Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection.

INTRODUCTION: Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS: Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS: A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION: The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE: Prognostic, level IV.

New insights into classification, epidemiology and microbiology of SSTIs, including diabetic foot infections.

Skin and soft tissue infections (SSTIs) involve a heterogeneous group of entities with different clinical presentations classified according to several specific criteria. Because of their great variability, their incidence and prevalence is difficult to accurately determine. Yet it is generally thought that the rate of SSTIs is globally increasing due to an aging population, strictly associated with the increase in the number of critical and immunocompromised patients. The aetiology of SSTIs is also extremely variable, reflecting the noteworthy heterogeneity of their clinical presentations and their epidemiology. Gram-positive are far more prevalently than Gram-negative cocci responsible for STTIs globally considered including both aerobe and anaerobe microorganisms. The emergence of multidrug-resistance bacteria represents a serious public health threat which is making antimicrobial therapy less efficacious and more challenging by the day.

[Pathogenesis, classification and diagnosis of necrotizing soft tissue infections]. / Pathogenese, Klassifikation und Diagnose der nekrotisierenden Weichteilinfektionen.

Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

Proposed epidemiological case definition for serious skin infection in children.

AIM: Researching the rising incidence of serious skin infections in children is limited by the lack of a consistent and valid case definition. We aimed to develop and evaluate a good quality case definition, for use in future research and surveillance of these infections. METHODS: We tested the validity of the existing case definition, and then of 11 proposed alternative definitions, by assessing their screening performance when applied to a population of paediatric skin infection cases identified by a chart review of 4 years of admissions to a New Zealand hospital. RESULTS: Previous studies have largely used definitions based on the International Classification of Diseases skin infection subchapter. This definition is highly specific (100%) but poorly sensitive (61%); it fails to capture skin infections of atypical anatomical sites, those secondary to primary skin disease and trauma, and those recorded as additional diagnoses. Including these groups produced a new case definition with 98.9% sensitivity and 98.8% specificity. CONCLUSION: Previous analyses of serious skin infection in children have underestimated the true burden of disease. Using this proposed broader case definition should allow future researchers to produce more valid and comparable estimates of the true burden of these important and increasing infections.

Classification of diabetic foot infections.

The treatment of diabetic foot ulcers is first determined by the presence or absence of infection. Whereas noninfected ulcers typically respond to pressure relief and debridement, the treatment of infected ulcers depends on the degree of systemic involvement and the type and number of invading pathogens. This is the basis of the new classification system proposed by the Infectious Diseases Society of America and briefly described herein. The full report should be available later this year in Clinical Infectious Diseases.

An evidence-based approach to diabetic foot infections.

Foot infections are a major complication of diabetes mellitus and contribute to the development of gangrene and lower extremity amputation. Recent evidence indicates that persons with diabetes are at greater risk for infection because of underlying neuropathy, peripheral vascular disease, and impaired responses to infecting organisms. This article reviews the underlying pathophysiology, causes, microbiology, and current management concepts for this potentially limb-threatening complication. Multidisciplinary management consisting of teams of specialists with a focus on limb preservation can make significant improvements in outcomes, including a reduction in rates of lower extremity amputation.

[Histopathological findings of Buruli ulcer: cases from Benin in west Africa].

"AFIP classification" by light microscopy was of help to analyze the skin lesions of Buruli ulcer, in which the histopathology were classified into 6 stages i.e. active, healing, active but healing, consistent with active and chronic stages. In this paper, skin lesions biopsied from 41 cases of Buruli ulcer were observed by light microscopy. Those were sent from Benin in west Africa at 1997, and under the control of Armed Forces Institute of Pathology(AFIP) in Washington DC, USA. Each age, sex, biopsy lesions and histopathological stage and corresponding characteristic histopathological findings of 41 cases except that of chronic stage were analyzed and herewith reported by this paper.

[Ten clues to the histopathologic diagnosis of infectious skin diseases]. / Zehn Clues zur histopathologischen Diagnose von infektiösen Hautkrankheiten.

