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Improving Quality Metrics with a Day-only Skin Abscess Protocol: Experience from Australia. World J Surg 2023; 47:1486-1492. [PMID: 36813864 PMCID: PMC9946283 DOI: 10.1007/s00268-023-06941-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Skin abscesses are a common emergency presentation often requiring incision and drainage; however, issues with theatre access lead to delays in management and high costs. The long-term impact in a tertiary centre of a standardised day-only protocol is unknown. The aim was to evaluate the impact of day-only skin abscess protocol (DOSAP) for emergency surgery of skin abscesses in a tertiary institution in Australia and to provide a blueprint for other institutions. METHODS A retrospective cohort study analysed several time periods: Period A (July 2014 to 2015, n = 201) pre-DOSAP implementation, Period B (July 2016 to 2017, n = 259) post-DOSAP, and Period C (July 2018 to 2022, n = 1,625) prospectively analysed four 12-month periods to assess long-term utilisation of DOSAP. Primary outcomes were length of stay and delay to theatre. Secondary outcome measures included theatre start time, representation rates and total costs. Statistical analysis using nonparametric methods was used to analyse the data. RESULTS There was a significant decrease in ward length of stay (1.25 days vs. 0.65 days, P < 0.0001), delay to theatre (0.81 days vs. 0.44 days, P < 0.0001) and theatre start time before 10AM (44 cases vs. 96 cases, P < 0.0001) after implementation of DOSAP. There was a significant decrease in median cost of admission of $711.74 after accounting for inflation. Period C reported 1,006 abscess presentations successfully managed by DOSAP over the four-year period. CONCLUSION Our study demonstrates the successful implementation of DOSAP in an Australian tertiary centre. The ongoing utilisation of the protocol demonstrates the ease of applicability.
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Karamchandani MM, De La Cruz Ku G, Sokol BL, Chatterjee A, Homsy C. Management of Gynecomastia and Male Benign Diseases. Surg Clin North Am 2022; 102:989-1005. [DOI: 10.1016/j.suc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Theroux L, Steere M, Katz E, Jewell R, Gardner A. A Goat Cadaver as a Cost-effective Resource for Teaching Emergency Medicine Procedures in Kijabe, Kenya. Pediatr Emerg Care 2022; 38:e1097-e1103. [PMID: 34225331 DOI: 10.1097/pec.0000000000002486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A pediatric emergency medicine and critical care fellowship was recently developed in Kenya through the University of Nairobi/Kenyatta National Hospital and AIC Kijabe Hospital. As part of this training, a week-long trauma and emergency medicine course was developed with emphasis on trauma and emergency medicine procedures. Given limited resources, we developed a course with simulation of procedures centered around utilization of a goat cadaver. OBJECTIVE The aim of the study was to describe fellow and faculty experiences and perspectives when using a goat cadaver to teach emergency medicine procedures by simulation in Kijabe, Kenya. METHODS A 5-day course was given to 2 fellows with a variety of didactics and simulations after which fellows completed a questionnaire to rate their satisfaction with the content and teaching effectiveness. RESULTS The course was rated very highly, with an average content satisfaction score of 4.5 5 and average teaching effectiveness score of 4.4 of 5. Qualitative faculty feedback was positive, with specific learnings allowing ongoing adaptation of this model. CONCLUSIONS A goat cadaver is a cost-effective resource not often considered that can be adequately used to teach several emergency medicine skills by simulation.
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Affiliation(s)
- Lindly Theroux
- From the Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Eric Katz
- From the Wake Forest University School of Medicine, Winston-Salem, NC
| | - Rebekah Jewell
- From the Wake Forest University School of Medicine, Winston-Salem, NC
| | - Alison Gardner
- From the Wake Forest University School of Medicine, Winston-Salem, NC
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Han L, Zhao Z, Zhang J, Kong X, Yang C, Peng L, Lv LY, Li C, Wang S, Wei GH. Experience performing partial fistulectomy through a single incision to treat pyriform sinus fistula in children. Int J Pediatr Otorhinolaryngol 2021; 151:110973. [PMID: 34781114 DOI: 10.1016/j.ijporl.2021.110973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/14/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The surgical treatment of pyriform sinus fistula (PSF) is improving. The aim of this study was to investigate the effect of partial fistula excision in children with PSF assisted by using methylene blue. METHODS According to the method used to treat PSF infection, the patients were divided into a conservative treatment group, a single incision group (the children drained the abscess through the incision at the dermatoglyph of the cricothyroid joint), and a non single incision group (the children drained the abscess through the incision in the most obvious area of the abscess or ulceration). The data were retrieved from the electronic medical records (EMRs) and hospital information system (HIS). The patient and observer scar assessment scale (POSAS) scores at 6 months after fistula resection were compared. RESULTS A total of 239 patients diagnosed with PSF underwent partial resection of the fistula through cervical approach with methylene blue. The success rate of the operation was 100%. The average operation time was 32 ± 13.2 min. The average hospital stay was 1 ± 0.2 days. There were 2 cases of transient hoarseness and 6 cases of wound infection. There were 17 patients in the conservative treatment group, 81 patients in the single incision group and 145 patients in the nonsingle incision group. The average POSAS scores of the three groups were 2.56 ± 0.6, 3.12 ± 0.84 and 4.56 ± 1.56, respectively, with significant differences among the three groups (P < 0.05). CONCLUSIONS Partial fistulectomy assisted by using methylene blue through a single incision in the neck for the treatment of PSF in children yields a high success rate, fewer postoperative complications and greater comfort than traditional surgery. This alternative surgery can be used to treat PSF in children.
