How to manage skin and soft-tissue infections in the emergency department

Abstract

Purpose of reviewOur purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3–30% of all cases presenting to an ED, of which 25–40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures.Recent findingsRecent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods.SummaryThe ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.

Treating necrotizing skin and soft-tissue infections

“…If no multi-drug resistance (MDR) is suspected, piperacillin-tazobactam or meropenem may be used empirically, according to the local/regional prevalence of Enterobacterales producing extended-spectrum beta-lactamases (ESBLs) [1]. In selected cases, when risk factors for MDR are present (e.g., local ecology, colonization, health care-related acquisition, or previous antimicrobial therapy) treatment should include anti methicillin-resistant Staphylococcus aureus (MRSA) coverage (vancomycin, linezolid, or daptomycin) and/or MDR Gram-negative activity (ceftazidime-avibactam, ceftolozane-tazobactam, or cefiderocol) [11,12] (ESM).…”

Current approach to skin and soft tissue infections. Thinking about continuity of care

“…SSTI accounts, by some estimates, for 3-30% of all hospital visits to the emergency departments (ED) [ 7 , 8 ] and is one of the five entities with the greatest variability in clinical decisions [ 9 ]. An estimated 12-40% [ 10 , 11 ] of SSTI seen in the ED are later admitted to the hospital, and 0.7% to intensive care unit [ 12 ]. Sepsis occurs in 4-8% of all patients who suffer from complicated skin and soft tissue infections (cSSTI), in which signs or symptoms related to sepsis may occur [ 13 ].…”