Skin and soft tissue (SSTI) sepsis (surgery, antimicrobial therapy and more)

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1 Skin and soft tissue (SSTI) sepsis (surgery, antimicrobial therapy and more) Christian Eckmann Antibiotic Stewardship Expert ECDC Chief of Staff Department of General, Visceral and Thoracic Surgery Klinikum Peine Medical University Hannover Germany SSTI sepsis case report

2 SSTI sepsis case report (continued) Skin and soft tissue sepsis Non-standardized term preliminary definition: all cssti, in which signs and symptoms of sepsis occur cssti studies: 4-8% sepsis (bacteremia?) Necrotizing STI: very frequently associated with sepsis/septic shock Incidence: 2-4/ per year Eckmann C Curr Opin Infect Dis 2016

3 % mortality in SSTI defined by signs of sepsis 33% 17% 11% 1% Severity class (n) Marwick, et al. J Antimicrob Chemother. 2011; 66: Severity of cssti defined by depth of infection Impetigo Folliculitis Ecthyma Furunculosis Carbunculosis Erysipelas Cellulitis Spreading skin infections Ambulant non-surgically Necrotizing fasciitis Life-threatening infections Myonecrosis (clostridial and non-clostridial) Life-threatening surgically Adapted from Nichols RL & Florman S. Clin Infect Dis. 2001;33(Suppl 2):S84 93; Adapted from Stevens DL, et al. Clin Infect Dis. 2005;41:

4 % Epidemiology of severe sepsis Aetiology top 3 55 % 38% 30% 25 % 10 % 8 % Green = Engel C. et al. Intensive Care Med 2007 Blue = Kumar A et al. Chest 2009; 136:1237 SSTI sepsis diagnostic approach Eckmann C. Curr Opin Infect Dis 2016

5 NSTI diagnostic and therapeutic approach Early signs/uncertainty Late signs = clear diagnosis MRI Scoring-systems Antibiotics alone Wait and see Deep incision in OR NSTI negative NSTI pos. Radical debridement (delayed) Wound closure Eckmann C. Curr Opin Infect Dis 2016 Diagnosis and treatment of NSTI IDSA guidelines Stevens D et al. Clin Infect Dis 2014

6 cssti source control aspects Eckmann C. Curr Opin Infect Dis 2016 Source control in cssti different measures just take the line out......or do a little bit more 12

7 Timing of surgery in necrotizing fasciitis Chao WN et al. Am J Surg 2013;106:32-39 Significant increase in mortality! n=121 Vibrio vulnificus-induced necrotizing fasciitis Frequency of pathogens isolated from SSTIs among hospitalized patients in the SENTRY Antimicrobial Surveillance Programs Proportion of patients (%) 1 2 CoNS, Coagulase-negative Staphylococcus; MRSA, methicillin-resistant Staphylococcus aureus; SSTI, skin and soft tissue infections; VRE, Vancomycin resistant enterococci. Adapted from 1. Rennie RP, et al. Diagnost Microbiol Infect Dis. 2003;45(4):287 93; 2. Jones ME, et al. Eur J Clin Microbiol Infect Dis. 1999;18:403 8.

8 Resistant bacteria in NSTI 2015 Results of a prospective observational trial Eckmann C et al. Surg Infect 2015 Empirical treatment 189 hospitalized patients with SSTI Class I: oral active against S. pyogenes and S. aureus Class II: iv against S. pyogenes and S. aureus Class III: iv against S. pyogenes and S. aureus Class IV: iv against S. pyogenes, S. aureus, Gram negative bacteria and anaerobic bacteria that included a drug that reduces toxin production by S. pyogenes (clindamycin or linezolid) 8% Class I (88) Class II Class III (56) (33) Severity class (n) SSTI, skin and soft-tissue infections; iv, intravenous. Adapted from Marwick C, et al. J Antimicrob Chemother. 2011;66: Class IV (12)

9 Treatment of NSTI IDSA guidelines Stevens D et al. Clin Infect Dis 2014 Treatment of NSTI IDSA guidelines Stevens D et al. Clin Infect Dis 2014

10 cssti clinical response with tigecycline mono or combination therapy Clinical Response (%) Germany (n =127) Italy (n = 41) Spain 1 a (n = 3) Spain 2 (n = 14) Total (n = 185) APACHE II <15 APACHE II >15 APACHE, Acute Physiology and Chronic Health Evaluation; EOT, end of treatment Montravers P, et al. J Antimicrob Chemother. 2013;68(Suppl 2):ii15 ii24. Tigecycline treatment in NSTI Results of a prospective observational trial Collective: Multicentre n=50 Mean APACHE II: 20 Mortality: 20% Eckmann C et al. Surg Infect 2015

11 Hyperbaric oxygenation (HBO) in NSTI design: review results: 3 studies with non significant trend in terms of reduced mortality and number of debridements 4 studies without any effect conclusion: inconsistent data routine use cannot be recommended Jallali N et al. Am J Surg 2005; 189: 462 cssti value of adjunctive measures Eckmann C. Curr Opin Infect Dis 2016

12 SSTI sepsis value iv immunoglobulin G 23 Madsen MB. Crit Care 2017 Skin and soft tissue sepsis summary SSTI sepsis third most frequent cause of septic shock SSTI sepsis occurs in 4 8% of all cssti SSTI sepsis usually requires rapid surgical intervention Broad spectrum antibiotics (+ Clindamycin/Linezolid) is recommended as initial empirical antimicrobial treatment; De escalation possible Mortality rates range between 20 40% Don t miss your appointments at the dentist