Management of acute bacterial skin and skin structure infections in India: are we equipped to meet the challenges of the growing menace of methicillin-resistant Staphylococcus aureus?

Staphylococcus aureus (S. aureus) is a Gram-positive facultative anaerobic bacterium that colonizes the skin and nasal passages of humans. The incidence of invasive S. aureus infections has increased over the past decades and is associated with poor outcomes and high mortality rates. S. aureus is responsible for almost one-third of acute bacterial skin and skin structure infections with methicillin-resistant Staphylococcus aureus (MRSA) accounting for a large proportion of these. The S. aureus strains prevalent inIndia are more aggressive and there are recent reports of the emergence of the more virulent multidrug resistant lineages ST2371 and ST8. Management of these infections is complicated by the fact that antimicrobial stewardship is non-existent, the choice of treatment is often empirical and available treatment options are limited due to a high prevalence of resistance strains. Currently available anti-MRSA agents include vancomycin, teicoplanin, linezolid, daptomycin, tigecycline, and clindamycin. However, the emergence of resistant strains and several undesirable features related to the safety and tolerability of these agents have limited the options available for the management of MRSA infections. A newer, safe and efficacious antibiotic is thus an unmet need for the management of MRSA in patients with acute bacterial skin and skin structure infections. In this review we explore the current and future trends in the management of acute bacterial skin and skin structure infections highlighting the challenges in their management in India, and current progress in the development of some novel drugs for the management of MRSA infections.

Management of Wounds of Peripheral Arterial Disease Using Platelet Rich Plasma.

Arterial ulcers are caused by inadequate perfusion of skin and subcutaneous tissues. The key treatment is correcting the underlying medical problem and re-perfusion of the affected tissue. Interventional procedures like angiography, transluminal angioplasty, and stenting have hazards like bleeding, hematoma formation, false aneurysm formation etc. This study was conducted to investigate the effect of platelet-rich plasma (PRP) on the rate of healing of peripheral arterial wounds. MethodsA randomized controlled trial was conducted with 80 participants admitted with peripheral arterial disease in Acharya Vinoba Bhave Rural Hospital, Wardha district, Maharashtra, from September 2017 - August 2019. Data was entered into MS Excel and was analysed for descriptive statistics. 40 patients each were allotted randomly to control group and treatment group. In the control group, conventional dressings was done with hydrogen peroxide and betadine. Wounds were treated with PRP infiltration in the treatment group. Outcome was compared between both groups. ResultsMean surface area of wound in control group reduced from baseline 2262.5 mm2 to 1758.4 mm2 (29.89% reduction) in ulcer surface area, and 2298.9 mm2 to 1158.1 mm2 (66.22% reduction) in treatment group (p= 0 at the end of study) at the end of two months. Standard deviation of the same (Control: 1739.2 mm2 to 1566.3 mm2 vs Treatment: 1906.5 mm2 to 1402.4 mm2). Rate of epithelization was faster in treatment group (8.92 mm2/day vs 17.27 mm2/day, p=0 at the end of study). PRP resulted in early healing of ulcers with earlier reduction in wound surface area. ConclusionsPRP is an effective method for healing of wounds resulting from peripheral arterial disease.

Pattern of diabetic foot - presentation and complications in rural Indian population.

Background: Foot ulcer is one of the most common and deadest complications of diabetes mellitus. This is also a frequent cause of hospitalization and disability. Most of the patients with diabetic foot ulcers living in developing countries present to healthcare facilities fairly late with advanced foot ulcers because of poor economic status, inadequate knowledge of self-care, sociocultural reasons and poor and inadequate diabetes healthcare. Methods: A prospective study was conducted in the department of Surgery, JNMC Sawangi (Meghe), Wardha of DMIMS (DU) with the aim to evaluate the pattern of distribution of foot ulcers in diabetic foot patients and related complications. We enrolled 30 diabetic patients in the study, of these 21 (70%) were males and 9 (30%) were females with male to female ratio 2.33. Results: The mean age of presentation was 52.93 ± 14.10 and the mean duration of diabetes was 8.20 ± 10.06. The maximum numbers of lesion was present in the region of second to fifth metatarsal (53.33%), followed by heel (26.66%) and great toe (10%). Maximum patients 9 (30%) had grade II lesions as per Wagner’s classification and 12 (40%) had II B as per University of Texas diabetic wound classification. Associated deformity was present in 36.66%, insensitivity to the 5.07 S-W monofilaments in 56.66%, impaired vibration in 43.33%, and abnormal Achilles tendon reflex in 40%. Ankle–brachial index <0.8 was present in 33.33%. Only 13.33% patients were using customized footwear whereas 46.66% were walking barefoot, the difference was statistically significant P = 0.0027. Conclusion: The health education to promote Knowledge, Attitude, Behavior and Practice (KABP) is essential to prevent diabetes associated foot complications.

