SSTI指南强调诊断技能和谨慎治疗

美国感染性疾病学会（IDSA）关于皮肤和软组织感染的新版实践指南强调了仔细分析感染类型、流行病学背景、患者健康状态，以及选择最合理的治疗药物和剂量。

这部新版指南发表在6月18日在线版《临床感染性疾病》杂志上（doi:10.1093/cid/ciu296），对2005年发表的前一版本进行了更新，涵盖从动物叮咬引起的健康宿主感染到免疫功能低下患者的危及生命感染的各个方面。新版指南还强调准确识别病原体，并提醒临床医生临床表现可以非常相似。

指南主要作者、爱达荷州博伊斯退伍军人事务部的Dennis Stevens医生指出：“与其他指南不同的是，这部指南并没有将复杂的问题简化为在2种药物或药物组合之间进行选择。皮肤与软组织感染（SSTI）有多种致病因素和不同表现，取决于宿主的免疫状态。SSTI非常复杂，的确需要思维敏锐的医生考虑诸多因素。”

这部指南是由10名作者起草的，提供了治疗非化脓性和化脓性感染的新规范，针对二者中的轻度、中度和重度感染分别制订了临床路径。例如，对于化脓性感染，如果患者没有全身受累的征象，则不推荐使用抗生素，而仅需切开引流。

对于有一定程度全身受累的中度化脓性感染，新版指南认为应当在切开引流后进行培养和药敏试验，并且推荐采用复方新诺明和多西环素进行经验性治疗。当确定病原为耐甲氧西林金黄色葡萄球菌（MRSA）时，推荐使用复方新诺明；对于甲氧西林敏感性金黄色葡萄球菌（MSSA）感染，推荐使用多西环素。

提出这一新规范的目的是“促使临床医生思考”。Stevens医生在接受采访时表示：“我们试图让临床医生不仅考虑病原体，而且基于患者的病情严重程度选择合理的治疗方式。新规范不赞成用昂贵的四代抗生素治疗每一例患者这种下意识行为，而是提供清晰的合理治疗路径。”

在抗生素治疗失败、免疫功能低下、发热且白细胞计数增高，或者有其他重度感染证据的患者中，“我们不会冒险，而是建议立即采用能覆盖所有病原——包括耐药菌株——的抗生素进行治疗”。新近获准的药物dalbavancin和tedizolid可有效治疗MRSA引起的SSTI。

这部新版指南的目标人群是急诊科、全科、内科、普外科、骨科、妇科、皮肤科、感染科和肿瘤科的医生。

该指南中提出的另一项规范涉及术后伤口感染。该规范简要介绍了需要使用抗生素、只需拆开缝合线、或对灾难性感染在48 h内进行全力救治等情况的临床线索。新版指南还针对正在接受抗癌治疗、使用免疫抑制药物、接受器官移植或患有HIV/AIDS的患者提出了推荐意见。

Stevens医生指出，免疫功能低下患者是治疗难度最大的一类患者，因为此类患者可能有大量抗生素暴露史，易发生耐药菌感染，并且常常被真菌和寄生虫等正常人群中罕见的病原感染。“这是首次通过指南正式地告诉临床医生如何应对此类患者的SSTI。”

这部指南的编写工作得到了IDSA的资助。Stevens医生报告称无利益冲突。指南作者之一的Alan L. Bisno披露称获得了UpToDate的酬金，另外5名作者Henry F. Chambers、E. Patchen Dellinger、Ellie J. C. Goldstein、Sherwood L. Gorbach和Sheldon L. Kaplan披露称与多家药企存在利益关系。

爱思唯尔版权所有  未经授权请勿转载

 

By: JENNIE SMITH, Internal Medicine News Digital Network

New practice guidelines on skin and soft tissue infections from the Infectious Diseases Society of America stress careful clinical attention to the type of infection, the epidemiological setting in which the infection occurred, the health status of the patient, and the selection and dosage of the most appropriate treatment agents.

