Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature

Sonography of monkeypox cutaneous lesions

The present global outbreak of monkeypox has reached more than 79,000 cases by November 2022. While clinical features have been extensively studied, ultrasound findings in monkeypox skin lesions have not been described to date. In our work, we performed a complete sonographic study with Doppler and elastography of 3 patients with polymerase chain reaction-proven monkeypox. The most characteristic findings in skin lesions were hyperechoic epidermal thickening, dermo-hypodermal thickening with focal hypoechogenicity and increased intralesional vascularization. Regarding lymphadenopathies, we found vascularization of hilar distribution and an increased cortical stiffness and shoft hiliar area.

Current international and national guidelines for managing skin and soft tissue infections

PURPOSE OF REVIEW

Skin and soft tissue infections account for a significant percentage of both community and nosocomial infections. Several nosological entities are included in this concept. However, there is a very scarce body of doctrine for their treatment based on randomised trials. Therefore, we considered it necessary to review current treatment guidelines to bring new recommendations and improvements to our colleagues. In this review of recent literature, we identified updated guidelines in this area by searching the databases PubMed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip and Sumsearch using the terms: soft tissue infection, therapy, guideline.

RECENT FINDINGS

Developments focus on using new antimicrobials and on the prescription of shorter antibiotic treatment courses.

SUMMARY

With the development of new drugs and the current evidence of their use, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life, which allows weekly administration, can reduce hospital admission and length of stay with fewer healthcare resources. Shorter courses of antibiotics are recommended. The role of stewardship programmes will continue to expand. The surgical indication and its value are evident in many patients. Therefore, management should rely on a collaborative group with experience in this disease.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Correlation between visual inspection/physical exam and point-of-care ultrasound exam in the evaluation of neonatal peripheral intravenous catheter site

BACKGROUND

A peripheral intravenous catheter (PIVC) is used to administer IV fluids and medications. The most common PIVC complication is peripheral intravenous extravasation and infiltration (PIVE/I). Early visual inspection and physical exam (VI/PE) of the insertion site performed by a registered nurse (RN) are essential to prevent or limit tissue damage caused by displaced PIV catheters. Skin ultrasound (US) of the PIVC site provides rapid, real-time, high-resolution images of the anatomic structures at the point of care (POC).

OBJECTIVES

To correlate the standard practice of clinical assessment (VI/PE) with POC-US exam to determine the location and function of PIVC suspicious for malfunctioning.

DESIGN/METHODS

PIVC sites suspicious of malfunctioning were assessed by RN and findings were recorded in the electronic medical record. POC-US exam of the PIVC site was performed immediately after VI/PE. Sonographic exam included B-mode assessment of the PIVC site subcutaneous tissue characteristics and PIVC location as assessed by the Doppler flow tracing during RN's normal saline flush. RN's decision to continue or discontinue the PIVC was based solely on her/his VI/PE.

RESULTS

Forty-four infants were studied. We found sufficient disagreement between the two methodologies (p = .0074), with discordance noted in 15 (34.1%) cases. In 29 (65.9%) cases there was concordance between VI/PE and POC-US, 18 to remove and 11 not to remove PIVC (Gwet AC1 correlation coefficient = 0.34). There was no significant correlation between VI/PE finding of tissue edema, the most common initial clinical evaluation sign, and POC-US finding of tissue edema or fluid pockets (p = .67, p = .21 respectively). RN's findings during the PIVC flush with normal saline (NS) were in perfect agreement with the findings of the Doppler signal on POC-US (Gwet's AC1 = 0.82) as well as with the final US-based decision to remove PIVC (p < .0001).

CONCLUSION

We found only a fair correlation between RN's VI/PE of the suspicious PIVC site and the POC-US exam of the same site. However, our data suggest that in the evaluation of questionable PIVC, POC-US could be used in conjunction with VI/PE. This combination may improve the accuracy of decisions to remove or maintain PIVCs, which will result in a decreased number of PIVC placement attempts and complications.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Point-of-Care Ultrasound Used to Distinguish Between Superficial Skin Abscess and Deep Mediastinal Abscess: A Case Report

BACKGROUND

Skin and soft tissue infections (SSTIs) are an increasingly common complaint in the emergency department (ED), but physical examination does not reliably identify abscesses or accurately determine which skin lesions require incision and drainage. Point-of-care ultrasound (POCUS) improves management of soft tissue skin infections by detecting occult abscess, preventing unnecessary procedures, and identifying more complex disease requiring further imaging.

CASE REPORT

Here, we report a case in which POCUS drastically changed the management of what initially appeared to be an uncomplicated superficial skin abscess but was actually a much more serious mediastinal infection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance and utility of POCUS to enhance the physical examination in suspected SSTIs. Because POCUS is easy, accurate, low risk, and can change management, we recommend its consideration as a standard component of the ED work up for SSTIs.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

What's new in the epidemiology of skin and soft tissue infections in 2018?

PURPOSE OF REVIEW

Skin and soft tissue infections (SSTIs) are among the most common infections in outpatients and the most frequent infectious cause of referrals to emergency departments in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology of SSTIs.

RECENT FINDINGS

Staphylococcus aureus and streptococci predominate and methicillin-resistant S. aureus (MRSA) poses additional challenges; community-acquired-MRSA in some areas is superseding methicillin-susceptible S. aureus and multidrug resistance is evolving. Incidence data of SSTIs from United States show a decreasing trend, whereas trends of hospitalization rates were increasing. Despite low mortality associated with SSTIs, high rates of treatment failure and relapses are of concern. Diagnosis and management decisions in the emergency department (ED) lack validated tools for prediction of clinical response particularly among elderly, immunocompromised, obese, and patients with comorbidities. A variety of modifiable and nonmodifiable risk factors of the host and data from local epidemiology should be considered to prevent recurrence and treatment failure.

