The Limited Utility of Routine Culture in Pediatric Pilonidal, Gluteal, and Perianal Abscesses.

BACKGROUND: Pilonidal, buttock, and perianal abscesses are common reasons for surgical consultation in the pediatric emergency department. Treatment typically includes a bedside incision and drainage, often followed by an abscess culture, and a course of oral antibiotics. We aimed to study the impact of culture data on changes in management and clinical outcomes. We hypothesized that management is unaffected by culture data, and therefore, fluid culture from pilonidal, buttock, and perianal abscesses in the pediatric population may represent an unnecessary laboratory test and cost. MATERIALS AND METHODS: A single institution's electronic medical record was searched between February 1, 2013 and August 1, 2017, identifying 249 pediatric patients meeting the inclusion criteria: age 0 to 18 y; diagnosis of pilonidal, buttock, or perianal abscess; bedside incision and drainage. Patients were divided into two different comparison groups for data analysis based on the presence or absence of culture and recurrence or no recurrence. RESULTS: Culture results directly altered management in only 5 patient encounters (2.7% of all cultured). When comparing groups by culture or no culture, no statistically significant difference in recurrence rate (P = 0.4) was noted. When comparing groups by recurrence versus no recurrence, we found no statistically significant difference between sex, resident type, vessel loop use, packing use, or antibiotic use (P > 0.05). CONCLUSIONS: We conclude that microbiological culture results are of limited utility in the management of pediatric pilonidal, buttock, and perianal abscesses as they do not appear to alter treatment, and omission of culture is not associated with failure of surgical management.

Routine operative swab cultures and post-operative antibiotic use for uncomplicated perianal abscesses are unnecessary.

BACKGROUND: Routine swab cultures for perianal abscesses remain commonplace in surgical practice. However, patients are often discharged post-operatively prior to the culture results being made available. Consequently, intra-operative swab cultures rarely impact subsequent management and outcomes. Similarly, the use of broad-spectrum antibiotics for perianal abscesses post-drainage also remains prevalent, albeit with questionable benefit. METHODS: The records of all patients diagnosed with perianal abscess from January 2011 to December 2011 were reviewed. Patients with complicated perianal abscesses or recurrent abscesses previously treated before the study period were excluded. The demographics, medical co-morbidities, intra-operative findings, swab cultures, microbiological results and use of post-operative antibiotics were reviewed. Subsequent wound healing and follow-up were also recorded. RESULTS: Two hundred and seven patients were admitted to our institution for perianal abscesses in 2011. After excluding 35, the remaining 172 patients were analysed. One hundred and thirty-four patients (78%) had swab cultures performed intra-operatively but 80% of these were discharged prior to the culture results being available. One hundred and eight (63%) were discharged with outpatient antibiotics. During the index admission and subsequent follow-up, swab culture results were not documented to be reviewed by the attending physician 96.5% of the time. Sixteen patients required repeat surgery for recurrence of anorectal sepsis. We found that the use of antibiotics after the index surgery did not confer a statistically significant benefit. CONCLUSION: Routine swab cultures are unnecessary and do not affect management and outcome. The use of post-operative antibiotics may reduce the rates of recurrence, but this benefit was not found to be statistically significant.

Ultrasound-Guided Percutaneous Catheter Drainage of Large Breast Abscesses in Lactating Women: How to Preserve Breastfeeding Safely.

INTRODUCTION: Management of breast abscess in lactating women remains controversial. During pregnancy, women may develop different kinds of benign breast lesions that could require a surgical incision performed under general anesthesia with consequent breastfeeding interruption. The purpose of this study was to prospectively evaluate the management of large breast abscesses with ultrasound-assisted drainage aiming at breastfeeding preservation. MATERIALS AND METHODS: 34 lactating women with a diagnosis of unilateral breast abscess have been treated with an ultrasound (US)-assisted drainage of the abscess. A pigtail catheter was inserted into the fluid collection using the Seldinger technique under US guide and connected to a three stop way to allow drainage and irrigation of the cavity until its resolution. RESULTS: All procedures have been found safe and well tolerated. No recurrence was observed and breastfeeding was never interrupted. CONCLUSIONS: The described technique allows to avoid surgery and to preserve breastfeeding in well-selected patients with a safe, well-tolerated and cost-effective procedure.

Bacteriological study in perianal abscess is not useful and not cost-effective.

