Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features

Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study

We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.

A case-control study of the risk factors for fistula-in-ano in infants and toddlers

BACKGROUND

Limited data are available regarding the risk factors for fistula-in-ano (FIA) in infants and toddlers, potentially affecting their daily lives.

OBJECTIVES

The purpose of this study was to identify potential risk factors for FIA in infants and toddlers, in order to implement early preventive interventions, avoid disease progression, and develop therapeutic strategies.

DESIGN AND SETTINGS

A retrospective case-control study was conducted, comparing 41 infants and toddlers diagnosed with FIA with 41 healthy controls, between August 2020 and December 2021.

INDEPENDENT VARIABLES

(a) maternal characteristics during pregnancy and delivery, (b) perinatal characteristics, dietary behaviors, and defecation-related behaviors in infants and toddlers, (c) family dietary behaviors.

RESULTS

Mothers of infants and toddlers with FIA had given birth more times in the past, while the infants and toddlers themselves had less mealtime, a higher rate of exclusive breastfeeding, frequent loose stools, and a larger proportion of used wipes, experiencing perianal skin anomalies. The logistic regression analysis revealed that there are four significant risk factors associated with the development of FIA in infants and toddlers, including the number of previous deliveries by the mother (OR 6.327), defecation frequency score (OR 5.351), stool consistency score (OR 5.017), and cleaning with wipes after defecation (OR 8.089).

CONCLUSION

Based on our data, it appeared that FIA in infants and toddlers could be attributed to several factors. These included an increased number of previous deliveries by mothers, frequent loose stools, and repeated wipe use. To prevent the occurrence and worsening of the disease, it is important to improve the frequency and consistency of stooling and provide proper care. Further research is required to verify these findings in other clinical settings.

Aerobic Microbiological Spectrum and Antibiotic Resistance in Children Operated for Anorectal Abscesses

(1) Background: Anorectal abscesses are a relatively rare pathology in childhood. Most often, male children under 1 year of age are affected. The importance of microbiological examination for the diagnosis and treatment of such patients remains debatable among surgeons, resulting in scarce data being available in the literature. We aimed to identify the aerobic microbiological spectrum and antibiotic resistance of isolates in children undergoing operation to treat anorectal abscesses. (2) Methods: We performed a case series of 102 children diagnosed and operated for anorectal abscesses over a period of 10 years (2010-2019). Purulent wound exudate was used for microbiological evaluation, which was subsequently cultured on 5% sheep-blood agar and eosin-methylene blue agar. For microbiological identification, conventional biochemical tests and semi-automated (API 20, bioMerieux, Marcy-l'Étoile, France) tests were used, as well as automated systems (Vitek-2 Compact, bioMerieux, France). Antimicrobial susceptibility testing was performed by the disk diffusion method of Bauer-Kirby and by determining the minimal inhibitory concentrations for glycopeptides. The results were interpreted according to the EUCAST standard for the corresponding year. (3) Results: Microbiological testing in children operated for anorectal abscesses mainly identified the gut commensals that normally reside in the rectal mucosa. Monocultures were found in just over half of the cases. Escherichia coli, Klebsiella pneumoniae complex, and Proteus mirabilis were the most frequently isolated. In addition, Staphylococcus aureus was found in 7% of patients. In Gram-negative bacteria, antibiotic resistance was most often observed in penicillins, cephalosporins, sulfonamides, and fluoroquinolones. (4) Conclusions: The increasing rates of antimicrobial resistance impose the need for the local monitoring of circulating commensal bacteria associated with anorectal abscesses in children to guide antibiotic therapy when indicated.

Effect of Comprehensive Nursing on Pain Relief, Comfort and Burden of Family Care of Infantile Anal Fistula

Objective

To explore the effect of comprehensive nursing on pain relief, comfort and burden of family care of infantile anal fistula.

Methods

This was a randomized, double-blind, controlled clinical trial. A total of 106 cases of children with anal fistula from January 2021 to December 2021 were selected and divided into observation group and control group, there were 53 cases in each group. The control group were underwent with routine nursing intervention. The observation group were underwent with video health education, peer support, music relaxation training, physiotherapy and auricular point pressing on the basis of routine nursing therapy and other measures (comprehensive nursing). The wound healing time, comfort score, complication rate and family care burden of two groups were compared.

