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

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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


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…


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


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.

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

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February 2, 2015

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