Management of Skin and Soft-Tissue Infections in Urgent Care (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Course

Skin and soft-tissue infections (SSTIs) are common presentations in urgent care settings. An understanding of the etiologies and pathophysiology of common SSTIs (cellulitis, abscesses, and necrotizing SSTIs) will help guide the diagnosis and treatment of these infections. In this issue, you will learn:

The differences between nonpurulent, purulent, and necrotizing SSTIs.

How to differentiate an SSTI from noninfectious or chronic conditions that have similar signs and symptoms.

How the history of the type of exposure can help deduce the likely involved organism and guide treatment.

The signs that put necrotizing SSTIs on the differential, even when there is no gas, crepitus, bullae, or necrosis visible.

The benefits of the loop drainage technique for incision and drainage of abscesses.

Antibiotic therapy options based on the causative pathogen.

CHARTING & CODING: Learn how to select the appropriate level of service for encounters with patients who present to urgent care with an SSTI.

1. Abstract
2. Case Presentations
3. Introduction
4. Etiology and Pathophysiology
   1. Classifications of Necrotizing Soft-Tissue Infections
5. Differential Diagnosis
6. Urgent Care Evaluation
   1. History
   2. Physical Examination
7. Diagnostic Studies
   1. Imaging
   2. Laboratory Studies
8. Treatment
   1. Reference Guidelines
   2. Considerations in Suspected MRSA Infection
   3. Prescribing Antibiotics After Incision and Drainage of Simple Abscess
   4. Treatment of Necrotizing Soft-Tissue Infection
9. Special Populations
   1. Intravenous Drug Users
   2. Immunocompromised Patients
   3. Diabetic Patients
10. Controversies and Cutting Edge
    1. Wound Irrigation
    2. Wound Packing
    3. Loop Drainage
    4. New Antibiotic Therapies
11. Disposition
12. Summary
13. Time- And Cost-Effective Strategies
14. 2 Things That Will Change Your Practice
15. Risk Management Pitfalls for Urgent Care Patients with Skin and Soft-Tissue Infections
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Charting & Coding: What You Need to Know
    1. Documentation
    2. Medical Decision Making
       1. Problems Addressed
       2. Complexity of Data
       3. Risk of Morbidity and/or Mortality
       4. Summary
19. Clinical Pathway for Managing Skin and Soft-Tissue Infections in Urgent Care
20. References

Abstract

Skin and soft-tissue infections (SSTIs) are common presentations in ambulatory settings. 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. The utility of diagnostic studies such as ultrasound are also discussed. 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.

Case Presentations

A 35-year-old man presents with a circular, slightly raised, 4-cm “spider bite” on his left lower leg that has associated warmth, erythema, tenderness, and fluctuance...

• The patient reports that the lesion appeared 2 days ago, and that he has had similar-appearing lesions in the past; he doesn’t actually recall a spider bite.
• He is afebrile and hemodynamically stable, but he states that the area is fairly painful.
• You are concerned for an abscess and plan to perform I&D. What, if any, additional tests or therapies are necessary?

A 32-year-old woman presents with a tender, swollen, erythematous area of her left arm at the level of the antecubital fossa...

• Chart review confirms your suspicion of IV drug use, and the patient admits that she “shoots up” heroin on a near daily basis.
• She denies ever sharing needles, and does not wish to pursue testing for blood-borne pathogens.
• The patient is afebrile and slightly hypertensive, but otherwise has normal vital signs and a nontoxic appearance.
• The area of fluctuance is about 6 cm in diameter and is surrounded by 8-10 cm of oval-shaped erythema.
• Does this patient need ED evaluation, or can she be managed in the urgent care setting? Are blood and wound cultures necessary in this case?

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Clinical Pathway for Managing Skin and Soft-Tissue Infections in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Spelman D, Baddour LM. Cellulitis and skin abscess: epidemiology, microbiology, clinical manifestations, and diagnosis. UpToDate. 2021. Updated October 10, 2022. Accessed June 10, 2023. (Review article)

3. * 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

4. Helman A. EM cases: skin and soft tissue infections – myths and misperceptions. Accessed June 10, 2023. (Review article)

5. Santistevan J. Necrotizing fasciitis: pearls & pitfalls. Updated October 22, 2015. Accessed June 10, 2023. (Review article)

8. * 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 Infect Dis. 2014;59(2):147-159. (Practice guidelines) DOI: 10.1093/cid/ciu444

9. * 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

18. Mueller A, Sweeny A. Cellulitis disposition: discharge versus admission. emDocs. Updated May 3, 2021. Accessed June 10, 2023. (Review article)

20. 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

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Keywords: cellulitis, abscess, necrotizing, erysipelas, purulent, MRSA, saltwater, freshwater, dermatitis, gout, cobblestoning, antibiotics, loop drainage