Acil servise başvuran yumuşak doku enfeksiyonlarının değerlendirilmesi
Evaluation of soft tissue infections admitted to the emergency department
Yazar: GÖKÇE RABİA ALİŞAN
Danışman: DOÇ. DR. NEZİHAT RANA DİŞEL
Çukurova Üniversitesi / Tıp Fakültesi / Acil Tıp Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2021
Konu: İlk ve Acil Yardım = Emergency and First Aid
Dizin: Acil servis-hastane = Emergency service-hospital ; Acil tıp = Emergency medicine ; Enfeksiyon = Infection ; Kan kültürü = Blood culture ; Risk faktörleri = Risk factors ; Tedavi = Treatment ; Yaralar ve yaralanmalar = Wounds and injuries ; Yumuşak doku = Soft tissue

Özet:
Amaç: Acil servise başvuran ve Yumuşak Doku Enfeksiyonu tanısı alan hastaların tanı, takip ve yatış sürecinde nelere dikkat edilmeli, hangi hastalardan kültür alınırsa bu hastaların tekrarlı başvurusu, uzun süren yatışları ve komplikasyonlarının önüne geçilir sorularına cevap aramayı, YDE'nin Acil Serviste yönetimiyle ilgili ek önerilerde bulunmayı amaçlamaktayız.

	Materyal ve Metot: Bu prospektif ve kesitsel klinik çalışmaya 1 Aralık 2019-31 Temmuz 2020 tarihleri arasında, Çukurova Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı Acil Servisi'ne başvuran ve Yumuşak Doku Enfeksiyonu tanısı alan hastalardan çalışmaya katılmaya yazılı onam veren 18 yaşından büyük hastalar dahil edildi. Bu çalışma Çukurova Üniversitesi Tıp Fakültesi Girişimsel olmayan Klinik Çalışmalar Etik Kurulundan onaya ile gerçekleştirilmiştir. Çalışmaya katılmayı kabul eden hastalardan başvuru anında tanı-takip-yönetim-yatış kararı için rutin tetkiklerin (biyokimya, hemogram ve sedimentasyon) yanı sıra alınacak olan kan örneklerinde CRP ve sedimentasyon bakıldı. Hastaya ait genel risk faktörleri ve YDE'ye ait risk faktörleri, son 1 ay içinde kullandıkları antibiyotikler, son 3 ayda Acil Servise başvuru sayıları, öykülerinde travma, cerrahi ya da hayvan ısırığının olup olmadığı sorgulandı. Hastalardan acilde kültür alınamadığı için yattıkları klinikte ya da takip edildikleri polikliniklerde gerek görülen hastaların kültürü alındı. YDE olan tırnaktan nativ yapıldı sonuçlar kaydedildi.

