Management of Pediatric Skin Infections in the Emergency Department
0
TOC Will Appear Here

Evidence-Based Management Of Skin And Soft-Tissue Infections In Pediatric Patients In The Emergency Department

2,650 views
Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.
Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Etiology And Pathophysiology
    1. Staphylococcus aureus
    2. Streptococcus pyogenes
    3. Other Pathogens
  7. Differential Diagnosis
    1. Impetigo
    2. Folliculitis
    3. Furuncles, Carbuncles, And Abscesses
    4. Cellulitis
    5. Periorbital And Orbital Cellulitis
    6. Erysipelas
    7. Ecthyma
    8. Necrotizing Fasciitis
    9. Staphylococcal Scalded Skin Syndrome
    10. Toxic Shock Syndrome
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
  10. Diagnostic Studies
    1. Gram Stain And Culture
    2. Blood Cultures And Other Blood Tests
    3. Radiographic Studies
    4. Ultrasound
  11. Treatment
    1. Impetigo
    2. Folliculitis
    3. Furuncles, Carbuncles, And Abscesses
    4. Cellulitis
    5. Periorbital And Orbital Cellulitis
    6. Erysipelas
    7. Ecthyma
    8. Necrotizing Fasciitis
    9. Staphylococcal Scalded Skin Syndrome
    10. Toxic Shock Syndrome
  12. Special Circumstances
    1. Bites
    2. Immunocompromised Patients
    3. Neonatal Infections
    4. Hand Infections
      1. Paronychia
      2. Felon
      3. Herpetic Whitlow
      4. Other Hand Infections
    5. Surgical Site Infections
  13. Controversies/Cutting Edge
    1. Methicillin-Resistant Staphylococcus aureus Decolonization
    2. New Treatments For Methicillin-Resistant Staphylococcus aureus
    3. Vaccines
  14. Disposition
  15. Summary
  16. Abbreviations
  17. Case Conclusions
  18. Risk Management Pitfalls In Skin And Soft-Tissue Infections
  19. Time- And Cost-Effective Strategies
  20. Clinical Pathway For Emergency Department Management Of Skin And Soft Tissue Infections
  21. Tables and Figures
    1. Figure 1. Impetigo Skin And Soft Tissue Infections In The ED
    2. Figure 2. Bullous Impetigo
    3. Figure 3. Cellulitis
    4. Figure 4. Orbital Cellulitis
    5. Figure 5. Erysipelas
    6. Figure 6. Ecthyma
    7. Figure 7. Cigarette Burn
    8. Figure 8. Orbital Cellulitis Computed Tomography Scan
    9. Figure 9. Cellulitis On Ultrasound
    10. Figure 10. Cellulitis And Abscess On Ultrasound
    11. Figure 11. Paronychia
    12. Table 1. Treatment Of Impetigo
    13. Table 2. Treatment Recommendations And Dosing For Methicillin Sensitive Staphylococcus aureus Methicillin Resistant Staphylococcus aureus And Streptococcal Skin Infections
    14. Table 3. Summary Of Common Skin And Soft Tissue Infections
  22. References

Abstract

Skin and soft-tissue infections are among the most common conditions seen in children in the emergency department. Emergency department visits for these infections more than doubled between 1993 and 2005, and they currently account for approximately 2% of all emergency department visits in the United States. This rapid increase in patient visits can be attributed largely to the pervasiveness of community-acquired methicillin-resistant Staphylococcus aureus. The emergence of this disease entity has created a great deal of controversy regarding treatment regimens for skin and soft-tissue infections. This issue of Pediatric Emergency Medicine Practice will focus on the management of children with skin and soft-tissue infections, based on the current literature.

Case Presentations

A 7-month-old, otherwise healthy, boy is brought to the emergency department with irritability and lethargy 3 days after undergoing elective circumcision. By history, he has been afebrile. His mother noted a faint red rash and swelling around the scrotum that extends up the abdomen. He is afebrile and normotensive on arrival, but he is tachycardic to 180 beats/min and tachypneic to 59 breaths/min, and his oxygen saturation is 91% on room air. On genitourinary examination, you note a circumcised penis with some erythema and edema near the glans. The scrotum appears normal, and both testes are palpable and nontender. The perineum appears normal. There is a faint erythematous area, approximately 10 cm in diameter that extends to the right upper leg. An ecchymotic lesion with a central bulla measuring 2 cm by 2 cm is noted in the right inguinal area. No crepitus is palpated in the involved area. You are worried that this child’s lesions have progressed from a localized infection to a systemic one. The mother asks what is wrong with her baby…

A 2-year-old, otherwise healthy, girl is brought to the emergency department with a rash on her face. Her mother notes that the rash started 3 days ago after her child sustained a cut on the inside of her nose. The mother notes that the child seems to be in pain when the rash is touched, and the child frequently rubs her face. She is afebrile and has no associated symptoms other than nasal congestion. The physical examination is notable for honey-colored crusted lesions around her nose and upper face. The medical student who is rotating through the department this month asks you what this rash is and how to treat it...

