Epidemiology and Outcomes of Hospitalizations with Complicated Skin and Skin-Structure Infections: Implications of Healthcare-Associated Infection Risk Factors

Zilberberg, Marya D.; Shorr, Andrew F.; Micek, Scott T.; Hoban, Alex; Pham, Victor; Doherty, Joshua A.; Ramsey, Andrew M.; Kollef, Marin H.

doi:10.1086/648083

Cited by 52 publications

(69 citation statements)

References 28 publications

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“…We are aware of only two previous retrospective cohort studies that considered origin of infection in patients hospitalized for cSSTI. Health care-associated infection occurred in 27.2% of 12,506 pa- tients with skin, soft tissue, and bone and joint infections in a multi-institutional study by Lipsky et al (16) and 73.6% of 717 patients with cSSTI in a single-center study by Zilberberg et al (29). This variability may be attributable to differences in study populations and criteria for defining health care-associated infection, such as the time frame to define previous hospitalization and previous antibiotic use.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections in Hospitalized Patients

Zervos

Freeman

et al. 2012

J Clin Microbiol

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Complicated skin and soft tissue infections (cSSTIs) are among the most rapidly increasing reasons for hospitalization. To describe inpatients with regard to patient characteristics, cSSTI origin, appropriateness of initial antibiotics, and outcomes, we performed a retrospective cohort study in patients hospitalized for cSSTI. To identify independent predictors of outcomes, we performed multivariate analyses. Of 1,096 eligible patients, 48.7% had health care-associated (HCA) cSSTI and 51.3% had community-acquired (CA) cSSTI. After adjustment for baseline variables, hospital length of stay (LOS) was longer for HCA than for CA cSSTI (difference, 2.1 days; 95% confidence interval [CI], 0.8 to 3.5; P < 0.05). Other covariates associated with a longer LOS were need for dialysis (regression coefficient ؎ standard error, 4.5 ؎ 1.1) and diabetic wound diagnosis (2.6 ؎ 1.0) (all P < 0.05). In the subset with culture-positive cSSTI within 24 h of admission, the most common pathogen was Staphylococcus aureus (298/449 [66.4%]), of which 74.8% (223/298) were methicillin-resistant S. aureus (MRSA). Eighty-three patients (18.5%) received inappropriate initial antibiotics. After adjustment for other variables, the following were associated with inappropriate initial therapy: direct admission to hospital (not via emergency department), cSSTI caused by MRSA or mixed pathogens, and cSSTI caused by pathogens other than S. aureus or streptococci (all P < 0.05). We did not find an association between inappropriate therapy and outcomes, except in the subset with ulcers (adjusted odds ratio, 11.8; 95% CI, 1.3 to 111.1; P ‫؍‬ 0.03). More studies are needed to examine the impact of HCA cSSTI and inappropriate initial therapy on outcomes.

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Section: Discussionmentioning

confidence: 99%

Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections in Hospitalized Patients

Zervos

Freeman

et al. 2012

J Clin Microbiol

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“…We have previously reported on the characteristics and outcomes of this cohort, including both community-acquired and HCA-cSSSI patients. 16 …”

Section: Methodsmentioning

confidence: 99%

“…HCAI was defined as any cSSSI in a patient with a history of recent hospitalization (within the previous year, consistent with the previous study 16 ), receiving antibiotics prior to admission (previous 90 days), transferring from a nursing home, or needing chronic dialysis. We defined a polymicrobial infection as one with more than one organism, and mixed infection as an infection with both a gram-positive and a gram-negative organism.…”

Section: Definitionsmentioning

confidence: 99%

Hospitalizations with healthcare‐associated complicated skin and skin structure infections: Impact of inappropriate empiric therapy on outcomes

