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Concomitant infection rare, treatment failure common in infants with SSTI
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A recent investigation in Hospital Pediatrics revealed that children aged younger than 90 days presenting with skin and soft tissue infections often experienced treatment failure that led to hospital revisitation, but rarely developed concomitant bacterial infections.
“Skin and soft tissue infections (SSTIs), most commonly cellulitis or cutaneous abscess, are an increasingly common cause of pediatric hospital visits, including among infants,” Gabrielle Hester, MD, MS, of the department of hospital medicine at Children’s Hospitals and Clinics of Minnesota, and colleagues wrote. “First, we found a low rate of identified invasive bacterial infections, among infants [aged younger than] 90 days presenting for a hospital encounter for SSTI.
“Second, SSTI treatment failure was a common cause for hospital revisit, particularly in patients with perianal location of infection.”
The researchers analyzed medical records of 172 children aged younger than 90 days diagnosed with SSTI at one of 22 EDs in Utah from July 2004 through 2011. Patient records were examined for urinary tract infections and invasive bacterial infections, as well as any unplanned change in care at a hospital revisitation within 14 days of the patient’s initial discharge.
Study data revealed that 17% of infants were febrile, and 53% had at least one sterile site culture confirmed for bacterial infection. The overall proportion of concomitant bacterial infection was 0.58% (95% CI, 0.01%-3.2%). However, only 76 patients had blood cultures obtained. Furthermore, the one case of concomitant infection also was in the febrile group, resulting in a rate of 4% for febrile children with confirmed concomitant infection.
Sixteen patients revisited a hospital due to treatment failure, of which eight had a change in antibiotics, 11 underwent a new procedure such as an incision or drainage, and three were admitted to the hospital.
“Clinicians may consider limiting evaluation for urinary tract infection and invasive bacterial infection in afebrile infants presenting with SSTI if other criteria for more extensive evaluation are not met and if identification is unlikely to change management,” Hester and colleagues wrote. “A clear short-term follow-up care plan is important for infants with SSTI, especially those with perianal infections, who … may experience a higher rate of treatment failure.”– by David Costill
Disclosure: Hester reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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C. Buddy Creech, MD, MPH
At the risk of being too cynical, there are times on the clinical service when I feel as if Hippocrates’ maxim of “First, do no harm,” has been contorted to “First, do no tests.” In an age of cost restraint and in the hopes of challenging practices that lack evidence, we sometimes struggle to strike the correct balance. This is precisely the reason that studies such as this by Hester et al are critical in redefining our practice patterns as the epidemiology of infectious diseases evolves or is better understood.
The notion that children with skin and soft tissue infections, including those that are febrile, are unlikely to have an invasive bacterial infection has been suggested previously. This study takes that observation a bit further by demonstrating that even febrile infants, where practice patterns exhibit an abundance of caution, are unlikely to have a urinary tract infection or bacteremia in the setting of SSTI. While the sample size is small, these data indicate that well under 1% of study subjects experienced an invasive bacterial infection (1 case of bacteremia in 172 subjects); importantly, this proportion is less than the frequency of false positive cultures, which is estimated to range from 1-5%. Additionally, the treatment failure rate of nearly 10% is consistent with previous reports, including those from our group, and highlights the importance of close follow-up of infants and young children with SSTI.
Diagnostic tests are a crucial aspect of patient care; however, the characteristics of those tests, modified by the specific disease state and age, are important variables in defining whether the test is appropriate. In the case of young children and older infants with febrile SSTI, it would appear that “First, do no blood cultures” is a very reasonable place to land.
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