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Affiliation(s)
- Liling Han
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Zhenzhen Zhao
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Jun Zhang
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China.
| | - XiangRu Kong
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Chao Yang
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Liang Peng
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Lin Ya Lv
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - ChangChun Li
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Shan Wang
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
| | - Guang Hui Wei
- Department of Surgical Oncology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing Key Laboratory of Pediatrics, China
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Bharath A, Madabhushi SSC. An Absorbing Improvement for Space Infection Decompression: A Novel Drainage Device. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:327-337. [PMID: 34785960 PMCID: PMC8590833 DOI: 10.2147/mder.s320723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Infection of the facial spaces and the associated exudate can often necessitate surgical intervention. Whilst traditional decompression methodologies have reduced the mortality rate from complications such as Ludwig’s Angina, there has been relatively little innovation in the procedure to minimize treatment times and patient distress. Negative pressure wound therapy, which can yield improvements to treatment time, wound healing and patient experience, has gained traction in abscess treatments in other parts of the body but seen limited adoption in maxillofacial surgeries. Methods A focused literature review explores the existing treatment methodologies for infected facial space decompression and identifies obstacles to implementing negative pressure wound therapy in maxillofacial surgeries. A novel drainage tool, which features a sleeved sponge over a perforated drainage tube, is proposed. Virtual prototyping and structural analyses of the novel drainage device including a parametric design study are presented. Results The parametric study validates the proposed tool’s biocompatibility in terms of overall flexural and axial stiffness between the tool and complex structures in the head and neck. Ultimately, this work presents a necessary first step in the development of specialized drainage tools to promote the adoption of negative pressure wound therapy for infections of facial spaces.
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Affiliation(s)
- Ansha Bharath
- Government Dental College and Research Institute, Bangalore, India
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Three things. Br Dent J 2020; 229:701. [DOI: 10.1038/s41415-020-2464-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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7
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Thomas O, Ramsay A, Yiasemidou M, Hardie C, Ashmore D, Macklin C, Bandyopadhyay D, Bijendra Patel, Burke JR, Jayne D. The surgical management of cutaneous abscesses: A UK cross-sectional survey. Ann Med Surg (Lond) 2020; 60:654-659. [PMID: 33304582 PMCID: PMC7718210 DOI: 10.1016/j.amsu.2020.11.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022] Open
Abstract
Aim Cutaneous abscesses are one of the most common acute general surgery presentations. This study aimed to understand the current practice in the management of cutaneous abscesses in the United Kingdom (UK), once the decision has been made that acute surgical incision and drainage (I&D) is required. Method General surgeons from across the UK were surveyed on their opinions on the optimum management of cutaneous abscesses. Outcomes measured included anaesthesia, incision technique, antibiotic administration, departmental abscess pathways, and post-drainage management. A combination of Likert scales, multiple-choice questions, and short answer questions were used. Comparisons were made of Likert scales between regions using a two-sample independent t-test. The survey was peer reviewed and distributed through the Association of Coloproctology of Great Britain and Ireland (ACPGBI) network between April and June 2018. Results Sixty-one responses were collected from surgeons throughout the UK. Of these respondents, 69% indicated that cutaneous abscesses would always or usually require a General Anaesthetic (GA) for treatment, and 82% indicated that abscesses were at least sometimes not treated until the next day due to a lack of resources. While 79% of surgeons stated that pus swabs are always or are usually taken, 44% of respondents never or rarely chased the results. The main indications for giving antibiotics were sepsis/systemically unwell patients, and cellulitis. 31% of responding centres had an abscess management protocol, and 82% of respondents confirmed that they would always pack the abscess wound post-operatively. Conclusion ‘Incision and drainage’ is currently the most widely used technique for the surgical management of cutaneous abscess. However, this study demonstrates the significant variability in the use of anaesthesia, antibiotics, packing and the use of protocols to guide and streamline patient management. There are no current NICE guidelines specifically covering cutaneous abscess management. There is significant practice variation in the management of cutaneous abscesses across the UK. Wound packing is still commonplace, despite guidelines recommending that there is evidence that it should be avoided. New recommendations on the use of antibiotics whilst treating cutaneous abscesses are yet to be taken up by most surgeons. Surgically managed cutaneous abscesses in the UK are preferably managed under a general anaesthetic.
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Affiliation(s)
- Owen Thomas
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - Alistair Ramsay
- The John Golligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - Marina Yiasemidou
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - Claire Hardie
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - Daniel Ashmore
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | | | | | - Bijendra Patel
- Barts Health NHS Trust, Whitechapel Rd, London, E1 1FR, UK
| | - Joshua R Burke
- The John Golligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, LS9 7TF, UK.,Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - David Jayne
- The John Golligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, LS9 7TF, UK.,Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, LS9 7TF, UK
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Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. Langenbecks Arch Surg 2020; 406:981-991. [DOI: 10.1007/s00423-020-01941-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022]
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9
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Ni Z, Sun J, Qi S. Therapeutic Effect of Topical Negative Pressure Therapy/Vacuum-Associated Closure Therapy on Cephalic Facial Skin Abscess. Surg Infect (Larchmt) 2020; 21:722-725. [PMID: 32109192 DOI: 10.1089/sur.2019.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of topical negative pressure therapy/vacuum-associated closure (TPN/VAC) in the treatment of cephalic facial skin abscess with infection. Methods: Forty-seven patients with cephalic facial skin abscesses were divided into two groups. The observation group was treated with negative pressure sealing drainage technique and primary wound suture. The control group was treated with abscess incision and drainage first; the second stage was wound suture after three to five days. The time and times of wound dressing, the pain score during wound dressing, the time of antibiotic use, and the recurrence rate were observed. Results: The wound healing time of the observation group was seven days, which was better than that of the control group for 10-12 days. The time of dressing change in the observation group was 14.9 ± 2.0 minutes (11-19 minutes), and the time of dressing change in the control group was 14.6 ± 2.6 minutes (10-20 minutes). There was no difference between the two groups (p > 0.05). The total number of dressing changes per patient in the observation group was three to five times, and the total number of dressing changes per patient in the observation group was five to eight times. There was a statistically significant difference between the two groups (p < 0.05). The pain score of the observation group was 3.2 ± 0.6 points (2-4 points), and the pain score of the control group was 5.1 ± 0.8 points (4-7 points). The difference between the two groups was statistically significant (p < 0.05). There was no recurrence in the observation group and two cases in the control group. Conclusion: Local negative pressure closed drainage technology can shorten the patient's healing course and reduce the duration of treatment, reduce the pain of dressing changes, improve prognosis, and have satisfactory therapeutic effect. It is a simple, effective, and safe technology, which is worthy of clinical application.
