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Background: Safe consumption sites (SCS) are an evidence-based intervention to prevent drug use-related harm. In late 2014, an organisation in an undisclosed location in the USA opened an unsanctioned SCS., Objective: To evaluate whether use of the unsanctioned SCS affected medical outcomes., Design: A prospective cohort study., Setting: Neighbourhoods surrounding the SCS., Participants: People who injected drugs were recruited and interviewed at baseline and 6 and 12 months from 2018 to 2020., Intervention: People using the SCS could bring pre-obtained drugs to consume via injection, which were monitored by trained staff with naloxone., Main Measures: Any overdose, number of non-fatal overdoses, skin and soft tissue infections, emergency department utilisation, number of emergency department visits, hospitalisation and number of nights spent in hospital., Key Results: A total of 494 participants enrolled in the study; 59 (12%) used the SCS at least once. We used propensity score weighting to analyse the association between SCS utilisation and measures. People using the SCS were 27% (95% CI: 12-46%) less likely to visit the emergency department, had 54% (95% CI: 33-71%) fewer emergency department visits, were 32% (95% CI: 4-57%) less likely to be hospitalised, and spent 50% (95% CI: 1-85%) fewer nights in hospital. Though not significant, people using the SCS had a lower likelihood of overdosing and slightly higher likelihood of skin and soft tissue infections., Conclusions: Our findings support the use of SCS in the USA to reduce the growing burden of acute care service utilisation related to injection drug use., (© 2021. The Author(s) under exclusive licence to Society of General Internal Medicine.)

To our knowledge, this is the first work on drug susceptibility patterns of rapid growing mycobacteria from Latin America. The susceptibility patterns for 14 antimicrobial agents of the three most important species that cause skin infections in Venezuela were determined as follows: 63 strains belonging to Mycobacterium abscessus group, 66 strains of the Mycobacterium fortuitum group, and 13 Mycobacterium chelonae strains. The M. abscessus group strains were resistant to most antibiotics tested while M. fortuitum strains were relatively susceptible to a large number of antibiotics. We demonstrate the presence of an inducible and truncated erm(41) gene in M. abscessus group, namely M. abscessus subsp. massiliense. We show the variations in susceptibility to antimicrobial agents within and between the mycobacterial species and compare our susceptibility patterns with those reported from other countries. We conclude that the identification of mycobacteria to the species level can guide the antibiotic treatment, but that it is always important to consider drug susceptibility testing when rapidly mycobacteria are isolated.

Acute bacterial skin and skin structure infections (ABSSSI) is a common cause of acute admissions worldwide, but the disease is not well understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. To understand the utility of blood cultures and the association between bacteremia and mortality in patients with ABSSSI, we conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in patients with ABSSSI. A retrospective cohort study of hospitalized adult patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016. A total of 1322 hospitalized patients with ABSSSI are included. The overall mortality rate is 2.1% (28/1322), and 122 patients had positive blood culture results. Comorbidities that are significant risk factors for a positive blood culture include diabetes mellitus and chronic kidney disease. Significant risk factors evident in laboratory evaluations include high C-reactive protein (CRP) level (> 20 mg/dL), hyperglycemia, and hypoalbuminemia. Bacteremia is also a significant factor associated with mortality. A blood culture should be considered for patients with ABSSSI with diabetes mellitus or chronic kidney disease or those exhibiting abnormal CRP, glucose, or albumin levels because of the positive correlation between bacteremia and mortality.

New Zealand children suffer from high rates of skin and soft tissue infection (SSTI). Staphylococcus aureus colonisation is known to increase the risk of nosocomial infection. We aimed to determine whether S. aureus colonisation also increased the risk of community-onset SSTI. This study, performed within the Growing Up in New Zealand cohort, used interview and administrative data, and bacterial culture results from the nose, throat, and skin swabs collected at 4½ years of age. Multivariable log-binomial regression was used to derive adjusted risk ratios. S. aureus was isolated from 2225/5126 (43.4%) children. SSTI affected 1509/5126 (29.4%) children before age five. S. aureus colonisation at any site was associated with SSTI (aRR = 1.09, 95%CI 1.01-1.19), particularly in the year prior to swab collection (aRR = 1.18, 95%CI 1.02-1.37). The strongest association was between skin colonisation and SSTI within the year prior to swab collection (aRR = 1.47, 95%CI 1.14-1.84). Socioeconomic and ethnic variables remained independent determinants of SSTI. S. aureus colonisation was associated with an increased risk of community-onset SSTI. Socioeconomic and ethnic factors and eczema had independent effects on SSTI risk. Interventions which reduce the prevalence of S. aureus colonisation may be expected to reduce the incidence of community-onset SSTI.

