Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort

Abstract

Background: Skin and soft tissue infections (SSTIs) are increasing. Frequent over-and under-treatment has been reported, including non-purulent SSTIs where cases demanding surgery or broad-spectrum therapy often are hard to identify. Our aim was to measure the predictive power of a modified severity score and use it to identify areas of improvement in antimicrobial therapy of non-purulent SSTIs. Methods: We prospectively included adult patients admitted to hospital with non-purulent SSTIs. A modified Dundee score at admission was calculated retrospectively, and associations between severity and outcomes were analysed. We evaluated appropriateness of treatment in relation to severity scores, and assessed adverse effects of broad-spectrum therapy. Results: We included 200 cases with cellulitis and 19 cases with necrotising soft tissue infections (NSTIs). Thirty-two per cent were categorised as severity class I, 15% as class II, 28% as class III and 25% as class IV (most severe). In class I, 66 out of 69 cases did not have a complicated course. All but one NSTI case were identified by the class IV criteria. Over-treatment was common and mostly seen in class I. Broad-spectrum antibiotics or clindamycin use was associated with an increased risk of diarrhoea. Prolonged treatment (>14 days) was associated with age, severity and surgery. Conclusions: The modified Dundee score proved valuable in identifying those with the lowest risk of complication and the most severe infections, and could serve as a useful clinical tool in the emergency department. Frequent over-treatment and associated adverse effects were confirmed, underscoring the need for improved risk assessment.

Pathogenese, Klinik und Therapie des Erysipels

“…Im Gegensatz hierzu gibt es für das Erysipel -nicht zuletzt aufgrund des akuten Auftretens und der guten Behandelbarkeit mittels Antibiotika -bislang keinen Score, der zur Objektivierung der Krankheitsaktivität und des Therapieansprechens in der klinischen Routine etabliert ist. Einzelne Scores, wie etwa zur Bestimmung des Risikos der Entwicklung einer hämorrhagischen Unterform des Erysipels oder zur Bestimmung der Notwendigkeit der intravenösen Antibiotikaapplikation (Melbourne ASSET Score) sowie die Anwendung des modifizierten Dundee-Scores, mit welchem Patienten in 4 "severity classes" eingeteilt werden, wurden in der medizinischen Literatur publiziert [32][33][34][35]. So werden in der klinischen Routine in der Regel die klinische Symptomatik beziehungsweise die Entzündungsparameter als Maß der Krankheitsaktivität herangezogen.…”

‘Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis’ – Author's reply

“…One of the main issues in the design of any follow-up studies remains the lack of reference standards for the diagnosis and cure of cellulitis which can be used for inclusion of patients and determination of cure. Included patients could be stratified by the (modified) Dundee classification, as this severity score seems to have proven its value in multiple cohorts [5].…”

Deep skin and soft tissue infection of the neck – first sign of unrecognized diabetes mellitus

“…Skin and soft tissue infections (SSTIs) are common infectious disorders, while complicated SSTI (cSSTIs) representing the more severe subtype developing deepseated infection, a requirement for surgical intervention, the presence of systemic signs of infection, and the presence of complicating comorbidities [1]. These disorders require initiation of appropriate empiric broad-spectrum antimicrobial therapy, early aggressive surgical intervention for drainage of abscesses and debridement, and identification of responsible bacteria and appropriate de-escalation of antimicrobial therapy [2]. Carbuncles and cSSTIs may be a symptom of unrecognized diabetes mellitus [3].…”