Nocardiosis diseminada a punto de partida de infeccion de piel y partes blandas. Serie de casos de un centro de tercer nivel / Disseminated nocardiosis at the starting point of skin and soft parts infection. Series of cases from a third level center

Nocardia es una bacteria grampositiva con amplia distribución en el medio ambiente. Puede producir variadas de infecciones. Si bien, las vías respiratorias son la principal puerta de entrada de Nocardia sp. ­y como consecuencia de lo mismo 50% de los pacientes posee compromiso pulmonar- las infecciones por Nocardia van desde infecciones de piel y partes blandas hasta abscesos cerebrales. La piel puede ser el órgano de afectación primaria y el primer signo clínico de infección o formar parte de una infección diseminada. La nocardiosis diseminada, es una grave enfermedad que involucra a dos sitios no contiguos de infección o el rescate del agente causal en hemocultivos. Afecta a pacientes debilitados con condiciones o con cierto grado de inmunodepresión; particularmente de inmunidad celular; como trasplantados de órganos sólido o hematopoyeticos, uso de corticoides, neoplasias, VIH, alcoholismo ­aunque se describen infecciones en pacientes inmunocompetentes­. El diagnóstico es dificultoso y la sospecha clínica es fundamental para el inicio de la terapéutica. Se describen dos casos de infecciones de piel y partes blandas ocasionadas por Nocardia; de evolución subaguda-cronica;. Una de ellas localizada: micetoma de pie, la segunda, una celulitis abdominal recurrente complicada con compromiso sistémico; en ambas estuvo presente la demora en el diagnóstico.

Nocardia is a gram-positive bacteria with wide distribution in the environment. It can cause a wide range of infections. Although the respiratory tract is the main entry point for Nocardia sp. ­ and as a consequence of the same, 50% of patients have lung involvement ­ nocardia infections range from skin and soft tissue infections to brain abscesses. The skin can be the primary organ of involvement and the first clinical sign of infection or be part of a disseminated infection, secondary to a primary pulmonary form. Disseminated nocardiosis is a serious disease that involves two non-contiguous sites of infection or the recovery of the causative agent in blood cultures. It commonly affects patients with weakened conditions or a certain degree of immunosuppression; particularly cellular immunity, such as solid or hematopoietic organ transplants, use of corticosteroids, neoplasms, HIV, alcoholism - although infections are described in immunocompetent patients. The diagnosis is difficult and clinical suspicion is essential for the initiation of therapy. Two cases of skin and soft tissue infections caused by Nocardia were described of subacute-chronic evolution. One of them localized: mycetoma of the foot, the second, a recurrent abdominal cellulites complicated with systemic involvement; Delay in diagnosis was present in both

Conceptos para la identificación y abordaje dela gangrena de Fournier / Concepts for the identification and approach of Fournier's gangrene

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing", "wound infection", "therapy"[subheading] y "GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

Introduction. Fournier's gangrene is a fulminant and progressive necrotizing fasciitis of synergistic polymicrobial infectious origin that affects the perianal, perineal, genital and abdominal regions. Its incidence is greater in men, the average age of reported presentation is 54.7 ± 15.6 years; its mortality is 3-67%, although there are studies that report a mortality of 7.5% in men and 12.8% in women. Methodology. A review of the literature was carried out in the databases and information sources: PubMed, Scielo, and Google Scholar, published between 1950 and 2018 using terms such as "Fournier Gangrene", "Fasciitis, Necrotizing", Wound Infection, "therapy"[Subheading] and "GRADE Approach". A second review was performed for articles in Latin American Spanish up to 2020 using the same sources and keywords. Results. Articles that reported definitions, historical data, diagnostic and therapeutic updates were selected, performing an updated review. Informed consent was requested for the use of images.Conclusion. Fournier's gangrene continues to be a potentially lethal surgical emergency, thanks to the research carried out, progress has been made in its treatment, improving results. It is important to analyze the risk factors for each patient and its etiology to establish the most appropriate treatment

Características clínicas y microbiológicas de infecciones de piel y partes blandas en pacientes pediátricos de dos hospitales de Buenos Aires / Skin and soft tissue infections in pediatrics

