Ultrasound in Emergency Medicine
Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections

https://doi.org/10.1016/j.jemermed.2018.07.010Get rights and content

Abstract

Background

Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches.

Objective

To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting.

Methods

Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7–10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians.

Results

In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty.

Conclusions

Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.

Introduction

Over the past two decades, ambulatory and emergency department (ED) visits for skin and soft tissue infections (SSTIs) have doubled in number, with a current estimate of more than 14 million encounters annually in the United States. This rise in SSTIs is largely attributable to the increase in incidence of cellulitis and abscess, as well as the rising prevalence of community-associated methicillin resistant Staphylococcus aureus 1, 2, 3, 4. Among patients younger than 18 years, SSTI-related outpatient visits, incision and drainage rate, and hospitalization rate have nearly doubled from 1997 to 2005, more than any other age group 2, 5.

Skin abscess is typically managed with incision and drainage (surgical management), whereas antibiotics alone (medical management) is generally sufficient for cellulitis. Nevertheless, abscess and cellulitis can have very similar appearance on physical examination, creating a clinical dilemma given the differing treatment modalities. Prior investigations have found that clinical assessment alone has a high rate of inaccuracy with respect to distinguishing abscess from cellulitis, or whether an incision and drainage is indicated 6, 7.

Recently, point-of-care ultrasound (POCUS) has emerged as a promising tool to aid in distinguishing abscess from cellulitis in the ED setting. Several studies attest to the superior sensitivity and specificity of POCUS compared with physical assessment alone, and the positive effect of POCUS in improving bedside treatment decisions for pediatric SSTI 8, 9, 10, 11. Limitations of these studies include small sample sizes, single-site studies, and lack of a control group. Most importantly, there are no published studies directly comparing the outcomes of pediatric SSTI patients treated with POCUS guidance vs. those treated based solely on physical examination findings.

The current study examines the outcome of POCUS vs. clinical assessment alone on the management of pediatric SSTIs in the ED setting. We examined the effect of POCUS utilization on treatment failure rate as well as process outcomes including ED length of stay and resource utilization.

Section snippets

Study Design and Setting

This was a prospective, multicenter, cohort observational study of children presenting to the ED with SSTIs between March 1, 2014 and July 31, 2016. Study sites included seven institutions across North America (six in the United States, one in Canada) with a combined annual volume of more than 350,000 pediatric visits. All participating institutions had separate pediatric EDs where children were seen by board certified/eligible emergency physicians or pediatric emergency physicians. All were

Results

A total of 328 subjects (334 lesions) were consented and enrolled. Seven subjects were excluded due to age, lesion size, or POCUS performance by noncredentialed staff. A total of 321 subjects were analyzed, of which 299 (93.0%; 305 lesions) had complete follow-up. There were 209 subjects (69.9% of total included) with 214 lesions in the POCUS group and 90 subjects with 91 lesions in the non-POCUS group (Figure 1). Patient demographics are summarized in Table 1. Locations and clinical

Discussion

In this prospective, multicenter, cohort study, we found that the use of POCUS did not reduce the overall treatment failure rate in pediatric SSTIs when compared with clinical assessment alone. In addition, management of SSTIs with POCUS did not reduce hospital admission rate after ED discharge, recurrent abscesses, unscheduled returns to ED, re-instrumentation or new incision and drainage, or initiation/change in antibiotics. There was also no significant difference between the POCUS and

Conclusions

Point-of-care ultrasound use did not result in a lower treatment failure rate compared with clinical assessment alone in pediatric ED patients presenting with SSTIs in our study. However, providers who used POCUS reported it to be frequently beneficial in terms of formulation and change in patient management plans, particularly in cases of high clinical uncertainty. Future studies focusing on limiting POCUS to those with equivocal physical examination findings and using randomization with

Acknowledgment

The initial phase of this study was supported by the American College of Emergency Physicians Section of Pediatric Emergency Medicine Research Seed Grant.

References (18)

There are more references available in the full text version of this article.

Cited by (18)

  • Essential Point-of-Care Ultrasound Insights for 2024

    2024, Seminars in Ultrasound, CT and MRI
  • Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

    2021, Journal of Emergency Medicine
    Citation Excerpt :

    Two larger, more recent studies show similar results. A 2016 study of 148 pediatric patients found that US changed management in 27% of cases (with the change deemed correct in 95% of those cases), and a subsequent 2018 study of 321 pediatric participants found that management changed in 23% of cases (14,15). In both studies, changes occurred to avoid unnecessary I&D as well as to perform it when deemed necessary.

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

    2021, Journal of Emergency Medicine
    Citation Excerpt :

    Due to the difficulty distinguishing an abscess from cellulitis or other subcutaneous processes by physical examination alone, particularly in the presence of edematous or indurated overlying skin, point-of-care ultrasound (POCUS) is increasingly recognized as a powerful tool to supplement physical examination when evaluating SSTIs. Several recent studies demonstrate that POCUS improves management of SSTIs by preventing unnecessary invasive procedures, detecting occult abscess, or identifying more complex disease requiring further imaging (3–7). 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.

  • Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis

    2020, Annals of Emergency Medicine
    Citation Excerpt :

    Overall, point-of-care ultrasonography resulted in a change in management in 301 of 2,107 patients (14.3%). Three studies did not collect data on the appropriateness of these management changes.8,14,15 Among the remaining 6 studies (n=1,715 cases), point-of-care ultrasonography led to a correct change in management in 177 cases (10.3%; 95% CI 8.9% to 11.8%) and led to an incorrect change in management in 12 cases (0.7%; 95% CI 0.3% to 1.1%).9-13,17

View all citing articles on Scopus
View full text