	Bulgular: Çalışmamıza dahil edilen YDE tanılı 60 hastanın 45'inin erkek (% 75), 15'inin kadın (% 25) olup yaş ortalamaları 58,03±17,28 iken, % 23,3 (n=14)'ünün 61 ila 70 yaş aralığında olduğu belirlendi. Hastaların tanıları incelendiğinde 60 hastanın 18'i apse,13'üselülit, 13'ü diyabetik ayak, beşi mantar, dörtü erizipel, ikisi dekübit yarası, ikisi karbonkül ve birer tane bülloz pemfigoid, greft rejeksiyonu, nekrotizan fasiyit tanısı aldılar. Tanı grupları ile yaş bulguları arasında anlamlı bir farklılık gözlenmedi(p>0,05). Çalışmamıza dahil edilen hastaların 46 (% 76,7)'sının ek hastalık vardı. Hastaların 30 (% 50)'unda DM, 22 (% 36,7)'sinde HT bulgusuna rastlanırken, 10 (% 16,7) hastada KAH hastalık öyküsü olduğu tespit edildi. 65 yaş üzerinde olan hastalarda ek hastalık (p=0,025) ve HT (p=0,022) görülme sıklığı, 65 yaş ve altında olan hastalara göre anlamlı yüksek olduğu gözlendi 
	Çalışmamızda yer alan hastaların 11 (% 18,3) yatırıldığı, yatışı olan hastalardan bir (% 9,1)'inin Endokrinoloji, dört (% 36,4)'ünde Enfeksiyon hastalıkları, iki (% 18,1)'sinin Genel Cerrahi, dört (% 36,4)'ünün Ortopedi servisinde yattıkları gözlendi. Hastaların 17 (% 28,3)'sinde geçmiş hastalık öyküsü olduğu saptanırken, 15 (% 88,2)'ünde travma varlığı, birer hastada ise cerrahi (% 5,9), hayvan ısırığı (% 5,9) bulguları tespit edildi.
	Çalışmamıza dahil edilen hastalardan 37 (% 61,7)'sinden kan kültürü, 33 (% 55,0)'ünden ise yara kültürü alındı. Kan kültürü alınan hastalardan 29 (% 78,4)'unda üreme olmadı. Üç (% 8,1) hastada MRSA, 2 (% 5,4) hastada Staf. epidermis, birer hastada E.coli (% 2,7), gram pozitif koklar (% 2,7) ve S.aureus (% 2,7) üredi.
	Yara kültürü alınan hastalardan 10 (% 30,3)'unda üreme gözlenmezken, yedi (% 21,4) hastada MRSA, İkişer hastada ESBL-E.Coli (% 6,1), Morgonella-Morganii (% 6,1) ve S. Epidermidis (% 6,1), Birer hastada ise C. Albicans (% 3,0), Enterecoc (% 3,0), Enterecoccus Faecalis (% 3,0), Enterecoccus-acinetobacter (% 3,0), ESBL-Klebsiella (% 3,0), S.aureus (% 3,0), S. Hominis (% 3,0), S.aureus (% 3,0), Strep.agalactia (% 3,0) ve VRE üremesi oldu. Hastaların kan kültürü değişkeni ile yaş bulguları arasındaki farklılıklar anlamlı bulunmazken (p>0,05), yara kültürü alınan hastaların yaş ortalamaları, yara kültürü alınmayan hastalara göre anlamlı düşük bulundu (p<0,05).
	Çalışma hastalarından 40 (% 66,7)'ına nativ yapılmazken, nativ yapılan hastaların 11 (% 55,0)'inde negatif, 9 (% 45,0) ise pozitiflik saptandı. Kadın hastalarda nativ bulgularının pozitif (p=0,421) görülme sıklıklarının düşük olduğu gözlenirken, son 1 ayda antibiyotik kullanımı (p=0,283), yatış varlığı (p=0,847) ve öykü varlığının (p=0,620) görülme sıklıkları yüksek ancak farkın anlamlı olmadığı saptandı (p>0,05). Altmış beş yaş üzerinde olan hastalarda nativ negatif ve pozitif olmasına göre görülme sıklıklarının yüksek(p=0,482), son 1 ayda antibiyotik kullanımlarının (p=0,665), yatış (p=0,785) ve öykü varlığının (p=0,293)bulgularının görülme