Results

After intervention, the scores of pain degree in the observation group were significantly lower than those in the control group (4.02 ± 0.85 vs 5.89 ± 2.36, p < 0.05), and the scores of comfort degree in the observation group were higher than those in the control group (70.23 ± 5.98 vs 46.88 ± 5.23, p < 0.05). After intervention, the wound healing time of the observation group was shorter than that of the control group (3.98 ± 0.63 vs 5.77 ± 1.02, p < 0.05), and the crying times of the observation group were less than that of the control group (1.22 ± 0.26 vs 4.02 ± 0.48, p < 0.05). After intervention, the total scores of family members' care load in the observation group were significantly lower than those in the control group (37.26 ± 4.78 vs 55.99 ± 5.02, p < 0.05).

Conclusion

Comprehensive nursing can effectively promote wound healing in infantile anal fistula, reduce pain, prompt children's comfort, reduce the number of children crying, and reduce the burden of care for children's families.

Risk factors for therapy failure after incision and drainage alone for perianal abscesses in children

Background

It is well known that recurrent perianal abscesses (PAs) and fistula-in-ano (FIA) are the main causes of therapy failure following incision and drainage (I&D) for PAs. But few studies have focused on the risk factors for therapy failure after I&D for PAs in children. In this study, we retrospectively examine the risk factors for therapy failure after I&D for PAs in children in a pediatric tertiary care institution.

Methods

A retrospective review of all outpatient children with PA treated by I&D at Beijing Children's Hospital between January 2021 and December 2022 was performed. A follow-up was conducted in October 2023. Patients with other predisposing factors for perianal infection, such as inflammatory bowel disease, hematologic tumor, and anorectal surgery, were excluded from this study. Logistic regression yielding odds ratios (ORs) was used to assess the significance of variables for therapy failure.

Results

Of 160 children initially identified, follow-up was available for 146, with a total of 172 treatments. A total of 91% of children were male. The median (interquartile range) age at I&D was 2 (1, 15) months. The median follow-up duration was 20 (14, 25) months. Therapy failure occurred in 25 (15%) treatments performed for the prevention of recurrence of PA and in 35 (20%) treatments for the prevention of development of FIA. In the univariate analysis, a history of PA (P = 0.001), history of I&D (P = 0.014), and multilocal occurrence (P = 0.003) were associated with therapy failure. A sitz bath after I&D (P = 0.016) and regular cleaning of the wound after I&D (P = 0.024) were associated with therapy success. In the multivariate analysis, a history of PA (P = 0.015, OR = 3.374) and multilocal occurrence (P = 0.012, OR = 4.649) were independently associated with therapy failure. Regular cleaning of the wound (P = 0.017, OR = 0.341) and sitz bath (P = 0.001, OR = 0.128) after I&D were independently associated with therapy success.

Conclusions

A history of PA and multilocal occurrence were predictor factors for therapy failure before I&D. Regular cleaning of the wound and sitz bath after I&D were protective factors for therapy success. Therefore, regular cleaning of the wound and sitz bath after I&D should be emphasized in all children with PAs, especially in those with a history of PA and multilocal occurrence.

Natural course of perianal abscess in infants: a real-world study

Natural course of perianal abscess (PA) in infancy remains obscure. This study aimed to investigate the natural course of infants with PA after conservative treatment. A retrospective cohort study was conducted in infants with PA who were treated conservatively (due to the parents' refusal of surgery), for more than 2 months between 2014 and 2020 at a single tertiary center. 153 patients (149 boys and 4 girls) were identified. The median follow-up was 5.3 years (range 3-8.2 years). Initially, 119 patients (77.8%) were completely cured by conservative treatment, and 34 (22.2%) failed. Among the 34 patients, 23 continued conservative treatment (20 cure, 3 fistula formation) and 11 underwent surgery. After conservative treatment, the rate of fistula formation, abscess recurrence, and new-onset abscess were 15.0%, 4.6%, and 6.5%, respectively. Overall, 139 patients (90.8%) were cured conservatively without surgery, and 11 (7.2%) underwent surgical management. In addition, 3 (2.0%) patients developed fistula-in-ano (under observation). PA in infants may be a time-limited and self-limited condition. Conservative management should be the first choice of treatment in most cases. Longer periods of conservative treatment may achieve better clinical outcomes in selected cases. There will be a percentage of patients (about 10%) that would require surgical treatment.

