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

Garyphallia Poulakou; Efthymia Giannitsioti; Sotirios Tsiodras

Disclosures

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

In This Article

Overall Management of Skin and Soft Tissue Infections

Recent guidance has been published on the treatment of SSTIs.[9] Contemporary evidence indicates that early initiation of antibiotics for SSTI at the ED was associated with significantly better outcomes.[42,45] As a general principle, empirical antibiotics should target S. pyogenes and S. aureus and cover for MRSA/CA-MRSA and other possible pathogens depending on the clinical features and epidemiological risk.[9,16] USSTIs represent areas for improvement, as clinicians continue prescribing antibiotics (even more than two) postdrainage, but frequently inactive against MRSA.[58] Moreover, suboptimal management of SSTIs was reported in nursing homes.[59,60] Identification and management of SSTIs in ICU-admitted patients is completely different from community-acquired counterparts and MDR bacteria should be considered.[61] Outpatient parenteral treatment (OPAT) also needs attention, as more than 70% of OPAT patients administered vancomycin for SSTIs had subtherapeutic drug levels.[62] On the contrary, OPAT with daptomycin was safe,[63] whereas daptomycin dosing exceeding 6 mg/kg/day in more than 1000 inpatients within the EU-CORE study was proven safe.[64] A large-scale pharmacokinetic study across 12 European countries revealed the risk of suboptimal treatment of MRSA in cSSTIs with more than 40% of patients on vancomycin receiving inadequate dose, whereas the majority of patients administered first-line teicoplanin and daptomycin (96 and 80%, respectively) received higher than labeled cSSTI doses.[65] Wise selection of candidates for outpatient treatment and transition from i.v. to oral treatment is very important to avoid irrational healthcare expenditures.[23,26] Of note, poor adherence to oral, postdischarge antibiotic treatment for staphylococcal SSTIs was associated with treatment failure.[44] A Cochrane analysis including nine Randomised-controlled trials (RCTs) showed a better outcome and shorter length of hospital stay with linezolid than with vancomycin, but results are prone to biases.[66] An RCT showed superiority of a 7-day treatment with trimethoprim 320 mg/sulphomethoxazole 1600 mg over placebo for uSSTIs: increased clinical cure, reduction of surgical drainage and reinfections (per protocol [PP] 7.2; 95% confidence interval [CI], 3.2–11.2; P < 0.001, PP 5.2; 95% CI, -8.2 to -2.2) and (PP 7.2 s; 95% CI, –10.4 to –4.1) respectively.[67] Tigecycline alone or in combinations with other antimicrobials was demonstrated effective in 50 patients with necrotizing SSTIs within 163 patients with complicated SSTIs[68] as well as in abdominal skin infections.[69] A retrospective multicenter study across 12 European centers in patients with peripheral vascular disease and/or diabetes showed significant benefit of linezolid over vancomycin in terms of hospital stay and treatment duration.[70]

Management of uSSTIs is a perfect target for antimicrobial stewardship interventions, as an overcoverage of gram negatives and anaerobes has been empirically initiated in almost half of SSTIs' adult hospitalized patients.[23–25,38]

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