Alan L. Bisno

Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections

EXECUTIVE SUMMARYSoft-tissue infections are common, generally of mild tomodest severity, and are easily treated with a variety ofagents. An etiologic diagnosis of simple cellulitis is fre-quently difficult and generally unnecessary for patientswith mild signs and symptoms of illness. Clinical as-sessment of the severity of infection is crucial, and sev-eral classification schemes and algorithms have beenproposed to guide the clinician [1]. However, mostclinical assessments have been developed from eitherretrospective studies or from an author’s own “clinicalexperience,” illustrating the need for prospectivestudieswith defined measurements of severity coupled to man-agement issues and outcomes.Until then, it is the recommendation of this com-mittee that patients with soft-tissue infection accom-panied by signs and symptoms of systemic toxicity (e.g.,fever or hypothermia, tachycardia [heart rate,

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panels recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis

Alan L. Bisno, Michael A. Gerber, Jack M. Gwaltney, Jr., Edward L. Kaplan, and Richard H. Schwartz Department of Medicine, University of Miami School of Medicine and Veterans Affairs Medical Center, Miami, Florida; 2 Cincinnati Children’s Hospital Medical Center and University of Cincinnati School of Medicine, Ohio; University of Virginia School of Medicine, Charlottesville, Inova Fairfax Hospital for Children, Falls Church, Virginia; and Department of Pediatrics, University of Minnesota Medical School, Minneapolis

Molecular basis of group A streptococcal virulence

The group A streptococcus (GAS) (Streptococcus pyogenes) is among the most common and versatile of human pathogens. It is responsible for a wide spectrum of human diseases, ranging from trivial to lethal. The advent of modern techniques of molecular biology has taught much about the organisms virulence, and the genomes of several GAS types have now been deciphered. Surface structures of GAS including a family of M proteins, the hyaluronic acid capsule, and fibronectin-binding proteins, allow the organism to adhere to, colonise, and invade human skin and mucus membranes under varying environmental conditions. M protein binds to complement control factors and other host proteins to prevent activation of the alternate complement pathway and thus evade phagocytosis and killing by polymorphonuclear leucocytes. Extracellular toxins, including superantigenic streptococcal pyrogenic exotoxins, contribute to tissue invasion and initiate the cytokine storm felt responsible for illnesses such as necrotising fasciitis and the highly lethal streptococcal toxic shock syndrome. Progress has been made in understanding the molecular epidemiology of acute rheumatic fever but less is understood about its basic pathogenesis. The improved understanding of GAS genetic regulation, structure, and function has opened exciting possibilities for developing safe and effective GAS vaccines. Studies directed towards achieving this long-sought goal are being aggressively pursued.

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America a

Abstract The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

Nosocomial Septicemia Due to Multiply Antibiotic-Resistant Staphylococcus epidermidis

Thirteen episodes of Staphylococcus epidermidis sepsis occurred over a 20-month period in 11 patients receiving general surgical and medical care. These episodes were characterized by fever, toxicity, multiple positive blood cultures, and uniformly colonized intravascular catheters. An additional 16 patients had possible sepsis. Four associated deaths occurred; all three patients autopsied had multiple pulmonary abscesses in which gram-positive cocci were profusely present. In individual patients, prolonged episodes of septicemia were confirmed by multiple blood culture isolates of S. epidermidis, identical in antibiotic resistance pattern, phage type, and biotype. A prominent feature of the S. epidermidis isolates was resistance to many commonly used antimicrobial agents. Case-control studies and review of laboratory records indicated a significant association between multiply resistant S. epidermidis blood isolates and prolonged hospitalization and parenteral hyperalimentation. Most of these patients were hospitalized in the intensive care unit; nose and hand cultures taken from the personnel showed frequent carriage of multiply resistant S. epidermidis Staphylococcus epidermidis associated with intravascular devices may produce life-threatening bloodstream infections.

Executive Summary: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panels recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

Executive Summary: Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

The syndrome of asplenia, pneumococcal sepsis, and disseminated intravascular coagulation.

Abstract Disseminated intravascular coagulation with Waterhouse-Friderichsen syndrome occurred during the course of fatal pneumococcal sepsis in a previously healthy woman. At postmortem examinatio...

Recurrent Cellulitis After Saphenous Venectomy for Coronary Bypass Surgery

We describe a previously unreported complication of coronary artery bypass grafting, recurrent cellulitis. Five patients had 20 episodes of acute cellulitis, each occurring in the lower extremity in which saphenous venectomy had been done. The cases were striking because the patients presented with high fever and considerable systemic toxicity. The appearance of the lesions, presence in one case of obvious associated lymphangitis, and prompt response in three instances to therapy with penicillin alone all suggest group A streptococcal infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus strain was isolated from the lesion. The pathogenesis of this syndrome remains obscure but, based on our understanding of postsurgical erysipelas, this cellulitis likely results from the interplay of several factors, including local compromise of lymphatic drainage, direct bacterial invasion, and acquired hypersensitivity to streptococcal exotoxins.