European Journal of Cardiovascular Medicine

Infections affecting the skin and underlying subcutaneous tissue, underlying fascia, or underlying muscles are referred to as skin and soft tissue infections. From minor skin infections to potentially fatal necrotizing fasciitis, skin and soft tissue infections (SSTIs) can take many different forms. [1,2]

It will be challenging to diagnose and treat infections ranging from mild to severe due to their variable presentation, overlapping etiology, and severity. Determining the severity is crucial for lowering morbidity and mortality as well as for early and efficient SSTI management.

Understanding the anatomical relationships between skin and soft tissue, as well as recognizing the results of physical examinations, are essential steps in making an accurate diagnosis. Aspiration of tissues, biopsy, and radiography procedures may be required to determine the extent of infection and to evaluate deep-seated collections.

Antibiotics administered orally or intravenously can be used to treat SSTIs, and treatment durations vary. Based on the severity of the infection and the etiological factors, empirical therapy is advised. It is advised to switch to culture-specific treatment in order to maintain effectiveness and avoid resistance.

In the end, extensive and forceful surgical exploration and debridement are critical for both diagnosis and treatment, especially in immunocompromised hosts or patients suffering from myonecrosis or necrotizing infections. Ultrasonography, CT scans, or MRIs may also be useful for determining the extent of the infection for early medical or surgical evaluation. [3, 4] Several surgical options have been found to reduce the morbidity, mortality, length of antibiotic administration, and length of hospital stay of admitted patients, including fasciotomy, routine surgical debridement, and abscess drainage.

OBJECTIVES

1. To study the clinical profile of patients with community acquired skin and soft tissue infections
2. (SSTIs) coming to a tertiary level hospital.
3. To evaluate the existing method of severity stratification of SSTIs specific to the groups of patients.
4. To identify factors responsible for prolonged stay and poor outcome in patients with SSTIs

Study design: Case series study

Study period: 18 months, January 2023 - June 2024

Sample size: 125 patients

Study centre: Department of General Surgery, Rajarajeswari Medical College and Hospital

Sampling technique and study population: Convenient sampling. All consecutive cases coming to the General Surgery OPD and Emergency.

Inclusion criteria:

1. Presence of at least 2 of the following clinical signs and symptoms of local infection:

• Swelling
• Pain out of proportion to the clinical findings
• Erythema
• Induration
• Abscess formation
• Tenderness on palpation

2. Presence of even one of the following systemic conditions:

• Body temperature >40 degree Celsius or <35 degree Celsius
• WBC counts > 15000
• Wound culture or Gram stain positive.

3. Diagnosis of Severe infections like necrotising fasciitis, Fournier’s gangrene.

Exclusion criteria:

1. Patients with trivial injury
2. Patients with hospital acquired infection
3. Patients should not have been admitted within 4 weeks of presentation
4. All patients less than 12 years of age
5. Sites of infection other than skin i.e. osteomyelitis, meningitis, bacteria, etc.

Statistical methods applied: 

Data collected was analysed using Descriptive and Inferential Statistics. Analysis was done both manually and by using a computer.

Calculated data was arranged in a systemic manner, presented in various bar graphs, pie charts and figures, and statistical analysis was made to evaluate the objectives of this study with the aid of Statistical Package for Social Science (SPSSv23) and MS Excel.  

Figure 2. Sex distribution of cases

Figure 4. Comorbid conditions in cases of soft tissue infections

Figure 5. Distribution of organisms obtained in pus culture

Figure 6. Complications associated with soft tissue infections

Figure 8. Management of cases with soft tissue infections

The current study was carried out at Rajarajeswari Medical College and Hospital in Bengaluru, in the Department of Surgery. We conducted a prospective study on 125 patients who were hospitalized with a diagnosis of soft-tissue infection. Every patient who was enrolled has finished the research.

Distribution of age and sex:
Skin and soft tissue infections (SSTIs) affected 125 patients in the current study, with the age group of 21–40 years old accounting for 40% of cases and the age group of 41–60 years old for 30%. Patients over 80 years old were the least affected group (5%), as they are less likely to visit hospitals [Figure 1]. In line with earlier epidemiological research showing a male predominance in SSTIs, the gender distribution was biased toward men (60%), as opposed to women (40%). [Figure 2].

 
Clinical presentation:

 The most common presentation in this study was abscesses (48%), which were followed by sebaceous cysts (7%), ulcers and cellulitis (13%), and abscesses. In line with the disease's epidemiology, Fournier's gangrene was comparatively uncommon (6%) and only affected men [Figure 3].

 
Comorbid conditions:
Diabetes is a major risk factor in this study, as evidenced by the fact that the majority of patients (55%), followed closely by type 2 diabetes mellitus (30%), had no comorbidities. Hypertension and ischaemic heart disease were less common comorbid conditions. Comorbid conditions linked to soft-tissue infections were present in 52% of cases [Figure 4].

Microbiological Culture Study:
The most frequently cultured organisms were Staphylococcus aureus (38%) and Escherichia coli (26%). As is typical of SSTI pathogens, Pseudomonas aeruginosa accounted for 18% of isolates, while Klebsiella species (5%), Citrobacter freundii (3%), and Proteus species (2%) were less frequently found [Figure 5].

Complications:
40% of patients in our study experienced complications, with renal disease accounting for the majority at 40%. Multi-organ dysfunction syndrome, heart disease, and respiratory disease came in second and third, respectively, at 30% and 10%. These results highlight the potential systemic effects of SSTIs, particularly in cases where diagnosis and treatment are postponed [Figure 6].

