Bacterial skin and soft tissue infections (SSTIs) in adults encompass a wide spectrum of conditions that range from mild superficial infections to severe, life-threatening conditions. These infections are primarily caused by various bacterial pathogens and can present with diverse clinical manifestations. Understanding the types, causes, clinical features, diagnosis, and treatment options for bacterial SSTIs is crucial for effective management and prevention. This article explores the common bacterial SSTIs encountered in adults, their etiology, risk factors, clinical presentation, diagnostic approach, and therapeutic strategies.

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Types of Bacterial Skin and Soft Tissue Infections

1. Cellulitis

Definition: Cellulitis is a common bacterial infection that affects the deeper layers of the skin and subcutaneous tissues.

Etiologic Agents: Typically caused by Streptococcus pyogenes (Group A Streptococcus) and Staphylococcus aureus (including MRSA).

Clinical Features:

• Red, swollen, and tender skin
• Warmth and induration at the affected site
• Fever and chills in systemic cases
• Possible lymphangitis (red streaks)

Diagnosis:

• Clinical examination
• Blood cultures if systemic symptoms are present
• Imaging studies (e.g., ultrasound) to assess the extent if necessary

Treatment:

• Oral antibiotics (e.g., penicillin, dicloxacillin) for mild cases
• IV antibiotics (e.g., ceftriaxone, vancomycin) for severe cases or MRSA infections
• Supportive measures (e.g., elevation, pain management)

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2. Abscesses

Definition: Abscesses are localized collections of pus within tissues, commonly involving hair follicles.

Etiologic Agents: Staphylococcus aureus (including MRSA) is the predominant causative organism.

Clinical Features:

• Painful, fluctuant, and erythematous nodules or lumps
• Pus drainage upon incision or spontaneous rupture
• Fever and systemic symptoms in severe cases

Diagnosis:

• Clinical examination
• Aspiration of pus for Gram stain and culture
• Imaging (ultrasound, CT) if deep or extensive

Treatment:

• Incision and drainage (I&D) for localized abscesses
• Antibiotics if systemic symptoms or extensive involvement (e.g., vancomycin for MRSA)
• Wound care and follow-up to monitor for recurrence

3. Erysipelas

Definition: Erysipelas is a superficial bacterial infection involving the dermis and upper subcutaneous tissues.

Etiologic Agents: Predominantly caused by Streptococcus pyogenes (Group A Streptococcus).

Clinical Features:

• Well-demarcated, raised, erythematous plaque with sharp borders
• Pain, warmth, and swelling at the affected site
• Fever, chills, and systemic symptoms in severe cases

Diagnosis:

• Clinical examination (characteristic appearance)
• Blood cultures if systemic symptoms are present

Treatment:

• Oral antibiotics (e.g., penicillin, cephalosporins)
• Supportive measures (e.g., rest, elevation)
• Hospitalization and IV antibiotics for severe cases

4. Folliculitis

Definition: Folliculitis is inflammation of hair follicles, presenting as pustules or papules.

Etiologic Agents: Often caused by Staphylococcus aureus; can also be due to Pseudomonas aeruginosa (hot tub folliculitis) or fungal infections.

Clinical Features:

• Clusters of small, erythematous papules or pustules around hair follicles
• Itching, tenderness, and occasionally pain
• Systemic symptoms rare unless extensive or complicated

Diagnosis:

• Clinical examination
• Gram stain or culture of pus if diagnosis uncertain or treatment-resistant

Treatment:

• Topical antibiotics (e.g., mupirocin, clindamycin) for mild cases
• Oral antibiotics (e.g., dicloxacillin, cephalexin) for more severe or widespread infections
• Addressing predisposing factors (e.g., shaving practices, hot tub hygiene)

5. Necrotizing Fasciitis

Definition: Necrotizing fasciitis is a rare but severe soft tissue infection involving rapid necrosis of fascial planes and surrounding tissues.

Etiologic Agents: Typically polymicrobial with aerobes (e.g., Streptococcus pyogenes, Staphylococcus aureus) and anaerobes (e.g., Clostridium species).

