Management of skin and soft-tissue infections: 2018 WSES/SIS-E consensus statement

World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E) have released a consensus statement on Management of skin and soft-tissue infections. The consensus statement has appeared in World Journal of Emergency Surgery.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs may affect any part of the body and are a frequent clinical problem in surgical departments. Successful management of patients with severe SSTIs involves prompt recognition, appropriate antibiotic therapy, timely surgical debridement or drainage, and resuscitation when required.

During the consensus conference, 17 panellists presented the statements developed for each of the main questions regarding the diagnosis and management of SSTIs. An agreement on all the statements was reached and a consensus statement released.

• The term "skin and soft-tissue infections" describes a wide heterogeneity of clinical conditions. We recommend that the necrotizing or non-necrotizing character of the infection, the anatomical extension, the characteristics of the infection (purulent or not purulent), and the clinical condition of the patient should be always assessed independently to classify patients with soft-tissue infections (recommendation 1C).


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  Recent global guidelines for the prevention of SSIs can support healthcare workers to develop or strengthen infection prevention and control programs, with a focus on surgical safety, as well as antimicrobial resistance action plans. We recommend that all healthcare workers adopt these evidence-based recommendations in their clinical practice (recommendation 1C).

  
  


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  Incisional SSIs require prompt and wide opening of the surgical incision. We recommend antibiotic therapy for incisional SSIs with any Systemic Inflammatory Response Syndrome criteria or signs of organ failure such as hypotension, oliguria, decreased mental alertness, or in immunocompromised patients (recommendation 1C).

  
  


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  We recommend that impetigo, erysipelas, and cellulitis should be managed by antibiotics against Gram-positive bacteria (recommendation 1C).

  
  

  Empiric therapy for community-acquired MRSA (CA-MRSA) should be recommended for patients at risk for CA-MRSA or who do not respond to first line therapy (recommendation 1C).

  
  

  Incision and drainage is the primary treatment for simple abscesses or boils. We recommend not to use antibiotics for simple abscesses or boils (recommendation 1C).

  
  


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  Complex skin and subcutaneous abscesses are typically well circumscribed and respond to incision and drainage. We recommend antibiotic therapy if systemic signs of infection are present, in immunocompromised patients, if source control is incomplete or in cases of abscess with significant cellulitis (recommendation 1C).

  
  

  We recommend empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria (recommendation 1C).

  
  


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  Irrigation of the wound and debridement of necrotic tissue are the most important factors in the prevention of infection and can substantially decrease the incidence of invasive wound infection. Antibiotic prophylaxis is not generally recommended (recommendation 1C).

  
  

  For patients with systemic signs of infection, compromised immune status, severe comorbidities, associated severe cellulitis, severe and deep wounds, a broad-spectrum antibiotic effective against aerobic, and anaerobic organisms is always required (recommendation 1C).

  
  


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  We recommend to administer antibiotics directed against MRSA as an adjunct to incision and drainage based on local epidemiology (area with more than 20% of MRSA in invasive hospital isolates or high circulation of MRSA in the community), specific risk factors for MRSA, and clinical conditions (recommendation 1C).

  
  


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  For oral antibiotic coverage of MRSA in patients with SSTI, we suggest the following agents: linezolid (recommendation 1A), trimethoprim-sulfamethoxazole (TMP-SMX) (recommendation 1B), a tetracycline (doxycycline or minocycline) (recommendation 1B), or tedizolid (Recommendation 1A).

  
  


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  Patients with NSTIs should be classified into the following:
  

  
  

  
  
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    High risk of poor outcome.

    
    
  
  
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    Mild/moderate risk of poor outcome.

    
    
  
  

  
  

  
  
  
  

  Scores used for severity assessment of patients with necrotizing infections may be useful in the emergency room or outside the intensive care unit (ICU) and may identify patients early, who require surgical treatment and perioperative intensive care management (recommendation 1C).

  
  


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  A multidisciplinary team is mandatory for the management of NSTIs. Depending on the time line, various specialties are involved. Specific attention should be given to the long-term management of these patients (recommendation 1C).

  
  


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  Clinical signs of NSTI include pain out of proportion, edema extending beyond the erythema, and fever. A rapidly progressive soft-tissue infection should always be suspected as a necrotizing infection (recommendation 1C).

  
  


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  Provide (surgical) source control in patients with NSSTI as soon as possible, but at least within the first 12 h after admission, in patients with a high suspicion for necrotizing infection. Early source control, antimicrobial therapy, and (organ) supportive measures are the cornerstone of treatment in patients with sepsis or septic shock caused by NSSTI (recommendation 1B).

  
  


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  Consider to plan the first re-exploration within 12–24 h and to repeat re-exploration(s) until the patient is free of necrosis (recommendation 1C).

  
  


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  Supportive treatment in managing necrotizing infections must be early and aggressive to halt progression of the inflammatory process (recommendation 1A).

  
  


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  AB103 (Reltecimod) is a new agent for modulation of inflammation after necrotizing infections. Further study is warranted to establish efficacy (no recommendation).

  
  


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  In the absence of definitive clinical trials, antibiotic therapy should be administered until further debridement is no longer necessary, the patient has improved clinically, and fever has resolved for 48–72 h (recommendation 1C).

  
  

  Procalcitonin monitoring may be useful to guide antimicrobial discontinuation (recommendation 2B).

  
  


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  We suggest to consider negative pressure wound therapy (NPWT) for wound care after complete removal of necrosis in necrotizing infections (recommendation 1C).