BACKGROUND: The detection of gut organisms in perianal abscesses has been postulated to suggest an underlying communication with the anal canal. However, recent studies appear to contradict this observation. The aim of this study is to determine the value of bacteriological studies in perianal abscesses. METHODS: A retrospective study of all patients who have had a surgical drainage of their perianal abscesses with concomitant microbiological examination from January 2010 to December 2012 was performed. Patients with known underlying anal fistula, Crohn's disease or previous perianal operations were excluded. RESULTS: A total of 164 patients, median age of 42.0 years (range 8-87) comprising of 78.7% males formed the study group. Gut organisms were cultured in 143 (87.2%) samples while 12 (7.3%) demonstrated skin organisms and nine did not yield any bacterial growth (5.5%). Twenty-nine (17.7%) patients developed anal fistula and 34 (20.7%) patients had a recurrence of the perianal abscess. The median follow-up period was 1450 (14-2391) days. There was no significant association between the presence of gut organism and development of fistulas (odds ratio = 0.48; 95% confidence interval = 0.17-1.37) or recurrence of perianal abscess (odds ratio = 1.66; 95% confidence interval = 0.46-6.01). CONCLUSION: Bacteriological culture in perianal abscess is not useful for predicting the development of anal fistula or abscess recurrence. Hence, there is no need to perform this investigation on a routine basis.

Direct molecular versus culture-based assessment of Gram-positive cocci in biopsies of patients with major abscesses and diabetic foot infections.

Major abscesses and diabetic foot infections (DFIs) are predominant subtypes of complicated skin and skin structure infections (cSSSIs), and are mainly caused by Staphylococcus aureus and ß-hemolytic streptococci. This study evaluates the potential benefit of direct pathogen-specific real-time polymerase chain reaction (PCR) assays in the identification of causative organisms of cSSSIs. One-hundred and fifty major abscess and 128 DFI biopsy samples were collected and microbial DNA was extracted by using the Universal Microbe Detection kit for tissue samples. Pathogen-specific PCRs were developed for S. aureus and its virulence factor Panton-Valentine leukocidin (PVL), Streptococcus pyogenes, S. agalactiae, S. dysgalactiae, and the S. anginosus group. Identification by pathogen-specific PCRs was compared to routine culture and both methods were considered as the gold standard for determination of the sensitivity and specificity of each assay. Direct real-time PCR assays of biopsy samples resulted in a 34 % higher detection of S. aureus, 37 % higher detection of S. pyogenes, 18 % higher detection of S. agalactiae, 4 % higher detection of S. dysgalactiae subspecies equisimilis, and 7 % higher detection of the S. anginosus group, compared to routine bacterial culture. The presence of PVL was mainly confined to S. aureus isolated from major abscess but not DFI biopsy samples. In conclusion, our pathogen-specific real-time PCR assays had a higher yield than culture methods and could be an additional method for the detection of relevant causative pathogens in biopsies.

Pediatric head and neck complications of Streptococcus pneumoniae before and after PCV7 vaccination.

OBJECTIVE: To discuss pediatric head and neck complications of pneumococcal infections before and after the introduction of the PCV7 vaccine. STUDY DESIGN: Cross-sectional analysis of a national database. STUDY SETTING: Kids National Inpatient Database. METHODS: A retrospective review of the Kids National Inpatient Database yielded 31,738 pediatric reports involving complications of meningitis, mastoiditis, periorbital cellulitis, and Bezold abscesses due to Streptococcus pneumoniae diagnoses. Each report was analyzed for incidence, length of stay, mean hospital cost, and inpatient admittance from the emergency department. Finally, we calculated the expected annual incidence of each complication via variance-weighted analysis to determine the expected incidence if the vaccine was not administered. RESULTS: We identified a significant decrease in the incidence of several complications after the introduction of the PCV7 vaccine and also when comparing these findings to our predicted incidence calculations if the vaccine was not administered. Inpatient admittance from the emergency department for Bezold abscess, periorbital cellulitis, mastoiditis, and meningitis was significantly increased in the pediatric age group (ages 1-4; P < .05). Furthermore, there was a significant increase in the cost to provide care for each of the described conditions (P < .05). CONCLUSIONS: The PCV7 vaccine produced a measurable reduction in head and neck complications associated with S pneumoniae. However, our data suggest that these benefits were also met with increased inpatient admittance from the emergency department, hospital costs, and length of stay, each of which may be attributed to the selection of a more pathogenic subtype.

Health and economic burden of post-partum Staphylococcus aureus breast abscess.