sıklarının ise düşük olduğu ancak istatistiksel anlamlı olmadığı tespit edildi (p>0,05).Kan kültürü alınan hastalarda nativ bulgularının pozitif (p=0,313) ve öykü varlığı (p=0,382) görülme sıklıklarının düşük olduğu gözlenirken, son 1 ayda antibiyotik kullanımı (p=0,518) ve yatış varlığının görülme sıklıkları yüksek olmasına karşın, elde edilen farkın anlamlı olmadığı saptandı (p>0,05).Yara kültürü alınan hastalarda nativ bulgularının negatif ve pozitif olmasına göre karşılaştırıldığında (p=0,406), yatış (p=0,524) ve öykü varlığının (p=0,127) görülme sıklığının yüksek, son 1 ayda antibiyotik kullanımlarının (p=0,852) görülme sıklarının ise düşük olduğu gözlenmesine karşın, elde edilen farklılık anlamlı bulunmadı (p>0,05).Kan ve yara kültürü varlığı ile son 3 ayda acile başvuru sıklıkları arasında anlamlı bir farklılık gözlenmedi (p>0,05). Kan ve yara kültürü alınan hastalarda laboratuar değerlerindeki farklılıkların istatistiksel anlamlı olmadığı görüldü.
	Hastaların Acil Servise başvurularında son 1 ayda antibiyotik kullanımları sorğulandı. Antibiyotik kullanımları incelendiğinde; 28 (% 75,6)'inde amoksisilik-klavulanik asit, ikişer hastada Meropem-linozolid (% 5,4) ve siprofloksasin- amoksisilik-klavulanik asit (% 5,4), birer hastada ise ertopenem (% 2,7), rifampisin (% 2,7), sefalosporin (% 2,7), tazocin (% 2,7) ve tigesiklin (% 2,7) kullandıkları gözlendi.
	Yatırılan hastaların son üç ayda Acile Servise başvuru sayısı 2 ve üzeri olma sıklığı anlamlı yüksek bulunurken (p=0,014), son bir ayda antibiyotik kullanım varlığı yüksek ancak anlamlı bulunamadı (p>0,05) Hastalarda ek hastalık varlığı tekil ve ikiden fazla olanlarda yatış varlığı daha sık gözlenmesine karşın elde edilen fark anlamlı bulunmadı (p>0,05). Hastaların labaratuvar bulgularında yatış varlığı olan hastalarda WBC, CRP düşükken, sedimentasyon bulguları daha yüksek bulundu (p<0,001).
	Tartışma ve Sonuç: Literatürde yumuşak doku enfeksiyonu tanılarında en sık görülen bakterilerle bizim kültürde ürettiklerimiz arasında farklılıklar tespit ettik. Aramızdaki bu farklılıkların, hastanemizde hastalara ampirik tedavi başlanıp bu tedavilere yanıt vermeyen, komplike enfeksiyon gelişen hastalardan kültür alınmasına ve buna bağlı antibiyotiklere dirençli bakterilerin üremesine bağlıyoruz. Antibiyotik tedavisine yanıt vermeyen hastaların buna bağlı çoklu Acil Servis başvuruları oluyor. Buradan yola çıkarak Acil Servise başvuran yumuşak doku enfeksiyonlarını ayrıntılı değerlendirip ateş, beyaz küre yüksekliği, eşlik eden ek hastalığı olan hastalardan, doğru antibiyotik seçimi ve hastanın komplike yumuşak doku enfeksiyonuna gidişini, tekrarlı Acil Servise başvurusunu engellemek, uzun süren hastane yatışlarının önüne geçmek için yara ve kan kültürleri Acil Serviste alınmasının, hastaların bu kültür sonuçları ile gerekirse Ayaktan Parenteral Antibiyotik Tedavisi (APAT) planlanması için Enfeksiyon Hastalıkları polikliniğine yönlendirilmesinin faydalı olacağını düşünüyoruz.