Objectives: We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics., Methods: We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method., Results: The survey response rate was 36.9% (n=391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10., Conclusions: The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.

Objective: to investigate an outbreak of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) USA300 in a hospital setting, and the effect of infection control measures., Design: outbreak investigation and retrospective chart review., Setting: local inpatient and outpatient clinic., Patients: all patients with a history of skin and soft tissue infections with culture-confirmed methicillin-resistant Staphylococcus aureus USA 300 infection from September, 2014, through June, 2015., Interventions: an outbreak investigation with a "search and destroy" policy was carried out. A review of infection control practices was conducted. Chart reviews were conducted to study the management and outcomes of the patients. Infection control measures included education and cultures of skin colonization sites (anterior nares, pharynx, perineum). Specific decontamination schemes for uncomplicated and complicated carriers were enforced. Separate decontamination schemes for neonates and children under 5 years of age were implemented., Results: between September 2014 and June 2015, 12 clinical cases and six carriers were identified. Of the twelve clinical presentations with positive cultures, eight were children. Of the four patients who had a relapse, three were children (75%). After outbreak investigation and infection control measures have been implemented, three persistent carriers remained. A policy of periodic screening, consultation, and watchful waiting for skin infections was instituted for these patients. No new cases linked to the CA-MRSA outbreak have since been reported., Conclusion: we report the first Belgian outbreak of CA-MRSA USA300 in this article. A strict search and destroy strategy and continued surveillance are required in the management of CA-MRSA USA300.

Comparatively few studies have been published describing Staphylococcus aureus/MRSA epidemiology in Central Asia including Pakistan. Here, we report the genotyping of Staphylococcus aureus strains (that include both methicillin-susceptible and methicillin-resistant Staphylococcus aureus) from community- and hospital-acquired skin and soft-tissue infections in a tertiary care hospital in the Malakand district of the Khyber Pakhtunkhwa Province of Pakistan. Forty-five isolates of Staphylococcus aureus were characterized by microarray hybridization. Twenty isolates (44 %) were MRSA, whereas 22 (49 %) were PVL-positive. Fourteen isolates (31 %) harboured both mecA and PVL genes. The dominant clones were CC121-MSSA (n = 15, 33 %) and the PVL-positive "Bengal Bay Clone" (ST772-MRSA-V; n = 13, 29 %). The PVL-positive CC8-MRSA-IV strain "USA300" was found once. The pandemic ST239-MRSA-III strain was absent, although it has previously been observed in Pakistan. These observations require a re-assessment of schemes for initial antibiotic therapy to cover MRSA and they emphasise the need for a rapid and non-molecular test for PVL.

Skin and soft tissue infections (SSTIs) are common in the era of community-associated methicillin-resistant Staphylococcus aureus (MRSA) among human immunodeficiency virus (HIV)-infected patients, but the risk factors are not well defined. We sought to elucidate the risk factors for SSTI occurrence in an HIV cohort. This investigation was a retrospective, single-center cohort study, carried out during the period 2005-2009. In this cohort of 511 HIV-infected individuals, 133 SSTIs occurred in 87 individuals over 1,228.6 person-years of follow-up, for an incidence of 108 SSTIs/1,000 person-years [95 % confidence interval (CI) 87-135]. The incidence declined significantly over time (p < 0.01). In a multivariable Cox regression, diabetes [hazard ratio (HR) 2.01; 95 % CI 1.04-3.89], psoriasis (HR 5.77; 95 % CI 1.86-17.9), lymphedema (HR 6.84; 95 % CI 2.59-18.1), intravenous catheter presence (HR 3.38; 95 % CI 1.00-11.5), and HIV viral load greater than 1,000 copies/mL (HR 2.13; 95 % CI 1.33-3.41) were most strongly associated with development of the first SSTI. Trends toward an association between SSTI risk and Medicaid insurance (HR 1.67; 95 % CI 0.98-2.83) and sexually transmitted disease during follow-up (HR 1.66; 0.99-2.78) were present. CD4+ count and trimethoprim-sulfamethoxazole use were not associated with SSTI risk. HIV-infected individuals are at high risk for SSTIs. In a primarily urban, African-American cohort, we found that a number of immunologic and demographic factors were associated with SSTI risk.