Zilberberg

Shorr

Micek

et al. 2010

Journal of Hospital Medicine

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OBJECTIVE:Inappropriate empiric therapy worsens outcomes in certain healthcare-associated infections (HCAI). We studied the association of inappropriate empiric therapy with outcomes in patients with HCA complicated skin and skin structure infections (cSSSI). DESIGN:A single-center retrospective cohort study. PATIENTS: Hospitalized with a culture-positive cSSSI. MEASUREMENTS: We defined HCA-cSSSI as having !1 of these risk factors: (1) recent hospitalization, (2) recent antibiotics, (3) hemodialysis, (4) transfer from a nursing home, and inappropriate treatment as no antimicrobial therapy active against the pathogen(s) within 24 hours of obtaining culture specimen. We performed descriptive and multivariate statistics to compute the impact of inappropriate empiric therapy on outcomes. Hospital length of stay (LOS) served as primary and mortality as secondary outcomes. RESULTS:Of the 717 patients with culture-positive cSSSI, 527 (73.5%) had HCAI, of whom 405 (76.9%) received appropriate treatment. A higher proportion of those receiving inappropriate than appropriate treatment had a decubitus ulcer (29.5% vs. 10.9%, P < 0.001), a device-associated infection (42.6% vs. 28.6%, P ¼ 0.004), or bacteremia (68.9% vs. 57.8%, P ¼ 0.028). The frequency of methicillin-resistant Staphylococcus aureus (MRSA) did not differ between the groups. The low overall unadjusted mortality rate did not vary based on initial treatment. In a multivariable analysis adjusting for potential confounders inappropriate therapy had an attributable increase in hospital LOS of 1.8 days (95% CI, 1.4-2.3).CONCLUSION: Similar to other populations with HCAI, HCA-cSSSI patients are likely to receive inappropriate empiric therapy for their infection. This early exposure is associated with a significant prolongation of the hospitalization by nearly 2 days.

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“…33 Health caree associated risk factors include hospitalization within the previous year, antibiotic use within the previous 90 days, dialysis dependence, or transfer from a nursing home. Communityacquired cSSTIs are commonly caused by S aureus, and health careeassociated cSSTIs are likely to be mixed infections that also include Enterococcus species and gram-negative organisms.…”

Section: Health Careeassociated Infectionsmentioning

confidence: 99%

“…Communityacquired cSSTIs are commonly caused by S aureus, and health careeassociated cSSTIs are likely to be mixed infections that also include Enterococcus species and gram-negative organisms. 33 Mixed infections can increase mortality, length of stay, and hospital charges compared with gram-positive or gram-negative infections alone. 8 Methicillin-Resistant S aureus Initially, CA-MRSA was reported in specific populations (eg, intravenous [IV] drug users and athletes) 34,35 but currently is so common in the community that historically high-risk groups are no longer clinically useful.…”

Section: Health Careeassociated Infectionsmentioning

confidence: 99%

Hospitalist Perspective on the Treatment of Skin and Soft Tissue Infections

Amin

Cerceo

Deitelzweig

et al. 2014

Mayo Clinic Proceedings

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The prevalence of skin and soft tissue infections (SSTIs) has been increasing in the United States. These infections are associated with an increase in hospital admissions. Hospitalists play an increasingly important role in the management of these infections and need to use hospital resources efficiently and effectively. When available, observation units are useful for treating low-risk patients who do not require hospital admission. Imaging tools may help to exclude abscesses and necrotizing soft tissue infections; however, surgical exploration remains the principal means of diagnosing necrotizing soft tissue infections. The most common pathogens that cause SSTIs are streptococci and Staphylococcus aureus. Methicillin-resistant S aureus (MRSA) is a prevalent pathogen, and concerns are increasing regarding the unclear distinctions between community-acquired and hospital-acquired MRSA. Other less frequent pathogens that cause SSTIs include Enterococcus species, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa. Cephalexin and clindamycin are suitable options for infections caused by streptococcal species and methicillin-susceptible S aureus. The increasing resistance of S aureus and Streptococcus pyogenes to erythromycin limits its use in these infections, and better alternatives are available. Parenteral cefazolin, nafcillin, or oxacillin can be used in hospitalized patients with nonpurulent cellulitis caused by streptococci and methicillin-susceptible S aureus. When oral MRSA therapy is indicated, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, or linezolid is appropriate. Vancomycin, linezolid, daptomycin, tigecycline, telavancin, and ceftaroline fosamil are intravenous options that should be used in MRSA infections that require patient hospitalization. In the treatment of patients with SSTIs, hospitalists are at the forefront of providing proper patient care that reduces hospital costs, duration of therapy, and therapeutic failures. This review updates guidelines on the management of SSTIs with a focus on infections caused by S aureus, particularly MRSA, and outlines the role of the hospitalist in the effective management of SSTIs.

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Epidemiology and Outcomes of Hospitalizations with Complicated Skin and Skin-Structure Infections: Implications of Healthcare-Associated Infection Risk Factors

Cited by 52 publications

References 28 publications

Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections in Hospitalized Patients

Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections in Hospitalized Patients

Hospitalizations with healthcare‐associated complicated skin and skin structure infections: Impact of inappropriate empiric therapy on outcomes

Hospitalist Perspective on the Treatment of Skin and Soft Tissue Infections

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