Anahtar Kelimeler: Yumuşak Doku Enfeksiyonu, yara kültürü, kan kültürü, Risk faktörleri, Acil Servis, Tedavi.

Abstract:
Purpose: It was aimed with this study to reveal what to pay attention in the diagnosis, follow-up and hospitalization process of the patients who were admitted to the emergency department and diagnosed with Soft Tissue Infection (STI), to find answers of the preventable questions about repeated admissions, prolonged hospitalizations and complications of the patients from whom culture was taken and additional recommendations related with the management of STI in the emergency department.

	Material and Method: The patients aged over 18 who admitted to emergency department of Çukurova University, Faculty of Medicine, Department of Emergency Medicine between December 1, 2019 and July 31, 2020, who were diagnosed with Soft Tissue Infection and who gave written consent to participate were included in this prospective and cross-sectional clinical study. This study was conducted upon the approval of the Non-Interventional Clinical Studies Ethics Committee of Çukurova University Faculty of Medicine. CRP and sedimentation of the patients who agreed to participate in the study were checked in their blood samples at the time of admission in addition to routine examinations (biochemistry, hemogram and sedimentation) for the decision of diagnosis-follow-up-management-hospitalization. General risk factors belonging to the patient and risk factors of STI, the antibiotics which they used in the last 1 month, the number of admissions to the Emergency Department in the last 3 months, and whether there was trauma, surgery or animal bites in their history were questioned. As the cultures could not be taken from the patients in the emergency department, the cultures of the patients were taken in the clinic where they were hospitalized or the polyclinics where they were followed when considered necessary. Native was made from the nail with STI and the results were recorded.

	Findings: It was determined that of the 60 patients who were diagnosed with STI and who were included in our study, 45 were male (75%), 15 were female (25%), and the mean age was 58.03 ± 17.28, while 23.3% (n = 14) of the patients were aged between 61 and 70. When the diagnoses of the patients were considered, it was seen that 18 of the 60 patients were diagnosed with abscess, 13 of them were diagnosed with cellulitis, 13 of them were diagnosed with diabetic foot, 5 of them were diagnosed with fungal, 4 of them were diagnosed with  erysipelas, 2 of them were diagnosed with decubitus wounds, 2 of them were diagnosed with carbuncles and 1 of them was diagnosed with bullous pemphigoid, 1 of them was diagnosed with graft rejection and 1 of them was diagnosed with necrotizing fasciitis. No significant difference was observed between the diagnosis groups and age findings (p>0,05). 46 (76.7%) of the patients who were included in our study had an additional disease. While 30 (50%) patients had DM, 22 (36.7%) patients had HT findings and 10 (16.7%) patients had a history of CAD. The prevalence of comorbidity (p = 0.025) and HT (p = 0.022) was found to be significantly higher in patients over 65 years of age compared to patients aged 65 and under.
	Of the patients who participated in our study, 11 (18.3%) of them were hospitalized. Of these patients, one (9.1%) of them was hospitalized in Endocrinology Service, four (36.4%) of them were hospitalized in Infectious Diseases Service, and two (18.1%) of them were hospitalized in General Surgery Service and four (36.4%) of them were hospitalized in the Orthopedics service. While 17 (28.3%) of the patients had history of past disease, 15 (88.2%) of them had trauma existence, one of them had surgery (5.9%) and one of them had animal bite (5.9%) findings.
	Blood culture was taken from 37 (61.7%) of the patients who were included in our study, and culture of wound was taken from 33 (55.0%) of the patients. No reproduction was observed in 29 (78.4%) of the patients from whom blood culture was taken. MRSA reproduced in 3 (8.1%) patients, Staf. Epidermis reproduced in 2 (% 5,4) patients, E.coli reproduced in 1 patient (2.7%), gram positive cocci reproduced in 1 patient (2.7%) and S.aureus reproduced in 1 patient (2.7%).
	No reproduction was observed in 10 (30.3%) of the patients from whom culture of wound was taken, while 7 (21.4%) patients had MRSA, two patients had ESBL-E.Coli (6.1%), two patients had Morgonella-Morganii (6.1%), two patients had S. Epidermidis (6.1%), one patient had C. Albicans (3.0%), one patient had Enterecoc (3.0%), one patient had Enterecoccus Faecalis (3.0%), one patient had Enterecoccus-acinetobacter (3.0%), one patient had ESBL-Klebsiella (3.0%), one patient had S.aureus (3.0%), one patient had S. Hominis (3.0%), one patient had S.aureus (3.0%), one patient had Strep.agalactia (3.0%) and one patient had VRE reproduction. While no significant difference was observed between the blood culture variables and age findings of the patients (p> 0.05), it was found that the mean age of the patients with culture of wound was significantly lower than the patients without culture of wound (p <0.05).