A 7-week-old boy presents with 2 days of vomiting and diarrhea. According to his mother, he was born fullterm with no complications. She had no infections during the pregnancy, and her group B Streptococcus swab was negative. The boy has been afebrile, and has had good urine output. He has not had a cough or congestion. On examination, the infant is afebrile with normal vital signs. His anterior fontanelle is open, soft, and flat, and the head, eyes, ears, nose, and throat examination is normal. Upon removing the child’s clothes, an erythematous peeling rash is noted on the neck, axillae, inguinal folds, and genitalia. Gentle traction over the involved skin results in skin sloughing. His abdomen is noted to be soft and nontender, and his extremities are normal without any rash. The mother is unsure of how long the rash has been there and asks you if the rash is normal…

Introduction

Skin and soft-tissue infections (SSTIs) are some of the most common conditions seen in children in the emergency department (ED). These infections can range from benign lesions (such as impetigo) to severe life-threatening infections (such as necrotizing fasciitis). Emergency clinicians should be able to recognize the common SSTIs frequently encountered in the ED and be prepared to treat them appropriately. The approach to common SSTIs has been drastically altered by the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), leading many physicians to alter their practice accordingly.

Critical Appraisal Of The Literature

A search was performed in PubMed for articles published from 2007 to 2014 pertaining to children aged < 18 years using multiple combinations of the search terms skin and soft-tissue infections, cellulitis, impetigo, staphylococcal scalded skin syndrome, toxic shock syndrome, MRSA, erysipelas, and hand infections. The Cochrane Database of Systematic Reviews was also consulted. Articles relevant to pediatric skin and soft-tissue infections were selected and reviewed. More than 400 articles were reviewed, 137 of which were chosen for inclusion in this review, including a number of randomized controlled trials, metaanalyses, and clinical practice guidelines. The latest practice guidelines for the diagnosis and management of skin and soft-tissue infections by the Infectious Diseases Society of America are included.

Risk Management Pitfalls In Skin And Soft-Tissue Infections

1. “The area in question was not fluctuant, so I did not think there was an abscess to drain.”

Clinical examination alone can be sufficient to diagnose an abscess that requires drainage. However, when an abscess is not clinically evident, the use of ultrasound may improve the accuracy of the diagnosis.77

2. “The patient had facial swelling, but I did not evaluate his teeth.”

Facial cellulitis is often associated with odontogenic infections. All patients with facial swelling should receive a careful oral examination, and they may require follow-up with a dentist for tooth extraction.

3. “The patient only complained of a rash on the arm, so I didn’t look elsewhere.”

All patients with skin and soft-tissue infections should be examined in a hospital gown so as not to miss other signs of infection. Staphylococcal scalded skin syndrome, for example, tends to start centrally and spread centripetally. If the patient is not fully examined, the central erythroderma may be missed, and the patient may be inappropriately treated.

4. “The neonate looked well, and the rash was small, so I did not perform a complete sepsis evaluation.”

In all but the simplest of infections, neonates should undergo a complete sepsis evaluation and immediate and aggressive antibiotic therapy.

5. “I tightly packed the abscess cavity to encourage continued drainage.”

Theoretically, packing a wound prevents the incision in the skin layer from closing prematurely to allow for continued drainage. However, packing is painful and may lead to increased healing times.86 Studies have shown no difference in failure rates, pain scores, or healing times between abscesses that are packed versus not packed.85 Additionally, patients who received no packing reported less pain.86 Wound packing, therefore, may be an unnecessary step, but more research needs to be performed to determine whether or not wound packing should be used.

6. “I didn’t drain the paronychia, because it would be too painful for the patient.”

If there is abscess formation present, it should be evacuated. Untreated paronychia can develop into a felon, which require more extensive incision and drainage.