Las infecciones de piel y partes blandas (IPPB) en niños son una de las principales causas de prescripción de antimicrobianos. El objetivo del estudio fue describir las características clínicas y microbiológicas de las IPPB ambulatorias de niños asistidos en dos hospitales zonales. Se realizó un estudio prospectivo entre el 1/11/2017 y el 1/11/2018. Se incluyeron pacientes entre 1 mes y 15 años internados en dos hospitales. Se evaluó: edad, sexo, localidad, factores predisponentes, tipo de IPPB, muestras biológicas realizadas, aislamiento microbiológico, tratamiento empírico indicado y evolución del cuadro. Se realizó antibiograma y determinación genética. Se calculó chi2, IC95, OR; α=5%. N= 94. 58,7% masculinos. 12 pacientes <1 año, 85 >1 año (promedio de edad 4 años, 1-15). El 36% de Tandil y 63,8% de Florencio Varela. El 59,6% corresponden a IPPB purulentas. Se aislaron microorganismos en un 59,6%. Los aislamientos principales: SAMR (40,4%), SAMS (7,4%), S. agalactiae (2,1%) y S. pyogenes (2,1%). El 100% de SAMR son portadores de gen mecA y SCCmec tipo IV, sin multirresistencia. No hubo diferencia estadística entre los factores de riesgo evaluados para el desarrollo de IPPB por SAMR. El 52,1% de los niños recibió tratamiento antibiótico combinado, siendo la más indicada TMS-SMX + CLI en 36 eventos. (38,3%). La evolución fue favorable: no hubo diferencia significativa entre el subgrupo que se aisló SAMR y el que no se aisló SAMR; 91,9% (34/37) y 92,6% (50/54) correspondientemente (chi2: 0,01; p= 0,97 IC95: 0,26-3,88). El principal agente etiológico fue SAMRco, debiendo adecuar los tratamientos a este microorganismo.

Skin and soft tissue infections (SSIs) in children are one of the main causes of antimicrobial prescription. The aim of the study was to describe the clinical and microbiological characteristics of outpatient SSIs in children attended in two hospitals. A prospective study was conducted between 11/1/2017 and 11/1/2018. Patients between 1 month and 15 years old, hospitalized were included. We evaluated: age, sex, locality, predisposing factors, type of IPPB, biological samples taken, microbiological isolation, empirical treatment indicated and evolution of the condition. An antibiogram and genetic determination were performed. Chi2, CI95, OR; α=5% were calculated. N= 94. 58.7% male. 12 patients <1 year, 85 >1 year (mean age 4 years, 1-15). 36% were from Tandil and 63.8% from Florencio Varela. 59.6% corresponded to purulent SSIs. The diagnostic yield was 59.6%. Main isolates: MRSA (40.4%), MSSA (7.4%), S. agalactiae (2.1%) and S. pyogenes (2.1%). 100% of MRSA carried the mecA gene and SCCmec type IV, with no multidrug resistance. There was no statistical difference between the risk factors evaluated. 52.1% of children received combined antibiotic treatment, the most indicated being TMS-SMX + CLI in 36 events. (38,3%). Evolution was favorable: there was no significant difference between the subgroup that isolated MRSA and the subgroup that did not isolate MRSA; 91.9% (34/37) and 92.6% (50/54) respectively (chi2: 0.01; p= 0.97 CI95: 0.26-3.88). The main etiological agent was MRSA, and treatments should be adapted to this microorganism

Infección de piel y tejidos blandos por Burkholderia stabilis en un niño con quemaduras graves / Skin and soft tissue infection due to Burkholderia stabilis in a severely burned child

Resumen Las heridas por quemadura representan un grave problema, sobre todo en la población pediátrica, dada la severidad de su presentación y la morbimortalidad asociada. La infección es la complicación más frecuente y grave en el paciente quemado. Las bacterias que conforman el complejo Burkholderia cepacia (CBc) son capaces de causar enfermedades en plantas, humanos y animales. En el hombre pueden establecer infecciones crónicas y frecuentemente graves, por lo general en pacientes con fibrosis quística y en inmunocomprometidos. El CBc está compuesto por al menos 22 especies filogenéticamente muy relacionadas. El objetivo de esta publicación fue describir el primer caso de una infección de piel y partes blandas por Burkholderia stabilis, una especie poco frecuente, en un niño con grandes quemaduras en la Argentina. Las especies del CBc son intrínsecamente resistentes a la mayoría de los antimicrobianos disponibles clínicamente, como aminoglucósidos, quinolonas, polimixinas y β-lactámicos. Esto representa un serio problema en el momento de tratar las infecciones por las escasas opciones terapéuticas.

Abstract Burn wounds represent a serious problem, especially in the pediatric population, given the severity of their presentation and the associated morbidity and mortality. Infection is the most frequent and serious complication in the burned patient. Burkholderia cepacia (CBc) complex bacteria are capable of causing disease in plants, humans, and animals. In human beings they can establish chronic and frequently serious infections, generally in patients with cystic fibrosis and in immunocompromised patients. The CBc is composed of 22 phylogenetically closely related species. The objective of this publication was to describe the first report of a skin and soft tissue infection by Burkholderia stabilis, a rare species, in a child with extensive burns in Argentina. CBc species are inherently resistant to most clinically available antimicrobials, such as aminoglycosides, quinolones, polymyxins, and β-lactams. This represents a serious problem when treating infections, due to the limited therapeutic options.