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Affiliation(s)
- Zhimin Ni
- The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiachen Sun
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shiling Qi
- The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Elias M, Patel S, Schwartz RA, Lambert WC. The color of skin: red diseases of the skin, nails, and mucosa. Clin Dermatol 2019; 37:548-560. [PMID: 31896409 DOI: 10.1016/j.clindermatol.2019.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Red color is pervasive in local and systemic skin conditions. It is a color that often reflects variations of dermal blood flow and extends beyond the rubor and calor of inflammation. The pathophysiology of red skin involves remote and local chemical mediators that dilate arteriolar smooth muscle and increase blood flow to superficial vessels and capillary beds. Incident light hits hemoglobin, which preferentially absorbs light of shorter wavelengths, such as blue, and reflects warmer colors. Due to its pervasiveness and consistency, red color is a useful descriptive factor in helping narrow a differential diagnosis. Red skin disorders include a variety of conditions involving endocrine mediators, cardiovascular responses, and the disruption of the skin barrier. An understanding of the blood's role in these disorders equips clinicians to generate differential diagnoses through the lens of pathophysiology. Dermatologists can improve management by considering red skin as part of systemic disease rather than as an isolated incident.
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Affiliation(s)
- Marcus Elias
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Shreya Patel
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - W Clark Lambert
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Pathology and Laboratory Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
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11
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Gao G, Jiang YW, Jia HR, Wu FG. Near-infrared light-controllable on-demand antibiotics release using thermo-sensitive hydrogel-based drug reservoir for combating bacterial infection. Biomaterials 2018; 188:83-95. [PMID: 30339942 DOI: 10.1016/j.biomaterials.2018.09.045] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/16/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
A near-infrared (NIR) light-triggerable thermo-sensitive hydrogel-based drug reservoir that can realize on-demand antibiotics release and hyperthermia-assisted bacterial inactivation was prepared to combat bacterial infection and promote wound healing. The drug reservoir was fabricated by mixing ciprofloxacin (Cip, a potent antibiotic)-loaded polydopamine (PDA) nanoparticles (NPs) and glycol chitosan (GC) to form an injectable hydrogel (PDA NP-Cip/GC hydrogel, abbreviated as Gel-Cip). On the one hand, the positive charge of GC and the adsorbability of PDA NPs made bacteria be readily trapped on the surface of Gel-Cip. On the other hand, the Gel-Cip exhibited minimal leakage under physiological conditions, but could boost Cip release upon NIR light irradiation. Meanwhile, NIR light irradiation could activate the photothermal PDA NPs, and the generated local hyperthermia induced the destruction of the bacterial integrity, leading to bacterial inactivation in a synergistic way. Moreover, the exceptional bacterial killing activity and outstanding wound healing ability of the system were also verified by the S. aureus-infected mouse skin defect model. Taken together, the light-activatable hydrogel-based platform allows us to release antibiotics more precisely, eliminate bacteria more effectively, and inhibit bacteria-induced infections more persistently, which will advance the development of novel antibacterial agents and strategies.
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Affiliation(s)
- Ge Gao
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, 2 Sipailou Road, Nanjing 210096, PR China
| | - Yao-Wen Jiang
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, 2 Sipailou Road, Nanjing 210096, PR China
| | - Hao-Ran Jia
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, 2 Sipailou Road, Nanjing 210096, PR China
| | - Fu-Gen Wu
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, 2 Sipailou Road, Nanjing 210096, PR China.
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Khan A, Wilson B, Gould IM. Current and future treatment options for community-associated MRSA infection. Expert Opin Pharmacother 2018; 19:457-470. [PMID: 29480032 DOI: 10.1080/14656566.2018.1442826] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Community-associated MRSA (CA-MRSA) represents a global epidemic which beautifully encapsulates the fascinating ability of bacterial organisms to adapt quickly on an evolutionary basis to the extreme selective pressure of antibiotic exposure. In stark contrast to Healthcare-associated MRSA (HA-MRSA), it has become apparent that CA-MRSA is less straight forward of a challenge in terms of controlling its transmission, and has forced clinicians to adjust empiric management of clinical syndromes such as skin and soft tissue infection (SSTI) as well as pneumonia. AREAS COVERED This review details the history and epidemiology of CA-MRSA, while covering both current and future treatment options that are and may be available to clinicians. The authors reviewed both historic and more recent literature on this ever-evolving topic. EXPERT OPINION While development of new anti-MRSA agents should be encouraged, the importance of antimicrobial stewardship in the battle to stay ahead of the curve with regards to the ongoing control of the MRSA epidemic should be emphasised.