In the UK, methicillin-resistant Staphylococcus aureus (MRSA)-associated skin and soft tissue infections (SSTIs) are predominantly managed in the hospital using intravenous (IV) glycopeptides. We set out to explore the potential for and relative healthcare costs of earlier hospital discharge through switch to oral antibiotic therapy (linezolid or rifampicin and doxycycline) or continuation of IV therapy (teicoplanin) via an outpatient parenteral antimicrobial therapy (OPAT) service. Over 16 months, 173 patients were retrospectively identified with MRSA SSTI, of whom 82.8 % were treated with IV therapy. Thirty-seven patients were potentially suitable for earlier discharge with outpatient therapy. The model assumed 3 days of inpatient management and a maximum of 14 days of outpatient therapy. For the status quo, where patients received only inpatient care with IV therapy, hospital costs were calculated at £12,316 per patient, with 97 % of costs accounted for by direct bed day costs. The mean total cost savings achievable through OPAT or oral therapy was estimated to be £6,136 and £6,159 per patient treated, respectively. A significant proportion of patients with MRSA SSTI may be suitable for outpatient management with either oral therapy or via OPAT, with the potential for significant reduction in healthcare costs.

Background: Community-associated methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of skin and soft tissue infection (SSTI) worldwide. The prevalence of MRSA in SSTIs across Canada has not been well described. Studies in the United States have shown significant geographic variability in the prevalence of MRSA. This study characterizes the geographic prevalence and microbiology of MRSA in patients presenting to Canadian emergency departments with SSTIs., Methods: Using a prospective, observational design, we enrolled patients with acute purulent SSTIs presenting to 17 hospital emergency departments and 2 community health centres (spanning 6 Canadian provinces) between July 1, 2008, and April 30, 2009. Eligible patients were those whose wound cultures grew S. aureus. MRSA isolates were characterized by antimicrobial susceptibility testing and pulsed-field gel electrophoresis. All patients were subjected to a structured chart audit, and patients whose wound swabs grew MRSA were contacted by telephone to gather detailed information regarding risk factors for MRSA infection, history of illness, and outcomes., Results: Of the 1,353 S. aureus-positive encounters recorded, 431 (32%) grew MRSA and 922 (68%) wounds grew methicillin-susceptible S. aureus. We observed significant variation in both the prevalence of MRSA (11-100%) and the proportion of community-associated strains of MRSA (0-100%) across our study sites, with a significantly higher prevalence of MRSA in western Canada., Interpretation: MRSA continues to emerge across Canada, and the prevalence of MRSA in SSTIs across Canada is variable and higher than previously expected.

This study investigated the clinical characteristics of patients with skin and soft-tissue infections (SSTIs) due to Aeromonas species. Patients with SSTIs caused by Aeromonas species during the period from January 2009 to December 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. A total of 129 patients with SSTIs due to Aeromonas species were identified. A. hydrophila (n = 77, 59.7 %) was the most common pathogen, followed by A. veronii biovar sobria (n = 22, 17.1 %), A. veronii biovar veronii (n = 20, 15.5 %), A. caviae (n = 9, 7.0 %), and A. schubertii (n = 1, 0.8 %). The most common isolates obtained from patients with polymicrobial infections were Klebsiella species (n = 33), followed by Enterococcus spp. (n = 24), Enterobacter spp. (n = 21), Escherichia coli (n = 17), Staphylococcus spp. (n = 17), Streptococcus spp. (n = 17), and Acinetobacter spp. (n = 15). Liver cirrhosis and concomitant bacteremia were more common among patients with monomicrobial Aeromonas SSTIs than among patients with polymicrobial SSTIs. Nine (7 %) patients required limb amputations. The in-hospital mortality rate was 1.6 %. In conclusion, Aeromonas species should be considered as important causative pathogens of SSTIs, and most infections are polymicrobial. In addition, the clinical presentation differs markedly between patients with monomicrobial and those with polymicrobial Aeromonas SSTIs.