Resumo As feridas por queimadura representam um grave problema, principalmente na população pediátrica, devido à gravidade de sua apresentação e morbimortalidade associada. A infecção é a complicação mais frequente e grave do paciente queimado. As bactérias que compõem o complexo Burkholderia cepacia (CBc) são capazes de causar doenças em plantas, humanos e animais. No homem, podem estabelecer infecções crônicas e freqüentemente graves, geralmente em pacientes com fibrose cística e imunocomprometidos. O CBc é composto, no mínimo, por 22 espécies filogeneticamente muito relacionadas. O objetivo desta publicação é descrever o primeiro caso de uma infecção de pele e tecidos moles por Burkholderia stabilis, uma espécie rara, em uma criança com queimaduras extensas na Argentina. As espécies do CBc são inerentemente resistentes à maioria dos antimicrobianos disponíveis clinicamente, como aminoglicosídeos, quinolonas, polimixinas e β-lactâmicos. Isso representa um problema sério na hora de tratar as infecções devido às opções terapêuticas limitadas.

Uso ambulatorio de cefalosporinas en una población colombiana: estudio de prescripción-indicación / Outpatient cephalosporin use in a Colombian population: prescription-indication study

INTRODUCCIÓN: El uso indebido de cefalosporinas puede provocar resistencia de las bacterias. OBJETIVO: Determinar el perfil de prescripción e indicación de cefalosporinas en un grupo de pacientes afiliados al Sistema de Salud de Colombia. MÉTODOS: Estudio transversal. A partir de una base de datos poblacional se obtuvo una muestra aleatoria de pacientes atendidos en consulta ambulatoria para identificar las indicaciones de cefalosporinas en registros clínicos. Se evaluaron variables farmacológicas relacionadas con formulación no indicada según guías de práctica clínica. RESULTADOS: En 381 pacientes, con edad media 41,2 ± 15,4 años, el 61,4% (n = 234) eran mujeres. Cefalexina fue la más utilizada (n=318; 83,5%), con duración media del tratamiento de 7,3 ± 3,2 días, seguida de cefradina (n = 43, 11,3%) y ceftriaxona (n = 20, 5,2%). Se prescribieron para infecciones de piel y tejidos blandos (n = 177; 46,4%, de las cuales 47,5% eran purulentas), del tracto urinario (n = 70; 18,4%), de vías respiratorias superiores (n = 57; 15,0%), e infecciones de transmisión sexual (n = 21; 5,5%). Estaban indicadas en 169 pacientes (44,4%), pero sólo 103 (60,9%) tenían prescripciones que cumplían las recomendaciones de dosificación. CONCLUSIONES: Más de la mitad de pacientes prescritos con cefalosporinas en un contexto ambulatorio tenían prescripciones consideradas no indicadas, en particular por su uso en infecciones de piel y tejidos blandos purulentas.

BACKGROUND: Misuse of cephalosporins can lead to bacterial resistance. Aim: To determine the prescription profile and indication of cephalosporins in the patients affiliated to the Colombian Health System. METHODS: Cross-sectional study. From a population database, a random sample of patients treated in an outpatient consultation was obtained, to identify the indications of the prescribed cephalosporins in their clinical record. Pharmacological variables, and those related to non-indicated formulations were evaluated according to the clinical practice guidelines. RESULTS: In 381 patients, the mean age was 41.2 ± 15.4 years, and 61.4% (n = 234) were women. Cefalexin was the most widely used (n=318; 83.5%), with a mean duration of treatment of 7.3 ± 3.2 days; followed by cefradine (n = 43; 11.3%), and ceftriaxone (n = 20; 5.2%). The most common uses were for skin and soft tissue infections (n = 177; 46.4% of which 47.5% were purulent), urinary tract infections (n = 70; 18.4%), upper respiratory airway infections (n = 57; 15.0%) and sexually transmitted diseases (n = 21; 5.5%). The use was considered indicated in 169 patients (44.4%), but only 103 (60.9%) had prescriptions that met the dosage recommendations from the clinical practice guidelines. CONCLUSIONS: More than half of the patients prescribed with cephalosporins in the outpatient setting had prescriptions considered not indicated, particularly for their use in purulent skin and soft tissue infections.

Myroides odoratimimus, una causa infrecuente de infección de tejidos blandos y osteomielitis / Myroides odoratimimus, a rare cause of soft tissue infection and osteomyelitis: case report

Resumen Las infecciones por bacterias gramnegativas del género Myroides son muy poco frecuentes y generalmente afectan la piel y tejidos blandos de pacientes con algún grado de inmunocompromiso. Presentamos un caso de una mujer de 23 años, con antecedentes de mielomeningocele operado y pie bot, que cursó con una infección profunda de la extremidad inferior derecha por Myroides odoratimimus. La identificación de especie se realizó con técnica de MALDI-TOF. El tratamiento fue inicialmente con meropenem y ajustado a ciprofloxacina, junto con realizar una amputación supramaleolar derecha.

Abstract Infections due to Gram-negative bacteria of the genus Myroides are very rare and generally affect the skin and soft tissues of patients with some degree of immunocompromise. We present a case of a 23-year-old patient with a history of myelomeningocele surgically resolved at 3 years of age and bot foot, who presented with a deep infection of the right lower extremity by Myroides odoratimimus. The species identification was carried out with MALDI-TOF and the treatment was initially carried out with meropenem and finally then ciprofloxacin, in addition to right supramaleolar amputation.