Perianal abscess in children: an evaluation of microbiological etiology and the effectiveness of antibiotics

PURPOSE

We aimed to evaluate the demographic characteristics of children with perianal abscess, distribution of microbiological etiology, antibiotic susceptibility, and identify the effectiveness and coverage of antibiotics due to culture results.

METHODS

A retrospective study was designed to evaluate pediatric patients with perianal abscesses between January 2013 and December 2022.

RESULTS

A total of 197 episodes in 135 patients were evaluated. The median age of the patients was 10 months (22 days-17 years). The isolated microorganisms were Gram-positive bacteria in 56 (28.4%) patients and Gram-negative bacteria in 141 (71.6%) patients. The most common isolated species was Escherichia coli (n = 70, 35.5%), followed by Klebsiella spp. (n = 48, 24.4%), Staphylococcus aureus (n = 37, 18.9%), and Enterobacter spp. (n = 9, 4.5%). Forthy-two percent (n = 58) of isolates were positive for extended-spectrum beta-lactamase, 8% (n = 11) were carbapenem-resistant in Gram-negative bacteria, and 37.5% (n = 21) were methicillin-resistant, 7.1% (n = 4) were vancomycin-resistant in Gram-positive bacteria. According to bacterial culture results, ertapenem plus glycopeptide had the highest antimicrobial coverage rate (92.3%), followed by ertapenem plus clindamycin (89.8%), ertapenem (81.7%), third-generation cephalosporin plus glycopeptide (82.2%), third-generation cephalosporin plus clindamycin (69.5%).

CONCLUSION

Ertapenem can be a good choice in the empirical treatment of perianal abscesses in children due to its high coverage rate.

Incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation

OBJECTIVES

To describe the incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation.

METHODS

We included 45 patients with perianal inflammation who underwent ultrasonography. To demonstrate the diagnostic performance of ultrasound for fistula-in-ano, a definite diagnosis of perianal abscess, and fistula-in-ano was determined as that proven through magnetic resonance imaging (MRI) or computed tomography (CT). The absence or presence of perianal abscess and fistula-in-ano on ultrasonography was recorded.

RESULTS

Among the 45 patients, on ultrasound, perianal abscess and fistula-in-ano were detected in 22 (48.9%) and 30 (68.2%) patients, respectively. Nine patients had MRI or CT and a definite diagnosis of perianal abscess or fistula-in-ano; accuracy, negative predictive value, and positive predictive value of ultrasound for perianal abscess were 77.8% (7/9; 95% confidence interval [CI]: 40.0%-97.1%), 66.7% (2/3; 95% CI: 9.4%-99.2%), 83.3% (5/6; 95% CI: 35.9%-99.6%), and those of fistula-in-ano were 100% (9/9; 95% CI: 66.4%-100%), 100% (8/8; 95% CI: 63.1%-100%), and 100% (1/1; 95% CI: 2.5%-100%), respectively.

CONCLUSIONS

Perianal abscess and fistula-in-ano were detected by ultrasound in half of the patients with perianal inflammation. Accordingly, ultrasound has an acceptable diagnostic performance for perianal abscess and fistula-in-ano.

