Outcomes After Skin and Soft Tissue Infection in Infants 90 Days Old or Younger

Abstract

A B S T R A C T BACKGROUND AND OBJECTIVES:Skin and soft tissue infections (SSTIs) are an increasingly common cause of pediatric hospital visits among infants. The optimal evaluation strategy for younger infants with SSTI is unknown because there is little information about outcomes including risks of concomitant bacterial infections and treatment failure. This study was designed to determine rates of concomitant invasive bacterial infection and hospital revisits for treatment failure as well as factors associated with treatment failure in infants presenting with SSTI. METHODS:Retrospective study of patients #90 days of age who received care from the 22 emergency departments and hospitals in the Intermountain Healthcare system from July 1, 2004 to December 31, 2011, with a primary discharge diagnosis of SSTI. Concomitant bacterial infections were defined as urinary tract infection (UTI; culture-confirmed) or invasive bacterial infection (IBI; culture-confirmed bacteremia and/or meningitis). Treatment failure was defined as any unplanned change in care at hospital revisit within 14 days of discharge. RESULTS:The study included 172 infants; 29 (17%) were febrile, and 91 (53%) had $1 sterile site culture performed. One case of bacteremia in a febrile infant was identified giving an overall proportion with UTI/IBI of 0.58% (95% confidence interval 0.01%-3.2%). Sixteen infants (9.3%; 95% confidence interval 5.4%-14.7%) returned for treatment failure. Perianal location (P 5 .03) and private insurance status (P 5 .01) were associated with more treatment failures compared with other locations or payer types. No patients returned for missed UTI/IBI. CONCLUSIONS:Concomitant bacterial infections were rare in infants with SSTI, with none identified in afebrile infants. Treatment failure of SSTI leading to hospital revisit was common.

Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections

“…For example, fever was not reliably coded in our study, and compared with other similar investigations, assignment of ICD-9-CM codes for fever was low. 5 Lack of reliable fever coding limits our ability to examine the impact of fever on antibiotic prescribing and limits our ability to make any recommendations regarding the appropriate treatment of SSTI in the setting of fever. The use of an administrative data set also limits our ability to evaluate the association of patient presentation with clinical decision-making.…”

“…Infants were considered for inclusion on the basis of the presence of an ICD-9-CM principal diagnosis for an SSTI, including cellulitis, abscess, carbuncle, furuncle, or mastitis (Supplemental Table 4). [2][3][4][5]17,18 If an infant had multiple hospitalizations within a 30-day period, only the first hospitalization was considered an index admission; subsequent ED revisits or hospitalizations were considered returns and were defined as same-, related-, or all-cause returns.…”

“…2,3 Among infants ,60 days of age, clinical practice varies greatly in the evaluation of SSTIs. 4,5 This variation may reflect health care provider concern for a possible increased risk of concomitant invasive bacterial infections (IBIs) because of the immaturity of the infant immune system. 6 Variation in patient evaluation likely extends beyond diagnostic testing practices to include the decision of which antibiotics to empirically administer, specifically the decision to administer narrow-spectrum (ie, SSTI-directed) antibiotics or broad-spectrum antibiotics.…”

Periumbilical Skin and Soft-Tissue Infections Resulting From a Newborn Tracking Device

“…The clinical presentation and outcome of our newborns with PSSTI were consistent with other skin and soft-tissue infections in this age group. 4,5 Importantly, these cases were distinct from omphalitis, an infection of the umbilical remnant, which is usually polymicrobial and is often associated with significant clinical morbidity and may even be lethal. 6,7 In this disease, the umbilical cord itself may be a portal of entry for infection and when combined with necrotic tissue and/or thrombosed vessels may provide access to bloodstream.…”

Afebrile neonates with pustules should not be managed as febrile infants

“…The high prevalence of bacterial infection in febrile infants has led clinicians, perhaps reflexively, to manage afebrile infants age 60 days old or younger with skin and soft tissue infections in a similar manner. Prior studies have demonstrated that the majortity of these afebrile infants with skin and soft tissue infections undergo extensive testing even though the prevalence of invasive bacterial infection is as low as 0%, but the small sample sizes of these investigations have resulted in imprecision for these prevalence estimates. Therefore, it is reasonable practice for clinicians to evaluate for bacteremia in well‐appearing afebrile infants with cellulitis or abscesses pending a large, multicenter investigation …”