Community-genotype methicillin-resistant Staphylococcus aureus skin and soft tissue infections in Latin America: a systematic review

ABSTRACT Background: Community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) emerged in the 1990s as a global community pathogen primarily involved in skin and soft tissue infections (SSTIs) and pneumonia. To date, the CG-MRSA SSTI burden in Latin America (LA) has not been assessed. Objective: The main objective of this study was to report the rate and genotypes of community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) causing community-onset skin and soft tissue infections (CO-SSTIs) in LA over the last two decades. In addition, this research determined relevant data related to SSTIs due to CG-MRSA, including risk factors, other invasive diseases, and mortality. Data sources: Relevant literature was searched and extracted from five major databases: Embase, PubMed, LILACS, SciELO, and Web of Science. Methods: A systematic review was performed, and a narrative review was constructed. Results: An analysis of 11 studies identified epidemiological data across LA, with Argentina presenting the highest percentage of SSTIs caused by CG-MRSA (88%). Other countries had rates of CG-MRSA infection ranging from 0 to 51%. Brazil had one of the lowest rates of CG-MRSA SSTI (4.5-25%). In Argentina, being younger than 50 years of age and having purulent lesions were predictive factors for CG-MRSA CO-SSTIs. In addition, the predominant genetic lineages in LA belonged to sequence types 8, 30, and 5 (ST8, ST30, and ST5). Conclusion: There are significant regional differences in the rates of CG-MRSA causing CO-SSTIs. It is not possible to conclude whether or not CG-MRSA CO-SSTIs resulted in more severe SSTI presentations or in a higher mortality rate.

Uso de la escala LRINEC en pacientes con infecciones necrosantes en el miembro superior y su correlación con la morbimortalidad ortopédica / LRINEC score diagnostic value for necrotizing infections of the upper extremity and correlation with morbidity and mortality in orthopedics patients

Objetivo: Utilizar la escala LRINEC en pacientes con infecciones necrosantes de miembros superiores y evaluar su correlación con la morbimortalidad ortopédica. Materiales y Métodos: Se llevó a cabo una revisión sistemática de las historias clínicas de los pacientes operados por nuestro equipo, entre el 1 de marzo de 2015 y el 1 de marzo de 2020. Se registraron los puntajes de la escala LRINEC de cada paciente operado con diagnóstico clínico y posoperatorio de infección necrosante de partes blandas, así como sus antecedentes clínicos, el microorganismo, las complicaciones y la morbimortalidad ortopédica, y otros datos clínicos importantes (tiempo de internación en terapia intensiva, necesidad de asistencia respiratoria mecánica y de diálisis, cantidad de cirugías), y se los comparó con el puntaje. Resultados: Se analizaron 4126 historias clínicas de pacientes operados por nuestro equipo. Tres tuvieron infecciones necrosantes del miembro superior. El puntaje aplicado en forma retrospectiva determinó que todos tenían una alta probabilidad de sufrir una infección necrosante. Los pacientes con puntaje más alto desarrollaron más comorbilidades ortopédicas y clínicas. Conclusiones: La escala LRINEC es un instrumento reproducible para el diagnóstico de infecciones necrosantes de partes blandas y está relacionada con el número de complicaciones y la morbilidad ortopédica, aunque no necesariamente con la cantidad de cirugías realizadas. Nivel de Evidencia: II

Objective: To use the LRINEC scoring system for necrotizing infections of the upper extremity and study its correlation with morbidity and mortality in Orthopedics patients Materials and Methods: We conducted a systematic review of the medical records of patients operated on by our team between March 1, 2015, and March 1, 2020. Data collection included the LRINEC scores of every patient who underwent surgery and had a clinical and postoperative diagnosis of necrotizing soft tissue infection, as well as their clinical history, causative organism, complications, Orthopedics-related morbidity and mortality data, and other significant clinical data (length of intensive care stay, need for mechanical respiratory assistance, need for dialysis, number of surgeries), which were then compared with their respective LRINEC score. Results: The review included 4126 medical records of patients who had undergone surgery by our team. There were three recorded cases of necrotizing infections in the upper extremity. Their LRINEC scores were retrospectively calculated and all of them showed a high risk of developing a necrotizing infection. The patients with the highest scores developed more Orthopedics and other clinical conditions. Conclusions: The LRINEC score is a reproducible method for the diagnosis of necrotizing soft tissue infections and is related to the number of complications and orthopedic conditions, although not necessarily with the number of surgeries. Level of Evidence: II

Inflamación mixta severa con pérdida del techo del canal mandibular: una variación de las infecciones odontogénicas asociada a pericoronaritis / Severe mixed inflammation with loss of the mandibular canal roof: a variation in odontogenic infections associated with pericoronaritis

