Treatment of complicated skin and soft tissue infections.

Surg Infect (Larchmt). 2009 Oct;10(5):467-99

Authors: May AK, Stafford RE, Bulger EM, Heffernan D, Guillamondegui O, Bochicchio G, Eachempati SR,

BACKGROUND: Skin and soft tissue infections (SSTIs) may produce substantial morbidity and mortality rates, particularly those classified as complicated or necrotizing. OBJECTIVE: To weigh the strength of recommendations using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology and to provide evidence-based recommendations for diagnosis and management for SSTIs. DATA SOURCES: Computerized identification of published research and review of relevant articles. STUDY SELECTION: All published reports on the management of complicated and necrotizing SSTIs were evaluated by an expert panel of members of the Surgical Infection Society according to published guidelines for evidence-based medicine. The quality of the evidence was judged by the GRADE methodology and criteria. Practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACtion: Information on demographics, study dates, microbiology findings, antibiotic type, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted. Results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS: Current surgical and antibiotic management of complicated SSTIs is based on a small number of studies that often have insufficient power to draw well-supported conclusions, with the exception of antimicrobial therapy for non-necrotizing soft tissue infections, for which ample data are available.

PMID: 19860574 [PubMed - indexed for MEDLINE]

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Neutropenic enterocolitis.

Surg Infect (Larchmt). 2009 Jun;10(3):307-14

Authors: Ullery BW, Pieracci FM, Rodney JR, Barie PS

BACKGROUND: Neutropenic enterocolitis, sometimes called typhilitis, is the most common gastrointestinal infection related to neutropenia, but its rarity, confusing terminology, and protean, non-specific manifestations result in variable approaches to diagnosis and management. METHODS: Review of pertinent English-language literature. RESULTS: The true incidence of neutropenic enterocolitis is unknown, but may be 5% or more among adult patients receiving chemotherapy for solid malignant tumors. The incidence is reported to be slightly lower in children. Estimates are made complex by recent recognition that neutropenia of any cause may be associated with enterocolitis; reports of non-chemotherapy drug-associated cases are increasing. Mortality rates are reported currently to be between 30% to 50%. The exact pathogenesis is also unknown, and may contribute to the varied nomenclature in use. Gut mucosal ulcerations may result from direct drug-related cytotoxicity, or from neutropenia itself. Microbial invasion of the bowel wall proceeds unimpeded. Pathological changes include inflammation and edema, presumably followed by ulceration, transmural necrosis, and perforation. The classic clinical presentation consists of fever, abdominal pain, and neutropenia, but diagnosis is often hindered by subtle or non-specific clinical findings, making computed tomography the linchpin of diagnosis. The wide spectrum of clinical presentation requires an individualized approach to therapy. Medical management, including administration of granulocyte colony-stimulating factor, may be appropriate for patients who do not have gastrointestinal bleeding, peritonitis, or intestinal perforation. Surgical management is generally reserved for patients who fall into any of the exceptional categories, and consists usually of bowel resection and stoma creation. CONCLUSIONS: Neutropenic enterocolitis is a heterogeneous diseazse state with the capacity to affect many areas of the gastrointestinal tract, and disease severity that ranges from mild to fatal. A high index of suspicion is needed for all patients who present with fever and abdominal pain in the setting of neutropenia. Early detection allows a majority of cases to resolve with nonoperative management and supportive care, but surgical intervention is mandatory for peritonitis, bowel perforation, or gastyrointestinal hemorrhage that persists despite correction of coagulopathy.

PMID: 19566419 [PubMed - indexed for MEDLINE]

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Randomized, double-blind, placebo-controlled trial of effects of enteral iron supplementation on anemia and risk of infection during surgical critical illness.

