References
A prospective study on skin and soft tissue infections: a fact-finding mission from a tertiary centre in north India
Abstract
Objective:
Despite the high prevalence and poor outcome of skin and soft tissue infections (SSTIs), very few studies from India have dealt with the subject. We planned a prospective study of inpatients with SSTIs to study the aetiology, clinical presentation (severity) and outcome of patients with SSTIs in our facility.
Method:
Patients with SSTIs involving >5% body surface area (BSA) and/or systemic signs were admitted to the surgery department of a teaching tertiary level hospital in Delhi, India, and were clinically classified into cellulitis, necrotising soft tissue infections (NSTIs), pyomyositis, and abscess. Demographic and clinical variables such as: age; sex; occupation; history of trauma/insect or animal bites; duration of illness; presenting symptoms and signs; comorbid conditions; predisposing factors such as lymphoedema or venous disease; hospital course; treatment instituted; complications; hospital outcome; presence of crepitus, bullae, gangrene, muscle necrosis and compartment syndrome were recorded. The chief outcome parameters were death and length of hospital stay; others, such as abscess drainage, the need for plastic surgical procedures and amputations were also noted.
Results:
Out of 250 patients enrolled in the study, 145 (58%) had NSTIs, 64 (26%) had abscesses, 15 (6%) had cellulitis and 26 (10%) had pyomyositis. Mortality was observed with NSTIs (27/145, 19%) and with pyomyositis (3/26, 11.5%). Factors affecting mortality by univariate analysis in the NSTI group were: abnormal pulse; hypotension; tachypnea; bullae; increased blood urea and serum creatinine; inotrope or ventilator support (all with p<0.001); local tenderness, gangrene, dialysis support and BSA (9.33±6.44 versus 5.12±3.62; p<0.05 for the last four). No factor was found to be significant on multivariate analysis. Variables associated with hospital stay >12 days were immunocompromise, pus discharge, ulceration or gangrene, and after interventions such as blood transfusion, drainage or skin grafting.
Conclusion:
High prevalence of NSTI and pyomyositis with high mortality was observed in our SSTI patients, often in immunocompetent young individuals. Epidemiological studies focused on virulent strains of Staphylococcus aureus may be required to identify the cause, since Staphylococcal toxins have been implicated in other infections.
Skin and soft tissue infections (SSTIs) constitute a major health and socioeconomic challenge in India, frequently affecting low-resource areas and patients. Referral to specialist or equipped surgical units is often delayed. Treatment and follow-up are also prolonged and uncertain, especially for higher grades of infections. India is a vast geographical area and this, together with the above factors, makes data collection difficult. Hence, there are limited epidemiological data, even for this common health problem. In the few studies available from India, there are marked differences from Western data. The number of necrotising soft tissue infections (NSTIs) seen in our facility is significantly greater than that seen in developed countries.1,2 Bacteriology and antibiograms for our patients are not well-defined. The prevalence of meticillin-resistant Staphylococcus aureus (MRSA), a well-known pathogen in SSTIs, is highly variable. Phakade et al.3 studied 619 isolates from community-acquired SSTIs, and found no MRSA, despite Staphylococcus aureus being the predominant organism in 73% of cases. In contrast, hospital-acquired SSTIs had 45% of Staphylococcus aureus isolates as MRSA.3 Eshwara et al.4 found that MRSA (>50% cases) was a significant contributor to Staphylococcal bacteraemia and poor outcome. This makes it relevant to generate more data from our facility.
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