Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Skin and soft tissue infections are a common chief complaint in the emergency department. Research has shown that clinical examination alone can be unreliable in distinguishing between cellulitis and abscesses, a distinction that is important because they each require different treatments. Point-of-care ultrasonography has been increasingly studied as a tool to improve the diagnostic accuracy for these skin and soft tissue infections. The primary objective of this systematic review is to evaluate the diagnostic accuracy of point-of-care ultrasonography for abscesses. Subgroup analyses are performed for adult versus pediatric patients and high suspicion versus clinically unclear cases. Secondary objectives include the percentage of correct versus incorrect changes in management and reduction in treatment failures because of point-of-care ultrasonography. METHODS: PubMed, Scopus, Latin American and Caribbean Health Sciences Literature database, Cumulative Index of Nursing and Allied Health, Google Scholar, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were assessed from inception to July 26, 2019, for all prospective studies assessing the diagnostic accuracy of point-of-care ultrasonography for evaluation of skin and soft tissue abscesses. Data were dual extracted into a predefined work sheet and quality analysis was performed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Diagnostic accuracy was reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with 95% confidence intervals (CIs). RESULTS: We identified 14 studies comprising 2,656 total patients. Point-of-care ultrasonography was 94.6% sensitive (95% CI 89.4% to 97.4%) and 85.4% specific (95% CI 78.9% to 90.2%), with an LR+ of 6.5 (95% CI 4.4 to 9.6) and LR- of 0.06 (95% CI 0.03 to 0.13). Among cases with a high pretest suspicion for abscess or cellulitis, point-of-care ultrasonography was 93.5% sensitive (95% CI 90.4% to 95.7%) and 89.1% specific (95% CI 78.3% to 94.9%), with an LR+ of 8.6 (95% CI 4.1 to 18.1) and LR- of 0.07 (95% CI 0.05 to 0.12). Among cases that were clinically unclear, point-of-care ultrasonography was 91.9% sensitive (95% CI 77.5% to 97.4%) and 76.9% specific (95% CI 65.3% to 85.5%), with an LR+ of 4.0 (95% CI 2.5 to 6.3) and LR- of 0.11 (95% CI 0.03 to 0.32). Among adults, point-of-care ultrasonography was 98.7% sensitive (95% CI 95.3% to 99.8%) and 91.0% specific (95% CI 84.4% to 95.4%), with an LR+ of 10.9 (95% CI 6.2 to 19.2) and LR- of 0.01 (95% CI 0.001 to 0.06). Among pediatric patients, point-of-care ultrasonography was 89.9% sensitive (95% CI 81.8% to 94.6%) and 79.9% specific (95% CI 71.5% to 86.3%), with an LR+ of 4.5 (95% CI 3.1 to 6.4) and LR- of 0.13 (95% CI 0.07 to 0.23). Point-of-care ultrasonography led to a correct change in management in 10.3% of cases (95% CI 8.9% to 11.8%) and led to an incorrect change in management in 0.7% of cases (95% CI 0.3% to 1.1%). CONCLUSION: According to the current data, point-of-care ultrasonography has good diagnostic accuracy for differentiating abscesses from cellulitis and led to a correct change in management in 10% of cases. Future studies should determine the ideal training and image acquisition protocols.

Critical care burden of skin and soft tissue infection in Central Australia: More than skin deep.

OBJECTIVE: To describe the epidemiology, critical care resource use of and outcomes from an intensive care admission for a skin or soft tissue infection in Central Australia. DESIGN: Retrospective database review of prospectively collected data identifying all patients requiring admission for a life-threatening illness related to a skin or soft tissue infection. SETTING: Intensive care unit Alice Springs Hospital. PARTICIPANTS: All patients admitted with a primary diagnosis of skin or soft tissue infection between 2010 and 2016. MAIN OUTCOME MEASURE: Annualised incidence of skin or soft tissue infection requiring intensive care. Secondary outcomes examined resource use (length of stay, mechanical ventilation) and a description of the microbiology of skin or soft tissue infection in Central Australia. RESULTS: There were 80 admissions to the intensive care unit over the sampling period, yielding an annualised incidence of 24.2 intensive care unit admissions per 100 000 population. Eighty-five per cent were Indigenous with high rates of co-morbid disease including poorly controlled type 2 diabetes, haemodialysis-dependent chronic kidney disease and co-infection with human T-cell lymphocytic virus. The predominant type of skin or soft tissue infection was abscess, predominantly below the waist. Gram-positive cocci comprised 50% of the organisms cultured, and 20% of organisms were multi-resistant. Mortality was 0% and 1.3% at 28 and 90 days respectively. CONCLUSION: The annualised incidence of skin or soft tissue infection requiring intensive care support in Central Australia is higher than expected. This probably reflects the high burden of chronic disease and poor living conditions. While there is no mortality burden associated with skin or soft tissue infection in Central Australia, there is substantial morbidity. The data from this study adds weight to the call for improved primary health resources for this group.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection.