Objective: The objective of this study was to determine whether skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) in patients presenting to The Ottawa Hospital emergency departments (TOHEDs) differed from SSTIs caused by methicillin-susceptible Staphylococcus aureus (MSSA) with regard to risk factors, management, and outcomes., Methods: All patients seen at TOHEDs in 2006 and 2007 with SSTIs who yielded MRSA or MSSA in cultures from the site of infection were eligible for inclusion. We excluded patients with decubitus ulcers and infections related to diabetes or peripheral vascular disease. We used an unmatched case-control design. Cases were defined as patients with MRSA isolated from the infection site, and controls were defined as patients with MSSA isolated from the infection site. Data were collected retrospectively from health records and laboratory and hospital information systems., Results: A total of 153 patients were included in the study (81 cases and 72 controls). The mean age of cases was 37 years, compared to 47 years for the controls (p < 0.001). Cases were more likely to have transient residence (31% v. 3% [OR 15.6, 95% CI 3.9-61.8, p < 0.001]), present with abscesses (64% v. 15% [OR 9.9, 95% CI 4.3-23.7, p < .001]), have a documented history of hepatitis C infection (28% v. 3% [OR 13.9, 95% CI 3.9-55.0, p < 0.001]), and have a history of substance abuse (53% v. 10% [OR 10.5, 95% CI 4.4-25.1, p < 0.001]). Cases most commonly used crack cocaine and injection drugs., Conclusion: SSTIs caused by MRSA at TOHEDs mainly occur in a population that is young and transient with comorbidities such as hepatitis C and substance abuse.

Background: More than 30 years since it was developed for clinical use, the third-generation cephalosporin ceftriaxone remains the most commonly used agent for outpatient parental antimicrobial therapy (OPAT). Recent antimicrobial stewardship programmes have tended to restrict ceftriaxone use in hospitals to control antibiotic resistance and outbreaks of Clostridium difficle infection (CDI). Considering the expansion of OPAT programmes both in the UK and worldwide, revisiting the role of ceftriaxone in OPAT in the context of changing antimicrobial prescribing practices is timely., Aim of the Review: To identify the evidence base for OPAT, review current and historical data on indications for, and safety of ceftriaxone within the OPAT setting, and to provide some perspectives on the future role of ceftriaxone., Method: We searched PubMed and Scopus for articles published in English, and hand searched reference lists. We also conducted a complementary descriptive analysis of prospectively acquired data on the use of ceftriaxone in more than 1,300 OPAT episodes over a 10-year period in our UK centre., Results: Ceftriaxone has an excellent safety profile in the OPAT setting, and its broad spectrum of activity makes it an established agent in a wide range of clinical infection syndromes, such as skin and soft-tissue infection, bone and joint infection, streptococcal endocarditis and several others. Intriguingly, in contrast to the inpatient setting, liberal use of ceftriaxone in OPAT has not been strongly linked to CDI, suggesting additional patient and environmental factors may be important in mediating CDI risk.

The purpose of this investigation was to determine the prevalence of community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) and Panton-Valentine leucocidin (PVL)-positive S. aureus in general practice (GP) patients with skin and soft tissue infections (SSTI) in the northern (Groningen and Drenthe) and southern (Limburg) regions of The Netherlands. Secondary objectives were to assess the possible risk factors for patients with SSTI caused by S. aureus and PVL-positive S. aureus using a questionnaire-based survey. From 2007 to 2008, wound and nose cultures were obtained from patients with SSTI in general practice. These swabs were analysed for the presence of S. aureus and the antibiotic susceptibility was determined. The presence of the PVL toxin gene was determined by polymerase chain reaction (PCR) and the genetic background with the use of spa typing. A survey was performed to detect risk factors for S. aureus infection and for the presence of PVL toxin.S. aureus was isolated from 219 out of 314 (70%) patients with SSTI, of which two (0.9%) patients were MRSA-positive. In 25 (11%) patients, the PVL toxin gene was found. A higher prevalence of PVL-positive S. aureus of patients with SSTI was found in the northern region compared to the south (p < 0.05). Regional differences were found in the spa types of PVL-positive S. aureus isolates, and for PVL-negative S. aureus isolates, the genetic background was similar in both regions. The prevalence of CA-MRSA in GP patients with SSTI in The Netherlands is low. Regional differences were found in the prevalence of PVL-positive S. aureus isolates from GP patients with SSTI. Household contacts having similar symptoms were found to be a risk factor for SSTI with S. aureus.

