Point of Care Ultrasound Use by Associate Providers for Differentiating Abscess Versus Cellulitis Skin and Soft Tissue Infection in the Emergency Department

BackgroundSkin and soft tissue infections (SSTIs) are a common complaint in the ambulatory setting and pose a significant burden on the health care system.ObjectivesWe sought to determine the accuracy of ultrasound for detecting soft tissue abscesses by emergency medicine associate providers (APs).MethodsThis was a prospective observational study of adult patients with suspected SSTI in the emergency department of a rural tertiary care academic medical center. The AP performed and interpreted point-of-care ultrasound (POCUS) of the suspected infected area. Ultrasound images and interpretation were reviewed by the attending emergency physician with either rejection or agreement of the image interpretation, diagnosis, and management. If incision and drainage was performed, presence or absence of purulent drainage was recorded.ResultsSixty-four patients with suspected SSTI were enrolled: 29 had POCUS-proven abscesses and 33 had cellulitis; 2 were excluded. AP clinical evaluation alone for identifying abscess revealed sensitivity of 92.3 (74.9–99.1), specificity of 67.7 (49.5–82.6), positive predictive value of 68.6 (57.0–78.2), and negative predictive value of 92.0 (81.4–100). The use of POCUS by APs in addition to clinical examination demonstrated sensitivity of 96.2 (80.4–99.9), specificity of 93.9 (79.8–99.3), positive predictive value of 92.6 (76.5–98.0), and negative predictive value of 96.9 (81.9–99.5). p values were <0.05 for test characteristics. Ultrasound results changed SSTI management decisions in 10 of 62 (16.1%) patients, with the most common change being a new incision and drainage or needle aspiration. Agreement of the POCUS interpretation between APs and attending physicians was 96.8% with a κ of 0.94 (0.85–1.00).ConclusionWith modest training, APs can successfully use POCUS to identify abscesses in patients in the emergency department with SSTIs. POCUS increases the ability to rule in the diagnosis and changes management in a clinically relevant number of patients with SSTIs.     

Outpatient Management of Skin and Soft Tissue Infections Associated With Community-Associated Methicillin-Resistant Staphylococcus Aureus: An Evidence-Based Approach

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has recently been identified as the predominant causative bacterium for skin and soft tissue infections (SSTIs) in outpatient and emergency department patients. Given the increasing prevalence of CA-MRSA related to SSTIs, appropriate decisions based on evidence-based guidelines are essential in successful treatment. It is imperative for clinicians to stay informed about the epidemiological and treatment of emerging organisms in order to positively influence patient outcomes and eliminate the unnecessary use of antibiotics.     

Emergency Management of Pediatric Skin and Soft Tissue Infections in the Community‐associated Methicillin‐resistant Staphylococcus aureus Era

Objectives: Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. Methods: This was a cross‐sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list‐serv. Enrollment occurred via the list‐serv over a 3‐month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. Results: In total, 366 of 606 (60.3%) list‐serv members responded. The mean (± standard deviation [SD]) duration of practice was 13.6 (±7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim‐sulfa (27.0%), and first‐generation cephalosporins (22.7%); methicillin‐sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA‐MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim‐sulfamethoxazole (TMP‐Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA‐MRSA–inactive agents. All PEPs suspected CA‐MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA‐MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA‐MRSA prevalence for even common infections. Conclusions: Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated. ACADEMIC EMERGENCY MEDICINE 2010; 17:187–193 © 2010 by the Society for Academic Emergency Medicine     

Point-of-Care Ultrasound Used to Distinguish Between Superficial Skin Abscess and Deep Mediastinal Abscess: A Case Report

BackgroundSkin and soft tissue infections (SSTIs) are an increasingly common complaint in the emergency department (ED), but physical examination does not reliably identify abscesses or accurately determine which skin lesions require incision and drainage. Point-of-care ultrasound (POCUS) improves management of soft tissue skin infections by detecting occult abscess, preventing unnecessary procedures, and identifying more complex disease requiring further imaging.Case ReportHere, we report a case in which POCUS drastically changed the management of what initially appeared to be an uncomplicated superficial skin abscess but was actually a much more serious mediastinal infection.Why Should an Emergency Physician Be Aware of This?This case underscores the importance and utility of POCUS to enhance the physical examination in suspected SSTIs. Because POCUS is easy, accurate, low risk, and can change management, we recommend its consideration as a standard component of the ED work up for SSTIs.     

Point-of-Care Ultrasound is Associated With Decreased Length of Stay in Children Presenting to the Emergency Department With Soft Tissue Infection

Background

Point-of-care ultrasound (POCUS) is increasingly being used to differentiate cellulitis from abscess in the pediatric emergency department (ED). POCUS has also been shown to decrease length of stay (LOS) for other applications among adult patients.