OBJECTIVES: To determine the health and economic burdens of post-partum Staphylococcus aureus breast abscess. STUDY DESIGN: We conducted a matched cohort study (N = 216) in a population of pregnant women (N = 32,770) who delivered at our center during the study period from 10/1/03-9/30/10. Data were extracted from hospital databases, or via chart review if unavailable electronically. We compared cases of S. aureus breast abscess to controls matched by delivery date to compare health services utilization and mean attributable medical costs in 2012 United States dollars using Medicare and hospital-based estimates. We also evaluated whether resource utilization and health care costs differed between cases with methicillin-resistant and -susceptible S. aureus isolates. RESULTS: Fifty-four cases of culture-confirmed post-partum S. aureus breast abscess were identified. Breastfeeding cessation (41%), milk fistula (11.1%) and hospital readmission (50%) occurred frequently among case patients. Breast abscess case patients had high rates of health services utilization compared to controls, including high rates of imaging and drainage procedures. The mean attributable cost of post-partum S. aureus breast abscess ranged from $2,340-$4,012, depending on the methods and data sources used. Mean attributable costs were not significantly higher among methicillin-resistant vs. -susceptible S. aureus cases. CONCLUSIONS: Post-partum S. aureus breast abscess is associated with worse health and economic outcomes for women and their infants, including high rates of breastfeeding cessation. Future study is needed to determine the optimal treatment and prevention of these infections.

Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage.

INTRODUCTION: Deep neck space abscesses (DNAs) are relatively common otolaryngology-head and neck surgery emergencies and can result in significant morbidity with potential mortality. Traditionally, surgical incision and drainage (I&D) with antibiotics has been the mainstay of treatment. Some reports have suggested that ultrasound-guided drainage (USD) is a less invasive and effective alternative in select cases. OBJECTIVES: To compare I&D vs USD of well-defined DNAs, using a randomized controlled clinical trial design. The primary outcome measure was effectiveness (length of hospital stay (LOHS) and safety), and the secondary outcome measure was overall cost to the healthcare system. METHODS: Patients presenting to the University of Alberta Emergency Department with a well-defined deep neck space abscess were recruited in the study. Patients were randomized to surgical or US-guided drainage, placed on intravenous antibiotics and admitted with airway precautions. Following drainage with either intervention, abscess collections were cultured and drains were left in place until discharge. RESULTS: Seventeen patients were recruited in the study. We found a significant difference in mean LOHS between patients who underwent USD (3.1 days) vs I&D (5.2 days). We identified significant cost savings associated with USD with a 41% cost reduction in comparison to I&D. CONCLUSIONS: USD drainage of deep neck space abscesses in a certain patient population is effective, safe, and results in a significant cost savings to the healthcare system.

Socioeconomic implications of pediatric cervical methicillin-resistant Staphylococcus aureus infections.

OBJECTIVE: To study cervical methicillin-resistant Staphylococcus aureus (MRSA) infections using a national database with the goal of providing normative data and identifying variations in resource utilization. DESIGN: Retrospective review using a pediatric national data set (Kids' Inpatient Database 2009). SUBJECTS: Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for both MRSA and specific neck and pharyngeal infections. RESULTS: There were 26,829 admissions with MRSA; 3571 included a head and neck infection. The mean (SE) age at admission was 7.72 (0.20) years. Most patients (65.0%) were in the lower 2 socioeconomic quartiles; the most common payer was Medicaid (53.3%). The mean total charge per admission was $20,442. The mean (SE) length of stay (LOS) was 4.39 (0.15) days; there were significant differences among age (P < .001) and racial (P < .001) groups. A total of 1671 children underwent at least 1 surgical drainage procedure; there were statistically significant differences among racial (P < .001), age (P < .001), and socioeconomic (P = .048) groups. There were no regional variations in resource utilization when LOS, number of procedures, and total hospital charges were compared. CONCLUSIONS: Cervical MRSA infections have a large socioeconomic impact across the nation. There are differences among the various races in resource utilization. Younger children have longer hospitalizations, are more likely to need surgery, and require more intubations. Children from the lowest socioeconomic group require surgery more frequently, but their LOS is not statistically different when compared with the other 3 groups. Knowledge of such characteristics for cervical MRSA infections in children can facilitate targeted clinical interventions to improve care of affected populations.

[Assessment of efficacies of imipenem, cefoperazone-sulbactam and cefepime in rats with experimental thigh abscess model with multidrug resistant and susceptible Acinetobacter baumannii strains]. / Sefoperazon-sulbaktam, imipenem ve sefepimin antibiyoterapi etkinliklerinin çogul dirençli ve duyarli acinetobacter baumannii ile olusturulan deneysel ikili apse modelinde karsilastirilmasi.

