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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 30-33

Profile and outcome of patients presenting with skin and soft-tissue infections to the emergency department


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission18-Jul-2019
Date of Acceptance02-Aug-2019
Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_22_19

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  Abstract 

Background: Skin and soft-tissue infections (SSTIs) vary in presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. Early diagnosis is vital to reduce the complications. Materials and Methods: This prospective, observational, cohort study conducted between April 1, 2018 and June 30, 2018, in the emergency department (ED) of large tertiary care hospital in South India. In this study, all patients >15 years of age with traumatic or nontraumatic SSTI were enrolled consecutively, and SSTI associated with burns were excluded. The 353 patients were interviewed with a prestructured questionnaire and the statistical analysis was performed using SPSS 25.0. This study was aimed to find the incidence of SSTI and the outcome. Results: The cohort consists of… patients with age group between 40 and 65 years, and there was male predominance. Nonnecrotizing SSTI was the most common presentation. The incidence rate was 1.9%. Diabetes mellitus (DM) was the common risk factor n (%). Lower limbs were the most commonly affected site. The most common organism isolated in the blood and pus culture were Staphylococcus epidermidis and mixed flora. A large number (33.9%) of patients required in-patient care and surgical interventions. The mortality rate in our cohort was n (14%). Conclusion: The incidence of SSTI in patients presenting to the ED remains high. DM was the common risk factor, and many required inpatient care, and surgical intervention including amputation. Despite prompt diagnosis and management, mortality rate was still significant.

Keywords: Cellulitis, emergency department, infections, necrotizing, skin


How to cite this article:
Abhilash KP, Varghese S. Profile and outcome of patients presenting with skin and soft-tissue infections to the emergency department. Curr Med Issues 2019;17:30-3

How to cite this URL:
Abhilash KP, Varghese S. Profile and outcome of patients presenting with skin and soft-tissue infections to the emergency department. Curr Med Issues [serial online] 2019 [cited 2019 Sep 17];17:30-3. Available from: http://www.cmijournal.org/text.asp?2019/17/2/30/265820


  Introduction Top


Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, accounting for nearly 10% of hospital admissions for infections in the USA.[1] Diabetic patients are at a higher risk of developing chronic foot ulcers which can be limb or life-threatening.[2] Monomicrobial infections are usually caused by hemolytic Group A Streptococcus, Staphylococcusaureus, or Clostridia species. Group A streptococcal infection is associated with a streptococcal toxic shock—like syndrome[3],[4] complicated SSTI extend to the subcutaneous tissue, fascia, or muscle and require complex treatment, combining careful selection of antimicrobials with expeditious surgical intervention.[5] Careful assessment of risk factors and degree of severity, as well as obtaining a detailed medical history and performing a thorough physical examination are required to appropriately diagnose and manage a patient presenting with a SSTI.

Although there are several studies on SSTI conducted among the surgical inpatients, there is no previous study done in India to look at the incidence and spectrum of patients with SSTI presenting to the emergency department (ED). Hence, this study was aimed to evaluate the incidence, the profile of patients, need for surgical intervention, and their outcomes in the ED.


  Materials and Methods Top


This prospective, observational, cohort study was conducted between April 1, 2018 and June 30, 2018 at the adult ED of Christian Medical College, Vellore, which is a 2700-bedded tertiary referral center and is one of the largest hospitals in South India, with 45-bedded ED.

All patients above 15 years of age who presented to the ED with traumatic or nontraumatic SSTI were recruited consecutively during the study period. Patients were excluded if the SSTI was associated with burns. Patients who fulfilled the inclusion criteria were interviewed according to a prestructured questionnaire and the patient baseline characteristics, comorbidities, duration of onset of symptoms, site of infection, antibiotic treatment given outside, and clinical examination findings were recorded. After the initial stabilization by the ED team, the patients were handed over to the respective surgical departments for further management if necessary. Patients with uncomplicated SSTI were discharged by the ED team after a short observation period, and those who required surgery or prolonged observation were admitted in the respective wards, intensive care units, or shifted to operating room for emergency surgical interventions. The patients were followed up, the treatment offered was monitored and the outcome at ED, and at discharge from the hospital were recorded.

For the statistical analysis, the data were entered using EPIDATA software (EpiData Classic, Data Management and basic Statistical Analysis System. Odense Denmark, EpiData Association). Summary statistic used for reporting demographic and clinical characteristics. All categorical variables were reported using frequencies and percentages and continuous variables in terms of mean ± standard deviation all the statistical analyses were performed using SPSS Inc., Released 2007. SPSS for Windows, version 16.0, (Chicago, Ilinois, USA). This study was approved by the Ethics Committee and the Institutional Review Board and patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.


  Results Top


The incidence rate of SSTI at our ED was 18.21/1000 person-years. The baseline characteristics of the patients are described in [Table 1]. There was a male predominance of 67.1%, and the main comorbidity associated was diabetes n (%). The common occupation among patients with SSTI was homemakers (27.5%), followed by farmers (21%), nonprofessionals (15.3%), and daily laborers (9.6%). 63.2% of the patients with SSTI had presented to the ED within 2 weeks of symptoms. 13.6% of cases had prior antibiotic treatment. The clinical examination findings are outlined in [Table 2]. Lower limbs were the most affected site, which accounted for almost 75% of all the cases. 5.1% of cases were in shock, and 1.7% had altered sensorium. 43.63% were diagnosed to have necrotizing SSTI. Blood and pus culture microbiology is outlined in [Table 3]. The most common organism in blood culture was Staphylococcus epidermidis/coagulase-negative Staphylococcus followed by Streptococcus species. Pus culture microbiology showed that the most common organisms were mixed flora followed by methicillin-sensitive S. aureus and Streptococcus species [Table 4]. The outcome in the ED, at the point of discharge from the hospital, and the rate of surgical interventions are outlined in [Table 5]. Large number of cases (22.95%) preferred to continue treatment elsewhere and hence were discharged from the ED. Almost 44% of the cases required inpatient care and 34% of the cases were managed surgically.
Table 1: Baseline characteristics (n=353)