The guidelines, published online June 18 in Clinical Infectious Diseases (doi:10.1093/cid/ciu296), update those issued by IDSA in 2005 and cover everything from preventing infections caused by animal bites in healthy hosts to life-threatening infections in immunocompromised patients. They also emphasize accurate identification of pathogens, stressing that clinical presentations can be very similar.

"This is not one of those guidelines that boils complex issues down to a choice between a couple of different drugs or combinations of drugs," said Dr. Dennis Stevens of the Department of Veterans Affairs in Boise, Idaho, the guidelines’ lead author. "Skin and soft tissue infections [SSTIs] have multiple causes and different presentations, depending upon the immune status of the host. Here it’s much more complicated and really requires an astute physician to consider a number of things."

The guidelines, drafted by a 10-member panel, offer a novel algorithm for management of nonpurulent and purulent infections that aims to define a pathway for mild, moderate, and severe infections in each category. For example, no antibiotic is recommended for a purulent infection – only incision and drainage – if the patient has no signs of systemic involvement.

For moderate cases of purulent infection with some systemic involvement, incision and drainage should be followed by culture and sensitivity testing, the guidelines say, listing two antibiotics, trimethoprim-sulfamethoxazole and doxycycline, as appropriate for empiric treatment, while trimethoprim-sulfamethoxazole is recommended if the pathogen is found to be methicillin-resistant Staphylococcus aureus (MRSA) and dicloxacillin or cephalexin if it is methicillin-susceptible S. aureus (MSSA).

The purpose of the algorithm, expressed in the guidelines in chart form, "is to make the physician think," Dr. Stevens said in an interview. "There is a huge move to try and monitor antibiotic stewardship to prevent resistance, and we’re just trying to get the clinician to think of tier 1, tier 2, and tier 3 approaches, depending not only on the bug, but on how sick the patient is. Instead of a knee-jerk approach treating everybody with highly expensive IV antibiotics, [the algorithm] provides a clear pathway to treat appropriately."

In people with an abscess who have failed antibiotic treatment, are immunocompromised, or have fever and elevated white blood cell counts or other evidence of severe infection, "we’re not going to gamble," Dr. Stevens said, adding that the guidelines recommend prompt treatment using "an antibiotic that gets all of these organisms, including resistant ones." Newly approved agents dalbavancin and tedizolid are effective in treating SSTIs caused by MRSA, the guidelines note.

The guidelines are intended for use by clinicians in emergency departments, family practice, internal medicine, general surgery, orthopedics, gynecology, dermatology, infectious disease, and oncology.

Another algorithm charted in the guidelines covers wound infections following surgeries, which can involve multiple pathogens. The algorithm provides simple clinical clues as to which require antibiotics, a simple opening of the suture line, "or a full-court press for the kind of devastating infections that occur within the first 48 hours," Dr. Stevens said. Additional recommendations address infections that can occur in individuals receiving treatment for cancer or receiving immunosuppressant medications, or those who have had an organ transplant or who have HIV/AIDS.

Immunocompromised patients, Dr. Stevens said, are among the most challenging to treat because they may have a history of extensive antibiotic exposure, are likely to have infections with resistant bacteria, and often see involvement with fungal and parasitic agents that might be considered innocuous in normal individuals. "This is the first time physicians will have some decent guidelines about how to approach the problem of skin and soft tissue infections in these kinds of patients," he noted.

The guidelines’ development was funded by the IDSA. Dr. Stevens reported no conflicts of interest. Panel member Alan L. Bisno disclosed receiving honoraria from UpToDate, while five other members – Dr. Henry F. Chambers, Dr. E. Patchen Dellinger, Dr. Ellie J. C. Goldstein, Dr. Sherwood L. Gorbach, and Dr. Sheldon L. Kaplan – disclosed financial relationships with pharmaceutical manufacturers.