Intervention Effect of Evidence-Based Nursing on Postoperative Recovery of Vacuum Sealing Drainage in Patients with High Perianal Abscess with Magnetic Resonance Imaging Sequence Images

The purpose of this study was to evaluate the intervention effect of evidence-based nursing (EBN) on vacuum sealing drainage (VSD) recovery of patients with high perianal abscess after vacuum sealing drainage based on magnetic resonance imaging (MRI) sequence images. 60 patients with high perianal abscess were selected, and 30 patients before VSD were selected as the control group. Routine nursing was implemented in the control group, 30 patients after VSD were observed, and EBN was implemented in the observation group. The detection rates of various types of perianal abscess with different sequence combinations were studied, and the effects of EBN on pain and anal function scores of perianal abscess patients were analyzed. Anal function and defecation were assessed, and postoperative complications were calculated. Different combinations of MRI sequences can reach higher detection rates of intersphincter abscess and ischial anal abscess. The observation group had better pain relief and anal function recovery. The complication rate of the observation group was 16.67%, which was significantly lower than that of the control group (P < 0.05). It was confirmed that different MRI sequence combinations had higher detection rates for intersphincter abscess and ischial fossa abscess. EBN can promote the recovery of anal function and reduce complications in patients with perianal abscess.

Incision and Drainage With Primary Fistulotomy of Perianal Abscess Is Safe and Effective in Neonates: A Long-Term Follow-Up Study

OBJECTIVE

Perianal abscess (PA) in neonates is poorly understood, and its management remains controversial. The aim of this study was to compare incision and drainage (ID) with or without primary fistulotomy in the management of neonatal first-time PA.

METHODS

A retrospective comparative study was conducted for neonates with first-time PA treated with incision and drainage with primary fistulotomy (IDF) vs. ID between 2008 and 2017.

RESULTS

In total, 138 patients (137 boys and 1 girl) were identified; 65 in the IDF group and 73 in the ID group. The median follow-up was 6.5 years (range 4-13 years). Baseline characteristics were similar between the 2 groups. The cure rate in the IDF group (98.5%, 64/65) was significantly higher than that in the ID group (80.8%, 59/73; p = 0.001). The rate of fistula formation in the IDF group (1.5%, 1/65) was significantly lower than that in the ID group (13.7%, 10/73; p = 0.01). The rate of abscess recurrence was not statistically different (p = 0.12), even though the IDF group (0%, 0/65) seemed to have a better outcome than the ID group (5.5%, 4/73). No fecal incontinence was observed in any of our patients.

CONCLUSIONS

First-time PA in neonates can be treated safely and effectively by the IDF or by ID alone. The former may be advantageous over the latter in terms of the rate of cure and fistula formation.

Deep Learning-Based Computed Tomography Image Features in the Detection and Diagnosis of Perianal Abscess Tissue

The performance characteristics of deep learning fully convolutional neural network (DLFCNN) algorithm-based computed tomography (CT) images were investigated in the detection and diagnosis of perianal abscess tissue. 60 patients who were medically diagnosed as perianal abscesses in the hospital were selected as the experimental group, and 60 healthy volunteers were selected as the control group. In this study, the DLFCNN algorithm based on deep learning was compared with the CNN algorithm and applied to the segmentation training of CT images of patients with perianal abscesses. Then, the segmentation metrics Jaccard, Dice coefficient, precision rate, and recall rate were compared by extracting the region of interest. The results showed that Jaccard (0.7326) calculated by the CNN algorithm was sharply lower than that of the DLFCNN algorithm (0.8525), and the Dice coefficient (0.7264) was also steeply lower than that of the DLFCNN algorithm (0.8434) (P < 0.05). The thickness range of the epidermis and dermis in patients from the experimental group was 4.1–4.9 mm, which was markedly greater than the range of the control group (1.8–3.6 mm) (P < 0.05). Besides, the CT value of the subcutaneous fascia in the experimental group (−95.45 ± 8.26) hugely reduced compared with the control group (−76.34 ± 7.69) (P < 0.05). The accuracy rate of the patients with perianal abscesses was 96.67% by multislice spiral CT (MSCT). Therefore, the DLFCNN algorithm in this study had good stability and good segmentation effect. The skin at the focal site of anal abscess was obviously thickened, and it was simple and accurate to use CT images in the diagnosis of patients with perianal abscesses, which could effectively locate the lesion and clarify the relationship between the lesion and the surrounding structure.