Necrotizing Soft Tissue Infections: A Review of Diagnosis,Management, and Implications for NP Practice

Skin and soft tissue infections are among the most common diagnoses seen by nurse practitioners practicing in all settings. These infections range from mild, uncomplicated cellulitis to the more severe, complicated diagnosis of necrotizing soft tissue infections (NSTI). For patients presenting with symptoms of skin and soft tissue infections, differentiating NSTIs from less insidious infections is of paramount importance. NSTIs can be difficult to diagnose because the early presentation may be misleadingly straightforward; however, it is essential that NPs carefully consider NSTIs when a patient presents with the following cardinal skin signs: erythema, swelling, and warmth.     

创面负压封闭引流技术治疗皮肤软组织缺损的护理体会

目的探讨创面负压封闭引流技术（vacuum sealing drainage,VSD）治疗皮肤软组织缺损的效果及护理措施。方法总结2007年10月至2009年3月采用VSD治疗的38例皮肤软组织缺损患者的临床资料与护理措施。结果 38例患者均愈合良好,无一例发生严重感染或骨髓炎。结论 VSD配合精心护理,有利于皮肤软组织缺损患者更快、更好地康复。     

整形美容外科技术在颜面部皮肤软组织创伤修复中的应用

目的：探讨整形美容外科技术修复颜面部软组织创伤的临床效果。方法：回顾性分析2005年7月至2013年7月应用整形美容外科技术治疗颜面部软组织创伤125例患者的临床资料。结果：本组125例中,伤口I期甲级愈合124例,5天再次清创后伤口愈合1例。术后6个月,瘢痕呈暗红色线形,1年后瘢痕基本消褪,接近正常皮肤。结论：应用整形美容外科技术修复颜面部皮肤软组织创伤可明显减少外伤后畸形及瘢痕。     

Use of Ultrasound Elastography for Skin and Subcutaneous Abscesses

Objective. Elastography is a new adjunct to real‐time ultrasound imaging that overlays traditional B‐mode imaging with a color graphic representation of tissue elasticity. Soft tissue infections are common presenting conditions in the emergency department, and elastography has the potential to help in diagnosis and treatment of evolving soft tissue infections as they progress from induration to fluctuant abscesses, but to our knowledge, no studies of elastography in superficial soft tissue have been published. We hypothesized that elastography would provide increased information regarding skin abscesses. Methods. This was a prospective study of patients with suspected skin abscesses requiring surgical drainage in the emergency department of an urban tertiary care center. Abscesses were imaged with B‐mode imaging and elastography in orthogonal planes. Ultrasound images were analyzed for characteristics of the elastographic images. Results. A total of 50 patients with suspected skin abscesses underwent B‐mode imaging and elastography. Elastography accurately differentiated the induration surrounding the abscess from the surrounding healthy tissue, a differentiation that was not visible on B‐mode imaging. The elastographic properties of the abscess cavity were variable and not always seen, even with purulence identified during incision and drainage. In some cases, elastography identified abscess cavities not seen on B‐mode imaging. When seen, the abscess cavity could be characterized by elastographic color and speckle patterns. Conclusions. Elastography identified the tissue induration and some abscess cavities not seen on B‐mode imaging. It offers a way to characterize abscesses that may be useful clinically, but more research is needed.     

Management of bacterial skin and skin structure infections with polymicrobial etiology

Introduction: Skin and Soft Tissue Infections (SSTIs) are some of the most commonly occurring bacterial infections, with a wide range of possible etiological pathogens and a considerable variety of clinical presentations and severity; from mild to severe life-threatening infections. Several classifications have been proposed based on a specific variable, such as anatomical localization, skin extension, progression rate, clinical presentation, severity, and etiological agent.

Areas covered: The last criteria allows the differentiation of SSTIs as monomicrobial and polymicrobial. Among them, especially those infections with a long lasting or chronic course can be sustained by multiple microbial etiology. Most polymicrobial SSTIs can be included in the following: diabetes foot infections (DFIs), pressure ulcers infection, burn infection, and infected chronic ulcers.

Expert commentary: The medical management of these infections comprises the administration of wide a spectrum antibiotic, taking into consideration the frequent occurrence of multidrug resistant microorganisms as responsible agents. An appropriate deep tissue specimen for microbiological examination is a very important issue, especially for polymicrobial infections, sometimes permitting the distinction between real pathogens and contaminants avoiding more complex antibiotic treatments. This aspect must be strongly emphasized, as frequently superficial swabs remain the specimen of choice because they are easy to obtain.     

