VISIT US AT BOOTH # 203 AT THE ACEP PEDIATRIC ASSEMBLY IN NEW YORK, NY, MARCH 24-25, 2015 February 2015 Evidence-Based Management Volume 12, Number 2 Authors Of Skin And Soft-Tissue Jennifer E. Sanders, MD Pediatric Emergency Medicine Fellow, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Infections In Pediatric Patients New York, NY Sylvia E. Garcia, MD Assistant Professor of Pediatrics and Pediatric Emergency In The Emergency Department Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Abstract Peer Reviewers Jeffrey Bullard-Berent, MD, FAAP, FACEP Skin and soft-tissue infections are among the most common condi- Health Sciences Professor, Emergency Medicine and Pediatrics, University of California – San Francisco, Benioff tions seen in children in the emergency department. Emergency de- Children’s Hospital, San Francisco, CA partment visits for these infections more than doubled between 1993 Carla Laos, MD, FAAP and 2005, and they currently account for approximately 2% of all Pediatric Emergency Medicine Physician, Dell Children’s Hospital, Austin, TX emergency department visits in the United States. This rapid increase CME Objectives in patient visits can be attributed largely to the pervasiveness of community-acquired methicillin-resistant Staphylococcus aureus. The Upon completion of this article, you should be able to: 1. Describe the pathophysiology of community-acquired emergence of this disease entity has created a great deal of controver- methicillin-resistant Staphylococcus aureus. sy regarding treatment regimens for skin and soft-tissue infections. 2. Differentiate the clinical presentation of common skin and soft-tissue infections. This issue of Pediatric Emergency Medicine Practice will focus on the 3. Outline the management of common skin and soft-tissue management of children with skin and soft-tissue infections, based infections. on the current literature. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-in-Chief Ilene Claudius, MD Therapeutics; Research Director, Melissa Langhan, MD, MHS Christopher Strother, MD Associate Professor of Emergency Pediatric Emergency Medicine, BC Associate Professor of Pediatrics, Assistant Professor, Director, Adam E. Vella, MD, FAAP Medicine, Keck School of Medicine Children's Hospital, Vancouver, BC, Fellowship Director, Pediatric Undergraduate and Emergency Associate Professor of Emergency of the University of Southern Canada Emergency Medicine, Director of Simulation, Icahn School of Medicine, Pediatrics, and Medical California, Los Angeles, CA Education, Pediatric Emergency Medicine at Mount Sinai, New Alson S. Inaba, MD, FAAP Education, Director Of Pediatric Medicine, Yale School of Medicine, York, NY Ari Cohen, MD Associate Professor of Pediatrics, Emergency Medicine, Icahn New Haven, CT School of Medicine at Mount Sinai, Chief of Pediatric Emergency University of Hawaii at Mãnoa AAP Sponsor New York, NY Medicine Services, Massachusetts John A. Burns School of Medicine, Robert Luten, MD General Hospital; Instructor in Division Head of Pediatric Professor, Pediatrics and Martin I. Herman, MD, FAAP, FACEP Associate Editor-in-Chief Pediatrics, Harvard Medical Emergency Medicine, Kapiolani Emergency Medicine, University of Professor of Pediatrics, Attending Physician, Emergency Medicine Vincent J. Wang, MD, MHA School, Boston, MA Medical Center for Women and Florida, Jacksonville, FL Children, Honolulu, HI Department, Sacred Heart Associate Professor of Pediatrics, Marianne Gausche-Hill, MD, Garth Meckler, MD, MSHS Children’s Hospital, Pensacola, FL Keck School of Medicine of the FACEP, FAAP Madeline Matar Joseph, MD, FAAP, Associate Professor of Pediatrics, University of Southern California; Professor of Clinical Medicine, FACEP University of British Columbia; International Editor Associate Division Head, David Geffen School of Medicine Professor of Emergency Medicine Division Head, Pediatric Lara Zibners, MD, FAAP Division of Emergency Medicine, at the University of California at and Pediatrics, Chief and Medical Emergency Medicine, BC Honorary Consultant, Paediatric Children's Hospital Los Angeles, Los Angeles; Vice Chair and Chief, Director, Pediatric Emergency Children's Hospital, Vancouver, Emergency Medicine, St Mary's Los Angeles, CA Division of Pediatric Emergency Medicine Division, University BC, Canada Hospital, Imperial College Trust; Medicine, Harbor-UCLA Medical of Florida Medical School- Editorial Board Joshua Nagler, MD EM representative, Steering Group Center, Los Angeles, CA Jacksonville, Jacksonville, FL Assistant Professor of Pediatrics, ATLS ®-UK, Royal College of Jeffrey R. Avner, MD, FAAP Michael J. Gerardi, MD, FAAP, Stephanie Kennebeck, MD Harvard Medical School; Surgeons, London, England