INTRODUCTION: Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS: Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS: A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION: The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE: Prognostic, level IV.

New insights into classification, epidemiology and microbiology of SSTIs, including diabetic foot infections.

Skin and soft tissue infections (SSTIs) involve a heterogeneous group of entities with different clinical presentations classified according to several specific criteria. Because of their great variability, their incidence and prevalence is difficult to accurately determine. Yet it is generally thought that the rate of SSTIs is globally increasing due to an aging population, strictly associated with the increase in the number of critical and immunocompromised patients. The aetiology of SSTIs is also extremely variable, reflecting the noteworthy heterogeneity of their clinical presentations and their epidemiology. Gram-positive are far more prevalently than Gram-negative cocci responsible for STTIs globally considered including both aerobe and anaerobe microorganisms. The emergence of multidrug-resistance bacteria represents a serious public health threat which is making antimicrobial therapy less efficacious and more challenging by the day.

Identifying and acting on potentially inappropriate care? Inadequacy of current hospital coding for this task.

INTRODUCTION: Recent Australian attempts to facilitate disinvestment in healthcare, by identifying instances of 'inappropriate' care from large Government datasets, are subject to significant methodological flaws. Amongst other criticisms has been the fact that the Government datasets utilized for this purpose correlate poorly with datasets collected by relevant professional bodies. Government data derive from official hospital coding, collected retrospectively by clerical personnel, whilst professional body data derive from unit-specific databases, collected contemporaneously with care by clinical personnel. AIM: Assessment of accuracy of official hospital coding data for hyperbaric services in a tertiary referral hospital. METHODS: All official hyperbaric-relevant coding data submitted to the relevant Australian Government agencies by the Royal Hobart Hospital, Tasmania, Australia for financial year 2010-2011 were reviewed and compared against actual hyperbaric unit activity as determined by reference to original source documents. RESULTS: Hospital coding data contained one or more errors in diagnoses and/or procedures in 70% of patients treated with hyperbaric oxygen that year. Multiple discrete error types were identified, including (but not limited to): missing patients; missing treatments; 'additional' treatments; 'additional' patients; incorrect procedure codes and incorrect diagnostic codes. Incidental observations of errors in surgical, anaesthetic and intensive care coding within this cohort suggest that the problems are not restricted to the specialty of hyperbaric medicine alone. Publications from other centres indicate that these problems are not unique to this institution or State. CONCLUSIONS: Current Government datasets are irretrievably compromised and not fit for purpose. Attempting to inform the healthcare policy debate by reference to these datasets is inappropriate. Urgent clinical engagement with hospital coding departments is warranted.

[Issues of infection related to diabetic foot syndrome]. / Problematika infekce pri syndromu diabetické nohy.

Foot wounds are common problem in people with diabetes and now constitute the most frequent diabetes-related cause of hospitalization. Diabetic foot infections cause substantial morbidity and at least one in five results in a lower extremity amputation. They are are now the predominant proximate trigger for lower extremity amputations worldwide. One in five diabetic wounds present clinical signs of infection at primomanifestation. About 80 % of limb non-threating wounds can be succesfully healed using appropriate and comprehensive approach, including antimicrobial therapy, revascularisation and off-loading.

The classification and management of skin and soft tissue infections.

Skin and soft tissue infections (SSTIs) are a common problem in patients presenting to the emergency department, varying from mild local inflammation to necrotizing fasciitis. SSTI were the 2nd most common indication for antibiotic use in Europe in 2006. Currently, the National Institute of Clinical Excellence (a UK based independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health) has not published any guidelines for the classification and management of these patients. This is a review of the evidence around attempts at developing classification systems for SSTI and their management. It also considers the financial implications for both the patient and the healthcare system and the personal ramifications for patients.

[Pathogenesis, classification and diagnosis of necrotizing soft tissue infections]. / Pathogenese, Klassifikation und Diagnose der nekrotisierenden Weichteilinfektionen.

Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

Skin and soft-tissue infections: classifying and treating a spectrum.

Skin and soft-tissue infections (SSTIs) are a common presenting problem in both inpatients and outpatients. SSTIs have been broadly classified as complicated or uncomplicated, but specific disease processes and patient characteristics are important in guiding clinical management. Early recognition of the extent of infection, close follow-up, and familiarity with local antibiotic susceptibility data are critical to successful treatment.

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.

Necrotizing soft tissue infections in the intensive care unit.

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

Infecciones de piel y partes blandas / Skin and soft tissue infections

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[Skin and soft tissue infections: classification and epidemiology]. / Infezioni della cute e dei tessuti molli: classificazione ed epidemiologia.

In the present review, authors take into consideration the classification and the epidemiology of the skin and soft tissue infections (SSTIs), a set of commonly observed pathologies, which can present different features, relatively to site and localization, clinical characteristics, and aetiological agent, their severity being related to the depth of the interested sites. Given the variable presentation of SSTIs, an assessment of their incidence and prevalence is difficult. In general, the incidence of SSTIs has increased due to the ageing of the general population, the increased number of critically ill patients, the increased number of immunocompromised patients (HIV, cancer and organ transplant patients) and the recent emergence of multi-drug resistant pathogens.

[Skin and soft tissue infections: current therapeutic options]. / Infezioni della cute e dei tessuti molli: opzioni terapeutiche.

In the present review, the authors focus on skin and soft tissue infections (SSTIs), a set of commonly observed pathologies which can present different features in terms of site and localization, clinical characteristics, and the aetiological agent responsible; their severity is related to the depth of the affected sites. After a brief introduction to the diverse classification criteria which are currently adopted by various authors, the aetiology and role of the most frequently occurring pathogen, Staphylococcus aureus, often methicillin-resistant is discussed, as well as the possible therapeutic options. We first present the internationally recommended guidelines, and stress that SSTI management has to conform to different criteria, in accordance with the different clinical settings: mild infections require simple and cost-saving treatments while severe infections make timely and aggressive treatments mandatory. The review then reports the recent data concerning the efficacy of new antimicrobials for treating SSTIs. In particular, results observed with linezolid, tigecycline, and daptomycin are discussed.

Musculoskeletal infection: role of CT in the emergency department.

Musculoskeletal infection is commonly encountered in the emergency department and can take many forms, depending on the involvement of the various soft-tissue layers, bones, and joints. Infection may manifest as superficial cellulitis, necrotizing or nonnecrotizing fasciitis, myositis, a soft-tissue abscess, osteomyelitis, or septic arthritis. Because clinical parameters for the detection of musculoskeletal infection generally lack sensitivity and specificity, computed tomography (CT) plays an important role in the assessment of potential musculoskeletal infections in the emergency department. CT provides an analysis of compartmental anatomy, thereby helping to distinguish among the various types of musculoskeletal infection and to guide treatment options. Specific imaging features exist that help identify the numerous forms of infection in the bones and soft tissues, and CT is invaluable for detecting deep complications of cellulitis and pinpointing the anatomic compartment that is involved by an infection. Although all patients with musculoskeletal infection will require treatment with antibiotics, CT helps guide therapy toward emergency surgical débridement in cases of necrotizing fasciitis and toward percutaneous drainage in cases of abscess formation.

Necrotizing soft tissue infections: APACHE II score, dissemination, and survival.

BACKGROUND: First described more than a century ago, necrotizing soft tissue infections (NSTIs) continue to cause high mortality and morbidity. The aim of this study was to elucidate the factors affecting the outcome of patients presenting with an NSTI. METHODS: To determine the factors affecting mortality from NSTIs, the records of 67 patients were retrospectively assessed for the following parameters: age, sex, time between initiation of symptoms and admission to the clinic, presence of systemic coexisting disease, APACHE II score, origin of infection, dissemination of the NSTI, and method of therapy. RESULTS: The patients were 41 men (61.2%) and 26 women (38.8%) with a mean age of 54.9 +/- 1.73 years. The overall mortality rate was 49% (33/67). Multivariate analysis determined that APACHE II scores of 13 or higher (p = 0.001) and NSTI dissemination (p = 0.02) were risk factors affecting the mortality of patients with NSTIs. CONCLUSION: By considering these two factors, more accurate outcome prediction may be possible, which may be useful for directing the management of patients with NSTIs.

Necrotizing soft-tissue infection: diagnosis and management.

Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.