A rise in community-onset Staphylococcus aureus infections has been observed in European countries. To ascertain secular trends of S. aureus infections in primary healthcare in Denmark, we conducted this register-based study in the North Denmark region, during the period 1997-2008. We identified all skin and mucosa specimens obtained by general practitioners and all prescriptions for the preferred oral anti-staphylococcal antibiotic, dicloxacillin. Repeat observations within a 12-month period were excluded prior to the calculation of age and gender standardised incidence rates per 100,000 person-years. We included 108,758 specimens, of which 42,778 (39%) yielded S. aureus. The annual incidence rate of specimens doubled during the study period, reaching 2,399 in 2008. The overall rate of S. aureus isolates increased 2-fold to a stable rate at about 850, but for isolates from children and for impetigo specimens, the increase was steeper, with a peak in 2002. A total of 156,462 dicloxacillin prescriptions had been redeemed and the annual prescription rate increased 2.5-fold, peaking at 3,714 in 2007. In conclusion, the annual rates of specimens, S. aureus infections and dicloxacillin prescriptions more than doubled in primary healthcare during the 12-year study period. A major impetigo epidemic and calls for antibiotic stewardship with increased utilisation of specimens were contributing factors.

In order to evaluate the incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Portugal, we analyzed a collection of 38 S. aureus isolates recovered from 30 children attending the pediatric emergency department of a central hospital in Lisbon due to skin and soft tissue infections. Molecular characterization identified seven clonal lineages among the 35 methicillin-susceptible S. aureus (MSSA) isolates, of which the major lineage PFGE A/t159/ST121 included 63% of the isolates. The three MRSA isolates belonged to the Pediatric clone PFGE D/t535/ST5-IV (n = 2) and to the European CA-MRSA clone PFGE G/t044/ST80-IVc (n = 1). All isolates harbored several virulence factors, namely, leukocidins. Panton-Valentine leukocidin (PVL) was produced by isolates from five MSSA lineages and by the ST80 MRSA. Of interest, this is the first reported isolation of CA-MRSA ST80 in Portugal.

Skin and soft tissue infections (SSTIs) are common complications of illicit drug use. Studies at single, urban hospitals demonstrate high rates of emergency department visits and hospitalizations for these infections. This study sought to estimate nationwide and regional incidence and costs of hospitalizations for illicit drug users with SSTIs in the US. AHRQ's Nationwide Inpatient Sample was used to conduct a retrospective cross-sectional, time-series study. Hospitalizations of illicit drug users with SSTIs were identified using International Classification of Diseases, 9th Revision Clinical Modification codes. An estimated 106,126 hospitalizations for illicit drug users with SSTIs represented 0.07% of all US non-Federal hospitalizations from 1998 to 2001 and cost over 193 million dollars in 2001. Higher rates of hospitalization were found in the West, Northeast, and urban teaching hospitals. Hospitalization rates for illicit drug users with SSTIs vary significantly according to US region. Resources to reduce the incidence and severity of these infections should be targeted accordingly.

Objective: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), which is caused primarily by the Canadian methicillin-resistant Staphylococcus aureus-10 (CMRSA-10) strain (also known as the USA300 strain) has emerged rapidly in the United States and is now emerging in Canada. We assessed the prevalence, risk factors, microbiological characteristics and outcomes of CA-MRSA in patients with purulent skin and soft tissue infections (SSTIs) presenting to emergency departments (EDs) in the Greater Toronto Area., Methods: Patients with Staphylococcus aureus SSTIs who presented to 7 EDs between Mar. 1 and Jun. 30, 2007, were eligible for inclusion in this study. Antimicrobial susceptibilities and molecular characteristics of MRSA strains were identified. Demographic, risk factor and clinical data were collected through telephone interviews., Results: MRSA was isolated from 58 (19%) of 299 eligible patients. CMRSA-10 was identified at 6 of the 7 study sites and accounted for 29 (50%) of all cases of MRSA. Telephone interviews were completed for 161 of the eligible patients. Individuals with CMRSA-10 were younger (median 34 v. 63 yr, p = 0.002), less likely to report recent antibiotic use (22% v. 67%, p = 0.046) or health care-related risk factors (33% v. 72%, p = 0.097) and more likely to report community-related risk factors (56% v. 6%, p = 0.008) than patients with other MRSA strains. CMRSA-10 SSTIs were treated with incision and drainage (1 patient), antibiotic therapy (3 patients) or both (5 patients), and all resolved. CMRSA-10 isolates were susceptible to clindamycin, tetracycline and trimethoprim-sulfamethoxazole., Conclusion: CA-MRSA is a significant cause of SSTIs in the Greater Toronto Area, and can affect patients without known community-related risk factors. The changing epidemiology of CA-MRSA necessitates further surveillance to inform prevention strategies and empiric treatment guidelines.