Professor of Clinical Pediatrics FACEP, President-Elect Associate Professor, University Fellowship Director, Division of and Chief of Pediatric Emergency Associate Professor of Emergency of Cincinnati Department of Emergency Medicine, Boston Pharmacology Editor Medicine, Albert Einstein College Medicine, Icahn School of Pediatrics, Cincinnati, OH Children’s Hospital, Boston, MA James Damilini, PharmD, MS, of Medicine, Children’s Hospital at Medicine at Mount Sinai; Director, BCPS Montefiore, Bronx, NY Anupam Kharbanda, MD, MS James Naprawa, MD Pediatric Emergency Medicine, Research Director, Associate Associate Clinical Professor Clinical Pharmacy Specialist, Steven Bin, MD Goryeb Children's Hospital, Fellowship Director, Department of Pediatrics, The Ohio State Emergency Medicine, St. Associate Clinical Professor, Morristown Medical Center, of Pediatric Emergency Medicine, University College of Medicine; Joseph's Hospital and Medical Division of Pediatric Emergency Morristown, NJ Children's Hospitals and Clinics of Attending Physician, Emergency Center, Phoenix, AZ Medicine, UCSF Benioff Children’s Sandip Godambe, MD, PhD Minnesota, Minneapolis, MN Department, Nationwide Children’s Quality Editor Hospital, University of California, Vice President, Quality & Patient Hospital, Columbus, OH Tommy Y. Kim, MD, FAAP, FACEP San Francisco, CA Safety, Professor of Pediatrics and Steven Choi, MD Assistant Professor of Emergency Steven Rogers, MD Richard M. Cantor, MD, FAAP, Emergency Medicine, Attending Medical Director of Quality, Medicine and Pediatrics, Loma Assistant Professor, University of Director of Pediatric Cardiac FACEP Physician, Children's Hospital Linda University Medical Center and Connecticut School of Medicine, Inpatient Services, The Children’s Professor of Emergency Medicine of the King's Daughters Health Children’s Hospital, Loma Linda, CA; Attending Emergency Medicine and Pediatrics, Director, Pediatric System, Norfolk, VA Hospital at Montefiore; Assistant California Emergency Physicians, Physician, Connecticut Children's Professor of Pediatrics, Albert Emergency Department, Medical Ran D. Goldman, MD Riverside, CA Medical Center, Hartford, CT Director, Central New York Einstein College of Medicine, Professor, Department of Pediatrics, Bronx, NY Poison Control Center, Golisano University of British Columbia; Children's Hospital, Syracuse, NY Co-Lead, Division of Translational Case Presentations recognize the common SSTIs frequently encountered in the ED and be prepared to treat them appro- A 7-month-old, otherwise healthy, boy is brought to the priately. The approach to common SSTIs has been emergency department with irritability and lethargy 3 drastically altered by the emergence of community- days after undergoing elective circumcision. By history, associated methicillin-resistant Staphylococcus aureus he has been afebrile. His mother noted a faint red rash (CA-MRSA), leading many physicians to alter their and swelling around the scrotum that extends up the practice accordingly. abdomen. He is afebrile and normotensive on arrival, but he is tachycardic to 180 beats/min and tachypneic to 59 Critical Appraisal Of The Literature breaths/min, and his oxygen saturation is 91% on room air. On genitourinary examination, you note a circum- A search was performed in PubMed for articles cised penis with some erythema and edema near the glans. published from 2007 to 2014 pertaining to children The scrotum appears normal, and both testes are palpable aged < 18 years using multiple combinations of the and nontender. The perineum appears normal. There is a search terms skin and soft-tissue infections, cellulitis, faint erythematous area, approximately 10 cm in diameter impetigo, staphylococcal scalded skin syndrome, toxic that extends to the right upper leg. An ecchymotic lesion shock syndrome, MRSA, erysipelas, and hand infections. with a central bulla measuring 2 cm by 2 cm is noted in The Cochrane Database of Systematic Reviews was the right inguinal area. No crepitus is palpated in the in- also consulted. Articles relevant to pediatric skin and volved area. You are worried that this child’s lesions have soft-tissue infections were selected and reviewed. progressed from a localized infection to a systemic one. More than 400 articles were reviewed, 137 of which The mother asks what is wrong with her baby… were chosen for inclusion in this review, including A 2-year-old, otherwise healthy, girl is brought to a number of randomized controlled trials, meta- the emergency department with a rash on her face. Her analyses, and clinical practice guidelines. The latest mother notes that the rash started 3 days ago after her practice guidelines for the diagnosis and manage- child