Imipenem, cefaperazon-sulbactam and cefepime are the antibiotics of choice for the treatment of soft tissue infections due to Acinetobacter baumannii. In this study, it was aimed to determine the invivo and invitro efficacy of, these antibiotics against drug susceptible and multidrug resistant A.baumannii in an experimental abscess model. Abscess models were established in Wistar-Albino type female rats. Susceptibility tests were performed by E-test. Rats were divided randomly into four groups with eight rats in one group. Standard absorbent paper discs containing 6 log10 CFU microorganisms were used to form an abscess model. The first group was regarded as the control group and the other three groups were the study group each treated with one of the test antibiotics. Cardiac blood samples for serum antibiotic efficacy test, were obtained on the fourth day of treatment and 30 minutes after the last dose. The number of live bacteria at the area of infection was determined by colony count method. All of the three antibiotics reached sufficient concentration in sera of rats and there were no statistically important difference between the efficacies of these antibiotics (p= 0.778). In all of the antibiotic-treated groups, the weight of the abscess material were less, macroscopic views were smaller and the colony counts per gram of abscess tissue were less than the control group (p< 0.001). All antibiotics were effective against susceptible and resistant strains in vitro. No resistance was detected against imipenem, cefaperazon-sulbactam and cefepime in the course of therapy. Cefaperazone-sulbactam and cefepime were as effective as imipenem against susceptible and multi-drug resistant A.baumannii both in vivo and in vitro. Since irrational use of extended spectrum cephalosporins are frequently associated with the emergence of carbapenem resistant strains, the use of relatively narrow spectrum antibiotics should better be considered in the empirical treatment of A.baumannii infections.

Assessment of the microbiota of a mixed infection of the tongue using phenotypic and genotypic methods simultaneously and a review of the literature.

We assessed the microbiota of a tongue abscess in which twelve different aerobic and anaerobic bacteria were identified using fluorescent in situ hybridisation (FISH), sequencing of the 16S rRNA gene and phenotypic methods. By applying the 16S rRNA based probes directly on the clinical material, a quick insight of the bacteria present was obtained and the species which were not cultured but present in the abscess were identified.

Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes.

STUDY OBJECTIVE: To assess the effect of daptomycin compared with vancomycin on the clinical and economic outcomes in patients with complicated skin and skin structure infections. DESIGN: Prospective, open-label study. SETTING: Level 1 trauma center in Detroit, Michigan. PATIENTS: Fifty-three adult patients with complicated skin and skin structure infections at risk for methicillin-resistant Staphylococcus aureus (MRSA) infection who were treated with daptomycin and a matched cohort of 212 patients treated with vancomycin. INTERVENTION: Patients in the prospective arm received intravenous daptomycin 4 mg/kg every 24 hours for at least 3 days but not more than 14 days. Historical controls received at least 3 days of vancomycin dosed to achieve trough concentrations of 5-20 microg/ml. MEASUREMENTS AND MAIN RESULTS: Outcomes evaluated included blinded assessments of clinical resolution, duration of therapy, and costs. The most common diagnoses were cellulitis (31%), abscess (22%), and both cellulitis with abscess (37%). Microbiology differed significantly between groups, with S. aureus found in 27 patients (51%) in the daptomycin group and 167 patients (79%) in the vancomycin group and MRSA in 22 (42%) and 159 (75%), respectively (p<0.001). The proportions of patients with clinical improvement or resolution of their infections on days 3 and 5 were 90% versus 70% and 98% versus 81% in the daptomycin versus vancomycin groups, respectively (p<0.01 for both comparisons), and 100% at the end of therapy in both groups. Among patients with complete resolution of their infections (41 patients [77%] with daptomycin vs 89 patients [42%] with vancomycin, p<0.05), median duration of intravenous therapy was 4 and 7 days, respectively, (p<0.001), and hospital costs were $5027 and $7552 (p<0.001). CONCLUSIONS: Patients receiving daptomycin achieved more rapid resolution of symptoms and clinical cure and had a decreased duration of inpatient therapy compared with those receiving vancomycin. This study suggests that daptomycin is a cost-effective alternative to vancomycin for complicated skin and skin structure infections.

[Soft-tissue infections due to non-tuberculous mycobacteria following mesotherapy. What is the price of beauty]. / Infecciones en tejidos blandos por micobacterias no tuberculosas secundarias a mesoterapia. 'Cuánto vale la belleza?

