Cellulitis and other skin and soft-tissue infections (SSTIs) are common presentations in the emergency department. This review describes the varied etiologies and patient presentations of the more common SSTIs: cellulitis, abscesses, and necrotizing soft-tissue infections. A discussion of the common diagnoses masquerading as SSTIs is presented, as well as a stepwise approach to avoiding misdiagnosis. Diagnostic studies are also evaluated, including discussions on ultrasound, computed tomography, and clinical decision rules. This review also provides an evidence-based analysis of the controversies in management of abscesses, including the commonly utilized techniques of incision and drainage, irrigation, packing, and concurrent antibiotic therapy.
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Following are the most informative references cited in this paper, as determined by the authors.
2. * Stevens DL, Bisno AL, Chambers HF, et al. Executive summary: practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infec Dis. 2014;59(2):147-159. (Practice guidelines) DOI: 10.1093/cid/ciu444
3. Mueller A, Sweeny A. Cellulitis disposition: discharge versus admission. 2021. Accessed April 10, 2022. (Review article)
5. * Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010(6):CD004299. (Cochrane review; 25 randomized controlled trials) DOI: 10.1002/14651858.CD004299.pub2
6. * Spelman D, Baddour LM. Cellulitis and skin abscess: epidemiology, microbiology, clinical manifestations, and diagnosis. 2021. UpToDate. Accessed April 10, 2022. (Review article)
7. * Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. (Practice guideline) DOI: 10.1093/cid/ciq146
8. Santistevan J. Necrotizing fasciitis: pearls & pitfalls. 2021. emDocs. Accessed April 10, 2022. (Online review article)
10. Helman A. EM cases: skin and soft tissue infections – myths and misperceptions. 2018. emDocs. Accessed April 10, 2022. (Online review article)
13. * Barbic D, Chenkin J, Cho DD, et al. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open. 2017;7(1):e013688. (Systematic review and meta-analysis; 8 studies) DOI: 10.1136/bmjopen-2016-013688
22. * Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. (Retrospective observational study; 454 patients) DOI: 10.1097/01.ccm.0000129486.35458.7d
27. Wang W, Chen W, Liu Y, et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ Open. 2018;8(2):e020991. (Systematic review and meta-analysis; 4198 patients) DOI: 10.1136/bmjopen-2017-020991
38. American College of Emergency Physicians. State of the art: observation units in the emergency department. 2021. Accessed April 10, 2022. (ACEP policy resource and education paper)
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Keywords: cellulitis, abscess, necrotizing, erysipelas, purulent, MRSA, saltwater, dermatitis, gout, cobblestoning, POCUS, LRINEC, antibiotics, loop, drainage
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the May 2022 issue of Emergency Medicine Practice: Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (Infectious Disease CME and Pharmacology CME)
Kyle Howarth, MD; Joby Thoppil, MD, PhD; Gilberto A. Salazar, MD, FACEP, DABEMS
Marc Kanter, MD; Jennifer White, MD
May 1, 2022
May 31, 2025
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits and 1 Pharmacology CME credit.
Date of Original Release: May 1, 2022. Date of most recent review: April 10, 2022. Termination date: May 1, 2025.
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