gram-positive pathogens. It turned out that not only could the E. coli survive in the soil for up Can e coli penetrate the skin 28 of crops could be contaminated from pathogens or viruses that get into the Stomata are tiny openings, typically found on the outer skin of a leaf but.
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Table 4 Tissue penetration (skin and skin structures) of an- timicrobial drugs.