SUMMARY

An evolving epidemiology of SSTIs make microbiologic documentation and surveillance of local data imperative. New assessment algorithms with potential use in the ED are a priority. The universal applicability of international guidelines is questioned in this setting.

The what, when and how in performing and interpreting microbiological diagnostic tests in skin and soft tissue infections

PURPOSE OF REVIEW

To summarize and classify the most recent and relevant microbiological studies for each type of skin and soft tissue infection (SSTI).

RECENT FINDINGS

Following Infectious Diseases Society of America and Food and Drug Administration classifications of SSTIs, we differentiate between two large groups, the superficial or uncomplicated infections and the complicated infections with deep involvement. It is not usually necessary to obtain microbiological samples in uncomplicated infections, except in cases of recurrences or for epidemiological control purposes. In the case of complicated infections, the samples are of two different types: those obtained from the affected area (surgical samples, punctures of abscesses or swabs) and systemic samples (i.e. blood cultures). The clinical condition also determines the type of samples to be obtained. In cases of systemic involvement, blood cultures are mandatory. For immunocompromised patients, who may present atypical infections, detection of antigens, serologies or molecular biology techniques may be helpful. The rapid diagnosis is currently the goal to be pursued by implementing techniques such as matrix assisted laser desorption ionization-time of flight, commercial real-time PCR or the promising metagenomics.

SUMMARY

Microbiological diagnosis is one of the cornerstones of the management of SSTIs. Prompt obtaining and processing of the necessary samples, depending on the clinical situation of the patient, is of relevance in the decision-making process. Rapid and fluid reporting of the results (identification, mechanisms of resistance and antibiogram) will improve the management of these patients.

Cellulitis and Soft Tissue Infections

Cellulitis and soft tissue infections are a diverse group of diseases that range from uncomplicated cellulitis to necrotizing fasciitis. Management of predisposing conditions is the primary means of prevention. Cellulitis is a clinical diagnosis and thus is made on the basis of history and physical examination. Imaging may be helpful for characterizing purulent soft tissue infections and associated osteomyelitis. Treatment varies according to the type of infection. The foundations of treatment are drainage of purulence and antibiotics, the latter targeted at the infection's most likely cause.

In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis

OBJECTIVES

The primary objective of this systematic review was to determine the accuracy of point-of-care ultrasonography (POCUS) in diagnosing abscess in emergency department (ED) patients with skin and soft tissue infections (SSTI). The secondary objective was the accuracy of POCUS in the paediatric population subgroup.

SETTING

Prospective studies set in emergency departments.

PARTICIPANTS

Emergency department patients (adult and paediatric) presenting with SSTI and suspected abscess.

PRIMARY AND SECONDARY OUTCOME MEASURES

This systematic review was conducted according to Cochrane Handbook guidelines, and the following databases were searched: PubMed, MEDLINE, EMBASE and the Cochrane database of systematic reviews (1946-2015). We included prospective cohort and case-control studies investigating ED patients with SSTI and abscess or cellulitis, a defined POCUS protocol, a clearly defined gold standard for abscess and a contingency table describing sensitivity and specificity. Two reviewers independently ascertained all potentially relevant citations for methodologic quality according to QUADAS-2 criteria. The primary outcome measure was the sensitivity and specificity of POCUS for abscess. A preplanned subgroup (secondary) analysis examined the effects in paediatric populations, and changes in management were explored post hoc.

RESULTS

Of 3028 articles, 8 were identified meeting inclusion criteria; all were rated as good to excellent according to QUADAS-2 criteria. Combined test characteristics of POCUS on the ED diagnosis of abscess for patients with SSTI were as follows: sensitivity 96.2% (95% CI 91.1% to 98.4%), specificity 82.9% (95% CI 60.4% to 93.9%), positive likelihood ratio 5.63 (95% CI 2.2 to 14.6) and negative likelihood ratio 0.05 (95% CI 0.01 to 0.11).

CONCLUSIONS

A total of 8 studies of good-to-excellent quality were included in this review. The use of POCUS helps differentiate abscess from cellulitis in ED patients with SSTI.

TRIAL REGISTRATION NUMBER

CRD42015017115.

Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections

BACKGROUND

Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections (SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy.

OBJECTIVE

The objective was to describe the operating characteristics of point-of-care ultrasound (POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI.

METHODS

We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with their respective 95% confidence intervals (CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic (HSROC) model.

RESULTS

Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR- of 0.04 (95% CI = 0.02 to 0.08).

CONCLUSION

Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis.

An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department

BACKGROUND

The skin, soft tissue, and most parts of the musculoskeletal system are relatively superficial anatomical structures and ideal targets for ultrasound examination in the emergency departments. Soft tissue and musculoskeletal ultrasound applications are relatively underused compared to traditional emergency applications, such as trauma, abdominal aortic aneurysm, and chest and cardiovascular systems.

MAIN TEXT

It is important to have knowledge about sonoanatomy and landmarks within the skin, soft tissue, and musculoskeletal systems. Portable machines equipped with high-resolution transducers are now available to fulfill this field of applications in many emergency departments. After needling practice, emergency physicians can not only diagnose and identify pathological findings but also provide interventional procedures and treatments. In this review, we will introduce point-of-care ultrasound (POCUS) applications regarding the soft tissue and musculoskeletal systems: soft tissue infections, joint effusions, foreign bodies, long bone fractures, muscle and tendon injuries, vascular occlusions, and procedures.

CONCLUSIONS

With POCUS, emergency physicians can visualize the structures beneath the skin and provide better and safer cares in the emergency departments.