急诊医生用床边B超在浅表软组织异物取出中的价值

目的:总结急诊医生主导床旁B超声技术在浅表异物取出术中的应用价值。方法:采用便携式迈瑞型彩色超声诊断仪BD177921对65例外伤后浅表软组织内异物存留患者行超声诊断定位,引导手术实施,探取异物。结果:结合患者病史,B型超声在异物存留患者的诊断定位中准确率高,能引导手术取出异物。结论:急诊医生主导床旁B超声技术方便、安全、高效,在浅表软组织内异物的诊断定位及引导手术取出异物中有重要的临床价值。     

带腓肠神经伴行血管蒂筋膜皮瓣修复小腿及足踝部软组织缺损创面38例临床分析

目的:总结带腓肠神经伴行血管蒂筋膜皮瓣修复小腿及足踝部软组织缺损创面的临床效果。方法:回顾性分析2003年8月至2012年8月我科应用带腓肠神经伴行血管蒂筋膜皮瓣修复小腿及足踝部软组织缺损创面38例的临床资料。结果:35例术后皮瓣全部成活,创面一期愈合;3例皮瓣远端部分坏死,经清创换药、游离植皮后愈合。平均住院25天,术后30例经6个月至5年随访,皮瓣质地优良,外观与足踝关节功能恢复满意,感觉神经也部分恢复。结论:带腓肠神经伴行血管蒂筋膜皮瓣修复小腿及足踝部软组织缺损创面的临床效果好。     

Diagnostic and therapeutic evaluation of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA) skin and soft tissue infections in the emergency department

Background

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections commonly present as skin and soft-tissue infections (SSTIs). Treatment often includes incision and drainage with or without adjunctive antibiotics. Emergency department (ED) pharmacists wished to provide specific data to emergency physicians to better inform antibiotic choices for patients with SSTIs.

Study Objectives

The objectives of this study were to describe local susceptibility trends of CA-MRSA isolates obtained from patients with SSTIs and describe diagnostic and empiric therapeutic management of CA-MRSA SSTIs among ED health care providers at University of Utah Hospitals and Clinics.

Methods

Susceptibility of all unique CA-MRSA SSTI isolates for 2008 were identified and compiled into an antibiogram. ED providers evaluated their diagnostic and treatment habits using a self-assessment questionnaire, which was verified against charted information documented in the electronic medical records for patients presenting to the ED with a CA-MRSA SSTI.

Results

The ED antibiogram indicated that 57/58 (98%) CA-MRSA SSTI isolates were susceptible to sulfamethoxazole/trimethoprim (SMX/TMP); 50/58 (86%) isolates were susceptible to tetracycline, and 47/58 (81%) isolates were susceptible to clindamycin. Incision and drainage were performed in 23/25 (92%) patient cases, which was consistent with providers’ perceived habits (100%). SMX/TMP monotherapy was preferred among 23/35 (66%) providers, however, SMX/TMP combined with cephalexin was the antibiotic regimen prescribed in 9/22 (41%) patient cases.

Conclusions

Cephalexin was often added to cover for potential cellulitis due to Streptococcus spp., however, the surrounding erythema may simply be an extension of the CA-MRSA infection. Department-specific antibiograms are useful in guiding empiric antibiotic selection and may help providers judiciously prescribe antibiotics only when necessary.     

超声影像及彩色多普勒血流显像技术在骨及软组织血管瘤诊断中的价值

作者论述了应用超声影像和彩色多普勒血流显像技术诊断骨及软织织血管瘤的特征，通过57例血管瘤的超声影像与手术、病理、放射影像的对比分析，证实了超声影像检查是术前诊断血管瘤最可靠的检查方法。其中9例骨血管瘤显示不同程度的骨质破坏和实性低回声肿物；48例软组织血管瘤可见迂曲扩张的管状结构互相交通、挤压血管瘤时可见其内充盈彩色血流信号。     

B型超声及彩色多普勒血流显像在骨及软组织肿瘤中的应用

本文介绍骨及软组织肿瘤的超声影像特点。超声诊断在滑及软组织肿瘤领域中的独特表现许多方面优于Ｘ线、ＣＴ及ＭＲＩ影像检查，可为临床诊断，治疗提供可靠依据。     

Community-associated CMRSA-10 (USA-300) is the predominant strain among methicillin-resistant Staphylococcus aureus strains causing skin and soft tissue infections in patients presenting to the emergency department of a Canadian tertiary care hospital

