REVIEW URRENT C OPINION
Scratching the surface: a review of skin and soft tissue infections in children Daniel B. Fenster, Madeline H. Renny, Carrie Ng, and Cindy G. Roskind
Purpose of review We present data from recently conducted research on the diagnosis and management of skin and soft tissue infections (SSTIs) in children. Recent findings Current research in the area of SSTIs (cellulitis and abscess) has focused on the use of ultrasound, risk factors associated with bacteremia, antibiotic choice, and incision and drainage (I&D) practices. When clinical examination is equivocal at distinguishing abscess from cellulitis, ultrasound can aid in the diagnosis and alter management. Bacteremia is rare in immunocompetent children with uncomplicated SSTIs; blood cultures may be reserved for complicated cases and for those who are systemically ill. Despite the increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), I&D without antibiotics remains the first-line therapy for abscess. Antibiotics for uncomplicated cellulitis should target b-hemolytic streptococci and methicillin-susceptible S. aureus (MSSA). There are significant variations in pain and sedation practices for I&D, with substantive evidence for the use of topical anesthetics. Wound packing after I&D may not confer significant benefit. Summary Evidence to aid in the diagnosis and management of SSTIs in children has emerged in recent years; however, larger prospective pediatric studies are needed. Keywords incision and drainage, methicillin-resistant Staphylococcus aureus, packing, skin and soft tissue infection
INTRODUCTION An estimated 385 000 patients less than 18 years of age present to the US emergency departments (EDs) annually for skin and soft tissue infections (SSTIs) [1]. When evaluating patients with SSTIs, specifically those with cellulitis and abscess, clinicians are faced with several questions: (1) (2) (3) (4)
Is there a need for ultrasound? What is the yield of blood cultures? Which antibiotic, if any, is indicated? How should pain and sedation be managed for the child undergoing incision and drainage (I&D)? (5) Does wound packing after I&D improve outcomes? In this review, we will provide the current best evidence for these questions.
IS THERE A NEED FOR ULTRASOUND? Clinicians primarily rely on physical examination to distinguish abscess from cellulitis. Physician
agreement regarding the presence or absence of a drainable fluid collection by clinical examination has been shown to be poor [2]. Needle aspiration can detect the presence of abscess in cases when the diagnosis is uncertain; however, patients without abscesses are then subjected to unnecessary invasive procedures, and patients with abscesses may have a negative aspirate if blind needle aspiration is not performed in the correct location [3]. Ultrasound is 90–97% sensitive and 67–83% specific in detecting superficial abscesses when performed by point-of-care emergency sonographers [4–6]. Further, ultrasound is accessible and does not involve ionizing radiation [7]. One recent prospective pediatric study showed that in those Department of Pediatrics, Division of Emergency Medicine, Columbia University Medical Center, New York, USA Correspondence to Daniel B. Fenster, MS, MD, Division of Pediatric Emergency Medicine, 3959 Broadway, CHN 116, New York, NY 10032, USA. Tel: +1 212 305-9825; e-mail: [email protected] Curr Opin Pediatr 2015, 27:303–307 DOI:10.1097/MOP.0000000000000213
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KEY POINTS Ultrasound should be considered when the clinical examination for abscess is equivocal. Blood cultures are not indicated in the management of most children with uncomplicated SSTIs, as the rates of bacteremia are low. Antibiotics are not routinely indicated after I&D. Topical anesthetics are indicated for I&D. Wound packing after I&D may not confer significant benefit in many cases.
patients with SSTIs without clinically evident abscess, the sensitivity and specificity for detecting an abscess improved from 44 and 42%, respectively, with clinical examination alone, to 78 and 61%, respectively, when ultrasound evaluation was integrated [8 ]. Studies have also shown that the use of ultrasound as a supplement to physical examination can alter the management of cellulitis and abscess [4,6,9]. One study suggested that bedside ultrasound altered treatment in 22% of patients [4]. Ultrasound should be strongly considered in the SSTI diagnostic algorithm when the clinical examination is equivocal. Studies are emerging that assess the degree to which specific sonographic findings can fine tune abscess management. Gaspari et al. [10 ] derived a pilot clinical decision rule to evaluate the sonographic predictors of methicillin-resistant Staphylococcus aureus (MRSA) abscesses. They demonstrated that the lack of a well-defined edge, small volume, and irregular or indistinct shape were associated with MRSA [10 ]. The rule had a sensitivity of 89% and a specificity of 45% [10 ]. Mistry et al. [11] also found abscess volume to be smaller in cases of MRSA. Further research is needed to understand how specific sonographic features of abscess may be incorporated into clinical management. &&
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WHAT IS THE YIELD OF BLOOD CULTURES? Blood cultures are frequently obtained in children with SSTIs [12,13,14 ]. Data, however, suggest that the rate of bacteremia is low in patients with uncomplicated SSTIs, and blood cultures may only be appropriate for complicated SSTIs. Complicated SSTI has been defined as SSTI occurring from surgical or traumatic wounds, SSTI requiring surgical intervention (beyond I&D), and infected ulcers and burns [14 ]. In 1998, Sadow and Chamberlain’s series of 243 immunocompetent children with cellulitis found that only 5 patients (2%) had blood &&
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cultures that were positive and 13 (5.4%) that were contaminants. Of the five positive cultures, two patients had complicated SSTIs and three patients had superinfected lesions from varicella. They concluded that blood cultures are more frequently contaminated than truly positive in uncomplicated cellulitis and are, therefore, not cost-effective [12]. With the increased prevalence of communityacquired MRSA (CA-MRSA), new questions arose regarding the risk of bacteremia in children with SSTIs [15–18]. Wathen and Halloran [13] reviewed charts for 385 patients with cellulitis and found that, of 129 patients (33.5%) with blood cultures obtained, none were positive and 4 were contaminated (1%). The total cost of blood cultures in these patients was over $28 000 [13]. In another study, Malone et al. [14 ] reported no positive blood cultures and three contaminated cultures in a group of 480 pediatric inpatients with uncomplicated SSTIs for whom blood cultures were obtained. Hospital length of stay was higher in those for whom blood cultures were obtained (mean difference 0.91 days; P ¼ 0.044). In this study, 10/98 patients (12.5%) with complicated SSTIs had bacteremia [14 ]. These studies, though retrospective, provide evidence that blood cultures appear unnecessary in the management of immunocompetent children with uncomplicated SSTIs as the rates of bacteremia are extremely low. However, blood cultures should be obtained in children with complicated SSTIs. The 2014 Infectious Disease Society of America (IDSA) Practice Guidelines for the Diagnosis and Management of SSTIs do not recommend routine blood cultures for cellulitis. They do, however, recommend blood cultures in patients with malignancy, immunocompromised states, signs of systemic infection, immersion injuries, and animal bites. The guidelines do not specifically address obtaining blood cultures in healthy patients with abscess, but strongly recommend Gram stain and culture of drainage [19 ]. &&
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WHAT ANTIBIOTIC, IF ANY, IS INDICATED? Treatment options vary depending on the type of SSTI. In the algorithm for the management of SSTIs presented in the 2014 IDSA guidelines, clinicians must first determine whether the SSTI is purulent (i.e. abscess) or nonpurulent (i.e. cellulitis), and then evaluate the severity of the patient’s systemic symptoms and medical comorbidities prior to deciding on the treatment plan [19 ]. &&
Abscess The frequency of abscesses due to CA-MRSA is increasing [16–18]. Prior to this increase, several Volume 27 Number 3 June 2015
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studies demonstrated that I&D alone was sufficient [17,19 ]. The increased MRSA prevalence led to a reevaluation of the role of antibiotic therapy for abscesses [14 ,18,19 ]. In a noninferiority randomized trial of 161 children with cutaneous abscess, of which 80% were CA-MRSA-positive, I&D þ placebo was no worse than I&D þ trimethoprim/sulfamethoxazole (TMP-SMX) (mean failure rate difference was 1.2%). On follow-up, new lesions were more common in the placebo group (no antibiotics) at 10 days, but not different at 90 days [20]. Additional recent trials have found similar results, suggesting that antibiotics may not confer benefit above I&D alone in uncomplicated cases including when CA-MRSA is involved [20–22]. Several studies have assessed whether there are predictors of treatment failure, such as size of abscess, surrounding erythema, fever, or age. In a randomized trial, Chen et al. [22] compared clindamycin to cephalexin for the treatment of abscess after I&D in children. He found no difference in clinical improvement at 72 h follow-up irrespective of the size of induration (comparing greater than to less than 5 cm; 93 vs. 96%; P ¼ 0.27) or the size of erythema (comparing greater than or less than 5 cm; 97 vs. 95%; P ¼ 0.71). However, treatment failure was higher in those presenting with fever and age of less than 1 year (11% with fever vs. 3% without fever; P ¼ 0.03, and 24% for age 6–12 months vs. 3% for age > 1 year; P ¼ 0.004) regardless of the antibiotic used [22]. Duong et al. [20] also found that treatment failure (absence of clinical resolution at 10 days after I&D) was not associated with abscess size, erythema, or induration greater than or equal to 5 cm. Most recently, in a randomized controlled trial of adult patients with abscess receiving either TMP-SMX or placebo after I&D, Olderog et al. [23] found no difference in treatment failure (no decrease in abscess size at 48 h) on the basis of size of abscess or surrounding cellulitis. These studies suggest that size of abscess and surrounding erythema are not predictive of treatment failure, whereas young age and fever may be important factors to consider. Larger randomized trials are needed to clarify which children may benefit from antibiotic therapy and what factors increase the risk for treatment failure after I&D. On the basis of the recent data, the 2014 IDSA guidelines recommend I&D alone for the majority of abscesses. The guidelines recommend the consideration of antibiotics for patients with signs of systemic infection, immunocompromised hosts, multiple abscesses, extremes of ages, and lack of response to I&D alone. In cases where antibiotics are recommended, antibiotics active against MRSA should be chosen [19 ]. &&
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Cellulitis Cellulitis rarely has a culturable source, and needle aspiration of these infections has low yield, making the true microbiologic diagnosis unknown [24]. Empiric therapy is typically chosen to cover the two most common skin pathogens – b-hemolytic streptococci and S. aureus. The increase in the prevalence of CA-MRSA cultured from abscesses has led to uncertainty in the role of MRSA in cellulitis. As a result, practice in recent years has been to broadly treat cellulitis with antibiotics active against MRSA [15,18]. In a prospective study from 2010 of adult inpatients with cellulitis, Jeng et al. [25] found that over 70% of cases were due to b-hemolytic streptococci. Overall, 96% responded favorably to b-lactam antibiotics [25]. A retrospective study of over 2000 children from 2009 reported that for nondrained, noncultured SSTIs, clindamycin conferred no treatment benefit over b-lactams, but that treatment with TMP-SMX was associated with increased risk of treatment failure. Since TMP-SMX has poor activity against streptococci, this increased treatment failure suggests that streptococci remain a common cause of cellulitis in children [26]. Most recently, in a randomized controlled trial of 153 patients aged 3–74 years (median age 29 years) with cellulitis, resolution of symptoms 1 month after enrollment was similar in those who received cephalexin þ TMP-SMX (85%), or cephalexin þ placebo (82%). There was also no difference in cure rates if the patient had MRSA colonization of the nares. The authors concluded that in patients with cellulitis without abscess, adding TMP-SMX to cephalexin did not improve outcomes [27 ]. Despite the emergence of CA-MRSA, these studies provide evidence for the IDSA’s recommendation to treat cellulitis with an antibiotic active against streptococci. Coverage against methicillin-susceptible S. aureus (MSSA) can also be included. For mild infection, oral antibiotics are appropriate. For moderate infection with signs of systemic infection, parenteral antibiotics are recommended. Although MRSA is an unusual cause of cellulitis, coverage for streptococci and MRSA is recommended in patients with cellulitis associated with penetrating trauma, or evidence of MRSA infections elsewhere in the body. Additionally, for immunocompromised patients, broad-spectrum antibiotic coverage may be considered [19 ]. &
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HOW SHOULD PAIN AND SEDATION BE MANAGED FOR THE CHILD UNDERGOING I&D? Incision and drainage has been rated as the second most painful ED procedure [28]. There appears to be
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a significant variation in pain and sedation practice for pediatric patients undergoing I&D, with 44% receiving procedural sedation, 28% local anesthesia þ oral analgesia, 24% local anesthesia only, and 4% oral analgesia only [29].
Topical anesthesia The American Academy of Pediatrics states that ‘topical anesthetics should be considered in any patient undergoing a nonemergent invasive procedure on intact skin in the ED’, including I&D [30]. In some instances, the topical anesthetic may result in spontaneous abscess drainage, obviating the need for I&D. Retrospectively, CassidySmith et al. [31] noted that, of the 110 patients that had LMX4 (a topical anesthetic) placed on the surface of the abscess, 26 (24%) had spontaneous drainage occur as compared to 0 of the 59 without LMX4. Topical anesthetics should be strongly considered as one pain control measure for all abscesses requiring drainage.
Local anesthesia Subcutaneous injection of lidocaine is painful [32]. Bourne et al. [33] compared a transdermal lidocaine/ tetracaine patch to subcutaneous lidocaine/epinephrine for I&D. Patients receiving transdermal lidocaine/tetracaine had a mean Visual Analog Scale pain score of 10 points higher (on a 100-point scale) than patients receiving subcutaneous lidocaine/ epinephrine (P ¼ 0.04). Although statistically significant, the clinical significance of this effect is unclear. Subcutaneous lidocaine, though painful to administer, provides some anesthesia and should be considered as one aspect of pain control for I&D.
placement and removal are painful and often require additional healthcare visits, several recent studies have evaluated this practice. In 2009, O’Malley et al. [34] published a pilot randomized controlled trial of 48 adult ED patients with abscesses, comparing I&D with and without wound packing. At 48 h post I&D, the need for further intervention (defined as extension of the incision, further wound probing, irrigation, delayed wound packing, change of antibiotics, surgical consultation, hospital admission, or need for another follow-up ED visit) was similar in those receiving (17%) and those not receiving (20%) packing [risk difference 3%, 95% confidence interval (CI) 1.8 to 7.8%] [34]. Similarly, Kessler et al. [35] recently published the results of a randomized controlled trial of 57 ED patients aged below 25 years with abscesses, comparing I&D with and without wound packing. The primary outcome was treatment failure at 48 h, defined as the need for repeat I&D, re-exploration of the wound, a change in or initiation of antibiotics, delayed wound packing, or repeat ED visit. Treatment failure occurred in 59% of the patients without wound packing compared to 70% of patients who received wound packing (risk difference 11%, 95% CI 15 to 36%) [35]. Finally, in a clinical trial of 100 patients aged below 18 years, recurrence of abscess at 30 days was similar in those with (2.3%) and without (2.4%) packing [36 ]. These small studies suggest that wound packing may not confer significant benefits in those undergoing abscess I&D. Given the small sample sizes reported, larger trials are warranted. &
Analgesia and procedural sedation
CONCLUSION
The use of analgesia and procedural sedation for abscess I&D is variable. In 2012, Uspal et al. [29] found that only 44% of children undergoing I&D in a single pediatric ED received procedural sedation. Of those, 95% received ketamine [29]. The children more likely to receive sedation were younger and had larger areas of induration. There are no data comparing specific sedation regimens for I&D. In addition to local anesthesia, practitioners should consider using analgesia (oral, intranasal, or intravenous) with or without procedural sedation on a case-by-case basis, considering patient and parent preferences.
Children with uncomplicated SSTIs might benefit from an ultrasound to differentiate abscess from cellulitis when clinical examination is not definitive. Bacteremia is rare in children with uncomplicated SSTI without signs of systemic infection; blood cultures can be reserved for patients with signs of systemic infection, immunocompromised hosts, or those with complicated SSTIs. In well appearing children with cellulitis, antibiotics targeting bhemolytic streptococci and MSSA are indicated as first-line therapy. In cases of abscess that have undergone I&D, antibiotics should be considered for children younger than 1 year, those with signs of systemic illness, and those with immunocompromised states. Prior to I&D, all abscesses should have topical anesthetics applied, with consideration for local anesthesia. Procedural analgesia and sedation appear underutilized for these painful procedures. Small studies suggest that packing after I&D may be
DOES WOUND PACKING AFTER INCISION AND DRAINAGE IMPROVE OUTCOMES? The standard of care for abscess management is I&D followed by wound packing [19 ]. As packing &&
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unnecessary as a routine approach; however, larger studies are needed. Acknowledgements We would like to thank Dr Peter Dayan for his assistance with this review. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Mistry RD, Shapiro DJ, Goyal MK, et al. Clinical management of skin and soft tissue infections in the u.s. Emergency departments. West J Emerg Med 2014; 15:491–498. 2. Marin JR, Bilker W, Lautenbach E, Alpern ER. Reliability of clinical examinations for pediatric skin and soft-tissue infections. Pediatrics 2010; 126:925– 930. 3. Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. J Ultrasound Med 2012; 31:1509–1512. 4. Sivitz AB, Lam SHF, Ramirez-Schrempp D, et al. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med 2010; 39:637–643. 5. Berger T, Garrido F, Green J, et al. Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections. Am J Emerg Med 2012; 30:1569–1573. 6. Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2012; 30:1347–1351. 7. Whittle C, Schiappacasse G. Radiological imaging of soft tissue infections. In Signore A, Maria QA, editors. Diagnostic imaging of infections and inflammatory diseases: a multidisciplinary approach. First. Santiago, Chile: John Wiley & Sons, Inc.; 2014. 8. Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasound-assisted exam&& ination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med 2013; 20:545–553. This study evaluates the test characteristics of bedside emergency ultrasound in combination with clinical examination for SSTIs in children. 9. Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 2006; 13:384–388. 10. Gaspari RJ, Blehar D, Polan D, et al. The Massachusetts abscess rule: & a clinical decision rule using ultrasound to identify methicillin-resistant Staphylococcus aureus in skin abscesses. Acad Emerg Med 2014; 21:558–567. This study identifies sonographic features that differentiates MRSA abscesses from abscesses caused by other organisms. 11. Mistry RD, Marin JR, Alpern ER. Abscess volume and ultrasound characteristics Staphylococcus aureus infection. Pediatr Emerg Care 2013; 29:140– 144. 12. Sadow KB, Chamberlain JM. Blood cultures in the evaluation of children with cellulitis. Pediatrics 1998; 101:E4. 13. Wathen D, Halloran DR. Blood culture associations in children with a diagnosis of cellulitis in the era of methicillin-resistant Staphylococcus aureus. Hosp Pediatr 2013; 3:103–107. 14. Malone JR, Durica SR, Thompson DM, et al. Blood cultures in the evaluation of && uncomplicated skin and soft tissue infections. Pediatrics 2013; 132:454– 459. This study examines the utility of obtaining blood cultures in children with uncomplicated and complicated SSTIs in the era of CA-MRSA.
15. Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2008; 51:291–298. 16. Qualls ML, Mooney MM, Camargo CA, et al. Emergency department visit rates for abscess versus other skin infections during the emergence of communityassociated methicillin-resistant Staphylococcus aureus, 1997–2007. Clin Infect Dis 2012; 55:103–105. 17. Ray GT, Suaya JA, Baxter R. Microbiology of skin and soft tissue infections in the age of community-acquired methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2013; 76:24–30. 18. Herigon JC, Hersh AL, Gerber JS, et al. Antibiotic management of Staphylococcus aureus infections in US children’s hospitals, 1999–2008. Pediatrics 2010; 125:e1294–e1300. 19. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis && and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10–52. The IDSA’s most recent published guideline for the diagnosis and treatment of SSTIs. 20. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2010; 55:401–407. 21. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–287. 22. Chen AE, Carroll KC, Diener-West M, et al. Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections. Pediatrics 2011; 127:e573–e580. 23. Olderog CK, Schmitz GR, Bruner DR, et al. Clinical and epidemiologic characteristics as predictors of treatment failures in uncomplicated skin abscesses within seven days after incision and drainage. J Emerg Med 2012; 43:605–611. 24. Patel Wylie F, Kaplan SL, Mason EO, Allen CH. Needle aspiration for the etiologic diagnosis of children with cellulitis in the era of community-acquired methicillin-resistant Staphylococcus aureus. Clin Pediatr (Phila) 2011; 50:503–507. 25. Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore) 2010; 89:217–226. 26. Elliott DJ, Zaoutis TE, Troxel AB, et al. Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. Pediatrics 2009; 123:e959–e966. 27. Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness & of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis 2013; 56:1754–1762. A randomized, double-blind, placebo-controlled trial of patients with cellulitis comparing treatment with cephalexin þ TMP-SMX to cephalexin þ placebo. 28. Singer AJ, Richman PB, Kowalska A, Thode HC. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999; 33:652–658. 29. Uspal NG, Marin JR, Alpern ER, Zorc JJ. Factors associated with the use of procedural sedation during incision and drainage procedures at a children’s hospital. Am J Emerg Med 2013; 31:302–308. 30. Fein JA, Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2012; 130:e1391–e1405. 31. Cassidy-Smith T, Mistry RD, Russo CJ, et al. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Am J Emerg Med 2012; 30:104–109. 32. Partin WR, Colby D. Current diagnosis and treatment emergency medicine. In Stone C, Humphries R, editors. 7th ed. New York, NY: McGraw-Hill; 2011. 33. Bourne CL, Brewer KL, House J. Injectable lidocaine provides similar analgesia compared to transdermal lidocaine/tetracaine patch for the incision and drainage of skin abscesses: a randomized, controlled trial. J Emerg Med 2014; 47:367–371. 34. O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med 2009; 16:470–473. 35. Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care 2012; 28:514–517. 36. Leinwand M, Downing M, Slater D, et al. Incision and drainage of subcuta& neous abscesses without the use of packing. J Pediatr Surg 2013; 48:1962– 1965. The most recent study showing no benefit to wound packing after I&D.
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Scratching the surface: a review of skin and soft tissue infections in children Daniel B. Fenster, Madeline H. Renny, Carrie Ng, and Cindy G. Roskind
Purpose of review We present data from recently conducted research on the diagnosis and management of skin and soft tissue infections (SSTIs) in children. Recent findings Current research in the area of SSTIs (cellulitis and abscess) has focused on the use of ultrasound, risk factors associated with bacteremia, antibiotic choice, and incision and drainage (I&D) practices. When clinical examination is equivocal at distinguishing abscess from cellulitis, ultrasound can aid in the diagnosis and alter management. Bacteremia is rare in immunocompetent children with uncomplicated SSTIs; blood cultures may be reserved for complicated cases and for those who are systemically ill. Despite the increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), I&D without antibiotics remains the first-line therapy for abscess. Antibiotics for uncomplicated cellulitis should target b-hemolytic streptococci and methicillin-susceptible S. aureus (MSSA). There are significant variations in pain and sedation practices for I&D, with substantive evidence for the use of topical anesthetics. Wound packing after I&D may not confer significant benefit. Summary Evidence to aid in the diagnosis and management of SSTIs in children has emerged in recent years; however, larger prospective pediatric studies are needed. Keywords incision and drainage, methicillin-resistant Staphylococcus aureus, packing, skin and soft tissue infection
INTRODUCTION An estimated 385 000 patients less than 18 years of age present to the US emergency departments (EDs) annually for skin and soft tissue infections (SSTIs) [1]. When evaluating patients with SSTIs, specifically those with cellulitis and abscess, clinicians are faced with several questions: (1) (2) (3) (4)
Is there a need for ultrasound? What is the yield of blood cultures? Which antibiotic, if any, is indicated? How should pain and sedation be managed for the child undergoing incision and drainage (I&D)? (5) Does wound packing after I&D improve outcomes? In this review, we will provide the current best evidence for these questions.
IS THERE A NEED FOR ULTRASOUND? Clinicians primarily rely on physical examination to distinguish abscess from cellulitis. Physician
agreement regarding the presence or absence of a drainable fluid collection by clinical examination has been shown to be poor [2]. Needle aspiration can detect the presence of abscess in cases when the diagnosis is uncertain; however, patients without abscesses are then subjected to unnecessary invasive procedures, and patients with abscesses may have a negative aspirate if blind needle aspiration is not performed in the correct location [3]. Ultrasound is 90–97% sensitive and 67–83% specific in detecting superficial abscesses when performed by point-of-care emergency sonographers [4–6]. Further, ultrasound is accessible and does not involve ionizing radiation [7]. One recent prospective pediatric study showed that in those Department of Pediatrics, Division of Emergency Medicine, Columbia University Medical Center, New York, USA Correspondence to Daniel B. Fenster, MS, MD, Division of Pediatric Emergency Medicine, 3959 Broadway, CHN 116, New York, NY 10032, USA. Tel: +1 212 305-9825; e-mail: [email protected] Curr Opin Pediatr 2015, 27:303–307 DOI:10.1097/MOP.0000000000000213
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Emergency and critical care medicine
KEY POINTS Ultrasound should be considered when the clinical examination for abscess is equivocal. Blood cultures are not indicated in the management of most children with uncomplicated SSTIs, as the rates of bacteremia are low. Antibiotics are not routinely indicated after I&D. Topical anesthetics are indicated for I&D. Wound packing after I&D may not confer significant benefit in many cases.
patients with SSTIs without clinically evident abscess, the sensitivity and specificity for detecting an abscess improved from 44 and 42%, respectively, with clinical examination alone, to 78 and 61%, respectively, when ultrasound evaluation was integrated [8 ]. Studies have also shown that the use of ultrasound as a supplement to physical examination can alter the management of cellulitis and abscess [4,6,9]. One study suggested that bedside ultrasound altered treatment in 22% of patients [4]. Ultrasound should be strongly considered in the SSTI diagnostic algorithm when the clinical examination is equivocal. Studies are emerging that assess the degree to which specific sonographic findings can fine tune abscess management. Gaspari et al. [10 ] derived a pilot clinical decision rule to evaluate the sonographic predictors of methicillin-resistant Staphylococcus aureus (MRSA) abscesses. They demonstrated that the lack of a well-defined edge, small volume, and irregular or indistinct shape were associated with MRSA [10 ]. The rule had a sensitivity of 89% and a specificity of 45% [10 ]. Mistry et al. [11] also found abscess volume to be smaller in cases of MRSA. Further research is needed to understand how specific sonographic features of abscess may be incorporated into clinical management. &&
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WHAT IS THE YIELD OF BLOOD CULTURES? Blood cultures are frequently obtained in children with SSTIs [12,13,14 ]. Data, however, suggest that the rate of bacteremia is low in patients with uncomplicated SSTIs, and blood cultures may only be appropriate for complicated SSTIs. Complicated SSTI has been defined as SSTI occurring from surgical or traumatic wounds, SSTI requiring surgical intervention (beyond I&D), and infected ulcers and burns [14 ]. In 1998, Sadow and Chamberlain’s series of 243 immunocompetent children with cellulitis found that only 5 patients (2%) had blood &&
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cultures that were positive and 13 (5.4%) that were contaminants. Of the five positive cultures, two patients had complicated SSTIs and three patients had superinfected lesions from varicella. They concluded that blood cultures are more frequently contaminated than truly positive in uncomplicated cellulitis and are, therefore, not cost-effective [12]. With the increased prevalence of communityacquired MRSA (CA-MRSA), new questions arose regarding the risk of bacteremia in children with SSTIs [15–18]. Wathen and Halloran [13] reviewed charts for 385 patients with cellulitis and found that, of 129 patients (33.5%) with blood cultures obtained, none were positive and 4 were contaminated (1%). The total cost of blood cultures in these patients was over $28 000 [13]. In another study, Malone et al. [14 ] reported no positive blood cultures and three contaminated cultures in a group of 480 pediatric inpatients with uncomplicated SSTIs for whom blood cultures were obtained. Hospital length of stay was higher in those for whom blood cultures were obtained (mean difference 0.91 days; P ¼ 0.044). In this study, 10/98 patients (12.5%) with complicated SSTIs had bacteremia [14 ]. These studies, though retrospective, provide evidence that blood cultures appear unnecessary in the management of immunocompetent children with uncomplicated SSTIs as the rates of bacteremia are extremely low. However, blood cultures should be obtained in children with complicated SSTIs. The 2014 Infectious Disease Society of America (IDSA) Practice Guidelines for the Diagnosis and Management of SSTIs do not recommend routine blood cultures for cellulitis. They do, however, recommend blood cultures in patients with malignancy, immunocompromised states, signs of systemic infection, immersion injuries, and animal bites. The guidelines do not specifically address obtaining blood cultures in healthy patients with abscess, but strongly recommend Gram stain and culture of drainage [19 ]. &&
&&
&&
WHAT ANTIBIOTIC, IF ANY, IS INDICATED? Treatment options vary depending on the type of SSTI. In the algorithm for the management of SSTIs presented in the 2014 IDSA guidelines, clinicians must first determine whether the SSTI is purulent (i.e. abscess) or nonpurulent (i.e. cellulitis), and then evaluate the severity of the patient’s systemic symptoms and medical comorbidities prior to deciding on the treatment plan [19 ]. &&
Abscess The frequency of abscesses due to CA-MRSA is increasing [16–18]. Prior to this increase, several Volume 27 Number 3 June 2015
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Skin and soft tissue infections in children Fenster et al.
studies demonstrated that I&D alone was sufficient [17,19 ]. The increased MRSA prevalence led to a reevaluation of the role of antibiotic therapy for abscesses [14 ,18,19 ]. In a noninferiority randomized trial of 161 children with cutaneous abscess, of which 80% were CA-MRSA-positive, I&D þ placebo was no worse than I&D þ trimethoprim/sulfamethoxazole (TMP-SMX) (mean failure rate difference was 1.2%). On follow-up, new lesions were more common in the placebo group (no antibiotics) at 10 days, but not different at 90 days [20]. Additional recent trials have found similar results, suggesting that antibiotics may not confer benefit above I&D alone in uncomplicated cases including when CA-MRSA is involved [20–22]. Several studies have assessed whether there are predictors of treatment failure, such as size of abscess, surrounding erythema, fever, or age. In a randomized trial, Chen et al. [22] compared clindamycin to cephalexin for the treatment of abscess after I&D in children. He found no difference in clinical improvement at 72 h follow-up irrespective of the size of induration (comparing greater than to less than 5 cm; 93 vs. 96%; P ¼ 0.27) or the size of erythema (comparing greater than or less than 5 cm; 97 vs. 95%; P ¼ 0.71). However, treatment failure was higher in those presenting with fever and age of less than 1 year (11% with fever vs. 3% without fever; P ¼ 0.03, and 24% for age 6–12 months vs. 3% for age > 1 year; P ¼ 0.004) regardless of the antibiotic used [22]. Duong et al. [20] also found that treatment failure (absence of clinical resolution at 10 days after I&D) was not associated with abscess size, erythema, or induration greater than or equal to 5 cm. Most recently, in a randomized controlled trial of adult patients with abscess receiving either TMP-SMX or placebo after I&D, Olderog et al. [23] found no difference in treatment failure (no decrease in abscess size at 48 h) on the basis of size of abscess or surrounding cellulitis. These studies suggest that size of abscess and surrounding erythema are not predictive of treatment failure, whereas young age and fever may be important factors to consider. Larger randomized trials are needed to clarify which children may benefit from antibiotic therapy and what factors increase the risk for treatment failure after I&D. On the basis of the recent data, the 2014 IDSA guidelines recommend I&D alone for the majority of abscesses. The guidelines recommend the consideration of antibiotics for patients with signs of systemic infection, immunocompromised hosts, multiple abscesses, extremes of ages, and lack of response to I&D alone. In cases where antibiotics are recommended, antibiotics active against MRSA should be chosen [19 ]. &&
&&
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&&
Cellulitis Cellulitis rarely has a culturable source, and needle aspiration of these infections has low yield, making the true microbiologic diagnosis unknown [24]. Empiric therapy is typically chosen to cover the two most common skin pathogens – b-hemolytic streptococci and S. aureus. The increase in the prevalence of CA-MRSA cultured from abscesses has led to uncertainty in the role of MRSA in cellulitis. As a result, practice in recent years has been to broadly treat cellulitis with antibiotics active against MRSA [15,18]. In a prospective study from 2010 of adult inpatients with cellulitis, Jeng et al. [25] found that over 70% of cases were due to b-hemolytic streptococci. Overall, 96% responded favorably to b-lactam antibiotics [25]. A retrospective study of over 2000 children from 2009 reported that for nondrained, noncultured SSTIs, clindamycin conferred no treatment benefit over b-lactams, but that treatment with TMP-SMX was associated with increased risk of treatment failure. Since TMP-SMX has poor activity against streptococci, this increased treatment failure suggests that streptococci remain a common cause of cellulitis in children [26]. Most recently, in a randomized controlled trial of 153 patients aged 3–74 years (median age 29 years) with cellulitis, resolution of symptoms 1 month after enrollment was similar in those who received cephalexin þ TMP-SMX (85%), or cephalexin þ placebo (82%). There was also no difference in cure rates if the patient had MRSA colonization of the nares. The authors concluded that in patients with cellulitis without abscess, adding TMP-SMX to cephalexin did not improve outcomes [27 ]. Despite the emergence of CA-MRSA, these studies provide evidence for the IDSA’s recommendation to treat cellulitis with an antibiotic active against streptococci. Coverage against methicillin-susceptible S. aureus (MSSA) can also be included. For mild infection, oral antibiotics are appropriate. For moderate infection with signs of systemic infection, parenteral antibiotics are recommended. Although MRSA is an unusual cause of cellulitis, coverage for streptococci and MRSA is recommended in patients with cellulitis associated with penetrating trauma, or evidence of MRSA infections elsewhere in the body. Additionally, for immunocompromised patients, broad-spectrum antibiotic coverage may be considered [19 ]. &
&&
HOW SHOULD PAIN AND SEDATION BE MANAGED FOR THE CHILD UNDERGOING I&D? Incision and drainage has been rated as the second most painful ED procedure [28]. There appears to be
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a significant variation in pain and sedation practice for pediatric patients undergoing I&D, with 44% receiving procedural sedation, 28% local anesthesia þ oral analgesia, 24% local anesthesia only, and 4% oral analgesia only [29].
Topical anesthesia The American Academy of Pediatrics states that ‘topical anesthetics should be considered in any patient undergoing a nonemergent invasive procedure on intact skin in the ED’, including I&D [30]. In some instances, the topical anesthetic may result in spontaneous abscess drainage, obviating the need for I&D. Retrospectively, CassidySmith et al. [31] noted that, of the 110 patients that had LMX4 (a topical anesthetic) placed on the surface of the abscess, 26 (24%) had spontaneous drainage occur as compared to 0 of the 59 without LMX4. Topical anesthetics should be strongly considered as one pain control measure for all abscesses requiring drainage.
Local anesthesia Subcutaneous injection of lidocaine is painful [32]. Bourne et al. [33] compared a transdermal lidocaine/ tetracaine patch to subcutaneous lidocaine/epinephrine for I&D. Patients receiving transdermal lidocaine/tetracaine had a mean Visual Analog Scale pain score of 10 points higher (on a 100-point scale) than patients receiving subcutaneous lidocaine/ epinephrine (P ¼ 0.04). Although statistically significant, the clinical significance of this effect is unclear. Subcutaneous lidocaine, though painful to administer, provides some anesthesia and should be considered as one aspect of pain control for I&D.
placement and removal are painful and often require additional healthcare visits, several recent studies have evaluated this practice. In 2009, O’Malley et al. [34] published a pilot randomized controlled trial of 48 adult ED patients with abscesses, comparing I&D with and without wound packing. At 48 h post I&D, the need for further intervention (defined as extension of the incision, further wound probing, irrigation, delayed wound packing, change of antibiotics, surgical consultation, hospital admission, or need for another follow-up ED visit) was similar in those receiving (17%) and those not receiving (20%) packing [risk difference 3%, 95% confidence interval (CI) 1.8 to 7.8%] [34]. Similarly, Kessler et al. [35] recently published the results of a randomized controlled trial of 57 ED patients aged below 25 years with abscesses, comparing I&D with and without wound packing. The primary outcome was treatment failure at 48 h, defined as the need for repeat I&D, re-exploration of the wound, a change in or initiation of antibiotics, delayed wound packing, or repeat ED visit. Treatment failure occurred in 59% of the patients without wound packing compared to 70% of patients who received wound packing (risk difference 11%, 95% CI 15 to 36%) [35]. Finally, in a clinical trial of 100 patients aged below 18 years, recurrence of abscess at 30 days was similar in those with (2.3%) and without (2.4%) packing [36 ]. These small studies suggest that wound packing may not confer significant benefits in those undergoing abscess I&D. Given the small sample sizes reported, larger trials are warranted. &
Analgesia and procedural sedation
CONCLUSION
The use of analgesia and procedural sedation for abscess I&D is variable. In 2012, Uspal et al. [29] found that only 44% of children undergoing I&D in a single pediatric ED received procedural sedation. Of those, 95% received ketamine [29]. The children more likely to receive sedation were younger and had larger areas of induration. There are no data comparing specific sedation regimens for I&D. In addition to local anesthesia, practitioners should consider using analgesia (oral, intranasal, or intravenous) with or without procedural sedation on a case-by-case basis, considering patient and parent preferences.
Children with uncomplicated SSTIs might benefit from an ultrasound to differentiate abscess from cellulitis when clinical examination is not definitive. Bacteremia is rare in children with uncomplicated SSTI without signs of systemic infection; blood cultures can be reserved for patients with signs of systemic infection, immunocompromised hosts, or those with complicated SSTIs. In well appearing children with cellulitis, antibiotics targeting bhemolytic streptococci and MSSA are indicated as first-line therapy. In cases of abscess that have undergone I&D, antibiotics should be considered for children younger than 1 year, those with signs of systemic illness, and those with immunocompromised states. Prior to I&D, all abscesses should have topical anesthetics applied, with consideration for local anesthesia. Procedural analgesia and sedation appear underutilized for these painful procedures. Small studies suggest that packing after I&D may be
DOES WOUND PACKING AFTER INCISION AND DRAINAGE IMPROVE OUTCOMES? The standard of care for abscess management is I&D followed by wound packing [19 ]. As packing &&
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unnecessary as a routine approach; however, larger studies are needed. Acknowledgements We would like to thank Dr Peter Dayan for his assistance with this review. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Mistry RD, Shapiro DJ, Goyal MK, et al. Clinical management of skin and soft tissue infections in the u.s. Emergency departments. West J Emerg Med 2014; 15:491–498. 2. Marin JR, Bilker W, Lautenbach E, Alpern ER. Reliability of clinical examinations for pediatric skin and soft-tissue infections. Pediatrics 2010; 126:925– 930. 3. Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. J Ultrasound Med 2012; 31:1509–1512. 4. Sivitz AB, Lam SHF, Ramirez-Schrempp D, et al. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med 2010; 39:637–643. 5. Berger T, Garrido F, Green J, et al. Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections. Am J Emerg Med 2012; 30:1569–1573. 6. Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2012; 30:1347–1351. 7. Whittle C, Schiappacasse G. Radiological imaging of soft tissue infections. In Signore A, Maria QA, editors. Diagnostic imaging of infections and inflammatory diseases: a multidisciplinary approach. First. Santiago, Chile: John Wiley & Sons, Inc.; 2014. 8. Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasound-assisted exam&& ination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med 2013; 20:545–553. This study evaluates the test characteristics of bedside emergency ultrasound in combination with clinical examination for SSTIs in children. 9. Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 2006; 13:384–388. 10. Gaspari RJ, Blehar D, Polan D, et al. The Massachusetts abscess rule: & a clinical decision rule using ultrasound to identify methicillin-resistant Staphylococcus aureus in skin abscesses. Acad Emerg Med 2014; 21:558–567. This study identifies sonographic features that differentiates MRSA abscesses from abscesses caused by other organisms. 11. Mistry RD, Marin JR, Alpern ER. Abscess volume and ultrasound characteristics Staphylococcus aureus infection. Pediatr Emerg Care 2013; 29:140– 144. 12. Sadow KB, Chamberlain JM. Blood cultures in the evaluation of children with cellulitis. Pediatrics 1998; 101:E4. 13. Wathen D, Halloran DR. Blood culture associations in children with a diagnosis of cellulitis in the era of methicillin-resistant Staphylococcus aureus. Hosp Pediatr 2013; 3:103–107. 14. Malone JR, Durica SR, Thompson DM, et al. Blood cultures in the evaluation of && uncomplicated skin and soft tissue infections. Pediatrics 2013; 132:454– 459. This study examines the utility of obtaining blood cultures in children with uncomplicated and complicated SSTIs in the era of CA-MRSA.
15. Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2008; 51:291–298. 16. Qualls ML, Mooney MM, Camargo CA, et al. Emergency department visit rates for abscess versus other skin infections during the emergence of communityassociated methicillin-resistant Staphylococcus aureus, 1997–2007. Clin Infect Dis 2012; 55:103–105. 17. Ray GT, Suaya JA, Baxter R. Microbiology of skin and soft tissue infections in the age of community-acquired methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2013; 76:24–30. 18. Herigon JC, Hersh AL, Gerber JS, et al. Antibiotic management of Staphylococcus aureus infections in US children’s hospitals, 1999–2008. Pediatrics 2010; 125:e1294–e1300. 19. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis && and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10–52. The IDSA’s most recent published guideline for the diagnosis and treatment of SSTIs. 20. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2010; 55:401–407. 21. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–287. 22. Chen AE, Carroll KC, Diener-West M, et al. Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections. Pediatrics 2011; 127:e573–e580. 23. Olderog CK, Schmitz GR, Bruner DR, et al. Clinical and epidemiologic characteristics as predictors of treatment failures in uncomplicated skin abscesses within seven days after incision and drainage. J Emerg Med 2012; 43:605–611. 24. Patel Wylie F, Kaplan SL, Mason EO, Allen CH. Needle aspiration for the etiologic diagnosis of children with cellulitis in the era of community-acquired methicillin-resistant Staphylococcus aureus. Clin Pediatr (Phila) 2011; 50:503–507. 25. Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore) 2010; 89:217–226. 26. Elliott DJ, Zaoutis TE, Troxel AB, et al. Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. Pediatrics 2009; 123:e959–e966. 27. Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness & of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis 2013; 56:1754–1762. A randomized, double-blind, placebo-controlled trial of patients with cellulitis comparing treatment with cephalexin þ TMP-SMX to cephalexin þ placebo. 28. Singer AJ, Richman PB, Kowalska A, Thode HC. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999; 33:652–658. 29. Uspal NG, Marin JR, Alpern ER, Zorc JJ. Factors associated with the use of procedural sedation during incision and drainage procedures at a children’s hospital. Am J Emerg Med 2013; 31:302–308. 30. Fein JA, Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2012; 130:e1391–e1405. 31. Cassidy-Smith T, Mistry RD, Russo CJ, et al. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Am J Emerg Med 2012; 30:104–109. 32. Partin WR, Colby D. Current diagnosis and treatment emergency medicine. In Stone C, Humphries R, editors. 7th ed. New York, NY: McGraw-Hill; 2011. 33. Bourne CL, Brewer KL, House J. Injectable lidocaine provides similar analgesia compared to transdermal lidocaine/tetracaine patch for the incision and drainage of skin abscesses: a randomized, controlled trial. J Emerg Med 2014; 47:367–371. 34. O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med 2009; 16:470–473. 35. Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care 2012; 28:514–517. 36. Leinwand M, Downing M, Slater D, et al. Incision and drainage of subcuta& neous abscesses without the use of packing. J Pediatr Surg 2013; 48:1962– 1965. The most recent study showing no benefit to wound packing after I&D.
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