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Affiliation(s)
- A Khan
- a Department of Medical Microbiology , Aberdeen Royal Infirmary (ARI) , Aberdeen , Scotland
| | - B Wilson
- a Department of Medical Microbiology , Aberdeen Royal Infirmary (ARI) , Aberdeen , Scotland
| | - I M Gould
- a Department of Medical Microbiology , Aberdeen Royal Infirmary (ARI) , Aberdeen , Scotland
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Daum RS, Miller LG, Immergluck L, Fritz S, Creech CB, Young D, Kumar N, Downing M, Pettibone S, Hoagland R, Eells SJ, Boyle MG, Parker TC, Chambers HF. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med 2017; 376:2545-2555. [PMID: 28657870 PMCID: PMC6886470 DOI: 10.1056/nejmoa1607033] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Uncomplicated skin abscesses are common, yet the appropriate management of the condition in the era of community-associated methicillin-resistant Staphylococcus aureus (MRSA) is unclear. METHODS We conducted a multicenter, prospective, double-blind trial involving outpatient adults and children. Patients were stratified according to the presence of a surgically drainable abscess, abscess size, the number of sites of skin infection, and the presence of nonpurulent cellulitis. Participants with a skin abscess 5 cm or smaller in diameter were enrolled. After abscess incision and drainage, participants were randomly assigned to receive clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The primary outcome was clinical cure 7 to 10 days after the end of treatment. RESULTS We enrolled 786 participants: 505 (64.2%) were adults and 281 (35.8%) were children. A total of 448 (57.0%) of the participants were male. S. aureus was isolated from 527 participants (67.0%), and MRSA was isolated from 388 (49.4%). Ten days after therapy in the intention-to-treat population, the cure rate among participants in the clindamycin group was similar to that in the TMP-SMX group (221 of 266 participants [83.1%] and 215 of 263 participants [81.7%], respectively; P=0.73), and the cure rate in each active-treatment group was higher than that in the placebo group (177 of 257 participants [68.9%], P<0.001 for both comparisons). The results in the population of patients who could be evaluated were similar. This beneficial effect was restricted to participants with S. aureus infection. Among the participants who were initially cured, new infections at 1 month of follow-up were less common in the clindamycin group (15 of 221, 6.8%) than in the TMP-SMX group (29 of 215 [13.5%], P=0.03) or the placebo group (22 of 177 [12.4%], P=0.06). Adverse events were more frequent with clindamycin (58 of 265 [21.9%]) than with TMP-SMX (29 of 261 [11.1%]) or placebo (32 of 255 [12.5%]); all adverse events resolved without sequelae. One participant who received TMP-SMX had a hypersensitivity reaction. CONCLUSIONS As compared with incision and drainage alone, clindamycin or TMP-SMX in conjunction with incision and drainage improves short-term outcomes in patients who have a simple abscess. This benefit must be weighed against the known side-effect profile of these antimicrobials. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00730028 .).
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Affiliation(s)
- Robert S Daum
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Loren G Miller
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Lilly Immergluck
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Stephanie Fritz
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - C Buddy Creech
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - David Young
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Neha Kumar
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Michele Downing
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Stephanie Pettibone
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Rebecca Hoagland
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Samantha J Eells
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Mary G Boyle
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Trisha Chan Parker
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
| | - Henry F Chambers
- From the University of Chicago Hospitals, Chicago (R.S.D., N.K.); Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Los Angeles (L.G.M., S.J.E.), and University of California, San Francisco-San Francisco General Hospital, San Francisco (D.Y., M.D., H.F.C.); Morehouse School of Medicine and Emory University-Grady Memorial Hospital and Children's Healthcare of Atlanta, Atlanta (L.I., T.C.P.); Washington University School of Medicine-Barnes-Jewish Hospital and St. Louis Children's Hospital, St. Louis (S.F., M.G.B.); Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville (C.B.C.); EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.H.)
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14
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Yang C, Wang S, Li CC, Kong XR, Zhao Z, Deng XB, Peng L, Zhang J. A high-vacuum wound drainage system reduces pain and length of treatment for pediatric soft tissue abscesses. Eur J Pediatr 2017; 176:261-267. [PMID: 28013376 DOI: 10.1007/s00431-016-2835-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 11/30/2016] [Accepted: 12/18/2016] [Indexed: 01/08/2023]
Abstract
UNLABELLED Open incision and drainage (I&D) and wound packing is accepted as the standard treatment for soft tissue abscesses. However, conventional I&D has a number of problems in practice which prompt us to improve the I&D methods that would minimize the pain associated with packing during dressing changes. In order to compare the pain associated with dressing changes in the conventional I&D group to the vacuum system group and the treatment time of both groups, we performed a randomized trial in pediatric patients between 0 and 18 years of age who are undergoing abscess drainage in the operating room from April 2011 to April 2015. Patients treated with open I&D (n = 648) were compared to those treated with placement of high-vacuum wound drainage system (n = 776) through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed up in the outpatient clinics until the infection has been resolved. The mean FACES scale pain scores were significantly higher in the open I&D group than in the vacuum system group. The vacuum system group had a shorter length of stay and less need for community doctor or outpatient dressing changes than the open I&D group (p < 0.001). No recurrent abscesses were observed in the vacuum system group, and 10 patients in the open I&D group required another drainage at the exact same location. CONCLUSION High-vacuum wound drainage system was an efficient and safe alternative to the traditional I&D for community-acquired soft tissue abscesses with few complications in short term. What is Known: • Open incision and drainage (I&D) followed by irrigation and wound packing is the standard treatment for soft tissue abscesses. • The painful daily packing may cause emotional trauma to the child and lead to an unwelcoming challenge to the caretakers and health care providers. What is New: • We modified the method of I&D by adding primary suturing of the wound and placement of a high-vacuum wound drainage system. • This technique was proved to be an efficient and safe alternative to the traditional I&D method for soft tissue abscesses with small complications in short term.
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Affiliation(s)
- Chao Yang
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Shan Wang
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Chang-Chun Li
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Xiang-Ru Kong
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Zhenzhen Zhao
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Xiao-Bin Deng
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Liang Peng
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Jun Zhang
- Department of Pediatric Surgical Oncology, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China. .,Ministry of Education Key Laboratory of Child Development and Disorders, The Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.
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15
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Linder KE, Nicolau DP, Nailor MD. Epidemiology, treatment, and economics of patients presenting to the emergency department for skin and soft tissue infections. Hosp Pract (1995) 2017; 45:9-15. [PMID: 28055287 DOI: 10.1080/21548331.2017.1279519] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Skin and soft tissue infections (SSTIs) are among the most common bacterial diseases and represent a significant disease burden. The purpose of this study was to describe the real-world management of patients with SSTIs presenting to the emergency department (ED). METHODS This is a retrospective cohort study. Adult patients identified with a primary diagnosis of SSTI determined by ICD-9 codes were assessed from index presentation for up to 30 days. Records were reviewed 30 days prior to inclusion to ensure index hospitalization was captured. For recurrent visits, a similar strategy was implemented 30 days afterward. RESULTS Of 446 encounters screened, 357 were included; 106 (29.7%) were admitted to the hospital and 251 (70.3%) were treated outpatient. Of patients with a Charlson Comorbidity Index (CCI) score two or greater, 60.9% were treated as inpatients, whereas admission rates were 30.1% and 14.1% for patients with a CCI score of one and zero, respectively. Inpatients had an average length of stay (LOS) of 7.3 ± 7.1 days. No difference was detected in overall re-presentation to the facility 22.6% and 28.3% (p > 0.05) or in SSTI related re-presentation 10.4% and 15.1% (p > 0.05) between inpatient and outpatients. The most common gram-positive organisms identified on wound/abscess culture were MSSA (37.1% inpatients) and MRSA (66.7% outpatients). Mean total cost of care was $13,313 for inpatients and $413 for outpatients. CONCLUSION This analysis identifies opportunities to improve processes of care for SSTIs with the aim of decreasing LOS, reducing readmissions, and ultimately decreasing burden on the healthcare system.