Specific diagnoses of infectious skin diseases can be established in dermatopathology by several methods: by algorithms based on pattern analysis, by differential diagnosis of clinicopathologically similar disorders, by attention to pitfalls, by exceptions to the rules and finally, very elegantly by clues. Ten clues to specific diagnoses of infectious skin diseases which are of importance in routine practice are presented. Clue 1: Features of an angiocentric angiodestructive lymphoma in the centre of a wedge-shaped necrotic insect bite reaction are a clue to a bite by a spider. Clue 2: Parakeratosis with spiky imprints on the surface above features of an insect bite reaction are a clue to scabies. Clue 3: A faintly eosinophilic section of a skin specimen with prominent fibrin thrombi and extravasated erythrocytes are a clue to a septic fungal vasculitis. Clue 4: Infectious agents in association with otherwise typical features of leukocytoclastic vasculitis are a clue to septic vasculitis. Clue 5: Steel-grey nuclei with marginated nucleoplasm of keratinocytes are a clue to the diagnosis of early infection by herpes virus. Clue 6: Owleye-like cells are a clue to infection by cytomegalovirus. Clue 7: Detection of Entamoeba histolytica in perianal and perineal ulcers are a clue to amebiasis. Clue 8: Round-oval to rectangular spaces within the stratum spinosum of the epidermis are a clue to larva migrans. Clue 9: Macrophages and plasma cells in association with otherwise typical features of pityriasis lichenoides are a clue to secondary syphilis. Clue 10: A lichenoid infiltrate of lymphocytes and plasma cells are a clue to acrodermatitis chronica atrophicans.

Detection of a new Mycobacterium species in wild striped bass in the Chesapeake Bay.

Investigation into recent declines in striped bass health in the Chesapeake Bay in Maryland resulted in the isolation of a putative new species of Mycobacterium. This isolate was obtained from fish showing skin ulcers and internal granulomas in various organs. The isolate was slow growing at 28 degrees C; was nonchromogenic; showed no activities of nitrate reduction, catalase activity, Tween 80 hydrolysis, tellurite reduction, or arylsulfatase reduction; grew best at low salt concentrations; and was urease and pyrazinamidase positive. By PCR a unique insertional sequence was identified which matched nothing in any database. Analysis of the nearly complete 16S rRNA gene sequence also indicated a unique sequence which had 87.7% sequence homology to Mycobacterium ulcerans, 87.6% homology to Mycobacterium tuberculosis, and 85.9% homology to Mycobacterium marinum. Phylogenetic analysis placed the organism close to the tuberculosis complex. These data support the conclusion that the isolate probably represents a new mycobacterial species.

El cirujano de urgencia ante las infecciones cutáneas / The emergency surgeon in the skin infections

Se presenta una revisión bibliográfica en relación a las infecciones cutáneas más graves y la conducta que debe tener el cirujano de urgencia frente a ellas

[Cutaneous mycobacteriosis]. / Mycobactérioses cutanées.

Tuberculosis is reappearing, due to diminished surveillance, illegal immigration, the HIV epidemic and certainly also due to emerging resistance. The clinical expression of cutaneous tuberculosis depends on the stage of development, the clinical background and the virulence of the germ. Diagnosis is predominantly clinical, but laboratory results also play a role. Treatment involves the quadruple antibiotic treatment prescribed for any tubercular infection. Atypical mycobacteria are widespread throughout the environment and are pathogenic, but also saprophytic, comensal and opportunistic, figure a favourable setting in the immunodeficient individual. Following entry by penetrance, the early lesion is papulonodulary, nodulary, keratoid, crusted, ulcerated, sporotrichoid, generally without peripheral adenopathy. Histological examination discloses a granulomatous reaction limiting the development of the infection; such development is absent in the immunodeficient patient, thus explaining the spread. The most common mycobacterial infection in France, generally in the immunocompetent individual, is "aquarium disease" which follows a benign course; the most common in tropical areas is Mycobacterium ulcerans; whereas Mycobacterium avium intracellulare, fortuitum and chelonae cause, in the immunodeficient patient, severe and extensive infection. Treatment should start as soon as diagnosis is made and the germ identified.

Piodermites primárias / Primaries pyodermas

Os autores apresentam uma revisao sobre a classificaçao das piodermites.Inicialmente,expondo uma classificaçao atual das piodermites primárias com seus respectivos agentes etiólogicos,detalhando a seguir dados clínicos utilizados para a acaracterizaçao de cada tipo,para posterior tratamento.