On the pathophysiology and management of cellulitis
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Cellulitis is a bacterial skin and soft tissue infection. It is one of the most common infections requiring hospitalization, and one of the most common reasons for prescribing antibiotics. Despite the fact that it is a very visible infection, the underlying etiology is poorly understood. Many patients experience recurrences after the initial infection. Even though we have effective treatment options, studies on the most optimal or effective treatment are scarce. Recent concerns regarding antibiotic resistance have prompted studies to evaluate the minimum effective treatment duration in order to reduce antibiotic consumption. Reducing antibiotic consumption should lower the selective pressure that drives antibiotic resistance development. This thesis contains several studies. The most prominent one is a trial comparing the standard antibiotic therapy duration with a shorter therapy duration in patients hospitalized with cellulitis. Furthermore, current evidence on risk factors and etiology have been bundled into a novel model for the development of cellulitis. The skin microbiota of cellulitis patients has been analyzed in an effort to find correlations between aspects of the skin microbiota and the causative agent or disease characteristics. Changes in the coagulation and fibrinolysis system during cellulitis have been investigated. Finally, it shows the characteristics, clinical management and outcomes of a group of patients with cellulitis on the intensive care units. Thus, this thesis is on the pathophysiology and management of cellulitis.Keywords:
Etiology
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Neurological infections constitute an uncommon, but important aetiological cause requiring admission to an intensive care unit (ICU). In addition, health-care associated neurological infections may develop in critically ill patients admitted to an ICU for other indications. Central nervous system infections can develop as complications in ICU patients including post-operative neurosurgical patients. While bacterial infections are the most common cause, mycobacterial and fungal infections are also frequently encountered. Delay in institution of specific treatment is considered to be the single most important poor prognostic factor. Empirical antibiotic therapy must be initiated while awaiting specific culture and sensitivity results. Choice of empirical antimicrobial therapy should take into consideration the most likely pathogens involved, locally prevalent drug-resistance patterns, underlying predisposing, co-morbid conditions, and other factors, such as age, immune status. Further, the antibiotic should adequately penetrate the blood-brain and blood- cerebrospinal fluid barriers. The presence of a focal collection of pus warrants immediate surgical drainage. Following strict aseptic precautions during surgery, hand-hygiene and care of catheters, devices constitute important preventive measures. A high index of clinical suspicion and aggressive efforts at identification of aetiological cause and early institution of specific treatment in patients with neurological infections can be life saving.
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Empiric therapy
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Neurological infections constitute an uncommon, but important aetiological cause requiring admission to an intensive care unit (ICU). In addition, health-care associated neurological infections may develop in critically ill patients admitted to an ICU for other indications. Central nervous system infections can develop as complications in ICU patients including post-operative neurosurgical patients. While bacterial infections are the most common cause, mycobacterial and fungal infections are also frequently encountered. Delay in institution of specific treatment is considered to be the single most important poor prognostic factor. Empirical antibiotic therapy must be initiated while awaiting specific culture and sensitivity results. Choice of empirical antimicrobial therapy should take into consideration the most likely pathogens involved, locally prevalent drug-resistance patterns, underlying predisposing, co-morbid conditions, and other factors, such as age, immune status. Further, the antibiotic should adequately penetrate the blood-brain and blood- cerebrospinal fluid barriers. The presence of a focal collection of pus warrants immediate surgical drainage. Following strict aseptic precautions during surgery, hand-hygiene and care of catheters, devices constitute important preventive measures. A high index of clinical suspicion and aggressive efforts at identification of aetiological cause and early institution of specific treatment in patients with neurological infections can be life saving.
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Cellulitis is a common condition in equine practice and one that is frustrating to treat. Typically, antimicrobials and anti-inflammatories are administered and most cases resolve with time. Bacterial culture and susceptibility should be performed more frequently as they enable more responsible and informed decisions on antimicrobial choice to be made, especially when first ineffective. In cases that are refractory to initial treatment imaging modalities play a role in providing a better understanding of the extent of the underlying pathology and hence prognosis. Recurrence is common.
Lymphangitis
Refractory (planetary science)
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Currently, patients quite often and often uncontrollably take antibacterial drugs, which leads to the development of various complications from many organs and systems. One of the most common adverse reactions to taking antibiotics is antibiotic-associated diarrhea. Moreover, such a pathological condition is due to both the direct effect of the drug, and a change in the composition of the intestinal microflora. Despite the frequent occurrence of antibiotic-associated diarrhea, this problem raises many questions among practitioners, since the risk factors for its development and methods of prevention have not been fully studied. This is especially important in patients who have undergone surgical interventions, since the combination in this contingent of the appointment of broad-spectrum antibacterial drugs and altered body reactivity in most cases leads to the development of adverse effects.
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Open fracture
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Cellulitis is a severe infection of the soft tissues, with a variable aetiology from Gram-positive to Gram-negative bacteria and deep fungal infections, whose early recognition is mandatory to avoid potentially life threatening complications. Some pathogens might cause very similar clinical entities, and cellulitis differentiation at presentation towards abscess, necrotising fasciitis, and gangrene, requires expertise. Many mimics are also to be excluded, conditioning the treatment and patient’s prognosis. The dermatologist is in a lead position to avoid misdiagnosis, to evaluate the type of assessment, and address initial treatment. Besides, skin and soft tissue infections are a common reason for emergency room visits and hospital admission, lacking precise clinical definition and managed with empirical antibiotic treatments. History, physical examination and laboratory data can help characterise the severity of the disease, and the probability of complications development, mainly necrotising fasciitis. Several admittance scores have been proposed to address the emergency decisions, and guidelines for treatment proposed. The present review will focus on clinical challenges and actual open questions on cellulitis management.
Etiology
Gangrene
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