Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans.
APHP Medical and Infectious Diseases Intensive Care Unit (MI), Bichat-Claude Bernard Hospital.
Curr Opin Infect Dis. 2020 Apr;33(2):137-145. doi: 10.1097/QCO.0000000000000642.
This article summarizes the available evidence enabling a stratification of risk for multidrug-resistant bacteria (MDRB) in patients with skin and soft tissue infection (SSTI).
MDRB are increasingly reported in both healthcare-associated (HCA) and community-acquired (CA)-SSTI, including in patients with life-threatening presentations for whom early initiation of adequate antimicrobial therapy is pivotal to improve outcomes. Community-associated methicillin-resistant Staphylococcus aureus (MRSA) is now endemic in several geographical areas and may cause outbreaks in frail populations or other at-risk clusters. Pseudomonas aeruginosa and other nonfermenting Gram-negative pathogens are involved in CA-SSTI on an occasional basis, especially in patients with chronic wounds or recent antimicrobial exposure. The burden of HCA-SSTI because of MRSA, MR P. aeruginosa, MR Acinetobacter baumannii, extended-spectrum β-lactamase-producing Enterobacterales and vancomycin-resistant enterococci is amplifying in endemic settings. Severe comorbidities, prolonged hospitalization, invasive procedures, prior colonization or infection and antimicrobial exposure stand as the main risk factors for these conditions. Worryingly, carbapenemase-producing Enterobacterales are emerging as causative pathogens in HCA-SSTI.
The choice of empirical agents depends on the type and location of SSTI, place of onset, initial severity and whether the patient presents or not with risk factors for MDRB, with local epidemiology and prior antimicrobial use being among the main features to consider.
本文总结了现有的证据，使皮肤和软组织感染（SSTI）患者的多重耐药菌（MDRB）风险分层成为可能。
医源性（HCA）和社区获得性（CA）SSTI 中越来越多地报道了 MDRB，包括危及生命的患者，早期开始适当的抗菌治疗对改善预后至关重要。社区获得性耐甲氧西林金黄色葡萄球菌（MRSA）现在在几个地理区域流行，并可能在体弱人群或其他高危人群中引起暴发。偶尔会有假单胞菌和其他非发酵革兰氏阴性病原体引起 CA-SSTI，尤其是在慢性伤口或近期使用过抗菌药物的患者中。由于 MRSA、MR 铜绿假单胞菌、MR 鲍曼不动杆菌、产超广谱β-内酰胺酶的肠杆菌科和万古霉素耐药肠球菌，HCA-SSTI 的负担在流行地区正在增加。严重的合并症、长时间住院、侵入性操作、定植或既往感染以及抗菌药物暴露是这些情况的主要危险因素。令人担忧的是，产碳青霉烯酶的肠杆菌科正在成为 HCA-SSTI 的致病病原体。
经验性药物的选择取决于 SSTI 的类型和部位、发病部位、初始严重程度以及患者是否存在 MDRB 的危险因素，其中局部流行病学和既往抗菌药物使用是需要考虑的主要特征。