Objective: We sought to estimate the period prevalence of methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) and evaluate risk factors for MRSA SSTI in an emergency department (ED) population., Methods: We carried out a cohort study with a nested case-control design. Patients presenting to our ED with a wound culture and a discharge diagnosis of SSTI between January 2003 and September 2004 were dichotomized as MRSA positive or negative. Fifty patients with MRSA SSTI matched by calendar time to 100 controls with MRSA-negative SSTI had risk factors assessed using multivariate conditional logistic regression., Results: Period prevalence of MRSA SSTI was 54.8% (95% confidence interval [CI] 50.2%-59.4%). The monthly period prevalence increased from 21% in January 2003 to 68% in September 2004 (p < 0.01). Risk factors for MRSA SSTI were injection drug use (IDU) (odds ratio [OR] 4.6, 95% CI 1.4-16.1), previous MRSA infection and colonization (OR 6.4, 95% CI 2.1-19.8), antibiotics in 8 weeks preceding index visit (OR 2.6, 95% CI 1.2-8.1), diabetes mellitus (OR 4.1, 95% CI 1.4-12.1), abscess (OR 5.6, 95% CI 1.8-17.1) and admission to hospital in previous 12 months (OR 2.6, 95% CI 1.1-11.2)., Conclusion: The period prevalence of MRSA SSTI between January 2003 and September 2004 was 54.8% at our institution. There was a marked increase in the monthly period prevalence from the beginning to the end of the study. Risk factors are IDU, previous MRSA infection and colonization, prescriptions for antibiotics in previous 8 weeks and admission to hospital in the preceding 12 months. On the basis of local prevalence and risk factor patterns, emergency physicians should consider MRSA as a causative agent for SSTI.

Objective: To assess the incidence of postoperative wound infections related to treatment with medicinal leeches at Ghent University Hospital., Method: A 2-year retrospective analysis of bacteriologic culture results of soft tissue infections in patients treated with medicinal leeches., Results: Cultures of suspected wound infections were taken and susceptibility testing of isolates was performed on 17 of 47 patients (36.2%). Aeromonas was frequently isolated (18.5%)., Conclusions: A high incidence of infection during and after application of medicinal leeches, despite their external decontamination, necessitates an antibiotic prophylaxis. In particular Aeromonas must be covered, as soft tissue infections with these bacteria can give serious complications. The prophylactic antibiotic should cover the most frequent isolated species taking into account the importance of Aeromonas and the susceptibility pattern. Based on the results, fluoroquinolones seem to be a good choice. The authors believe that practical recommendations to hospital pharmacists on prophylaxis during Hirudo medicinalis treatment, might enhance the safety of it's use by reducing the number of infections.

Background: Soft tissue infections (STIs) from injection drug use are a common cause of Emergency Department visits, hospitalizations, and operating room procedures, yet little is known about factors that may predict the need for these costly medical services., Objective: To describe a cohort of injection drug users seeking Emergency Department care for STIs and to identify risk factors associated with hospitalization. We hypothesized that participants who delayed seeking care would be hospitalized more often than those who did not., Design: Cohort study using in-person structured interviews and medical record review. Logistic regression assessed the association between hospital admission and delay in seeking care as well as other demographic, clinical, and psychosocial factors., Participants: Injection drug users who sought Emergency Department care for STIs from May 2001 to March 2002., Results: Of the 136 participants, 55 (40%) were admitted to the hospital. Delay in seeking care was not associated with hospital admission. Participants admitted for their infection were significantly more likely to be living in a shelter (P = .01) and to report being hospitalized 2 or more times in the past year (P < .01)., Conclusions: We identified a subpopulation of injection drug users, mostly living in shelters, who were hospitalized frequently in the past year and who were more likely to be hospitalized for their current infections compared to others. As members of this subpopulation can be easily identified and located, they may benefit from interventions to reduce the health care utilization resulting from these infections.