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Affiliation(s)
- Kristin E Linder
- a Department of Pharmacy , Hartford Hospital , Hartford , CT , USA
| | - David P Nicolau
- b Center for Anti-Infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - Michael D Nailor
- a Department of Pharmacy , Hartford Hospital , Hartford , CT , USA.,c Department of Pharmacy Practice , University of Connecticut School of Pharmacy , Storrs , CT , USA
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16
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Smith SR, Newton K, Smith JA, Dumville JC, Iheozor‐Ejiofor Z, Pearce LE, Barrow PJ, Hancock L, Hill J. Internal dressings for healing perianal abscess cavities. Cochrane Database Syst Rev 2016; 2016:CD011193. [PMID: 27562822 PMCID: PMC8502074 DOI: 10.1002/14651858.cd011193.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40 per 100,000 of the adult population, and the standard treatment is admission to hospital for incision and drainage under general anaesthetic. Following drainage of the pus, an internal dressing (pack) is placed into the cavity to stop bleeding. Common practice is for community nursing teams to change the pack regularly until the cavity heals. Some practitioners in the USA and Australia make a small stab incision under local anaesthetic and place a catheter into the cavity which drains into an external dressing. It is removed when it stops draining. Elsewhere in the USA, simple drainage is performed in an outpatient setting under local anaesthetic. OBJECTIVES To assess the effects of internal dressings in healing wound cavities resulting from drainage of perianal abscesses. SEARCH METHODS In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries to identify ongoing and unpublished studies, and searched reference lists of relevant reports to identify additional studies. We did not restrict studies with respect to language, date of publication, or study setting. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) comparing any type of internal dressing (packing) used in the post-operative management of perianal abscess cavities with alternative treatments or different types of internal dressing. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment, and data extraction. MAIN RESULTS We included two studies, with a total of 64 randomised participants (50 and 14 participants) aged 18 years or over, with a perianal abscess. In both studies, participants were enrolled on the first post-operative day and randomised to continued packing by community district nursing teams or to no packing. Participants in the non-packing group managed their own wounds in the community and used absorbant dressings to cover the area. Fortnightly follow-up was undertaken until the cavity closed and the skin re-epithelialised, which constituted healing. For non-attenders, telephone follow-up was conducted.Both studies were at high risk of bias due to risk of attrition, performance and detection bias.It was not possible to pool the two studies for the outcome of time to healing. It is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing. One study reported a mean time to wound healing of 26.8 days (95% confidence interval (CI) 22.7 to 30.7) in the packing group and 19.5 days (95% CI 13.6 to 25.4) in the non-packing group (it was not clear if all participants healed). We re-analysed the data and found no clear difference in the time to healing (7.30 days longer in the packing group, 95% CI -2.24 to 16.84; 14 participants). This was assessed as very low quality evidence (downgraded three levels for very serious imprecision and serious risk of bias). The second study reported a median time to complete wound healing of 24.5 days (range 10 to 150 days) in the packing group and 21 days (range 8 to 90 days) in the non-packed group. There was insufficient information to be able to recreate the analysis and the original analysis was inappropriate (did not account for censoring). This second study also provided very low quality evidence (downgraded four levels for serious risk of bias, serious indirectness and very serious imprecision).There was very low quality evidence (downgraded for risk of bias, indirectness and imprecision) of no difference in wound pain scores at the initial dressing change. Both studies also reported patients' retrospective judgement of wound pain over the preceding two weeks (visual analogue scale, VAS) as lower for the non-packed group (2; both studies) compared with the packed group (0; both studies); (very low quality evidence) but we have been unable to reproduce these analyses as no variance data were published.There was no clear evidence of a difference in the number of post-operative fistulae detected between the packed and non-packed groups (risk ratio (RR) 2.31, 95% CIs 0.56 to 9.45, I(2) = 0%) (very low quality evidence downgraded three levels for very serious imprecision and serious risk of bias).There was no clear evidence of a difference in the number of abscess recurrences between the packed and non-packed groups over the variable follow-up periods (RR 0.72, 95% CI 0.22 to 2.37, I(2) = 0%) (very low quality evidence downgraded three levels for serious risk of bias and very serious imprecision).No study reported participant health-related quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size. AUTHORS' CONCLUSIONS It is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence or other outcomes. Despite this absence of evidence, the practice of packing abscess cavities is commonplace. Given the lack of high quality evidence, decisions to pack may be based on local practices or patient preferences. Further clinical research is needed to assess the effects and patient experience of packing.