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen first described among individuals with no contact with health care facilities. The purpose of this study was to determine the proportion of CA-MRSA, defined by pulsed field gel electrophoresis (PFGE), in MRSA skin and soft tissue infections presenting to the Emergency Department (ED). We also aimed to describe the laboratory and clinical characteristics of CA-MRSA infections. From June 1, 2001 to May 30, 2005, MRSA isolates from skin and soft tissue infections presenting to the ED were reviewed. They were characterized by antibiotic susceptibilities and PFGE, and the presence of staphylococcal cassette chromosome (SCC) mec type IVa and Panton-Valentine leukocidin (PVL) genes was assessed on representative isolates. The medical records were reviewed to define risk factors. There were 95 isolates available for analysis, of which 58 (61%) were CMRSA-10 (USA-300), the predominant clone from 2003 onward. All representative isolates (24%) tested in this group had PVL genes and SCCmec type IVa. Their antibiogram showed 100% susceptibility to trimethoprim-sulfamethoxazole, rifampin, and fusidic acid, and 79% to clindamycin. Clinical comparison of CMRSA-10 vs. hospital PFGE type strains showed 22% vs. 60%, respectively, for recent antibiotic use (p < 0.0001), 26% vs. 6%, respectively, for intravenous drug use (p < 0.05), and 57% vs. 6%, respectively, for soft tissue abscess (p < 0.001). CMRSA-10 is a major pathogen in skin and soft tissue abscesses in our ED. It has a characteristic susceptibility, and was associated with intravenous drug use, but not with recent antibiotic usage.     

66例皮肤组织完整性受损相关因素分析

分析66例神经内科皮肤组织完整性受损病人资料,认为皮肤组织完整性受损的相关因素有五个方面病理因素、情景因素、年龄因素、社会因素及医原性因素。     

Economic outcomes of inappropriate initial antibiotic treatment for complicated skin and soft tissue infections: a multicenter prospective observational study

This study examined economic outcomes associated with inappropriate initial antibiotic treatment (IIAT) in complicated skin and soft tissue infections using data from adults hospitalized and treated with intravenous antibiotic therapy. We specifically analyzed for the subsets of patients infected with methicillin-resistant Staphylococcus aureus (MRSA), with healthcare-associated (HCA) infections, or both. Data from 494 patients (HCA: 360; MRSA:175; MRSA + HCA: 129) showed the overall mean length of stay (LOS) was 7.4 days and 15.0% had the composite economic outcome of any subsequent hospital admissions, emergency department visits, or unscheduled visits related to the study infection. A total of 23.1% of patients had IIAT; after adjustments, these patients had longer LOS than patients without IIAT in the HCA cohort (marginal LOS = 1.39 days, P = 0.03) and the MRSA + HCA cohort (marginal LOS = 2.43 days, P = 0.01) and were significantly more likely to have the composite economic outcome in all study cohorts (odds ratio: overall = 1.79; HCA = 3.09; MRSA = 3.66; MRSA + HCA = 6.92; all P < 0.05).     

Hospitalist Perspective on the Treatment of Skin and Soft Tissue Infections

The prevalence of skin and soft tissue infections (SSTIs) has been increasing in the United States. These infections are associated with an increase in hospital admissions. Hospitalists play an increasingly important role in the management of these infections and need to use hospital resources efficiently and effectively. When available, observation units are useful for treating low-risk patients who do not require hospital admission. Imaging tools may help to exclude abscesses and necrotizing soft tissue infections; however, surgical exploration remains the principal means of diagnosing necrotizing soft tissue infections. The most common pathogens that cause SSTIs are streptococci and Staphylococcus aureus. Methicillin-resistant S aureus (MRSA) is a prevalent pathogen, and concerns are increasing regarding the unclear distinctions between community-acquired and hospital-acquired MRSA. Other less frequent pathogens that cause SSTIs include Enterococcus species, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa. Cephalexin and clindamycin are suitable options for infections caused by streptococcal species and methicillin-susceptible S aureus. The increasing resistance of S aureus and Streptococcus pyogenes to erythromycin limits its use in these infections, and better alternatives are available. Parenteral cefazolin, nafcillin, or oxacillin can be used in hospitalized patients with nonpurulent cellulitis caused by streptococci and methicillin-susceptible S aureus. When oral MRSA therapy is indicated, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, or linezolid is appropriate. Vancomycin, linezolid, daptomycin, tigecycline, telavancin, and ceftaroline fosamil are intravenous options that should be used in MRSA infections that require patient hospitalization. In the treatment of patients with SSTIs, hospitalists are at the forefront of providing proper patient care that reduces hospital costs, duration of therapy, and therapeutic failures. This review updates guidelines on the management of SSTIs with a focus on infections caused by S aureus, particularly MRSA, and outlines the role of the hospitalist in the effective management of SSTIs.