7. “I wasn’t sure if the patient had periorbital or orbital cellulitis, so I treated with oral antibiotics for a periorbital infection.”

Orbital cellulitis can be clinically distinguished from periorbital cellulitis by the presence of pain with eye movements, proptosis, limited eye movements, or decreased visual acuity. If there is any question of the presence of orbital cellulitis being present, the patient should undergo a CT scan.

8. “I treated the infected cat bite wound with clindamycin to cover CA-MRSA.”

Infected bite-related wounds usually have a polymicrobial etiology, and should be treated with antibiotics that are active against both aerobic and anaerobic bacteria, as well as gramnegative bacteria (eg, Pasteurella multocida), such as amoxicillin-clavulanate.

9. “I performed an incision and drainage on the abscess, but did not obtain culture of the purulent material, and now my patient has returned with a worsening infection.”

When possible, a culture should be obtained from purulent lesions. The results of wound cultures can help guide antimicrobial therapy in the event of treatment failure, and may spare the patient from receiving costly broad-spectrum antibiotics.

10. “I thought my patient may have necrotizing fasciitis, so I started broad-spectrum antibiotics and admitted him to the hospital.”

In patients suspected of having necrotizing fasciitis, emergent surgical consult is imperative. Antibiotics have little effect on the infection prior to surgery due to the poor vascular supply of the necrotic tissue. Delays in proper treatment can increase patient morbidity and mortality.