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Affiliation(s)
- Stella R Smith
- North Western DeaneryGeneral Surgery4th Floor3 PiccadillyManchesterUKM1 3BN
| | - Katy Newton
- North Western DeaneryGeneral Surgery4th Floor3 PiccadillyManchesterUKM1 3BN
| | - Jennifer A Smith
- North Western DeaneryGeneral Surgery4th Floor3 PiccadillyManchesterUKM1 3BN
| | - Jo C Dumville
- University of ManchesterSchool of Nursing, Midwifery and Social WorkManchesterUKM13 9PL
| | - Zipporah Iheozor‐Ejiofor
- University of ManchesterCochrane Wounds GroupJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Lyndsay E Pearce
- Central Manchester University Hospitals NHS Foundation TrustDepartment of SurgeryOxford RoadManchesterUKM13 9WL
| | - Paul J Barrow
- North Western DeaneryGeneral Surgery4th Floor3 PiccadillyManchesterUKM1 3BN
| | - Laura Hancock
- North Western DeaneryGeneral Surgery4th Floor3 PiccadillyManchesterUKM1 3BN
| | - James Hill
- Central Manchester University Hospitals NHS Foundation TrustDepartment of SurgeryOxford RoadManchesterUKM13 9WL
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17
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Talan DA, Mower WR, Krishnadasan A, Abrahamian FM, Lovecchio F, Karras DJ, Steele MT, Rothman RE, Hoagland R, Moran GJ. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med 2016; 374:823-32. [PMID: 26962903 PMCID: PMC4851110 DOI: 10.1056/nejmoa1507476] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND U.S. emergency department visits for cutaneous abscess have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). The role of antibiotics for patients with a drained abscess is unclear. METHODS We conducted a randomized trial at five U.S. emergency departments to determine whether trimethoprim-sulfamethoxazole (at doses of 320 mg and 1600 mg, respectively, twice daily, for 7 days) would be superior to placebo in outpatients older than 12 years of age who had an uncomplicated abscess that was being treated with drainage. The primary outcome was clinical cure of the abscess, assessed 7 to 14 days after the end of the treatment period. RESULTS The median age of the participants was 35 years (range, 14 to 73); 45.3% of the participants had wound cultures that were positive for MRSA. In the modified intention-to-treat population, clinical cure of the abscess occurred in 507 of 630 participants (80.5%) in the trimethoprim-sulfamethoxazole group versus 454 of 617 participants (73.6%) in the placebo group (difference, 6.9 percentage points; 95% confidence interval [CI], 2.1 to 11.7; P=0.005). In the per-protocol population, clinical cure occurred in 487 of 524 participants (92.9%) in the trimethoprim-sulfamethoxazole group versus 457 of 533 participants (85.7%) in the placebo group (difference, 7.2 percentage points; 95% CI, 3.2 to 11.2; P<0.001). Trimethoprim-sulfamethoxazole was superior to placebo with respect to most secondary outcomes in the per-protocol population, resulting in lower rates of subsequent surgical drainage procedures (3.4% vs. 8.6%; difference, -5.2 percentage points; 95% CI, -8.2 to -2.2), skin infections at new sites (3.1% vs. 10.3%; difference, -7.2 percentage points; 95% CI, -10.4 to -4.1), and infections in household members (1.7% vs. 4.1%; difference, -2.4 percentage points; 95% CI, -4.6 to -0.2) 7 to 14 days after the treatment period. Trimethoprim-sulfamethoxazole was associated with slightly more gastrointestinal side effects (mostly mild) than placebo. At 7 to 14 days after the treatment period, invasive infections had developed in 2 of 524 participants (0.4%) in the trimethoprim-sulfamethoxazole group and in 2 of 533 participants (0.4%) in the placebo group; at 42 to 56 days after the treatment period, an invasive infection had developed in 1 participant (0.2%) in the trimethoprim-sulfamethoxazole group. CONCLUSIONS In settings in which MRSA was prevalent, trimethoprim-sulfamethoxazole treatment resulted in a higher cure rate among patients with a drained cutaneous abscess than placebo. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00729937.).
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Affiliation(s)
- David A Talan
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - William R Mower
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Anusha Krishnadasan
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Fredrick M Abrahamian
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Frank Lovecchio
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - David J Karras
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Mark T Steele
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Richard E Rothman
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Rebecca Hoagland
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
| | - Gregory J Moran
- From the Departments of Emergency Medicine (D.A.T., A.K., F.M.A., G.J.M.) and Medicine, Division of Infectious Diseases (D.A.T., G.J.M.), Olive View-UCLA Medical Center, and the Department of Emergency Medicine, Ronald Reagan Medical Center (W.R.M), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; the Department of Emergency Medicine, Maricopa Medical Center, University of Arizona, and Mayo Graduate School of Medicine - both in Phoenix (F.L.); the Department of Emergency Medicine, Temple University Medical Center, Temple University School of Medicine, Philadelphia (D.J.K.); the Department of Emergency Medicine, Truman Medical Center, University of Missouri School of Medicine, Kansas City (M.T.S.); the Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore (R.E.R.); and Cota Enterprises, McLouth, KS (R.H.)
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Singer AJ, Talan DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-47. [PMID: 24620867 DOI: 10.1056/nejmra1212788] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Adam J Singer
- From the Department of Emergency Medicine, Stony Brook University, Stony Brook, NY (A.J.S.); the Departments of Emergency Medicine and Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA (D.A.T.); and the David Geffen School of Medicine at UCLA, Los Angeles (D.A.T.)
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Facing the danger zone: the use of ultrasound to distinguish cellulitis from abscess in facial infections. Case Rep Emerg Med 2014; 2014:935283. [PMID: 24851189 PMCID: PMC4006571 DOI: 10.1155/2014/935283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 11/07/2013] [Indexed: 11/17/2022] Open
Abstract
Physical exam alone is often insufficient to determine whether or not cellulitis is accompanied by an abscess. Bedside ultrasound can be a valuable tool in ruling out suspected abscess by allowing direct visualization of a fluid collection. The proximity of the infection to adjacent structures can also be determined, thus aiding clinical decision making. Patients with cellulitis near the eye and nose are of particular concern due to the adjacent facial structures and the anatomy of the venous drainage. Accurately determining the presence or absence of an associated abscess in these patients is a crucial step in treatment planning. The purpose of this report is to (1) emphasize the benefits of bedside ultrasound when used in conjunction with the physical exam to rule out abscess; (2) demonstrate the utility of bedside ultrasound in planning a treatment strategy for soft tissue infection; (3) depict an instance where ultrasound detected an abscess when computed tomography (CT) scan did not.