Drug related-soft tissue infections (DR-STIs) are a significant source of hospital utilization in inner-city urban areas where injection drug use is common but the magnitude of hospital utilization for DR-STIs outside of inner-city urban areas is not known. We described the magnitude and characteristics of hospital utilization for DR-STIs in urban versus rural counties in California. All discharges from all nonfederal hospitals in California in 2000 with ICD-9 codes for a soft tissue infection and for drug dependence/abuse were abstracted from the California Office of Statewide Health Planning and Development discharge database. There were 4,152 DR-STI discharges in 2000 from hospitals in 49 of California's 58 counties. Residents of 12 large metropolitan counties accounted for 3,598 discharges (87% of total). The majority of DR-STI discharges were from urban safety net hospitals with county indigent programs and Medicaid as the expected payment source and opiate related discharge diagnoses. Hospital utilization for DR-STIs in California is highest in large urban metropolitan counties, although DR-STI discharges are widespread. Increased access to harm reduction services and drug treatment may reduce government health care expenditures by preventing unnecessary hospital utilization for DR-STIs.

Antimicrobial resistance patterns among the principal bacterial pathogens from infections of the respiratory tract, blood, skin and soft tissue, and urinary tract of pediatric patients from the USA, Canada, Germany, France, and Italy were studied using the The Surveillance Network (TSN) database. Among Streptococcus pneumoniae isolates from respiratory tract infections, the prevalence of high-level penicillin resistance (MIC>/=2 microg/ml) ranged from 1.1 (Italy) to 36.2% (USA); erythromycin resistance was higher, ranging from 13.4 (Germany) to 63.8% (France). The prevalence of beta-lactamase-positive Haemophilus influenzae among isolates from lower respiratory tract infections ranged from <10 (Italy and Germany) to 38.4% (USA). Among isolates from blood and skin and soft tissue infections, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) ranged from 7.2% (Canada and Germany) to 27.3% (Italy). The prevalence of Escherichia coli and Klebsiella pneumoniae with putative extended-spectrum beta-lactamases among isolates from blood, urinary tract, and skin and soft tissue infections ranged from 0 (Germany and France) to 29.6% (Italy). With the exception of pseudomonal infections or infections with MRSA, amoxicillin-clavulanate retained moderate activity, whilst ceftriaxone and cefepime were the most effective broad-spectrum injectable agents. Meropenem was the most effective agent against Pseudomonas aeruginosa with <5% resistance. Low levels of resistance, along with acceptable safety profiles and the availability of convenient oral formulations, continue to support the use of ceftriaxone, cefepime, amoxicillin-clavulanate, and meropenem as viable options for the treatment of infections in pediatric patients.

The prevalence of soft tissue infections (abscesses, cellulitides, infected ulcers) among injection drug users (IDUs) is estimated to be between 21% and 32%. Little is known regarding the health care utilization associated with these infections. This study describes IDUs seeking emergency department (ED) care for soft tissue infections, their inpatient health care utilization, including operating room procedures, and the types and locations of infections associated with increased inpatient health care utilization. This study used a medical record case series of all IDUs seeking initial care for soft tissue infections at an urban, public emergency department from November 1999 through April 2000. Initial care for IDU-related soft tissue infections was sought by 242 patients. Most were male (63.6%), Caucasian (69.4%) and without health insurance (52.0%), and most had abscesses (72.3%). All patients with only cellulitis had arm or leg infections, while most abscesses were arm, deltoid, or buttock infections (81.1%). Forty percent of the patients were hospitalized, and 44.3% of the hospitalizations were for 3 or more days. Patients with only cellulitis were more likely to be hospitalized compared to those with abscesses. Among those with abscesses, deltoid abscesses were 5.2 times more likely to receive an operating room procedure compared to other abscess locations. IDUs with cellulitis and deltoid abscesses commonly required inpatient care and operating room procedures. The morbidity associated with such infections and the intensive use of hospital services needed to treat these infections provide strong rationale for the development of preventive interventions and improved care for this neglected clinical problem.