Las infecciones cuando pasan a ser crónicas y recurrentes como puede ser el caso de una pericoronaritis medicada, mas no tratada una y otra vez, traen como consecuencia resistencia y proliferación bacteriana. Se da el caso de formaciones de tejidos patológicos e imágenes radiográficas que orientan a posibles diagnósticos, que hasta no ser tratadas por medio de diferentes técnicas como la marsupialización o enucleación, con el complemento de la biopsia insicional o exicional que determina el tipo de patología presente. Esto lleva al objetivo general: determinar el tipo de lesión patológica presente en el ángulo y cuerpo mandibular asociado a la ud: 48 Objetivos específicos: Identificar la lesión patológica presente en Angulo y parte del cuerpo mandibular asociada a la ud: 48. Muestra: paciente de 30 años de edad, masculino, caso clínico de una inflamación mixta severa, la clínica y sus hallazgos radiográficos, se sospechaba de un posible queratoquiste, quiste dentígeros o quiste odontogénico ortoqueratinizado, extracción dental ud: 48, retiro y legrado del tejido circundante, toma de biopsia exicional, exámenes de laboratorio, ortopantomografia, tomografía, fotografías clínicas. Metodología: paradigma positivista, enfoque cuantitativo, diseño no experimental. Modalidad de campo, tipo estudio de caso. La entrevista, el instrumento guión de las preguntas para la historia clínica fueron la técnica y el instrumento. Resultados: inflamación mixta severa, lo cual procede de una infección asociada a pericoronaritis recurrente, esto mediante resultado histopatológico. Conclusiones: el estudio histopatológico es quien determina el diagnóstico final a pesar que la clínica induzca a posibles diagnósticos diferenciales(AU)

When infections become chronic and recurrent, such as a medicated pericoronitis, but not treated repeatedly, they result in resistance and bacterial proliferation. There is the case of pathological tissue formations and radiographic images that guide possible diagnoses, which until they are not treated by means of different techniques such as marsupialization or enucleation, with the complement of the incitional or exicional biopsy that determines the type of pathology present. This leads to the general objective: to determine the type of pathological lesion present in the mandibular angle and body associated with ud: 48. Specific objectives: Identify the pathological lesion present in Angle and part of the mandibular body associated with ud: 48. Sample: 30-year-old male patient, clinical case of severe mixed inflammation, clinical symptoms and radiographic findings, suspected of a possible keratocyst, dentigerous cyst or orthokeratinized odontogenic cyst, tooth extraction ud: 48, removal and curettage of the surrounding tissue, exicional biopsy, laboratory tests, orthopantomography, tomography, clinical photographs. Methodology: positivist paradigm, quantitative approach, non-experimental design. Field modality, case study type. The interview, the instrument script the questions for the clinical history were the technique and the instrument. Results: severe mixed inflammation, which comes from an infection associated with recurrent pericoronitis, this through histopathological result. Conclusions: the histopathological study is the one who determines the final diagnosis, despite the fact that the symptoms lead to possible differential diagnoses(AU)

Severe bacterial skin infections

Abstract The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term "necrotizing soft tissue infections". Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.

Infecciones graves de piel y partes blandas. Puesta al día / Severe skin and soft tissue infections. An update

Resumen Las infecciones graves de piel y partes blandas presentan una elevada morbimortalidad y requieren un complejo tratamiento quirúrgico. Su incidencia anual está estimada en 0.3 a 5 casos por 10 000 personas. Los agentes etiológicos más comunes son Streptococcus pyogenes, Staphylococcus aureus, anaerobios y bacilos Gram negativos. El diagnóstico precoz y el tratamiento oportuno, tanto empírico antibiótico como quirúrgico, determinan el pronóstico. Existen nuevas opciones terapéuticas para estas infecciones, especialmente las producidas por gérmenes multirresistentes. Un enfoque terapéutico multidisciplinario es fundamental para su correcto manejo.

Abstract Severe skin and soft tissue infections present a high morbidity and mortality and require a complex surgical treatment. Its estimated annual incidence is 0.3 to 5 cases per 10 000 people. The most common etiologic agents are Streptococcus pyogenes, Staphylococcus aureus, anaerobes and gram-negative bacilli. A prompt diagnosis and the timely initiation of an empirical antibiotic scheme and repeated surgical debridement can avert a worrisome outcome. New therapeutic options are promising, especially for infections caused by multidrug resistant germs. A multidisciplinary approach is fundamental for the correct management of these conditions.

Complete genome sequence of a methicillin-resistant Staphylococcus schleiferi strain from canine otitis externa in Korea

Infecção puerperal / Puerperal infection

Em 1992, a Organização Mundial da Saúde (OMS) propôs a seguinte definição: Sepse puerperal é uma infecção do trato genital ocorrendo, em qualquer momento, entre a ruptura das membranas ou o trabalho e o 42º dia após o parto, no qual estão presentes dois ou mais dos seguintes eventos: • Dor pélvica; • Febre (temperatura oral de 38,5 °C ou superior em qualquer ocasião); • Corrimento vaginal anormal, por exemplo, presença de pus; • Cheiro anormal/mau cheiro do corrimento vaginal; • Atraso na redução do tamanho do útero (<2 cm/dia durante os primeiros oito dias). 1. O conceito de infecção puerperal deve ser complementado com o de morbidade febril puerperal, pela dificuldade de caracterizar a infecção que ocorre logo após o parto. 2. Outras definições que se fazem necessárias são: • Bacteremia: presença de bactérias na corrente sanguínea; • Sepse: síndrome clínica caracterizada pela resposta da hospedeira a um processo infeccioso, acompanhada de uma resposta inflamatória sistêmica; • Sepse grave: sepse associada à disfunção de um ou mais órgãos (sistema nervoso central, renal, pulmonar, hepática, cardíaca, coagulopatia, acidose metabólica); • Choque séptico: sepse com hipotensão refratária à ressuscitação volêmica. 3. A OMS incluiu o termo "infecção puerperal", pois hoje estão morrendo mulheres com infecções de outros locais do corpo.