Clinical Features:

• Severe pain out of proportion to physical findings
• Rapidly spreading erythema, edema, and tissue destruction
• Systemic toxicity with fever, hypotension, and altered mental status

Diagnosis:

• Clinical suspicion based on presentation
• Imaging (CT or MRI) to assess extent of involvement
• Surgical exploration and tissue biopsy for definitive diagnosis

Treatment:

• Immediate surgical debridement of necrotic tissue
• Broad-spectrum IV antibiotics (e.g., vancomycin plus piperacillin-tazobactam or meropenem)
• Intensive care support including fluid resuscitation and hemodynamic support

6. Impetigo

Definition: Impetigo is a highly contagious superficial skin infection characterized by honey-colored crusts.

Etiologic Agents: Typically caused by Staphylococcus aureus (including MRSA) or Streptococcus pyogenes.

Clinical Features:

• Small vesicles or pustules that rupture and form golden-yellow crusts
• Itchy rash, particularly around the nose and mouth in children
• Minimal systemic symptoms unless secondary infection occurs

Diagnosis:

• Clinical examination (characteristic appearance)
• Gram stain or culture if diagnosis uncertain or treatment-resistant

Treatment:

• Topical antibiotics (e.g., mupirocin, fusidic acid) for localized disease
• Oral antibiotics (e.g., cephalexin, clindamycin) for widespread or severe cases
• Hygiene measures to prevent spread (e.g., handwashing, avoiding skin-to-skin contact)

Risk Factors for Bacterial SSTIs in Adults

Several factors predispose adults to bacterial SSTIs:

• Compromised Skin Integrity: Cuts, abrasions, surgical wounds
• Chronic Medical Conditions: Diabetes mellitus, peripheral vascular disease
• Immunosuppression: HIV/AIDS, chemotherapy, systemic corticosteroids
• Obesity: Increased risk of cellulitis and wound complications
• Intravenous Drug Use: Higher incidence of abscesses and necrotizing infections
• Advanced Age: Decreased immune function and skin integrity
• Environmental Exposures: Hot tubs (Pseudomonas), contact sports (Staphylococcus aureus)

Diagnosis of Bacterial SSTIs in Adults

Accurate diagnosis relies on clinical evaluation, microbiological testing, and sometimes imaging:

• Clinical Examination: Assessing for characteristic signs (e.g., erythema, warmth, tenderness)
• Microbiological Studies: Gram stain, culture, and sensitivity testing of wound or abscess drainage
• Imaging: Ultrasound or CT/MRI for deeper infections or to assess extent of involvement
• Blood Cultures: Especially in systemic infections or in immunocompromised patients

Treatment Strategies for Bacterial SSTIs in Adults

Treatment is tailored based on severity, type of infection, and microbiological findings:

• Antibiotic Therapy:
  • Empirical Therapy: Initiated based on clinical suspicion before microbiological results are available.
  • Definitive Therapy: Adjusted based on culture and sensitivity results.
  • Route of Administration: Oral for mild to moderate infections; IV for severe or systemic infections.
• Surgical Intervention:
  • Incision and Drainage (I&D): Essential for abscesses to facilitate drainage and resolution.
  • Debridement: Necessary in necrotizing fasciitis to remove necrotic tissue and improve outcomes.
• Supportive Care:
  • Pain Management: Analgesics to alleviate discomfort associated with SSTIs.
  • Wound Care: Regular dressing changes and wound monitoring to promote healing.
  • Fluid Resuscitation: Important in septic patients to maintain hemodynamic stability.

Prevention of Bacterial SSTIs in Adults

Preventive strategies aim to minimize risk factors and promote good hygiene practices:

• Wound Care: Prompt cleaning and dressing of wounds to prevent infection.
• Hand Hygiene: Regular handwashing with soap and water, especially after contact with potentially contaminated surfaces.
• Vaccination: Influenza and pneumococcal vaccines to reduce secondary bacterial infections.
• Skin Care: Moisturizing and protecting skin integrity to prevent breakdown.
• Education: Providing information on SSTIs, risk factors, and preventive measures to patients and caregivers.

Conclusion

Bacterial skin and soft tissue infections in adults encompass a diverse range of conditions that vary in severity and clinical presentation. Prompt recognition, accurate diagnosis, and appropriate management are essential to minimize complications and improve outcomes. Understanding the etiology, risk factors, clinical features, and treatment options for bacterial SSTIs empowers healthcare providers to deliver effective care tailored to individual patient needs. By implementing preventive strategies and promoting patient education, the burden of bacterial SSTIs can be reduced, contributing to better overall health outcomes in adult populations.