What Is New in the Management of Skin and Soft Tissue Infections in 2016?

Garyphallia Poulakou; Efthymia Giannitsioti; Sotirios Tsiodras


Curr Opin Infect Dis. 2017;30(2):158-171. 

In This Article

Assesment of Severity of Illness and Response to Treatment

Skin infections are highly variable in presentation, thus multiple severity-of-illness systems have been proposed. Nevertheless, no one system has gained universal acceptance, mainly because of overlapping definitions of infections and severity strata.[9] Validated severity of illness scoring is the cornerstone for decision-making, relating to inpatient/intravenous care or transition from i.v. to oral care. The Clinical Resource Efficiency Support Team (CREST) scoring system stratifies patients into four classes (from I, least severe to IV, most severe) based on the Standardized Early Warning Score. In a single-center study in United States, CREST criteria were retrospectively applied in 200 patients, the majority of them being classified as class I or II. Overtreatment, mainly because of unnecessary inpatient i.v. antimicrobial treatment or broad spectrum coverage was identified in 88 and 32% of patients class I and II, respectively (P 0.05). The study demonstrated the need of standardized decision tools in order to optimize the treatment of SSTIs.[23] In line with this observation, Claeys et al.[24] reported that 80.4% of ED patients and 74.2% of Observation unit (OU) patients were classified as CREST class I, whereas Marwick et al.[25] in a prospective study showed that 89 and 73% of patients CREST class I and II, respectively, were overtreated. Further to these observations Ektare et al.[26] demonstrated clearly potential cost savings with averted hospital admissions ranging from $13090 to $13473, indicating that hospital admission and length of stay were the major drivers of cost in the treatment of ABSSSIs.

Apart from rationalization of healthcare costs, early response to treatment is an important tool to guide appropriate antibiotic prescription and estimate future position of the newly launched antibacterials. In the REACH study encompassing 600 real-life patients hospitalized with cSSTIs in 2010–2011 across Europe, patients without an early response were more likely to be diabetic, have more severe disease and harbor difficult-to-treat microorganisms, including gram-negative bacteria and anaerobes; on the contrary, they experienced more complications and higher use of healthcare resources.[27] In another recent prospective study of cellulitis encompassing 216 patients, nonresponse at day 3 was associated with nonpharmacologic factors, such as female gender, cardiovascular disease, higher BMI, shorter duration of symptoms and nonerysipelas forms of cellulitis. As nonresponse at day 3 was not attributed to inappropriate treatment, in contrast to other studies, the authors argue against automatic-early treatment escalation[28] and call for watchful waiting in selected cases. Slower response in patients with comorbidities was also reported in recent randomized controlled trials.[29–34] Severity of SSTI has been shown to affect early response in some studies[35] but not in others.[27,28,34] The significance of assessing early response to treatment was comprehensively reviewed by Nathwani et al..[36] An updated algorithm for the management of SSTIs integrating risk factors for therapeutic decisions is proposed in Figure 1.[9,16,36]

Figure 1.

An algorithm for the management of skin and soft tissue infections, by evaluating early clinical response and the ability for early discharge with outpatient parenteral or per os antibiotic treatment (adapted from [9,16,36]). Abx, antibiotics; I&D, incision and drainage; ICU, intensive care unit; i.v., intravenous; LTCF, long-term care facility; MDR, multidrug-resistant; MRSA, methicillin-resistance Staphylococcus aureus; OPAT, outpatient parenteral treatment' Rx: treatment; SSTIs, skin and soft tissue infections.

The most important epidemiological studies in the last 1–1/2 year, evaluating response to treatment and risk factors for failure and/or recurrences, are shown in Table 3 . [21,37,38,39,40,41,42,43,44,45] In a recent meta-analysis of 10 studies, management failure rate ranged from 15 to 38%, being more frequent in the presence of fever, elevated inflammatory markers and exposure to MRSA, thus highlighting once more the importance of widely accepted decision-making tools.[46] Failure to cover for MRSA was also a frequent cause of recurrence and treatment failure.[16]