Clinical practice guidelines: An Opportunity to provide health care with excellence and the new Colombian Guidelines for the diagnosis and management of Skin and Soft tissue infections (SSTIs): [Editorial] / Guías de práctica clínica: Una oportunidad para proveer cuidado de salud de calidad y las nuevas guías colombianas para diagnóstico y manejo de infecciones de tejidos blandos (ITBs): [Editorial]

Clinical practice guidelines (CPGs) are "systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances"1. Guidelines are designed to support the decision-making processes in patient care and therefore can be used to reduce inappropriate discrepancies in clinical practice and to encourage the delivery of health care of better quality. Although CPGs can be developed either locally or nationally it is essential that guidelines be based on the best available research evidence. Then a detailed literature search should be done to find evidence from research studies about the suitability and effectiveness of different clinical approaches. However, in addition to the scientific evidence, the experience of clinical experts and mainly the expectations of patients must also be considered. At present, the advantage of the development of CPGs for a better clinical outcome is not discussed. But a limitation for their dissemination especially in low- and middle-income countries is time and resource consuming and sometimes the shortage of expert professionals' experts in the methodology. Therefore, strategies like using an alternative methodology such as the adaptation of CPGs is very important because not only decreases times but costs for their development.

Las guías de práctica clínica (GPC) son "declaraciones desarrolladas sistemáticamente para ayudar a los profesionales a tomar decisiones sobre la atención sanitaria adecuada en circunstancias clínicas específicas "1. Las guías están diseñadas para apoyar los procesos de toma de decisiones en la atención al paciente y, por tanto, pueden utilizarse para reducir las discrepancias inapropiadas en la práctica clínica y fomentar la prestación de una atención sanitaria de mayor calidad. Aunque las GPC pueden elaborarse a nivel local o nacional, es esencial que las directrices se basen en las mejores pruebas de investigación disponibles. Para ello, debe realizarse una búsqueda bibliográfica detallada para encontrar pruebas de estudios de investigación sobre la idoneidad y la eficacia de los distintos enfoques clínicos. Sin embargo, además de las pruebas científicas, también hay que tener en cuenta la experiencia de los expertos clínicos y, principalmente, las expectativas de los pacientes. En la actualidad, no se discute la ventaja del desarrollo de las GPC para un mejor resultado clínico. Pero una limitación para su difusión, especialmente en los países de ingresos bajos y medios, es el tiempo y los recursos que consumen y, a veces, la escasez de profesionales expertos en la metodología. Por lo tanto, estrategias como el uso de una metodología alternativa como la adaptación de las GPC es muy importante porque no sólo disminuye los tiempos sino los costes para su desarrollo.

Guía de Práctica Clínica para el Diagnóstico y Manejo de las Infecciones de Piel y Tejidos Blandos en Colombia / Clinical Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections in Colombia

Las infecciones de piel y tejidos blandos (IPTB) representan la tercera causa de consulta por enfermedad infecciosas a los servicios médicos, después de las infecciones respiratorias y urinarias. Se presenta una guía de práctica clínica (GPC) con 38 recomendaciones basadas en la evidencia, graduadas bajo el sistema SIGN, para el diagnóstico y tratamiento de pacientes adultos con IPTB en el contexto colombiano, posterior a un proceso de adaptación de GPC publicadas y la búsqueda sistemática y síntesis de literatura para la actualización de la evidencia científica. Además, se realizó un consenso de expertos para la evaluación de las potenciales barreras para la implementación de las recomendaciones y la evaluación del grado de recomendación en el contexto local.

Skin and soft tissue infections (SSTI) represent the third leading cause of infectious disease consultation for medical services after respiratory and urinary tract infections. This document generates a clinical practice guideline with 38 recommendations based on evidence, graduated under the SIGN system for the diagnosis and treatment for SSTI infections in adult patients in Colombia, following a process of adaptation of guidelines published, and the systematic search and synthesis of literature for the updating of scientific evidence. In addition, a consensus of experts was made for the evaluation of the potential barriers for the implementation of the recommendations and the evaluation of the degree of recommendation in the local context.