Tables and Figures

Table 1. Treatment Of Impetigo

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of communityassociated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298. (Retrospective data analysis)
  2. Edelsberg J, Taneja C, Zervos M, et al. Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516-1518. (Cross-sectional study)
  3. VandenBergh MF, Yzerman EP, van Belkum A, et al. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. J Clin Microbiol. 1999;37(10):3133-3140. (Prospective follow-up study; 17 participants)
  4. Eriksen NH, Espersen F, Rosdahl VT, et al. Carriage of Staphylococcus aureus among 104 healthy persons during a 19-month period. Epidemiol Infect. 1995;115(1):51-60. (Comparative study; 104 patients)
  5. Armstrong-Esther CA. Carriage patterns of Staphylococcus aureus in a healthy non-hospital population of adults and children. Ann Hum Biol. 1976;3(3):221-227. (Prospective study)
  6. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10(3):505-520. (Review)
  7. Williams RE. Healthy carriage of Staphylococcus aureus: its prevalence and importance. Bacteriol Rev. 1963;27:56-71. (Review)
  8. Fritz SA, Epplin EK, Garbutt J, et al. Skin infection in children colonized with community-associated methicillinresistant Staphylococcus aureus. J Infect. 2009;59(6):394-401. (Retrospective study; 1300 patients)
  9. Ellis MW, Hospenthal DR, Dooley DP, et al. Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers. Clin Infect Dis. 2004;39(7):971-979. (Prospective study; 812 patients)
  10. van Belkum A, Verkaik NJ, de Vogel CP, et al. Reclassification of Staphylococcus aureus nasal carriage types. J Infect Dis. 2009;199(12):1820-1826. (Prospective study; 51 patients)
  11. Brooks GF, Carroll KC, Butel JS, et al. The staphylococci. In: Jawetz, Melnick, & Adelberg’s Medical Microbiology. 26th ed. New York, NY: The McGraw-Hill Companies; 2013. (Textbook)
  12. Mistry RD. Skin and soft tissue infections. Pediatr Clin North Am. 2013;60(5):1063-1082. (Review)
  13. David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-687. (Review)
  14. Rathore MH, Kline MW. Community-acquired methicillinresistant Staphylococcus aureus infections in children. Pediatr Infect Dis J. 1989;8(9):645-647. (Case report; 1 patient)
  15. Mistry RD, Scott HF, Zaoutis TE, et al. Emergency department treatment failures for skin infections in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Emerg Care. 2011;27(1):21-26. (Retrospective cohort study; 148 patients)
  16. Rajendran PM, Young D, Maurer T, et al. Randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob Agents Chemother. 2007;51(11):40444048. (Randomized double-blind placebo-controlled trial; 166 patients)
  17. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674. (Prospective study; 422 patients)
  18. Naber CK. Staphylococcus aureus bacteremia: epidemiology, pathophysiology, and management strategies. Clin Infect Dis. 2009;48 Suppl 4:S231-S237. (Review)
  19. Naimi TS, LeDell KH, Como-Sabetti K, et al. Comparison of community- and healthcare-associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003;290(22):29762984. (Prospective cohort study; 1100 cases)
  20. Diep BA, Sensabaugh GF, Somboonna N, et al. Widespread skin and soft-tissue infections due to two methicillin-resistant Staphylococcus aureus strains harboring the genes for Panton-Valentine leucocidin. J Clin Microbiol. 2004;42(5):20802084. (Laboratory research)
  21. Larru B, Gerber JS. Cutaneous bacterial infections caused by Staphylococcus aureus and Streptococcus pyogenes in infants and children. Pediatr Clin North Am. 2014;61(2):457-478. (Review)
  22. Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis. 1995;1(3):69-78. (Review)
  23. Johnson DR, Stevens DL, Kaplan EL. Epidemiologic analysis of group A streptococcal serotypes associated with severe systemic infections, rheumatic fever, or uncomplicated pharyngitis. J Infect Dis. 1992;166(2):374-382. (Laboratory research)
  24. Nizet V, Beall B, Bast DJ, et al. Genetic locus for streptolysin S production by group A Streptococcus. Infect Immun. 2000;68(7):4245-4254. (Laboratory research)
  25. Fisher RG, Benjamin DK, Jr. Facial cellulitis in childhood: a changing spectrum. South Med J. 2002;95(7):672-674. (Retrospective study; 44 patients)
  26. Givner LB, Mason EO, Jr., Barson WJ, et al. Pneumococcal facial cellulitis in children. Pediatrics. 2000;106(5):E61. (Retrospective study; 52 patients)
  27. Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol Rev. 2011;24(2):231-246. (Review)
  28. Warren NG. Actinomycosis, nocardiosis, and actinomycetoma. Dermatol Clin. 1996;14(1):85-95. (Review)
  29. Lerner PI. Nocardiosis. Clin Infect Dis. 1996;22(6):891-903. (Review)