Surg Infect (Larchmt). 2009 Feb;10(1):9-19

Authors: Pieracci FM, Henderson P, Rodney JR, Holena DN, Genisca A, Ip I, Benkert S, Hydo LJ, Eachempati SR, Shou J, Barie PS

BACKGROUND: Critical illness is characterized by hypoferremia, iron-deficient erythropoiesis (IDE), and anemia. The relative risks and benefits of iron supplementation in this setting are unknown. METHODS: Anemic, critically ill surgical patients with an expected intensive care unit length of stay (ULOS) >or= 5 days were randomized to either enteral iron supplementation (ferrous sulfate 325 mg three times daily) or placebo until hospital discharge. Outcomes included hematocrit, iron markers (i.e., serum concentrations of iron, ferritin, and erythrocyte zinc protoporphyrin [eZPP]), red blood cell (RBC) transfusion, transfusion rate (mL RBC/study day), nosocomial infection, antibiotic days, study length of stay (LOS), ULOS, and death. Iron-deficient erythropoiesis was defined as an elevated eZPP concentration. RESULTS: Two hundred patients were randomized; 97 received iron, and 103 received placebo. Socio-demographics, baseline acuity, hematocrit, and iron markers were similar in the two groups. No differences were observed between the iron and placebo groups with respect to either hematocrit or iron markers following up to 28 days. However, patients treated with iron were significantly less likely to receive an RBC transfusion (29.9% vs. 44.7%, respectively; p = 0.03) and had a significantly lower transfusion rate (22.0 mL/day vs. 29.9 mL/day; p = 0.03). Subgroup analysis revealed that these differences were observed in patients with baseline IDE only. Iron and placebo groups did not differ with respect to incidence of infection (46.8% vs. 48.9%; p = 0.98), antibiotic days (14 vs. 16; p = 0.45), LOS (14 vs. 16 days; p = 0.24), ULOS (12 vs. 14 days; p = 0.69), or mortality rate (9.4% vs. 9.9%; p = 0.62). Conclusions: Enteral iron supplementation of anemic, critically ill surgical patients does not increase the risk of infection and may benefit those with baseline IDE by decreasing the risk of RBC transfusion. A trial comparing enteral and parenteral iron supplementation in this setting is warranted (ClinicalTrials.gov number, NCT00450177).

PMID: 19245362 [PubMed - indexed for MEDLINE]

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Economic consequences of failure of initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infections.

Surg Infect (Larchmt). 2008 Jun;9(3):335-47

Authors: Edelsberg J, Berger A, Schell S, Mallick R, Kuznik A, Oster G

BACKGROUND: Initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infection (cIAI) usually is empiric. We explored the economic consequences of failure of such therapy in this patient population. METHODS: Using a large U.S. multi-institutional database, we identified all hospitalized adults admitted between April 1, 2003, and March 31, 2004; who had any cIAI; underwent laparotomy, laparoscopy, or percutaneous drainage of an intra-abdominal abscess ("surgery"); and received intravenous (IV) antibiotics. Initial therapy was characterized in terms of all IV antibiotics received, on the day of or one day before initial surgery. Antibiotic failure was designated on the basis of the need for reoperation or receipt of other IV antibiotics postoperatively. Switches to narrower spectrum agents and changes in regimen prior to discharge with no other evidence of clinical failure were not counted as antibiotic failures. Using multivariable linear regression, duration of IV antibiotic therapy, hospital length of stay, and total inpatient charges were compared between patients who did and did not fail initial therapy. Mortality was compared using multivariable logistic regression. RESULTS: Among 6,056 patients who met the study entrance criteria, 22.4% failed initial antibiotic therapy. Patients who failed received an additional 5.6 days of IV antibiotic therapy (10.4 total days [95% confidence interval 10.1, 10.8] days vs. 4.8 total days [4.8, 4.9] for those not failing), were hospitalized an additional 4.6 days (11.6 total days [11.3, 11.9] vs. 6.9 total days [6.8, 7.0], respectively), and incurred $6,368 in additional inpatient charges ($16,520 [$16,131, $16,919] vs. $10,152 [$10,027, $10,280]) (all, p < 0.01). They also were more likely to die in the hospital (9.5% vs. 1.3%; multivariable odds ratio 3.58 [95% confidence interval 2.53, 5.06]). CONCLUSIONS: Failure of initial IV antibiotic therapy in hospitalized adults with cIAIs is associated with longer hospitalization, higher hospital charges, and a higher mortality rate.

PMID: 18570575 [PubMed - indexed for MEDLINE]

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