Changes in the classification and management of skin and soft tissue infections

Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used 'Eron classification' is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) 'Guidelines on the Management of Cellulitis in Adults' have not been validated in clinical trials. In the current issue of JAC, investigators at Ninewells Hospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.