  30. Al-Qattan MM, Helmi AA. Chronic hand infections. J Hand Surg Am. 2014;39(8):1636-1645. (Review)
  31. Esposito S, Picciolli I, Semino M, et al. Dog and cat bite-associated infections in children. Eur J Clin Microbiol Infect Dis. 2013;32(8):971-976. (Review)
  32. Lutz JK, Lee J. Prevalence and antimicrobial-resistance of Pseudomonas aeruginosa in swimming pools and hot tubs. Int J Environ Res Public Health. 2011;8(2):554-564. (Surveillance study; 108 samples, 3 hot tubs, 8 pools)
  33. Horseman MA, Surani S. A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection. Int J Infect Dis. 2011;15(3):e157-166. (Review)
  34. Cole C, Gazewood J. Diagnosis and treatment of impetigo. Am Fam Physician. 2007;75(6):859-864. (Review)
  35. Loffeld A, Davies P, Lewis A, et al. Seasonal occurrence of impetigo: a retrospective 8-year review (1996-2003). Clin Exp Dermatol. 2005;30(5):512-514. (Retrospective review; 1552 patients)
  36. Hirschmann JV. Impetigo: etiology and therapy. Curr Clin Top Infect Dis. 2002;22:42-51. (Review)
  37. Geria AN, Schwartz RA. Impetigo update: new challenges in the era of methicillin resistance. Cutis. 2010;85(2):65-70. (Review)
  38. Sladden MJ, Johnston GA. Current options for the treatment of impetigo in children. Expert Opin Pharmacother. 2005;6(13):2245-2256. (Review)
  39. Yu Y, Cheng AS, Wang L, et al. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. 2007;57(4):596-600. (Case report; 33 children)
  40. Lin YT, Lu PW. Retrospective study of pediatric facial cellulitis of odontogenic origin. Pediatr Infect Dis J. 2006;25(4):339342. (Retrospective study; 56 patients)
  41. Kokx NP, Comstock JA, Facklam RR. Streptococcal perianal disease in children. Pediatrics. 1987;80(5):659-663. (Retrospective chart review; 31 patients)
  42. Kliegman RM, Stanton B, St. Geme J, et al. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier; 2011. (Textbook)
  43. Brook I. Microbiology of perianal cellulitis in children: comparison of skin swabs and needle aspiration. Int J Dermatol. 1998;37(12):922-924. (Retrospective study; 10 patients)
  44. Wolf R, Orion E, Tuzun Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32(1):131-140. (Review)
  45. Gonzalez MO, Durairaj VD. Understanding pediatric bacterial preseptal and orbital cellulitis. Middle East Afr J Ophthalmol. 2010;17(2):134-137. (Review)
  46. Clarke WN. Periorbital and orbital cellulitis in children. Paediatr Child Health. 2004;9(7):471-472. (Review)
  47. Meara DJ. Sinonasal disease and orbital cellulitis in children. Oral Maxillofac Surg Clin North Am. 2012;24(3):487-496. (Review)
  48. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-912. (Review)
  49. Empinotti JC, Uyeda H, Ruaro RT, et al. Pyodermitis. An Bras Dermatol. 2012;87(2):277-284. (Review)
  50. Jaffe J, Ratcliff T. Infectious disease emergencies. In: Stone CK, Humphries RL, eds. CURRENT Diagnosis & Treatment Emergency Medicine. 7th ed. New York, NY: The McGraw-Hill Companies; 2011. (Textbook)
  51. Wasserzug O, Valinsky L, Klement E, et al. A cluster of ecthyma outbreaks caused by a single clone of invasive and highly infective Streptococcus pyogenes. Clin Infect Dis. 2009;48(9):1213-1219. (Prospective epidemiological study)
  52. Fustes-Morales A, Gutierrez-Castrellon P, Duran-Mckinster C, et al. Necrotizing fasciitis: report of 39 pediatric cases. Arch Dermatol. 2002;138(7):893-899. (Retrospective study; 39 patients)
  53. Legbo JN, Shehu BB. Necrotizing fasciitis: a comparative analysis of 56 cases. J Natl Med Assoc. 2005;97(12):1692-1697. (Comparative analysis; 56 cases)
  54. Bingol-Kologlu M, Yildiz RV, Alper B, et al. Necrotizing fasciitis in children: diagnostic and therapeutic aspects. J Pediatr Surg. 2007;42(11):1892-1897. (Retrospective study; 13 patients)
  55. Lancerotto L, Tocco I, Salmaso R, et al. Necrotizing fasciitis: classification, diagnosis, and management. J Trauma Acute Care Surg. 2012;72(3):560-566. (Review)
  56. Sadasivan J, Maroju NK, Balasubramaniam A. Necrotizing fasciitis. Indian J Plast Surg. 2013;46(3):472-478. (Review)
  57. Wang YS, Wong CH, Tay YK. Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol. 2007;46(10):1036-1041. (Retrospective chart review; 22 patients)
  58. Hanakawa Y, Stanley JR. Mechanisms of blister formation by staphylococcal toxins. J Biochem. 2004;136(6):747-750. (Laboratory research)
  59. Amagai M, Yamaguchi T, Hanakawa Y, et al. Staphylococcal exfoliative toxin B specifically cleaves desmoglein 1. J Invest Dermatol. 2002;118(5):845-850. (Review)
  60. Garcea G, Lloyd T, Jacobs M, et al. Role of microbiological investigations in the management of non-perineal cutaneous abscesses. Postgrad Med J. 2003;79(935):519-521. (Retrospective analysis)