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Table 2: Clinical examination findings, site of infection, prior antibiotic therapy elsewhere, diagnosis (n=353)

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Table 3: Organism grown in blood culture (n=206)

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Table 4: Organism grown in pus culture (n=172)

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Table 5: Emergency department and hospital outcome

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  Discussion Top


Our study showed an increased prevalence among men (67%) which is similar to studies by Eron et al. and Ellis Simonsen et al. who showed that the prevalence among men was 60%–70%[5],[6] Our patients had a mean age of 52 ± 14 years which is similar to other SSTI studies (reference) The incidence of SSTI was 18.21/1000 person-years which is similar to a study by Ellis Simonsen et al. where the incidence was 24·6/1000 person-years.[6] Prevalence of diabetes mellitus (DM) among the patients who presented to the ED with SSTI was 53%. Our study showed that the most common site of SSTI's were in the lower extremity which was 75% which is much higher than studies by Dong et al. which showed almost equal distribution between the upper and lower extremities.[7] Patients were analyzed based on their occupation as predominantly outdoor jobs versus patients who had office (indoor) jobs and our study found that the incidence of SSTI was almost same in the two groups 43% versus 47%, which might suggest that outdoor jobs may not predispose to SSTI. Eron et al. showed that DM was mainly associated bacterial causes such as S. aureus and Group B Streptococci, but our study showed that almost half of our patients with positive blood culture had S. epidermidis which was followed by Streptococcus species and only 7.4% grew S. aureus. Rennie et al. in their study on 1404 patients with SSTI in 24 sites in the United States and 5 Canadian Medical Centers as part of the SENTRY Antimicrobial Surveillance Program showed S. aureus to be the most common pathogen to be isolated which was consistent with our study.[8]

The outcome of our study showed that 43.9% of cases required admission for inpatient care, which is much higher than previous studies in the ED by Black and Schrock who proved that only 25.6% of patients required hospital admission.[9] The reason for this could be our hospital being a tertiary referral center. A large percentage of the SSTI were necrotizing (43.63%) and surgical interventions were required for majority of them. Mortality rate of SSTI at our institution was 14.16% which is lower when compared to a study done by Espandar et al. at Tehran University of Medical Sciences, Iran, where the mortality rate was found to be 20.8%.[10] The limitations of our study was that it was conducted in a single tertiary hospital with majority of our patients from the rural part of South India and pediatric patients with SSTI were not included.


  Conclusion Top


Prevalence of DM was very high among the patients who presented with SSTI. The incidence rates were similar among the patients doing indoor and outdoor jobs. The most common organism isolated in the blood and pus culture being S. epidermidis and mixed flora, respectively. A high percentage of patients were diagnosed to have a necrotizing SSTI and required inpatient care and surgical intervention. Despite appropriate conservative treatment, aggressive debridement, resuscitation and amputation, the morbidity and mortality was still significant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Miller LG, Eisenberg DF, Liu H, Chang CL, Wang Y, Luthra R, et al. Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010. BMC Infect Dis 2015;15:362.  Back to cited text no. 1
    
2.
Kao LS, Knight MT, Lally KP, Mercer DW. The impact of diabetes in patients with necrotizing soft tissue infections. Surg Infect (Larchmt) 2005;6:427-38.  Back to cited text no. 2
    
3.
Pessa ME, Howard RJ. Necrotizing fasciitis. Surg Gynecol Obstet 1985;161:357-61.  Back to cited text no. 3
    
4.
Chelsom J, Halstensen A, Haga T, Høiby EA. Necrotising fasciitis due to group A streptococci in Western Norway: Incidence and clinical features. Lancet 1994;344:1111-5.  Back to cited text no. 4
    
5.
Eron LJ, Lipsky BA, Low DE, Nathwani D, Tice AD, Volturo GA, et al. Managing skin and soft tissue infections: Expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52 Suppl 1:i3-17.  Back to cited text no. 5
    
6.
Ellis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, et al. Cellulitis incidence in a defined population. Epidemiol Infect 2006;134:293-9.  Back to cited text no. 6
    
7.
Dong SL, Kelly KD, Oland RC, Holroyd BR, Rowe BH. ED management of cellulitis: A review of five urban centers. Am J Emerg Med 2001;19:535-40.  Back to cited text no. 7
    
8.
Rennie RP, Jones RN, Mutnick AH, SENTRY Program Study Group (North America). Occurrence and antimicrobial susceptibility patterns of pathogens isolated from skin and soft tissue infections: Report from the SENTRY antimicrobial surveillance program (United States and Canada, 2000). Diagn Microbiol Infect Dis 2003;45:287-93.  Back to cited text no. 8
    
9.
Black N, Schrock JW. Evaluation of Skin and Soft Tissue Infection Outcomes and Admission Decisions in Emergency Department Patients. Emergency Medicine International; 2018. Available from: https://www.hindawi.com/journals/emi/2018/7142825/. [Last accessed on 2018 Dec 10] .  Back to cited text no. 9
    
10.
Espandar R, Sibdari SY, Rafiee E, Yazdanian S. Necrotizing fasciitis of the extremities: A prospective study. Strategies Trauma Limb Reconstr 2011;6:121-5.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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