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Marin JR, Dean AJ, Bilker WB, Panebianco NL, Brown NJ, Alpern ER. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med 2013; 20:545-53. [PMID: 23758300 DOI: 10.1111/acem.12148] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/17/2012] [Accepted: 01/30/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The objective was to evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients. METHODS This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two physicians agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two physicians either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit or within 2 days by follow-up assessment. RESULTS A total of 387 lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (κ = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference = -1.7%; 95% confidence interval [CI] = -3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference = -2.8%; 95% CI = -9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference = 33.9%; 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference = 19.3%; 95% CI = -13.8% to 52.4%). CONCLUSIONS For clinically evident lesions, the addition of ultrasound (US) did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE.
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Affiliation(s)
- Jennifer R. Marin
- Division of Emergency Medicine; Children's Hospital of Pittsburgh; Department of Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh; PA
| | - Anthony J. Dean
- Department of Emergency Medicine; University of Pennsylvania Perelman School of Medicine; Philadelphia; PA
| | - Warren B. Bilker
- Department of Biostatistics and Epidemiology; Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania Perelman School of Medicine; Philadelphia; PA
| | - Nova L. Panebianco
- Department of Emergency Medicine; University of Pennsylvania Perelman School of Medicine; Philadelphia; PA
| | - Naomi J. Brown
- Department of Pediatrics; Division of Emergency Medicine; A.I. duPont Hospital for Children; Wilmington; DE
| | - Elizabeth R. Alpern
- Division of Emergency Medicine; The Children's Hospital of Philadelphia; Department of Pediatrics; University of Pennsylvania Perelman School of Medicine; Philadelphia; PA
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Uehara K, Maeda A, Sakamoto E, Hiramatsu K, Takeuchi E, Sakaguchi K, Tojima Y, Takahashi Y, Ebata T, Nagino M. Phase II Trial of Adjuvant Chemotherapy with S-1 for Colorectal Liver Metastasis. Ann Surg Oncol 2013; 20:475-481. [DOI: 10.1245/s10434-012-2665-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Use of a Silver-Containing Hydrofiber Dressing for Filling Abscess Cavity Following Incision and Drainage in the Emergency Department. Adv Skin Wound Care 2013; 26:20-5. [DOI: 10.1097/01.asw.0000425936.94874.9a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kojic N, Pritchard EM, Tao H, Brenckle MA, Mondia JP, Panilaitis B, Omenetto F, Kaplan DL. Focal Infection Treatment using Laser-Mediated Heating of Injectable Silk Hydrogels with Gold Nanoparticles. ADVANCED FUNCTIONAL MATERIALS 2012; 22:3793-3798. [PMID: 24015118 PMCID: PMC3760432 DOI: 10.1002/adfm.201200382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Medical treatment of subcutaneous bacterial abscesses usually involves systemic high-dose antibiotics and incision-drainage of the wound. Such an approach suffers from two main deficiencies: bacterial resistance to antibiotics and pain associated with multiple incision-drainage-wound packing procedures. Furthermore, the efficacy of high-dose systemic antibiotics is limited because of the inability to penetrate into the abscess. To address these obstacles, we present a treatment relying on laser-induced heating of gold nanoparticles embedded in an injectable silk-protein hydrogel. Although bactericidal nanoparticle systems have been previously employed based on silver and nitric oxide, they have limitations regarding customization and safety. The method we propose is safe and uses biocompatible, highly tunable materials: an injectable silk hydrogel and Au nanoparticles, which are effective absorbers at low laser powers such as those provided by hand held devices. We demonstrate that a single 10-minute laser treatment of a subcutaneous infection in mice preserves the general tissue architecture, while achieving a bactericidal effect - even resulting in complete eradication in some cases. The unique materials platform presented here can provide the basis for an alternative treatment of focal infections.
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Affiliation(s)
| | | | | | | | | | | | - Fiorenzo Omenetto
- Corresponding authors: Fiorenzo Omenetto, David L. Kaplan, Tufts University, Department of Biomedical Engineering, 4 Colby St., Medford, Massachusetts 02155 U.S.A. Tel: 617-627-3251, Fax: 617-627-3231, ,
| | - David L. Kaplan
- Corresponding authors: Fiorenzo Omenetto, David L. Kaplan, Tufts University, Department of Biomedical Engineering, 4 Colby St., Medford, Massachusetts 02155 U.S.A. Tel: 617-627-3251, Fax: 617-627-3231, ,
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Chon SY, Doan HQ, Mays RM, Singh SM, Gordon RA, Tyring SK. Antibiotic overuse and resistance in dermatology. Dermatol Ther 2012; 25:55-69. [PMID: 22591499 DOI: 10.1111/j.1529-8019.2012.01520.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Antibiotics have a significant role in dermatology, treating a wide range of diseases, including acne, rosacea, inflammatory skin conditions and skin structure infections, such as cellulitis, folliculitis, carbuncles, and furuncles. Because of their consistent use, utility, and availability, antibiotics are susceptible to overuse within the medical practice, and, specific to this discussion, in the dermatologic setting. The issue of continuously increasing risk of antibiotic resistance remains an important concern to the dermatologist. The scope of this review will be to provide an overview of the common antibiotics used in the dermatologic setting with an emphasis on identifying areas of overuse, reported bacterial resistance, and discussion of clinical management aimed at decreasing antibiotic resistance.
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Affiliation(s)
- Susan Y Chon
- Department of Dermatology, University of Texas Medical School at Houston, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Malachowa N, Kobayashi SD, DeLeo FR. Community-associated methicillin-resistant Staphylococcus aureus and athletes. PHYSICIAN SPORTSMED 2012; 40:13-21. [PMID: 22759601 DOI: 10.3810/psm.2012.05.1960] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The remarkable ability of Staphylococcus aureus to develop antibiotic resistance in conjunction with the emergence of highly virulent and/or transmissible strains has established the pathogen as a leading cause of human bacterial infections worldwide. Historically, methicillin-resistant S aureus (MRSA) was found almost exclusively in hospitals and/or health care-related facilities. However, in the late 1990s, community-associated MRSA strains emerged in the United States and rapidly became the leading cause of community-associated bacterial infections. An enhanced understanding of the pathogenesis and epidemiology of this bacterium is fundamental for the prevention and/or treatment of community-associated MRSA infections. This review highlights salient features of S aureus biology that contribute to the exceptional ability of this pathogen to cause human disease, as well as discusses, in brief, the established approaches for treatment and prevention of infection.
