Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review

Anti-inflammatories as adjunct treatment for cellulitis: a systematic review and meta-analysis

OBJECTIVES

Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) as adjunct cellulitis treatment improves clinical response and cure.

METHODS

Systematic review and meta-analysis including randomized controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) vs. placebo or no intervention. Medline (PubMed), Embase (via Elsevier), and Cochrane CENTRAL were searched from inception to August 1, 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure.

RESULTS

Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95%CI 1.42-2.31, I2 = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95%CI 0.62-2.26), although heterogeneity was high (I2 = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (N = 3 trials) were infrequent.

CONCLUSIONS

For patients with cellulitis, the best available data suggest that oral nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies.

REGISTRATION

Open Science Framework:   https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81 .

Community-acquired Staphylococcus aureus skin and soft tissue infection risk assessment using hotspot analysis and risk maps: the case of California emergency departments

BACKGROUND

Community-acquired Staphylococcus aureus (CA-Sa) skin and soft tissue infections (SSTIs) are historically associated with densely populated urban areas experiencing high poverty rates, intravenous drug use, and homelessness. However, the epidemiology of CA-Sa SSTIs in the United States has been poorly understood since the plateau of the Community-acquired Methicillin-resistant Staphylococcus aureus epidemic in 2010. This study examines the spatial variation of CA-Sa SSTIs in a large, geographically heterogeneous population and identifies neighborhood characteristics associated with increased infection risk.

METHODS

Using a unique neighborhood boundary, California Medical Service Study Areas, a hotspot analysis, and estimates of neighborhood infection risk ratios were conducted for all CA-Sa SSTIs presented in non-Federal California emergency departments between 2016 and 2019. A Bayesian Poisson regression model evaluated the association between neighborhood-level infection risk and population structure, neighborhood poverty rates, and being a healthcare shortage area.

RESULTS

Emergency departments in more rural and mountainous parts of California experienced a higher burden of CA-Sa SSTIs between 2016 and 2019. Neighborhoods with high infection rates were more likely to have a high percentage of adults living below the federal poverty level and be a designated healthcare shortage area. Measures of population structure were not associated with infection risk in California neighborhoods.

CONCLUSIONS

Our results highlight a potential change in the epidemiology of CA-Sa SSTIs in California emergency departments. Future studies should investigate the CA-Sa burden in other geographies to identify whether this shift in epidemiology holds across other states and populations. Further, a more thorough evaluation of potential mechanisms for the clustering of infections seen across California neighborhoods is needed.

Imaging of MSK infections in the ER

Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.

Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review

Aim

To generate a landscape of the current knowledge in the interventional management and outcomes of purulent skin and soft tissue infections.

Design

This study is a scoping review.

Methods

Electronic searches were undertaken using CINAHL, Medline, Cochrane Library, British Nursing Index, Science Direct, the National Health Service knowledge and library hub, ClinicalTrials.gov, and MedNar. The population, concept, context framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were utilised, supporting a rigorous appraisal and synthesis of literature. Data Sources. The initial search and synthesis of literature were completed in January 2022 with repeat searches completed in March 2022 and July 2023. There were no imposed chronological parameters placed on the returned literature.

Results

Nineteen papers were reviewed. Incision and drainage with primary closure, needle aspiration, loop drainage, catheter drainage, and suction drainage are viable adjuncts or alternatives to the traditional surgical management of skin and soft tissue abscesses.

Conclusion

Despite the empirically favourable alternatives to the incision and drainage technique demonstrated, this does not appear to be driving a change in clinical practice. Future research must now look to mixed and qualitative evidence to understand the causative mechanisms of incision and drainage and its ritualistic practice. Implications. Ritual surgical practices must be challenged if nurses are to improve the treatment and management of this patient group. This will lead to further practice innovation. Impact: This study explored the challenges posed to patients, clinicians, nurses, and stakeholders, resulting from the ritualistic practice of the incision and drainage technique in purulent skin or soft tissue abscesses. Empirically and holistically viable alternatives were identified, impacting all identified entities and recommending a wider holistic study. Reporting Method. Adherence to EQUATOR guidance was achieved through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Prevalence of misdiagnosis of cellulitis: A systematic review and meta-analysis

BACKGROUND

There is no gold standard test to accurately identify patients with cellulitis and therefore misdiagnosis is common. Using the clinical impression of a dermatology or an infectious disease specialist as a reference standard, we sought to determine the prevalence of misdiagnosis of cellulitis among nonspecialist physicians.

METHODS

A systemic search was performed using MEDLINE, Cochrane Library, and EMBASE databases for studies reporting diagnostic accuracy of cellulitis. Inclusion criteria required dermatology or infectious disease consultation for all patients diagnosed with cellulitis by generalist physicians. We used random effects modeling to estimate the prevalence of misdiagnosis using consultant diagnosis as a reference standard.

RESULTS

Eight studies contributed to the analysis. For the seven studies involving inpatients, the results were sufficiently homogeneous to justify pooling data. Of 858 inpatients initially diagnosed with cellulitis, 335 (39%, 95% confidence interval: 31-47) received an alternative diagnosis from the specialist. Heterogeneity was large (I²  = 74%) and the greatest contributor to between-study variance was the year of publication. Alternative diagnoses were mostly noninfectious (68%, 221/327), with stasis dermatitis (18%, 60/327) being the most common. An abscess was the most common alternative infectious diagnosis (10%, 32/327).

DISCUSSION

Cellulitis is commonly misdiagnosed among inpatients, leading to unnecessary hospital admissions and antibiotic overuse. Most alternative diagnoses are noninfectious. Continuing medical education among general practitioners and urgent care providers will likely reduce cellulitis misdiagnoses.