Length of stay:
The various clinical presentations had a significant impact on the length of hospital stay. Patients with abscess, carbuncles, and surgical site infections had intermediate stays (average of 3 days), while those with sebaceous cysts had the shortest stays (average of 1 day). Given the severity and complexity of these conditions, patients with cellulitis and Fournier's gangrene had the longest stays (average 9 and 13 days, respectively), while diabetic foot infections required longer admissions (average 6 days) [Figure 7].

Management:
90% of the soft-tissue infection cases in this study were treated surgically, with patients undergoing fasciotomies, wound debridement, or abscess incision and drainage. In the remaining 10% of cases, no surgery was performed. The majority of our study's soft-tissue infection cases required surgery, highlighting the vital role that surgery plays in effectively treating SSTIs. [Fig. 8].

The current study was carried out at Rajarajeswari Medical College and Hospital in Bengaluru, in the Department of Surgery. We conducted a prospective study on 125 patients who were hospitalized with a diagnosis of soft-tissue infection. Ages 21 to 40 years old accounted for 40% of all soft-tissue infection cases, while those over 80 years old accounted for 5%.
Soft-tissue infections were more common in adult males in our study (60%) than in females. These results are consistent with earlier research showing that soft-tissue infections are prevalent in adult males, as reported by Lipsky et al. [5] and Ki and Rotstein [6].
The most frequent clinical manifestation of all soft-tissue infections was abscess formation (48%). In a related study, Ellis Simonsen et al. [7] found that the most frequent outcome of skin and soft-tissue infections (SSTIs) was abscess formation, which they attributed to the delayed presentation of these cases to the clinician.
Type 2 diabetes mellitus (30%) was the most frequently linked comorbid condition in the current study, accounting for 45% of cases. Our research supports the findings of Shen and Lu's study [8], which found that the most prevalent comorbid condition linked to soft-tissue infections was diabetes mellitus.
In soft-tissue infection cases, S. aureus was the most frequently cultured organism (38%), followed by E. coli (26%). This result is consistent with a study by Mohanty et al. [9], which found that S. aureus was the most frequently isolated bacteria in abscesses taken from soft-tissue infections, followed by E. coli and Pseudomonas species.
Surgery was used to treat about 90% of all soft-tissue infection cases. The majority of our study's soft-tissue infection cases required surgery, either debridement/excision or incision and drainage. Lee et al.'s study [10] concluded that the management of skin and soft-tissue abscesses could be achieved with incision and drainage alone, without the need for additional antibiotic therapy. In their study, Macfie and Harvey [11] found that the safest treatment for most abscesses was free drainage after incision and drainage. They added that regular use of the antibiotics was not advised and that they had no discernible effect on recovery time or recurrence. Consequently, our research aligns with the readily available literature on this topic.
According to the current study, timely surgical intervention is the most effective way to treat soft-tissue infections.
Renal failure accounted for 40% of the most frequent complications in soft-tissue infection cases. In their research, Thaichinda and Kositpantawong [12] found that acute renal failure and multi-organ system dysfunction were the most frequent complications in soft-tissue infection cases. As a result, our study's results are consistent with similar earlier research that has been referenced in the literature. In reality, even one unrelated factor, like septicemia or renal impairment, can set off a chain of events that leads to multi-organ failure. Patients with soft-tissue infections stayed an average of 4.45 days. This result is closely related to the study by Namiduru et al. [13], where the authors found that the patients' hospital stay was prolonged by 12.8 days due to soft-tissue infections. Comorbid conditions like diabetes and renal disease also increased the average length of hospital stay.
Diabetes mellitus combined with peripheral vascular disease or renal dysfunction increased mortality in our study. The factors influencing mortality in cases of NSTIs were described by Elliott et al. [14] in a retrospective study, and they were almost identical to those observed in our study with diabetes mellitus excluded.
Elliott et al. reiterated in their study that diabetes mellitus was not a risk factor for NSTI-related deaths. This disparity can be explained by the ways that the demographic trends of underdeveloped and developed nations differ, as well as the lack of tertiary care facilities in the former.
The current approach aids in both stratification and appropriate SSTI management. As indicated by the different clinical and demographic factors, it has helped manage cases according to their severity. However, some changes must be made to the current system. Our study determined which symptoms, signs, and other risk factors were statistically significant (P < 0.05) in influencing the outcome. When combined with the current schema, these elements can more clearly distinguish between mild cases and moderate-to-severe cases that need inpatient and outpatient care, respectively.
In addition to the risk factor previously mentioned in the literature, the study identified a number of other risk factors. These elements had an impact on the outcome and raised mortality and morbidity. In order to change the current stratification system, the following factors must be included: i) Male patients from lower socioeconomic backgrounds ii) Even if the body surface area (BSA) involved is less than 9%.
iii) Sensation loss iv) Loss of function and mobility v) Joint movement restriction vi) Gangrene presence vii) TLC > $15,000/month viii) Low blood sugar

Based on the patient's clinical and demographic characteristics, SSTIs can be classified as mild, moderate, or severe; Male patients from lower socioeconomic backgrounds who are more vulnerable to trauma because of their living and working circumstances were among the predisposing factors for SSTIs;
Diabetes mellitus and smoking are additional risk factors.
Hypertension, TLC > 15000, temperature above 38 C, hyponatremia,
The severity of the infection is increased when gangrene, bullae, or crepitus are present;
BSA > 9% indicates a severe infection, with the exception of infections affecting the hands, head, or scrotum, where gangrene and co-morbidities are linked. The degree of infection was further demonstrated by loss of feeling, restriction of joint movement, and loss of movement or function of the afflicted part; Based on the aforementioned results, a severity stratification algorithm is developed that can assist in the timely and appropriate management of patients who present to the surgical outpatient department (OPD) or emergency room with SSTIs, either through medical or surgical intervention, thereby lowering the morbidity and mortality linked to it.

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