What is the disparity in presentations, microbials, and patient outcomes of soft tissue infections between rural/remote and metropolitan areas in Western Australia?

Disparities in Soft Tissue Infections Between Rural/Remote and Metropolitan Western Australia

There is a significant disparity in the management and outcomes of soft tissue infections between rural/remote and metropolitan areas of Western Australia, with rural patients experiencing more than double the risk of mortality from major trauma compared to their metropolitan counterparts. 1

Current Epidemiological Landscape

Prevalence and Distribution

• Infectious diseases account for nearly 50% of all clinic presentations in remote Western Australian Aboriginal communities 2
• Skin infections represent the largest proportion (16%) of these presentations, followed by ear infections (15%) and upper respiratory infections (13%) 2
• 72% of Aboriginal children in remote Western Australia present at least once with skin infections 2
• Skin sores account for 75% of the overall burden of skin infections in these communities 2

Patient Demographics and Risk Factors

• In Western Sydney's experience with necrotizing soft tissue infections (NSTI):
  • Mean age: 52 years
  • Body mass index: 38.1
  • 55.6% male
  • 48% of Polynesian descent
  • 55.6% diabetic 3
• Common sites of NSTI include perineal (30.6%), lower limb (30.6%), perianal (19.3%), and trunk (11.1%) 3

Microbial Patterns

Causative Organisms

• Most community-acquired skin and soft tissue infections are caused by:
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Beta-hemolytic streptococcus 4
• A concerning increase in sulfamethoxazole/trimethoprim resistance in Staphylococcus aureus from 9% to 18% over one year has been observed in remote North Western Australia 5

Diagnostic Challenges

Access to Diagnostic Tools

• In remote areas, diagnostic capabilities are limited, with computed tomography having only 50% diagnostic accuracy for NSTI 3
• The Laboratory Risk Indicator for Necrotising infection (LRINEC) score is a useful adjunct in aiding clinical decision-making for NSTI 3
• Remote areas require a tailored diagnostic step-up approach based on available resources 6
• Ultrasound and plain X-ray may be useful diagnostic tools in remote areas with limited resources 6

Treatment Disparities

Timing of Care

• Mean time to definitive care:
  • Metropolitan areas: 59 minutes
  • Rural areas: 11.6 hours (p<0.0001) 1
• Patients transferred from other facilities or non-surgical teams experienced delays in:
  • Surgical review: 11.4 hours longer (p<0.03)
  • Operating time: 12.4 hours longer (p<0.04) 3
• Average time to surgical debridement for NSTI: 16.2 hours 3

Outcomes

• After adjusting for age, injury severity, and time effect, rural patients have a significantly increased risk of death (OR 2.60,95% CI 1.05-6.53, p=0.039) 1
• However, if rural patients survive to be retrieved to Perth by the Royal Flying Doctor Service, mortality outcomes become equivalent to metropolitan areas (adjusted OR 1.10,95% CI 0.66-1.84, p=0.708) 1
• Mean hospital length of stay for NSTI: 20.9 days 3
• 44.4% of NSTI patients require transfer for rehabilitation or plastic reconstruction 3

Antimicrobial Stewardship Challenges

Prescribing Patterns

• Community-based prescribing in remote areas often lacks antimicrobial stewardship oversight 5
• Antimicrobial Stewardship (AMS) Committees typically focus on hospital-based prescribing rather than community prescribing 5
• Regional skin infection protocols may not be regularly updated to reflect changing resistance patterns 5

Recommendations for Future Research and Interventions

Research Priorities

1. Conduct comprehensive epidemiological studies comparing microbial patterns between remote and metropolitan Western Australia
2. Investigate the impact of delayed surgical intervention on outcomes in remote settings
3. Evaluate the effectiveness of telehealth consultations for early diagnosis of serious soft tissue infections

Clinical Practice Improvements

1. Implement robust triage systems in remote areas based on physical examination findings 6
2. Establish clear transfer protocols to minimize delays in surgical review and intervention
3. Extend antimicrobial stewardship principles to community-based prescribing in remote settings 5
4. Regularly update regional skin infection protocols based on local antibiogram data

Public Health Measures

1. Develop targeted prevention programs for high-risk populations, particularly Aboriginal communities 2
2. Improve access to clean water and hygiene facilities in remote communities
3. Implement community education programs about early recognition and treatment of skin infections

Health System Reforms

1. Strengthen the integration between remote healthcare providers and tertiary centers
2. Enhance the capacity of the Royal Flying Doctor Service for timely retrieval of patients with severe infections
3. Develop standardized protocols for early source control of infections in remote settings 6
4. Ensure appropriate antimicrobial therapy based on local resistance patterns 6

The cornerstone of addressing these disparities lies in early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy, with standardization in applying guidelines to adequately manage soft tissue infections across all settings 6.