Site selection for vascular access creation in hemodialysis in end stage renal disease.

Background: Chronic kidney failure is characterized with progressive and irreversible diminishing of glomerular filtration rate. AVF has been unanimously considered the gold standard vascular access of choice for hemodialysis. Arterio-venous fistula (AVF) for hemodialysis should be created in patients with endogenous creatinine clearance < 20 mL/min/1,73m2. Aim of current study was to choose the proper site for arteriovenous fistula creation with minimal complications. Methods: It was a prospective study, carried out in the dept. of surgery from April 2008 to August 2013. A total of 140 patients were studied over the period. The fistulae were created using radial artery cephalic vein side to side and brachial artery cephalic vein side to side or end to side anastomosis. Statistical analysis used: Mean, Standard deviation, Standard error. Results: A total 140 patients were studied, out of them 104 were males and 36 were females. The radiocephalic site was used for 82 (58.57%) patients and 58 (41.43%) patients were operated on brachiocephalic site. The mean inner diameter of radial artery, brachial artery and cephalic vein (intima to intima) at elbow and wrist were 21.49001 ± 0.901 (SE - 0.28492), 3.72533 ± 1.06837 (SE - 0.30841) and 0.68079 ± 0.49551 (SE - 0.116790) respectively. The mean flows velocity of brachial and radial artery were 76.10526 ± 4.54477 (SE - 1.04264) and 52.64286 ± 5.5968 (SE - 1.495810) respectively. The success rate of AV fistula on table was 97.85% (137 out of 140). The incidence of complication was 18.57%. Conclusion: The site for fistula creation depends on the quality of the artery and vein. To achieve good success rates preoperative color Doppler is essential to evaluate the vessels. The complication rates can be minimised by following standard operating protocols.

Malnutrition in hospitalised patients; a real concern in surgical outcomes.

Background: Lack of appropriate nutritional support during hospitalization may worsen patients’ nutritional status and increases risk for infection, organ failure, decreased wound healing and suboptimal response to regular medical treatment. The prevalence and intensity of hospital malnutrition have been recognized as an important parameter in the outcome of disease. The study aimed at to determine incidence of malnutrition in hospitalized patients, the change in nutrition status during hospital stay and its effects on outcome of disease. Methods: It was a prospective study and conducted at a tertiary care hospital. Total 70 patients were studied. Each patient's nutritional status was determined from anthropometric data - body mass index, triceps skinfold thickness, mid-arm circumference, mid arm muscle circumference, MNA scoring, serum protein level changes during hospital stay. The next recording was done at 15 days and 30 days after discharge. Student’s t is test used for statistical analysis. Results: The statistical difference for various parameters of nutritional status was found significant at admission and discharge. Conclusions: The change in various parameter of nutritional status was observed in hospitalized patients. The treatment should be aimed at treating specific disorders along with nutritional correction. It is recommended to have dietary plans at the time of admission in consultation with the dietician.

Recurrent madura foot without draining sinuses: a case report.

Madura foot or mycetoma is a chronic granulomatous disease characterized by localized infection of subcutaneous tissues by actinomycetes or fungi. The recurrence rate for the disease if treated inadequately is very high. Recurrence presents with swelling and multiple discharging sinuses. This is an unusual presentation of the disease without discharging sinuses which is probable the first report of this kind in the literature. A 34 year old, male, presented with the painless, progressive swellings over right foot since 4 years. No sinuses or discharge could be found on skin surface. The postoperative recurrence rate is very high, and this can be local or distant at the regional lymph nodes. This could be due to the disease biology and behavior or inadequate surgical excision. Usually it presents with multiple sinus tracts, and granule. We reported a case with classical absence of sinus tracts in recurrent actinomycosis.