INTRODUCTION: Mesotherapy is widely used In Latin America for cosmetic purposes, particularly in obese individuals. We describe the clinical and epidemiological characteristics, microbiological diagnosis, treatment and follow-up of patients from Caracas (Venezuela) with soft tissue infection caused by non-tuberculous mycobacteria following mesotherapy. METHODS: Between March 2002 and December 2003, we evaluated 49 cases of skin and soft tissue infection following mesotherapy. Specimens obtained from the lesions and 15 products used in the mesotherapy procedure were cultured for the presence of non-tuberculous mycobacteria. Isolated mycobacteria were identified by PCR restriction fragment length polymorphism analysis of the hsp65 gene. RESULTS: Infection by non-tuberculous mycobacteria was confirmed in 81.6% of the 49 cases. Mycobacterium abscessus and M. fortuitum were the most common species, but M. chelonae, M. peregrinum, M. simiae and a new species that was designated "M. cosmeticum" were also isolated. Patients were treated with species-specific antibiotic agents for 3 to 18 months. Investigation into the source of the infection revealed that 21 patients were clustered within 3 different outbreaks and two products were found to be contaminated with M. fortuitum and M. abscessus, respectively. CONCLUSIONS: Physicians should be alerted to the possibility of infection by non-tuberculous mycobacteria in patients with a history of mesotherapy who develop late-onset skin and soft tissue infection, particularly if they do not respond to conventional antibiotic treatment.

Economic impact of the community-acquired methicillin-resistant Staphylococcus aureus epidemic on the Driscoll Children's Health Plan.

Cellulitis and abscess accounted for increasing percentages of inpatient (4.6-11.1%), outpatient (0.6-1.2%) and total (1.7-3.3%) expenses from 2001 through 2004. The per member per month expenses attributed to cellulitis and abscess increased from $0.74 in 2001 to $1.19 in 2004. The epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections in children has had a significant economic impact on the Driscoll Children's Health Plan.

Early and late assessment of internal drainage of chronic dacryocystitis.

To evaluate the efficacy of internal drainage of a lacrimal abscess, we treated 10 patients with pyocele of the lacrimal sac, who did not want to undergo operative intervention. A temporary nasolacrimal stent was placed in the nasolacrimal duct, and the pussy material was collected for microbiological examination to adjust the preliminary antibiotic treatment which was given systemically and locally. The stents were removed after the infection had subsided clinically. Three years later, there was a recurrence of the infection in only 1 patient. This internal drainage of the lacrimal sac, combined with systemic and local antibiotics, was successful in 90% of the patients.

Current best practices and guidelines. Assessment and management of complications in infective endocarditis.

The most important complications of endocarditis are congestive heart failure, paravalvular abscess formation, and embolism, especially stroke. In addition, endocarditis may be complicated by septic arthritis, vertebral osteomyelitis, pericarditis, metastatic abscesses and an array of renal problems ranging from immune-complex glomerulonephritis to renal abscesses. Adverse reactions associated with medical treatment of endocarditis can also result in significant complications such as ototoxicity and nephrotoxicity, skin rashes, and serum sickness. This review focuses on the cardiac, embolic, neurologic and renal complications of endocarditis and discusses how these complications influence the clinical management of individual cases in daily practice.

Risk assessment of organoleptic postmortem inspection procedures for pigs.

A systematic quantification of foodborne hazards in abnormal and normal tissues of pig carcases was undertaken to provide a risk-based assessment of the effectiveness of traditional organoleptic meat inspection. A total of 36,059 pigs, representing all major pig-producing areas and systems in Australia, were inspected on a seasonal basis at three abattoirs over 12 months. The prevalence of grossly detectable abnormalities of possible food-borne disease significance was recorded. A subset of the grossly detectable abnormalities, together with tissues classified by inspection as normal (controls) were submitted for the detection of a broad range of food-borne hazards. The potential exposure of consumers to hazards in fresh pork was characterised as the number of carcases per 10,000 containing hazards in selected tissues. The results indicated that the level of exposure of consumers to microbiological hazards in fresh pork is unlikely to be reduced significantly by the detection and removal of gross abnormalities in the tissues examined. On the basis of carcase throughput, the rate of contamination of normal lymph nodes was commonly 100 times higher, and no hazards were isolated from two types of grossly abnormal nodes. While further processing, cooking and handling may alter the exposure characterisation, the study nevertheless identifies the proportional contribution of abnormal and normal tissues to risks to consumers and clearly identifies the need for consideration of 'visual only' inspection in the re-evaluation of traditional inspection procedures.

Gonococcal endocarditis: assessment by transesophageal echocardiography.

Gonococcal endocarditis is a rare but aggressive infection that has an alarming rate of perivalvular abscess and mortality. We present a case of gonococcal endocarditis with intracardiac abscess and fistula diagnosed by transesophageal echocardiography. Given the often acute nature of gonococcal endocarditis and its propensity toward abscess formation, transesophageal echocardiography should be considered early in the course of this infection.