  61. * Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52. (Clinical practice guidelines)
  62. Fritsche TR, Jones RN. Importance of understanding pharmacokinetic/pharmacodynamic principles in the emergence of resistances, including community-associated Staphylococcus aureus. J Drugs Dermatol. 2005;4(6 Suppl):s4-s8. (Review)
  63. Khan MN, Vidya R, Lee RE. The limited role of microbiological culture and sensitivity in the management of superficial soft tissue abscesses. ScientificWorldJournal. 2006;6:1118-1123. (Retrospective chart review; 162 patients)
  64. Sadow KB, Chamberlain JM. Blood cultures in the evaluation of children with cellulitis. Pediatrics. 1998;101(3):E4. (Retrospective case series; 381 patients)
  65. * Malone JR, Durica SR, Thompson DM, et al. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics. 2013;132(3):454-459. (Retrospective chart review; 580 patients)
  66. Sigurdsson AF, Gudmundsson S. The etiology of bacterial cellulitis as determined by fine-needle aspiration. Scand J Infect Dis. 1989;21(5):537-542. (Prospective study; 94 cases)
  67. Duvanel T, Auckenthaler R, Rohner P, et al. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med. 1989;149(2):293-296. (Laboratory research)
  68. Howe PM, Eduardo Fajardo J, Orcutt MA. Etiologic diagnosis of cellulitis: comparison of aspirates obtained from the leading edge and the point of maximal inflammation. Pediatr Infect Dis J. 1987;6(7):685-686. (Prospective study; 21 patients)
  69. Wall DB, de Virgilio C, Black S, et al. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179(1):17-21. (Retrospective analysis; 21 cases, 21 controls)
  70. 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 cohort study; 314 patients)
  71. Jain S, Cooley A. Toxic shock syndrome. In: Strange GR, Ahrens WR, Schafermeyer RW, et al., eds. Pediatric Emergency Medicine. 3rd ed. New York, NY: The McGraw-Hill Companies; 2009. (Textbook)
  72. Fugitt JB, Puckett ML, Quigley MM, et al. Necrotizing fasciitis. Radiographics. 2004;24(5):1472-1476. (Case report)
  73. Yamaoka M, Furusawa K, Uematsu T, et al. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg. 1994;22(5):268-271. (Case report)
  74. Eustis HS, Mafee MF, Walton C, et al. MR imaging and CT of orbital infections and complications in acute rhinosinusitis. Radiol Clin North Am. 1998;36(6):1165-1183. (Review)
  75. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996;166(1):149152. (Review)
  76. Chao HC, Lin SJ, Huang YC, et al. Sonographic evaluation of cellulitis in children. J Ultrasound Med. 2000;19(11):743-749. (Prospective study; 86 patients)
  77. * Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasoundassisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013;20(6):545-553. (Prospective study; 387 lesions)
  78. Koning S, Van der Wouden JC, Chosidow O, et al. Efficacy and safety of retapamulin ointment as treatment of impetigo: randomized double-blind multicentre placebo-controlled trial. Br J Dermatol. 2008;158(5):1077-1082. (Randomized double-blind multicenter study; 213 patients)
  79. Oranje AP, Chosidow O, Sacchidanand S, et al. Topical retapamulin ointment, 1%, versus sodium fusidate ointment, 2%, for impetigo: a randomized, observer-blinded, noninferiority study. Dermatology. 2007;215(4):331-340. (Randomized observer-blinded noninferiority study; 519 patients)
  80. Koning S, van der Sande R, Verhagen AP, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2012;1:CD003261. (Review)
  81. * George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Br J Gen Pract. 2003;53(491):480487. (Meta-analysis; 16 studies)
  82. Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Rev Anti Infect Ther. 2004;2(3):439-446. (Review)
  83. Group A Streptococcal infections. Pickering LK, Baker CJ, Committee on Infectious Diseases, et al. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. (Report)
  84. Gaspari RJ, Resop D, Mendoza M, et al. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2011;57(5):483-491. (Prospective study; 101 patients)
  85. Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012;28(6):514517. (Randomized single-blind prospective study; 57 patients)
  86. O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009;16(5):470-473. (Prospective randomized single-blinded trial; 48 patients)
  87. Koehler MB, Nakayama DK. Treatment of cutaneous abscesses without postoperative dressing changes. AORN J. 2009;90(4):569-574. (Prospective study; 35 patients)
  88. Leinwand M, Downing M, Slater D, et al. Incision and drainage of subcutaneous abscesses without the use of packing. J Pediatr Surg. 2013;48(9):1962-1965. (Prospective study; 85 patients)