The SENTRY Antimicrobial Surveillance Programme was established to provide a coordinated, standardised, international surveillance on antimicrobial resistance. In one part of the programme, isolates from skin and soft tissue infections sent from 20 hospitals in 12 different European countries were investigated in the European coordinating centre. Of 1013 isolates, Staphylococcus aureus and Pseudomonas aeruginosa were the most significant species, constituting almost 50% of the referred isolates. Methicillin resistance in Staphylococcus aureus averaged 22% across Europe, only slightly less than that in isolates derived from blood. Less than 5% of the enterococcal isolates were resistant to vancomycin. Piperacillin/tazobactam was the most active penicillin-derived beta-lactam compound against Pseudomonas aeruginosa, inhibiting 91.3% of the isolates, while ceftazidime and cefepime were the most active cephalosporins, inhibiting 85.8% and 80.3% of the isolates, respectively. Putative extended-spectrum beta-lactamase production was not detected in Escherichia coli and was found in only 5.1% of the Klebsiella pneumoniae isolates. In general, strains of the family Enterobacteriaceae remained mostly susceptible to carbapenems, cefepime, and amikacin.

A study of determinants of outcome in adult patients with intra-abdominal or skin/soft tissue infections treated with cefotetan, cefoxitin, or ampicillin/sulbactam monotherapy was undertaken. Patients were matched for principal infectious process, surgery performed for the management of the infection, year of hospital admission, age, and sex. The criteria for inclusion, exclusion, and matching of patients and assignment of clinical and microbiological outcome were based on the 1992 Infectious Diseases Society of America/Federal Drug Administration guidelines for the evaluation of anti-infective drug products. One hundred and thirty-seven cases of intra-abdominal or skin and soft tissue infections treated with cefotetan (n = 47), cefoxitin (n = 43), or ampicillin/sulbactam (n = 47) monotherapy were selected without knowledge of outcome and analyzed using a single blinded analysis. The baseline characteristics did not differ between the treatment groups, nor did the rates of clinical or microbiological failure. A multivariate analysis showed that isolation of an organism resistant to the treatment regimen, including Pseudomonas spp., [odds ratio (OR) = 14.9, p = 0.001], being on antibiotic therapy at the time of admission (OR = 4.5, p = 0.007), and diagnosis of a complicated intra-abdominal infection (OR = 3.5, p = 0.014) were independently associated with clinical failure. These data support the assertion that antibiotic resistant organisms in mixed anaerobic/aerobic infections are associated with clinical failure and suggest that the antibiotic regimen should be modified to include Pseudomonas spp. in its spectrum when this organism is isolated from patients with such infections.

The epidemiology of community-acquired Pseudomonas aeruginosa infections in children during a one-year period (January through December 1993) was evaluated. A total of 6,859 clinical samples, each one representing a separate individual with suspected infection, were cultured. Pseudomonas aeruginosa was isolated from 218 children with various infections occurring in the following order of frequency: chronic suppurative otitis media, 76.3%; appendicitis/peritonitis, 10.3%; osteomyelitis, 8.9%; skin or soft tissue infection, 6.3%; acute conjunctivitis, 3.0%; and urinary tract infection, 0.1%. A variety of O serogroups were identified: O1 (15.2%), O6 (14.7%), O11 (12.4%), O10 (11.5%), O3 (10.6%), O5 (5.1%), and O9 (4.6%). Other serogroups and nontypable strains were recovered at a frequency of 11.2% and 14.7%, respectively. Nontypable strains predominated in chronic otitis media (18.9%), while serogroups O1 (18.3%), O6 (17.5%), and O11 (17.5%) were recovered most frequently among the typable isolates. Susceptibility of Pseudomonas aeruginosa to antipseudomonadal agents was extremely high. The rate of susceptibility to ceftazidime was 99.6%, to azlocillin 98.6%, to piperacillin 98.2%, to aztreonam 97.3%, to gentamicin and netilmicin 97.7%, and to ciprofloxacin 99.1%. All isolates were susceptible to tobramycin, imipenem, and amikacin. The results might suggest that community-acquired Pseudomonas aeruginosa infections in children can be treated successfully with any antipseudomonadal antibiotic.