Kish Troy D, Chang Mei H, Fung Horatio B
Pharmacy Service, James J. Peters Veterans Affairs Medical Center, Bronx, New York 10468, USA.
Am J Geriatr Pharmacother. 2010 Dec;8(6):485-513. doi: 10.1016/S1543-5946(10)80002-9.
Skin and soft tissue infections (SSTIs) have become the second most common type of infection among persons residing in long-term care facilities.
The purpose of this article was to review the latest information on SSTIs among the elderly, including age-related changes, challenges, and treatment strategies in the era of emerging bacterial resistance.
Relevant information was identified through a search of MEDLINE (1970-April 2010), International Pharmaceutical Abstracts (1970-April 2010), and Google Scholar using the terms skin and soft tissue infection, skin and skin structure infection, cellulitis, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Trials published since 1970 were selected for this review if they prospectively evaluated mostly adults (≥18 years of age), included >50 patients, and reported diagnostic criteria as well as clinical outcomes in patients treated for simple or complicated SSTIs.
Fifty-eight of 664 identified studies were selected and included in this review. A search of the literature did not identify any prospective clinical trials that were conducted exclusively in the elderly. Information on the treatment of SSTIs in the elderly was based solely on clinical studies that were conducted in adults in general. As recommended by the Infectious Diseases Society of America (IDSA) 2008 update, SSTIs should be suspected in elderly patients who have skin lesions and present with a decline in functional status, with or without fever. Patients who present with symptoms of systemic toxicity should be hospitalized for further evaluation. Current challenges in the management of SSTIs include the rapid emergence of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA), the emergence of macrolide-resistant streptococci within the past decade, and the lack of a reliable algorithm to differentiate potentially life-threatening SSTIs that require aggressive interventions and prompt hospitalization from those that can be managed in an outpatient setting. S aureus was the most common cause of SSTIs, being isolated in 42.8% (5015/11,723) of wounds, followed by streptococci. Common SSTIs in the elderly such as shingles, diabetic foot infections, infected pressure ulcers, and scabies, and their treatment were also discussed. Based on reviews of published trials, treatment of simple SSTIs generally consisted of administration of agents with activity against S aureus and Streptococcus species such as a penicillinase-resistant β-lactam, a first-generation cephalosporin, or clindamycin. Broadening of the antimicrobial spectrum to include gram-negative and anaerobic organisms should be implemented for complicated SSTIs such as diabetic foot infections and infected pressure ulcers. Local rates of MRSA, CA-MRSA, and macrolide-resistant streptococci should be considered when selecting empiric therapy.
A search of the literature did not identify any prospective clinical trials on the treatment of SSTIs in the elderly; therefore, it is recommended to follow treatment based on the current IDSA guidelines. More research and publications are needed to establish proper selection of antimicrobial agents, treatment strategies, and duration of therapy of SSTIs in the elderly population.
皮肤及软组织感染（SSTIs）已成为长期护理机构居住者中第二常见的感染类型。
本文旨在综述老年人SSTIs的最新信息，包括与年龄相关的变化、挑战以及在细菌耐药性不断出现的时代的治疗策略。
通过检索MEDLINE（1970年 - 2010年4月）、国际药学文摘（1970年 - 2010年4月）以及谷歌学术，使用皮肤及软组织感染、皮肤及皮肤结构感染、蜂窝织炎、治疗指南和老年人等检索词来识别相关信息。通过检索已识别文章的参考文献列表找到更多出版物。自1970年以来发表的试验若前瞻性评估的大多为成年人（≥18岁）、纳入患者>50例且报告了单纯或复杂SSTIs治疗患者的诊断标准及临床结局，则被选入本综述。
在664项已识别研究中，58项被选入本综述。文献检索未发现专门针对老年人进行的前瞻性临床试验。老年人SSTIs治疗的信息仅基于一般针对成年人进行的临床研究。如美国传染病学会（IDSA）2008年更新所推荐，对于有皮肤病变且功能状态下降、伴有或不伴有发热的老年患者，应怀疑患有SSTIs。出现全身中毒症状的患者应住院进一步评估。SSTIs管理当前面临的挑战包括社区获得性耐甲氧西林金黄色葡萄球菌（CA - MRSA）的迅速出现、过去十年中出现的大环内酯类耐药链球菌以及缺乏可靠的算法来区分需要积极干预和及时住院治疗的潜在危及生命的SSTIs与可在门诊处理的SSTIs。金黄色葡萄球菌是SSTIs最常见的病因，在42.8%（5015/11,723）的伤口中分离出，其次是链球菌。还讨论了老年人常见的SSTIs，如带状疱疹、糖尿病足感染、感染性压疮和疥疮及其治疗。基于对已发表试验的综述，单纯SSTIs的治疗通常包括给予对金黄色葡萄球菌和链球菌有活性的药物，如耐青霉素酶的β - 内酰胺类、第一代头孢菌素或克林霉素。对于复杂的SSTIs，如糖尿病足感染和感染性压疮，应扩大抗菌谱以包括革兰氏阴性菌和厌氧菌。选择经验性治疗时应考虑当地MRSA、CA - MRSA和大环内酯类耐药链球菌的发生率。
文献检索未发现关于老年人SSTIs治疗的前瞻性临床试验；因此，建议遵循当前IDSA指南进行治疗。需要更多的研究和出版物来确定老年人群中SSTIs抗菌药物的正确选择、治疗策略和治疗持续时间。