	While native was not performed in 40 (66.7%) of the patients in the study group, 11 (55.0%) of the patients on whom native was performed were found to be negative and 9 (45.0%) were positive. While it was observed that the prevalence of native findings in female patients was low (p = 0.421), the frequency of antibiotic use in the last 1 month (p = 0.283), presence of hospitalization (p = 0.847) and the presence of history (p = 0.620) were found to be high, but the difference was not significant. (p> 0.05). In patients aged over 65, the frequency of the prevalence was higher (p = 0.482) according to being negative and positive, However, the frequency of prevalence of the findings of the use of antibiotic in the last 1 month (p = 0.665), hospitalization (p = 0.785) and history (p = 0.293) was lower but the difference was not statistically significant (p> 0.05)
	While it was observed that the native findings were positive (p = 0.313) and the frequency of history presence (p = 0.382) was low in patients whose blood cultures were taken, the frequency of use of antibiotic in the last 1 month (p = 0.518) and the presence of hospitalization was high. However, the difference obtained was not significant (p> 0.05). When compared to negative and positive native findings in patients with culture of wound (p = 0.406), prevalence of hospitalization (p = 0.524) and the presence of history (p = 0.127) were high, and the frequency of antibiotic use in the last 1 month (p = 0.852) was low although the difference obtained was not found significant (p> 0.05). There was no significant difference between the presence of blood and wound culture and the frequency of admission to the emergency service in the last 3 months (p> 0.05). It was observed that the differences in laboratory values were not statistically significant in patients with cultures of blood and wound.
	Antibiotic use of the patients in the last 1 month was questioned during their admission to the Emergency Department. When antibiotic uses are considered, it was seen that 28 (75.6%) patients had used Amoxyclic-clavulanic acid, 2 (5.4%) patients had used Meropem-linozolide, 2 (5.4%) patients had used ciprofloxacin-amoxyclic-clavulanic acid, 1 (2.7%) patient had used ertopenem, 1 (2.7%) patient had used rifampicin, 1 (2.7%) patient had used cephalosporin, 1 (2.7%) patient had used tazocin and 1 (2.7%) patient had used tigecycline.
	While the frequency of the patients' 2 or more times admission to the Emergency Service in the last three months was found to be significantly higher (p = 0.014), the presence of antibiotic use in the last month was found to be high, but not significant (p> 0.05). Although the presence of hospitalization was observed more frequently in the patients with presence of singular or two or more comorbidities, the difference obtained was not significant (p> 0.05). While WBC and CRP were lower in patients with history of hospitalization in their laboratory findings, sedimentation findings were found to be higher (p <0.001).

	Discussion and Conclusion: We found differences between the most common bacteria seen in soft tissue infection diagnoses in the literature and those we produced in culture. We believe that these differences emerge as empirical treatment was initiated in our hospital, and cultures were taken from patients who did not respond to these treatments and developed complicated infections and grew bacteria which are resistant to antibiotics, correspondingly. The patients who do not respond to antibiotic treatment admit to emergency services multiple times. From this point of view, we believe that it would be beneficial to evaluate the soft tissue infections admitted to the Emergency Department in a detailed way. It would also be useful to take cultures of wound and blood in Emergency Departments, to choose the correct antibiotic, to prevent the patient's, who has fever, elevated white blood cell count or a comorbidity, progression to complicated soft tissue infection, to prevent admissions to the Emergency Department multiple times and long hospitalization duration and to guide these patients to Infectious Diseases Polyclinic to make a plan of Outpatient Parenteral Antibiotic Therapy (APAT) with these culture results.

Keywords: Soft Tissue Infection, Culture of wound, culture of blood, Risk factors, Emergency Service, Treatment.