  89. Tsoraides SS, Pearl RH, Stanfill AB, et al. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010;45(3):606-609. (Retrospective study; 115 patients)
  90. Ladd AP, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2010;45(7):1562-1566. (Retrospective chart review; 128 patients)
  91. * Singer AJ, Thode HC Jr. Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis. Emerg Med J. 2013. (Systematic review and meta-analysis; 4 trials, 589 patients)
  92. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60(4):539561. (Review)
  93. Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am. 2010;90(1):113-124. (Review)
  94. Hepburn MJ, Dooley DP, Skidmore PJ, et al. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004;164(15):16691674. (Prospective study; 121 patients)
  95. Jeng A, Beheshti M, Li J, et al. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore). 2010;89(4):217-226. (Prospective study; 248 patients)
  96. * 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: executive summary. Clin Infect Dis. 2011;52(3):285-292. (Clinical practice guidelines)
  97. So TY, Farrington E. Community-acquired methicillin-resistant Staphylococcus aureus infection in the pediatric population. J Pediatr Health Care. 2008;22(4):211-217; quiz 218-220.
  98. Chavez-Bueno S, Bozdogan B, Katz K, et al. Inducible clindamycin resistance and molecular epidemiologic trends of pediatric community-acquired methicillin-resistant Staphylococcus aureus in Dallas, Texas. Antimicrob Agents Chemother. 2005;49(6):2283-2288. (Laboratory research)
  99. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21(12):1157-1158. (Review)
  100. Shah VS. Infectious diseases. In: Shah BR, Lucchesi M, Amodio J, et al, eds. Atlas of Pediatric Emergency Medicine. 2nd ed. New York, NY: The McGraw-Hill Companies; 2013. (Textbook)
  101. Malghem J, Lecouvet FE, Omoumi P, et al. Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Joint Bone Spine. 2013;80(2):146-154. (Review)
  102. Patel GK. Treatment of staphylococcal scalded skin syndrome. Expert Rev Anti Infect Ther. 2004;2(4):575-587. (Review)
  103. Rudolph RI, Schwartz W, Leyden JJ. Treatment of staphylococcal toxic epidermal necrolysis. Arch Dermatol. 1974;110(4):559-562. (Prospective study; 18 patients)
  104. Schmidt H, Lissner R, Struff W, et al. Antibody reactivity of a standardized human serum protein solution against a spectrum of microbial pathogens and toxins: comparison with fresh frozen plasma. Ther Apher. 2002;6(2):145-153. (Laboratory analysis)
  105. Tenenbaum T, Hoehn T, Hadzik B, et al. Exchange transfusion in a preterm infant with hyperbilirubinemia, staphylococcal scalded skin syndrome (SSSS) and sepsis. Eur J Pediatr. 2007;166(7):733-735. (Case report)
  106. Kaul R, McGeer A, Norrby-Teglund A, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis. 1999;28(4):800807. (Prospective study; 53 patients)
  107. Darenberg J, Ihendyane N, Sjolin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis. 2003;37(3):333-340. (Prospective study; 21 patients)
  108. Shah SS, Hall M, Srivastava R, et al. Intravenous immunoglobulin in children with streptococcal toxic shock syndrome. Clin Infect Dis. 2009;49(9):1369-1376. (Multicenter retrospective cohort study)
  109. Townes DA. Human and Animal Bites. In: Strange GR, Ahrens WR, Schafermeyer RW, et al, eds. Pediatric Emergency Medicine. 3rd ed. New York, NY: The McGraw-Hill Companies; 2009. (Textbook)
  110. Wu TS, Leech SJ, Rosenberg M, et al. Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube placement at the bedside. J Emerg Med. 2009;36(3):280-284. (Prospective pilot; 3 children, 7 adults)
  111. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340(2):85-92. (Prospective study; 50 patients)
  112. Dryden MS. Complicated skin and soft tissue infection. J Antimicrob Chemother. 2010;65 Suppl 3:iii35-iii44. (Research)
  113. Muller LM, Gorter KJ, Hak E, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41(3):281-288. (Prospective cohort study; 7417 diabetic patients; 18,911 control patients)
  114. Van Hattem S, Bootsma AH, Thio HB. Skin manifestations of diabetes. Cleve Clin J Med. 2008;75(11):772-777 (Review)
  115. Fortunov RM, Hulten KG, Hammerman WA, et al. Community-acquired Staphylococcus aureus infections in term and near-term previously healthy neonates. Pediatrics. 2006;118(3):874-881. (Case report)
  116. Isaacs D. Skin and Soft Tissue Infections. Evidence-Based Neonatal Infections. John Wiley & Sons; 2013:117-127.
  117. Johnson JD, Malachowski NC, Vosti KL, et al. A sequential study of various modes of skin and umbilical care and the incidence of staphylococcal colonization and infection in the neonate. Pediatrics. 1976;58(3):354-361. (Prospective study)