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Affiliation(s)
- Natalia Malachowa
- Laboratory of Human Bacterial Pathogenesis, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institute of Health, Hamilton, MT 59840, USA.
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Blaivas M, Adhikari S. Unexpected findings on point-of-care superficial ultrasound imaging before incision and drainage. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:1425-1430. [PMID: 21968495 DOI: 10.7863/jum.2011.30.10.1425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Cutaneous abscesses are typically incised and drained on the basis of clinical assessment. In most cases this procedure is a safe practice. We report 6 cases in which point-of-care ultrasound interrogation of obvious abscesses revealed potential serious complications with planned incision and drainage. Management was altered in 5 of 6 cases, and potential vascular disasters were avoided. In 1 case, the ultrasound results were ignored, and incision and drainage was completed, confirming the suspected abscess was indeed a solid mass later diagnosed as a carcinoma. In this case series, point-of-care ultrasound interrogation provided rapid assessment and discovery of potentially catastrophic anatomic relationships, avoiding serious complications.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, North-side Hospital Forsyth, Cumming, GA 30041 USA.
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McNamara WF, Hartin CW, Escobar MA, Yamout SZ, Lau ST, Lee YH. An alternative to open incision and drainage for community-acquired soft tissue abscesses in children. J Pediatr Surg 2011; 46:502-6. [PMID: 21376200 DOI: 10.1016/j.jpedsurg.2010.08.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care. STUDY DESIGN A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups. RESULTS A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D. CONCLUSIONS Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.
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Affiliation(s)
- William F McNamara
- Department of Surgery, State University of New York at Buffalo, Buffalo, NY 14222, USA
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Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED. Am J Emerg Med 2011; 30:302-10. [PMID: 21277138 DOI: 10.1016/j.ajem.2010.11.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 11/22/2010] [Accepted: 11/30/2010] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines. OBJECTIVES The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I & D) technique, and to compare these practices with current evidence. METHODS Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics. RESULTS One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I & D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I & D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I & D, even in those with 2 cm or less abscesses (57.5%). CONCLUSIONS Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.
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Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF. 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:e18-55. [PMID: 21208910 DOI: 10.1093/cid/ciq146] [Citation(s) in RCA: 1868] [Impact Index Per Article: 143.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.
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Affiliation(s)
- Catherine Liu
- Department of Medicine, Division of Infectious Diseases, University of California-San Francisco, San Francisco, California94102, USA.
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Marin JR, Bilker W, Lautenbach E, Alpern ER. Reliability of clinical examinations for pediatric skin and soft-tissue infections. Pediatrics 2010; 126:925-30. [PMID: 20974788 PMCID: PMC3228243 DOI: 10.1542/peds.2010-1039] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To determine the interrater reliability of clinical examination by pediatric emergency medicine physicians for the diagnosis of skin and soft-tissue infections (SSTIs). METHODS A cross-sectional study of patients presenting to a pediatric emergency department with SSTIs was performed. Each lesion was examined by a treating physician and a study physician (from a pool of 62 physicians) at the bedside during the emergency department visit. The primary outcome was reliability, as measured with the weighted κ statistic, for determining whether the lesion was an abscess and whether the lesion required a drainage procedure. RESULTS A total of 371 lesions were analyzed for interrater reliability. The weighted κ value for diagnosis of the lesion as an abscess was 0.39 (95% confidence interval: 0.32-0.47), and that for assessment of the need for drainage was 0.43 (95% confidence interval: 0.36-0.51). Agreement was statistically more likely for lesions in children ≥ 4 years of age but was not more likely for lesions in nonblack patients, lesions in patients with a history of or exposure to a close contact with a SSTI, or lesions examined by 2 experienced pediatric emergency medicine physicians. CONCLUSIONS Among the 62 participating physicians at our site, the reliability of the clinical examination was poor. This may indicate that improved education and/or more-objective means for diagnosing these infections in the acute care setting are warranted. Additional studies are needed to determine whether these results are generalizable to other settings.
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Affiliation(s)
- Jennifer R. Marin
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Warren Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Talan DA. Lack of Antibiotic Efficacy for Simple Abscesses: Have Matters Come to a Head? Ann Emerg Med 2010; 55:412-4. [DOI: 10.1016/j.annemergmed.2010.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 02/21/2010] [Accepted: 02/23/2010] [Indexed: 10/19/2022]
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Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. A skin abscess model for teaching incision and drainage procedures. BMC MEDICAL EDUCATION 2008; 8:38. [PMID: 18598345 PMCID: PMC2453116 DOI: 10.1186/1472-6920-8-38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Accepted: 07/03/2008] [Indexed: 05/26/2023]
Abstract
BACKGROUND Skin and soft tissue infections are increasingly prevalent clinical problems, and it is important for health care practitioners to be well trained in how to treat skin abscesses. A realistic model of abscess incision and drainage will allow trainees to learn and practice this basic physician procedure. METHODS We developed a realistic model of skin abscess formation to demonstrate the technique of incision and drainage for educational purposes. The creation of this model is described in detail in this report. RESULTS This model has been successfully used to develop and disseminate a multimedia video production for teaching this medical procedure. Clinical faculty and resident physicians find this model to be a realistic method for demonstrating abscess incision and drainage. CONCLUSION This manuscript provides a detailed description of our model of abscess incision and drainage for medical education. Clinical educators can incorporate this model into skills labs or demonstrations for teaching this basic procedure.
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Affiliation(s)
- Michael T Fitch
- Emergency Medicine Educational Research and Development Group, Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Manthey
- Emergency Medicine Educational Research and Development Group, Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Henderson D McGinnis
- Emergency Medicine Educational Research and Development Group, Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Bret A Nicks
- Emergency Medicine Educational Research and Development Group, Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Manoj Pariyadath
- Emergency Medicine Educational Research and Development Group, Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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