Skip to main content Accessibility help
×
×
Home

Skin, Soft Tissue, Bone, and Joint Infections in Hospitalized Patients: Epidemiology and Microbiological, Clinical, and Economic Outcomes

  • Benjamin A. Lipsky (a1), John A. Weigelt (a2), Vikas Gupta (a3), Aaron Killian (a3) and Michael M. Peng (a3)...
Abstract
Background.

Infections involving skin, soft tissue, bone, or joint (SSTBJ) are common and often require hospitalization. There are currently few published studies on the epidemiology and clinical and economic outcomes of these infections, whether acquired in the community or healthcare setting, in a large population.

Objective.

To characterize outcomes of culture-proven SSTBJ infection in hospitalized patients, using information from a large database.

Design.

We identified patients hospitalized in 134 institutions during 2002-2003 for whom specific International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and a culture-positive SSTBJ specimen were recorded. Patients were classified into 4 clinical groups based on the type and clinical severity of infection. Patients in each group were further classified on the basis of whether their infection was community acquired or healthcare associated and whether it was complicated or uncomplicated.

Results.

We identified 12,506 patients with culture-positive infections and categorized them as having cellulitis (37.3%), osteomyelitis or septic arthritis (22.4%), surgical wound infection (26.1%), device-associated or prosthesis infection (7.2%), or other SSTBJ infection (6.9%). Monomicrobial infection was reported for 59% of patients, 54.6% of whom had Staphylococcus aureus as the etiologic agent. Of all S. aureus isolates recovered, 1,121 (28.0%) of 4,007 were resistant to methicillin. Healthcare-associated infections accounted for 27.2% of cases and were associated with a significantly greater mortality rate, a longer length of stay, and greater hospital charges, compared with community-acquired infections. Patients with a complicated infection (78.4%) had a significantly greater mortality rate, a longer length of stay, and greater hospital charges, compared with patients with an uncomplicated infection.

Conclusions.

SSTBJ infections are frequent among hospitalized patients. S. aureus caused infection in more than 50% of the patients studied, and 28.0% of the S. aureus isolates recovered were resistant to methicillin. Healthcare-associated and complicated infections are associated with a significantly higher mortality rate and more prolonged and expensive hospitalizations. These findings could assist in projects to revise current management strategies in order to optimize outcomes while restraining costs.