  118. Nguyen R, Bhat R, Teshome G. Question 2: Is a lumbar puncture necessary in an afebrile newborn infant with localised skin and soft tissue infection? Arch Dis Child. 2014;99(7):695-698. (Expert review)
  119. Clark DC. Common acute hand infections. Am Fam Physician. 2003;68(11):2167-2176. (Review)
  120. Feder HM, Jr., Long SS. Herpetic whitlow. Epidemiology, clinical characteristics, diagnosis, and treatment. Am J Dis Child. 1983;137(9):861-863. (Case reports; 8 patients)
  121. Gill MJ, Arlette J, Buchan K. Herpes simplex virus infection of the hand. A profile of 79 cases. Am J Med. 1988;84(1):89-93. (Case studies; 79 cases)
  122. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. (Retrospective study; 30,121 patients)
  123. Huizinga WK, Kritzinger NA, Bhamjee A. The value of adjuvant systemic antibiotic therapy in localised wound infections among hospital patients: a comparative study. J Infect. 1986;13(1):11-16. (Prospective study; 73 patients)
  124. Toshkova K, Annemuller C, Akineden O, et al. The significance of nasal carriage of Staphylococcus aureus as risk factor for human skin infections. FEMS Microbiol Lett. 2001;202(1):17-24. (Laboratory study; 12 patients)
  125. Ellis MW, Griffith ME, Dooley DP, et al. Targeted intranasal mupirocin to prevent colonization and infection by community-associated methicillin-resistant Staphylococcus aureus strains in soldiers: a cluster randomized controlled trial. Antimicrob Agents Chemother. 2007;51(10):3591-3598. (Prospective study; 134 patients)
  126. Whitman TJ, Herlihy RK, Schlett CD, et al. Chlorhexidineimpregnated cloths to prevent skin and soft-tissue infection in Marine recruits: a cluster-randomized, double-blind, controlled effectiveness trial. Infect Control Hosp Epidemiol. 2010;31(12):1207-1215. (Cluster-randomized double-blind controlled effectiveness trial; 1562 participants)
  127. * Fritz SA, Hogan PG, Hayek G, et al. Household versus individual approaches to eradication of community-associated Staphylococcus aureus in children: a randomized trial. Clin Infect Dis. 2012;54(6):743-751. (Prospective study; 183 patients)
  128. Burke SL, Rose WE. New pharmacological treatments for methicillin-resistant Staphylococcus aureus infections. Expert Opin Pharmacother. 2014;15(4):483-491. (Review)
  129. Zhanel GG, Calic D, Schweizer F, et al. New lipoglycopeptides: a comparative review of dalbavancin, oritavancin and telavancin. Drugs. 2010;70(7):859-886. (Review)
  130. Weisman LE, Thackray HM, Steinhorn RH, et al. A randomized study of a monoclonal antibody (pagibaximab) to prevent staphylococcal sepsis. Pediatrics. 2011;128(2):271-279. (Randomized double-blind placebo-controlled study; 88 patients)
  131. DeJonge M, Burchfield D, Bloom B, et al. Clinical trial of safety and efficacy of INH-A21 for the prevention of nosocomial staphylococcal bloodstream infection in premature infants. J Pediatr. 2007;151(3):260-265. (Prospective study; 1983 patients)
  132. * Benjamin DK, Schelonka R, White R, et al. A blinded, randomized, multicenter study of an intravenous Staphylococcus aureus immune globulin. J Perinatol. 2006;26(5):290-295. (Prospective study; 206 patients)
  133. Rupp ME, Holley HP, Jr., Lutz J, et al. Phase II, randomized, multicenter, double-blind, placebo-controlled trial of a polyclonal anti-Staphylococcus aureus capsular polysaccharide immune globulin in treatment of Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2007;51(12):4249-4254. (Randomized multicenter double-blind placebo-controlled trial; 40 patients)
  134. Shinefield H, Black S, Fattom A, et al. Use of a Staphylococcus aureus conjugate vaccine in patients receiving hemodialysis. N Engl J Med. 2002;346(7):491-496. (Double-blind trial; 1804 patients)
  135. Fowler VG, Allen KB, Moreira ED, et al. Effect of an investigational vaccine for preventing Staphylococcus aureus infections after cardiothoracic surgery: a randomized trial. JAMA. 2013;309(13):1368-1378. (Prospective study; 8031 patients)
  136. Steer AC, Dale JB, Carapetis JR. Progress toward a global group a streptococcal vaccine. Pediatr Infect Dis J. 2013;32(2):180-182.
  137. Heath PT. An update on vaccination against group B Streptococcus. Expert Rev Vaccines. 2011;10(5):685-694. (Review)
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Publication Information
Authors

Jennifer E. Sanders, MD; Sylvia E. Garcia, MD

Publication Date

February 2, 2015

Get Permission

Content You Might Be Interested In

Emergency Department Management of Rash and Fever in the Pediatric Patient (Infectious Disease CME and Pharmacology CME)

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.