Infección necrotizante de tejidos blandos: experiencia durante 15 años en un hospital pediátrico / Necrotizing soft tissue infections: experience over 15 years in a pediatric hospital

INTRODUCCIÓN: La Infección Necrotizante de tejidos blandos (INTB) tiene una elevada morbimortalidad. El objetivo de este trabajo es describir del manejo perioperatorio de menores de 15 años que cursaron con INTB durante 15 años en un Hospital pediátrico. MATERIAL Y MÉTODOS: serie de pacientes identificados INTB entre 2000 y 2015 en el Hospital Roberto del Río. Se describen variables demográficas, clínicas, vacuna, tratamiento, cirugías, complicaciones, microorganismos, seguimiento, y fallecimientos. RESULTADOS: 22 pacientes, con mediana de 2 años y 9 meses de edad. 50% estaban cursando con una varicela. Dos fallecieron. Ninguno era previamente vacunado contra el virus varicela zoster. La localización fue tronco (14), extremidades (7), cuello (1). Los pacientes conscientes presentaron hiperestesia cutánea. Se realizó aseo quirúrgico con una mediana de 6,8 horas desde el inicio de la hiperestesia y 2 horas desde la sospecha diagnóstica. Los microorganismos fueron: S. pyogenes (38%) y E. coli (31%). Los antibióticos más frecuentes fueron penicilina más clindamicina. La herida se manejó con cierre primario, injertos y/o colgajos. Cinco evolucionaron con secuelas que necesitaron tratamiento. CONCLUSIÓN: Se identificó que la INTB puede presentarse con varicela. Debe sospecharse en lesiones cutáneas e hiperestesia desproporcionada. Resección amplia y precoz son fundamentales para el tratamiento.

INTRODUCTION: Necrotizing soft tissue infection (NSTI) has a high morbidity and mortality. The objective of this study is to describe the perioperative management of children under 15 years of age who have had this condition for 15 years in a pediatric hospital. MATERIAL AND METHODS: cases series of patients identified by Pathological Anatomy with NSTI during 2000 and 2015 at the Dr. Roberto del Río Hospital. Demographic variables, treatment, antecedents of vaccination, surgeries, complications, microorganisms, follow-up, and deaths are described. RESULTS: 22 patients were identified, with a median of 2 years 9 months of age (interquartile range: 13 months to 5 years y 10 months). 50% of the cases were associated to chickenpox. Two died. No patient was previously vaccinated against varicella zoster virus. The location was trunk (14), extremities (7) and neck (1). All conscious patients presented cutaneous hyperesthesia. Surgical debridement was performed with a median of 6.8 hours from the onset of hyperesthesia and 2 hours from diagnostic suspicion. The most frequent microorganisms were: Streptococcus pyogenes (38%) and Escherichia coli (31%). The most frequent antibiotics used were penicillin plus clindamycin. The wound was handled with primary closure, grafts and / or flaps. Five patients evolved with sequelae that needed treatment. CONCLUSION: It was identified that STNI in children is associated with chickenpox. It should be suspected in cutaneous lesions and disproportionate hyperesthesia. Aggressive resection is essential for treatment

Caracterización fenotípica de variantes pequeñas de Staphylococcus aureus: un nuevo desafío / Phenotypic characterization of small colony variants of Staphylococcus aureus: a new challenge / Caracterizaçao fenotípica de pequenas variantes de Staphylococcus aureus: um novo desafio

En infecciones crónicas y recurrentes por Staphylococcus aureus se han descripto subpoblaciones de colonias pequeñas (VCPSa). El objetivo de este trabajo fue reconocer las características fenotípicas de VCPSa para optimizar su detección y caracterización a partir de materiales clínicos provenientes de infecciones crónicas. Se analizaron n=3 VCPSa de pacientes adultos con infecciones crónicas de tejidos blandos. Las muestras se inocularon en agar nutritivo, agar sangre, agar chocolate y agar Schaedler suplementado. Se realizaron tinción de Gram, catalasa, coagulasa libre, pruebas de dependencia para hemina, menadiona y timidina y, desarrollo/ataque del manitol en agar manitol salado. La sensibilidad antibiótica se efectuó en agar Mueller Hinton suplementado, según las pruebas de dependencia. Se investigó la presencia de proteína ligadora de penicilina anómala (PBP2´) por aglutinación con látex. Las VCPSa se detectaron en los medios de cultivo enriquecidos. Estas bacterias dieron positivas las pruebas de catalasa y coagulasa, y eran dependientes de menadiona y hemina. En los tres aislamientos se observó resistencia a cefoxitina y se detectó la PBP2´.

In chronic and recurrent infections, small colonies of Staphylococcus aureus subpopulations (SCVSa) have been observed. The objective of the present study was to recognize the phenotypic characteristics of SCVSa isolated from patients with chronic infections to optimize their detection. SCVSa of adult patients n=3 with chronic soft tissue infections were analyzed. Samples were inoculated on nutritive agar, blood-agar, chocolate agar and supplemented Schaedler agar. Subsequently, Gram stain, catalase, free coagulase, dependence tests for hemin, menadione and thymidine, and growth/fermentation of mannitol on salt mannitol agar were performed. Antibiotic susceptibility tests were performed by the agar diffusion method on supplemented Mueller Hinton agar, according to dependence assays results. Anomalous penicillin binding protein (PBP2') was investigated by latex agglutination. SCVSa were detected in all enriched culture media. They showed catalase and coagulase activities, and menadione and hemin dependence. By the agar diffusion test, cefoxitin resistance was found in all isolates; PBP2' was detected as well.