Copyright
Corresponding author
VA Puget Sound Health Care System (S-111-GIMC), 1660 South Columbian Way, Seattle, Washington 98108-1597 (balipsky@u.washington.edu or (Benjamin.Lipsky@med.va.gov)
References
Hide All
1.Eron, LJ, Lipsky, BA, Low, DE, Nathwani, D, Tice, AD, Volturo, GA. Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52(suppl 1):i317.
2.DiNubile, M, Lipsky, BA. Complicated infections of skin and skin structures: when the infection is more than skin deep. J Antimicrob Chemother 2004;53:ii37ii50.
3.Ciccarone, D, Bamberger, JD, Krai, AH, et al. Soft tissue infections among injection drug users—San Francisco, California, 1996-2000. MMWR Morb Mortal Wkly Rep 2001;50:381384.
4.Martone, WJ, Nichols, RL. Recognition, surveillance, and management of surgical site infections: introduction to the problem and symposium overview. Clin Infect Dis 2001;33:S67S68.
5.Lipsky, BA, Berendt, , AR, , Deery, HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885910.
6.Lazzarini, L, Conti, E, Tositti, G, de Lalla, F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect 2005;51:383389.
7.Fridkin, SK, Gaynes, RP. Antimicrobial resistance in intensive care units. Clin Chest Med 1999;20:303316.
8.Vinh, DC, Embil, JM. Rapidly progressive soft tissue infections. Lancet Infect Dis 2005;5:501513.
9.Davis, JS. Management of bone and joint infections due to Staphylococcus aureus. Intern Med J 2005;35:S79S96.
10.Carek, PJ, Dickerson, LM, Sack, JL. Diagnosis and management of osteomyelitis. Am Fam Physician 2001;63:24132420.
11.Doern, GV, Jones, RN, Pfaller, MA, Kugler, KC, Beach, ML. Bacterial pathogens isolated from patients with skin and soft tissue infections: frequency of occurrence and antimicrobial susceptibility patterns from the SENTRY Antimicrobial Surveillance Program (United States and Canada, 1997). Diagn Microbiol Infect Dis 1999;34:6572.
12.Fluckiger, U, Widmer, AF. Epidemiology of methicillin-resistant Staphylococcus aureus. Chemotherapy 1999;45:121134.
13.Dang, CN, Prasad, YD, Boulton, AJ, Jude, EB. Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet Med 2003;20:159161.
14.Mantey, I, Hill, RL, Foster, AV, Wilson, S, Wade, JJ, Edmonds, ME. Infection of foot ulcers with Staphylococcus aureus associated with increased mortality in diabetic patients. Comm Dis Public Health 2000;3:288290.
15.Moran, GJ, Krishnadasan, A, Gorwitz, RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006;355:666674.
16.Engemann, , JJ, , Carmeli, Y, Cosgrove, SE. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592598.
17.Iezzoni, LI, Ash, AS, Coffman, GA, Moskowitz, MA. Admission and mid-stay Medis Groups scores as predictors of hospitalization charges. Med Care 1991;29:210220.
18.Fine, MJ, Auble, TE, Yealy, DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243250.
19.Rello, J, Ollendorf, DA, Oster, G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:21152121.
20.Kollef, MH, Shorr, A, Tabak, YP, Gupta, V, Liu, LZ, Johannes, RS. Epidemiology and outcomes of healthcare-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005;128:38543862.
21.Tabak, YT, Johannes, RS, Silber, JH. Using automated clinical data for risk adjustment: development and validation of six disease-specific mortality predictive models for pay-for-performance. Med Care 2007;45:789805.
22.Office of Drug Evaluation IV, US Food and Drug Administration. Guidance for industry: uncomplicated and complicated skin and skin structure infections—developing antimicrobial drugs for treatment (draft). 1998. Available at: http://www.fda.gov/ohrms/dockets/98fr/2566dft.pdf. Accessed December 30, 2006.
23.Solomkin, JS, Bjornson, HS, Cainzos, M, et al. A consensus statement on empiric therapy for suspected gram-positive infections in surgical patients. Am J Surg 2004;187:134145.
24.Stevens, DL, Bisno, AL, Chambers, HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41:13731406.
25.National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992-June 2001, issued August 2001. Am J Infect Control 2001;29:404421.
26.Rennie, , RP, , Jones, , RN, , Mutnick, , AH, . Occurrence and antimicrobial susceptibility patterns of pathogens isolated from skin and soft tissue infections: report from the SENTRY Antimicrobial Surveillance Program (United States and Canada, 2000). Diagn Microbiol Infect Dis 2003;45:287293.
27.Rybak, MJ, LaPlante, KL. Community-associated methicillin-resistant Staphylococcus aureus: a review. Pharmacotherapy 2005;25:7485.
28.Szumowski, JD, Cohen, DE, Kanaya, F, Mayer, KH. Treatment and outcomes of MRSA infections at an ambulatory clinic. Antimicrob Agents Chemother 2007;51:423428.
29.Skiest, DJ, Brown, K, Cooper, TW, Hoffman-Roberts, H, Mussa, HR, Elliott, AC. Prospective comparison of methicillin-susceptible and methicillin-resistant community-associated Staphylococcus aureus infections in hospitalized patients. J Infect 2007;54:427434.
30.Crum, NF, Lee, RU, Thornton, SA, et al. Fifteen-year study of the changing epidemiology of methicillin-resistant Staphylococcus aureus. Am J Med 2006;119:943951.
31.Fejfarova, V, Jirkovska, A, Skibova, J, Petkov, V. Pathogen resistance and other risk factors in the frequency of lower limb amputations in patients with diabetes foot syndrome [in Czech]. Vnitr Lek 2002;48:302306.
32.Saravolatz, LD, Markowitz, N, Arking, L, Pohlod, D, Fisher, E. Methicillin-resistant Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak. Ann Intern Med 1982;96:1116.
33.Cosgrove, SE, Sakoulas, G, Perencevich, EN, Schwaber, MJ, Karchmer, AW, Carmeli, Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a metaanalysis. Clin Infect Dis 2003;36:5359.
34.Lesens, O, Methlin, C, Hansmann, Y, et al. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect Control Hosp Epidemiol 2003;24:890896.
35.Kozak, LJ, Owings, MF, Hall, MJ. National Hospital Discharge Survey: 2002 annual summary with detailed diagnosis and procedure data. Division of Health Care Statistics, National Center for Health Statistics. Hyattsville, MD: Department of Health and Human Services (DHHS);2005. Vital and Health Statistics Series 13, No. 158. DHHS publication 2005-1729. Available at: http://www.cdc.gov/nchs/data/series/sr_13/srl3_158.pdf. Accessed December 30, 2006.
36.Ramsey, SD, Newton, K, Blough, D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22:382387.
37.Lavery, LA, Armstrong, DA, Wunderlich, RP, Möhler, MJ, Wendel, CS, Lipsky, BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006;29:12881293.
38.Henke, PK, Blackburn, SA, Wainess, RW, et al. Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage. Ann Surg 2005;241:885894.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed