Patient Evaluation Overview

Clinically, SSTIs manifest as skin erythema, warmth, and edema. Erysipelas typically has an acute onset with fever, chills, and a clear line of demarcation between involved and uninvolved tissue. Cellulitis tends to develop over a few days. Other clinical features may include lymphangitic streaking with regional lymph node enlargement. On occasion, there may be associated bullae, vesicles, or petechiae.

Patients with preseptal cellulitis will invariably have eyelid swelling, ocular pain, and erythema. It is important to distinguish it from orbital cellulitis, which also presents with similar symptoms but in addition can manifest pain with eye movements, proptosis, and ophthalmoplegia with diplopia. Fever is more common in orbital cellulitis. Orbital cellulitis is a much more serious condition and can lead to visual impairment. If there is doubt whether the infection is preseptal or orbital, a computed tomography (CT) scan of the sinus and orbits is indicated.

Pain out of proportion to examination may be an early sign of life-threatening necrotizing fasciitis. Pain that precedes physical findings and delayed development of ecchymosis or sloughing of skin may be a manifestation of toxic shock syndrome. Gas gangrene should be suspected in the presence of severe pain with crepitus. Although evaluating a patient with cellulitis in the EDOU, it is important to determine whether the cellulitis is nonpurulent or purulent with drainage or exudates. This determination will guide the choice of initial antibiotic therapy. Often there will be an obvious abscess, but, when in doubt, bedside ultrasound can be a useful adjunct. For noncomplicated SSTIs, blood cultures are positive in less than 5% of cases and therefore not indicated. Similarly, for mild infections, a skin biopsy or needle aspiration is not necessary. Circumstances that prompt blood cultures include extensive skin involvement, systemic symptoms, or presence of comorbidities like neutropenia, conditions that usually require inpatient admission and would exclude the patient from EDOU management. If the SSTI is not responding to antibiotics, it is worthwhile to consider mimics like acute gout, insect bite with local inflammation, contact or stasis dermatitis, drug reaction, vasculitis, or panniculitis. Gram stain and culture of pus or exudates from cutaneous abscesses are recommended to help identify the causative organism, especially in the case of treatment failure. One exception is an inflamed epidermoid cyst, wherein Gram stain and culture are not recommended. Inflammation and purulence in an epidermoid cyst are a reaction to the rupture of cyst wall and extrusion of its contents into the dermis and not a result of an infectious process.

Factors associated with decision to hospitalize ED patients with SSTIs include patients with fever, larger lesions (erythema >10 cm), and comorbidities. Often the only reason for admission is to administer intravenous (IV) antibiotics. Such patients can be safely and effectively managed in an EDOU. Patients with cellulitis admitted to an EDOU are more likely to be obese, have chronic obstructive pulmonary disease or asthma, and meet at least one systemic inflammatory response syndrome (SIRS) criteria. Patients who meet sepsis criteria, have suspected necrotizing fasciitis, or have an expected length of stay greater than 48 hours should be excluded from the EDOU. The goal of EDOU care is to administer antibiotics, provide analgesics, elevate the involved extremity, and obtain consultation, imaging, and home care coordination if indicated. In a study of 192 children admitted to the EDOU for an SSTI, fever on ED presentation was associated with EDOU treatment failure, although the presence or magnitude of fever does not preclude EDOU or outpatient management.

Treatment Options

Avoiding unnecessary, broad-spectrum antibiotics should be the guiding principle in managing cellulitis in the EDOU. A recent study looking into the treatment of bacterial skin infections in EDOUs found less than half the patients were treated according to Infectious Diseases Society of America (IDSA) guidelines ( Fig. 2 ), 42% were overtreated, and 15% were undertreated. Patients greater than 50 years old were at risk for overtreatment, whereas women were likely to be undertreated. Patients with mild cellulitis can be treated with oral antibiotics. Patients with nonpurulent cellulitis are empirically treated with antibiotics to cover β-hemolytic streptococci and methicillin-sensitive S aureus . Dicloxacillin or cephalexin is an appropriate initial choice. Cure rates were comparable when compared with a combination of cephalexin and trimethoprim-sulfamethoxazole or cephalexin alone in a randomized trial of patients with cellulitis without abscess. It is reasonable to add MRSA coverage in communities where the prevalence of MRSA is greater than 30% and for patients with prior MRSA infection, recurrent infection, or lack of response to initial therapy.

Pharmacologic management of SSTIs in the observation unit. SMX, sulfamethoxazole; TMP, trimethoprim.

Patients with erysipelas and systemic manifestations are started with parenteral agents like cefazolin or ceftriaxone that have activity against β-hemolytic streptococci. Most of these patients will rapidly respond to initial therapy within 24 hours and can be transitioned to oral therapy with amoxicillin or oral penicillin. Cephalexin or clindamycin can be used if the patient is allergic to penicillin.

Purulent cellulitis is much more likely to be caused by CA-MRSA. MRSA was isolated from 59% of cases in a study of 422 patients with purulent soft tissue infections. Compared with hospital-associated MRSA, CA-MRSA tends to be more virulent, causing tissue necrosis and severe disease. The addition of systemic antibiotics to incision and drainage (I&D) of cutaneous abscesses does not improve cure rates, even in those due to MRSA, but have a modest effect on the time to recurrence of other abscesses. The decision to add antibiotic therapy should be based on presence or absence of SIRS, which is temperature greater than 38°C or less than 36°C, respiratory rate greater than 24, heart rate greater than 90 bpm, or white blood cell count greater than 12,000 or less than 400 cells/dL. Empiric therapy should include MRSA coverage pending results from culture and sensitivity of the pus. For moderate infection, oral therapy with trimethoprim-sulfamethoxazole or doxycycline is appropriate. For severe infections, parenteral therapy with IV vancomycin, daptomycin, linezolid, telavancin, or ceftaroline is indicated.

Infected animal bite–related wounds should be irrigated with copious fluid and approximated but not closed (with the exception of those on the face). The patient should be treated with antimicrobial agents active against both aerobic and anaerobic bacteria, such as amoxicillin-clavulanate. Other alternatives include second- or third-generation cephalosporins plus anaerobic coverage with clindamycin or metronidazole. Single-agent therapy with a carbapenem, moxifloxacin, or doxycycline is also appropriate. Tetanus status should be assessed and appropriate prophylaxis administered, if indicated.

Mild cases of preseptal cellulitis can be treated with clindamycin monotherapy or combination therapy with trimethoprim-sulfamethoxazole plus either amoxicillin, amoxicillin-clavulanic acid, cefpodoxime, or cefdinir for 7 to 10 days.

Often overlooked in the treatment of SSTIs is elevation of the affected area. It facilitates gravity drainage of edema and inflammatory substances. The skin should be hydrated with emollients to avoid dryness. It is important to treat underlying predisposing conditions like chronic venous insufficiency, tinea pedis, and lymphedema.

Evaluation of Outcome and Long-Term Recommendations

Patients with SSTIs managed in the EDOU should have the area of erythema marked with a pen. Lack of response or development of systemic symptoms in the first 24 hours should prompt consideration for imaging, expanding antibiotic coverage, and inpatient admission.

Patient Evaluation Overview

A good history and physical examination are important to narrow the diagnosis of the type of hand infection and to exclude mimics like inflammatory arthropathies, tendinitis, or pyoderma gangrenosum. Among other things, the history should include hand dominance and immune and tetanus immunization status. Physical examination should note if there is swelling, deformity, tenderness, erythema, fluctuance, crepitus, adenopathy, skin necrosis, or limited range of motion. Neurovascular status and alignment should be documented. Laboratory evaluation is tailored to the presentation and underlying patient condition. Blood cultures can be obtained if the patient is febrile or has the presence of one or more SIRS criteria. Complete blood count and renal or liver function can be ordered if the patient is immunocompromised or has known renal or hepatic impairment. If the patient has an open wound or if an I&D is performed, a sample should be sent for Gram stain as well as aerobic and anaerobic cultures. A plain radiograph should be obtained to look for a fracture, foreign body, osteomyelitis, or gas in the soft tissues. Imaging studies may be used to confirm osteomyelitis, fluid collection along tendon sheaths, or a soft tissue abscess. The area of erythema is outlined with an indelible marker to monitor progress. Acute paronychia is evidenced by erythema, swelling, and tenderness along the dorsolateral nail fold. Trauma from hangnails, manicures, or nail biting introduces bacteria into the area. An abscess can form along the nail fold and sometimes extend into the pulp space. Patients with pulp space infection or felon present with severe, throbbing pain, most commonly in the thumb and index fingers, often with a history of penetrating trauma. Pulp space infections account for 15% to 20% of all hand infections. A felon can sometimes be confused with a herpetic whitlow, a viral infection of the hand caused by inoculation of herpes simplex virus (HSV) into broken skin. HSV type 1 is the primary cause of herpetic whitlow in patients less than 10 year old, whereas adults can be infected with either HSV-1 or HSV-2. Patients present with a prodrome of influenza-like symptoms and fever, followed by tingling, burning, erythema, swelling, and 1- to 2-mm vesicles containing clear fluid in the involved digit. In contrast to a felon, the pulp space in herpetic whitlow is soft, not tense.

Treatment Options

Superficial infections, with the exception of necrotizing fasciitis, can be treated with antibiotics alone. On the other hand, deep infections usually need surgical debridement and irrigation in conjunction with antibiotic treatment. Oral antibiotics are appropriate for skin and other soft tissue infections. Initial choice of antibiotic should cover CA-MRSA. Trimethoprim-sulfamethoxazole and clindamycin are good first-line agents. IV antibiotics are recommended for bone or flexor sheath infections. Vancomycin and piperacillin/tazobactam are the most commonly used IV antibiotics. Animal bite wounds should be treated with irrigation and oral amoxicillin-clavulanate or IV ampicillin-sulbactam. If patients are allergic to penicillin, they can be treated with doxycycline, sulfamethoxazole-trimethoprim, or a fluoroquinolone plus clindamycin.

Splinting, elevation, and heat are important in the treatment of hand infections. Splinting protects the affected area, limits opening of tissue planes restricting the spread of infection, and decreases pain. Splinting in a position of function can help protect against flexion contractures, reduce stiffness, and hasten rehabilitation. The principle of elevation is to keep the hand above the level of the heart. Elevation helps to reduce edema by improving venous and lymphatic drainage. Short, frequent, warm soaks improve patient comfort, enhance antibiotic delivery to the tissue, and increase the delivery of inflammatory cells to the affected area by local vasodilation. Herpetic whitlow is self-limiting and resolves within 3 weeks without treatment. The vesicles drain and ulcerate before resolution and are contagious during the first 2 weeks. A dry dressing should be worn over the involved digit at all times during this period to prevent spreading the infection.

Evaluation of Outcome and Long-Term Recommendation

Patients who respond to therapy with either IV or oral antibiotics can be safely discharged from the EDOU. If a hand surgery service was consulted from the ED, they will follow the patient in the EDOU. If hand surgery was not consulted or is not available in the hospital, there should be an attempt to arrange a follow-up appointment with a hand surgeon upon discharge.

Patient Evaluation Overview

The typical clinical presentation of PTA is a severe sore throat (usually unilateral), fever, and a “hot potato” or muffled voice. Pooling of saliva or drooling may be present. Trismus, related to irritation and reflex spasm of the internal pterygoid muscle, occurs in nearly two-thirds of patients; it helps to distinguish PTA from severe pharyngitis or tonsillitis. Patients often have neck swelling and pain and may have ipsilateral ear pain. Weakness, fatigue, and decreased oral intake may occur as a result of discomfort.

The presence of trismus may limit the ability to perform an adequate examination. If there is doubt about whether the patient has a PTA, epiglottitis, or other deep neck space infection, imaging or examination in the operating room may be necessary.

Examination findings consistent with PTA include an extremely swollen and fluctuant tonsil with deviation of the uvula to the opposite side. Alternatively, there may be fullness or bulging of the posterior soft palate near the tonsil with palpable fluctuance. Cervical and submandibular lymphadenopathy may be present. Bilateral PTAs are rare, but have been reported.

Laboratory evaluation is not necessary to make a diagnosis of PTA, but may help gauge the level of illness and direct therapy. Throat culture for group A β-hemolytic streptococcus should be sent to the laboratory. Other studies include Gram stain, culture (aerobic and anaerobic), and susceptibility testing of abscess fluid if a drainage procedure is performed. Although these results rarely affect management of uncomplicated patients, cultures may help guide antimicrobial therapy in immunocompromised patients, those with complications, treatment failures, or extension of infection.

Imaging is usually not necessary to make the diagnosis of PTA. Indications for imaging may include the following:

• •
  

  Distinguishing cellulitis from abscess

  
  
• •
  

  Looking for spread of infection to the parapharyngeal space

  
  
• •
  

  Inadequate examination secondary to trismus

  
  
• •
  

  Exclusion of other conditions that present with sore throat and signs of respiratory obstruction, such as epiglottitis and retropharyngeal abscess ( Box 1 ).

  
  
  
  

  Box 1

  
  

  
  

  
  

  
  
  • 
    

    Epiglottitis

    
    
  • 
    

    Retropharyngeal abscess or cellulitis

    
    
  • 
    

    Abscess of the parapharyngeal space

    
    
  • 
    

    Severe tonsillopharyngitis

  
  

  
  

  Major considerations in the differential diagnosis of peritonsillar abscess
  
  

CT and intraoral ultrasound are similar in regard to PTA diagnosis. CT with IV contrast can distinguish PTA from cellulitis and also demonstrate the spread of infection to contiguous deep neck spaces. CT should be omitted in patients with moderate to severe respiratory distress, particularly when sedation is necessary; such patients generally undergo evaluation in the operating room, where, if necessary, an artificial airway can be established. Intraoral ultrasound is becoming the imaging of choice to distinguish PTA from cellulitis and to guide needle aspiration. However, intraoral ultrasonography may be limited by trismus. PTA appears as an echo-free cavity with an irregular border, and peritonsillar cellulitis appears as a homogeneous or striated area without a distinct fluid collection.

Clinical features and imaging cannot always distinguish PTA from cellulitis. A 24-hour trial of antimicrobial therapy (with or without antecedent imaging) may be helpful in this regard. Failure to respond to a trial of appropriate antibiotic therapy suggests PTA, whereas response to therapy suggests cellulitis. Response is defined by improvement in at least one clinical parameter: sore throat, fever, trismus, or tonsillar bulge.

Treatment Options

Antibiotic therapy should be directed to cover group A β-hemolytic streptococci, S aureus , and oral anaerobes. Although PTAs are polymicrobial infections, several studies have shown IV penicillin alone to be as clinically effective as broader-spectrum antibiotics, provided the abscess has been adequately drained. Some physicians choose to use broader spectrum antibiotics based on studies demonstrating more than 50% of aspirates show β-lactamase producing bacteria. Decision to add MRSA coverage depends on patient’s clinical condition and prevalence of MRSA in the community. Table 1 shows the most common organisms associated with peritonsillar infections, and Table 2 illustrates the proposed antimicrobial regimens for treatment.

Evidence regarding the benefits of glucocorticoids in the management of PTA is inconsistent. In one trial of 62 patients, glucocorticoids appeared to hasten symptomatic improvement in adolescent (>16 years) and adult patients treated with needle aspiration and IV antimicrobial therapy. In another small trial of 41 adult patients undergoing needle aspiration for PTA, IV dexamethasone was associated with less pain at 24 hours than placebo but no other benefits. In a retrospective case series of 249 episodes of PTA in children less than 18 years, glucocorticoids were used in 37% but without clear benefit or adverse outcomes.

Drainage, antimicrobial therapy, and supportive care are the cornerstones of management for PTA; peritonsillar cellulitis responds to antimicrobial therapy and supportive care alone. Supportive care includes provision of adequate hydration and analgesia and monitoring for complications.

Surgical intervention (eg, tonsillectomy or I&D) is reserved for those who do not respond to medical therapy. This strategy was evaluated in a retrospective series of 102 children (8 months to 19 years). Approximately 50% of patients responded to medical therapy and 50% underwent tonsillectomy, 80% of which had abscesses at the time of surgery. Children younger than 6 years were more likely to respond to medical therapy.

PTA usually requires surgical drainage through needle aspiration. Ultrasound may be used to guide the procedure. A meta-analysis found needle aspiration to be 94% (range 85%–100%) successful in acute resolution. Repeat aspiration may be necessary in 4% to 10% of patients.

Patients must be observed after the procedure to make sure they can tolerate oral antimicrobial therapy, pain medications, and liquids. Fig. 3 describes a proposed algorithm for patients presenting to the ED with PTA.

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