Nas infecções crônicas e recorrentes por Staphylococcus aureus, subpopulações de pequenas colônias (VCPSa) foram descritas. O objetivo desse trabalho foi reconhecer as características fenotípicas de VCPSa para otimizar sua detecção e caracterização a partir de materiais clínicos provenientes de infecções crônicas. Foram analisados n=3 VCPSa de pacientes adultos com infecções crônicas de tecidos moles. As amostras foram inoculadas em agar nutritivo, agar sangue; agar chocolate e agar Schaedler enriquecido. Foram realizados testes de coloração de Gram, catalase, coagulase livre, testes de dependência para hemina, menadiona e timidina, e desenvolvimento/fermentação do manitol em agar manitol salgado. A sensibilidade antibiótica foi realizada em agar Mueller Hinton suplementado, de acordo com os testes de dependência. Foi investigada a presença de proteína ligante de penicilina anômala (PBP2´) por aglutinação com látex. Os VCPSa foram detectados em meios de cultura enriquecidos. Estas bactérias deram positivas nos testes de catalase e coagulase positivos e eram dependentes de menadiona e hemina. A resistência à cefoxitina foi detectada nos três isolados e detectou-se a PBP2'.

Early switch/early discharge opportunities for hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections in Brazil

ABSTRACT Background: Early antibiotic switch and early discharge protocols have not been widely studied in Latin America. Our objective was to describe real-world treatment patterns, resource use, and estimate opportunities for early switch from intravenous to oral antibiotics and early discharge for patients hospitalized with methicillin-resistant Staphylococcus aureus complicated skin and soft-tissue infections. Materials/methods: This retrospective medical chart review recruited 72 physicians from Brazil to collect data from patients hospitalized with documented methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections between May 2013 and May 2015, and discharged alive by June 2015. Data collected included clinical characteristics and outcomes, hospital length of stay, methicillin-resistant Staphylococcus aureus-targeted intravenous and oral antibiotic use, and early switch and early discharge eligibility using literature-based and expert-validated criteria. Results: A total of 199 patient charts were reviewed, of which 196 (98.5%) were prescribed methicillin-resistant Staphylococcus aureus -active therapy. Only four patients were switched from intravenous to oral antibiotics while hospitalized. The mean length of methicillin-resistant Staphylococcus aureus-active treatment was 14.7 (standard deviation, 10.1) days, with 14.6 (standard deviation, 10.1) total days of intravenous therapy. The mean length of hospital stay was 22.2 (standard deviation, 23.0) days. The most frequent initial methicillin-resistant Staphylococcus aureus-active therapies were intravenous vancomycin (58.2%), intravenous clindamycin (19.9%), and intravenous daptomycin (6.6%). Thirty-one patients (15.6%) were discharged with methicillin-resistant Staphylococcus aureus -active antibiotics of which 80.6% received oral antibiotics. Sixty-two patients (31.2%) met early switch criteria and potentially could have discontinued intravenous therapy 6.8 (standard deviation, 7.8) days sooner, and 65 patients (32.7%) met early discharge criteria and potentially could have been discharged 5.3 (standard deviation, 7.0) days sooner. Conclusions: Only 2% of patients were switched from intravenous to oral antibiotics in our study while almost one-third were early switch eligible. Additionally, one-third of hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections were early discharge eligible indicating opportunity for reducing intravenous therapy and days of hospital stay. These results provide insight into possible benefits of implementation of early switch/early discharge protocols in Brazil.

Delafloxacin, a New Miracle in Antibiotics Armamentarium for Bacterial Infections

The persistent antibiotics resistant issue has emerged as an influencing factor to deteriorate community health. So, new antibiotics development is urgent for the treatment of bacterial infections. Alternatively, delafloxacin is an eminent new fluoroquinolone, and chemically distinct from older fluoroquinolones. There is lack of proton substituent that indicates the poor acidic property of the drug. It also has a good intracellular penetration capacity that increases the intensity of the bactericidal property in acidic environment. Delafloxacin is a super active drug against the skin and soft tissue infections (SSTIs) and community-acquired respiratory tract infections. Delafloxacin also exhibits better efficacy against pathogens which are resistant to other fluoroquinolones, such as methicillin-resistant Staphylococcus aureus (MRSA). Delafloxacin received approval from the US Food and Drug Administration (FDA) for the treatment of acute bacterial skin and skin structure infections (ABSSI). Phase III clinical trial among patients with community-acquired pneumonia (CAP) is ongoing to evaluate the effectiveness of delafloxacin. From the aforementioned arguments, delafloxacin will be a prominent candidate for the upcoming antibacterial agent. Similarly, delafloxacin can be a crucial drug to fight against ABSSI.