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Page 1
Advanced Emergency Nursing Journal
Vol. 42, No. 3, pp. 196-203
Copyright (c) 2020 Wolters Kluwer Health, Inc. All rights reserved.
Dermatology
D I L E M M A S
Column Editor: Nicole Martinez, PhD, RN, FNP-BC, ENP-C, PHN
Skin and Soft-Tissue Infections
It's More Than Just Skin Deep
Nicole Martinez, PhD, RN, FNP-BC, ENP-C, PHN
Abstract
Skin and soft-tissue infection (SSTI) are one of the most common infections in both the commu
nity and hospital settings and account for nearly 4.8 million emergency department visits annually.
These infections can vary in presentation, treatment, management, and potential for complication.
As emergency medicine providers, early recognition and diagnosis of the disease are key. Point-
of-care ultrasound is an invaluable tool that has contributed to the expeditious evaluation of these
diseases with ultimate guidance for clinical management for SSTIs. This article reviews 3 SSTIs-
cellulitis, abscess, and necrotizing fasciitis-and presents a common case study for consideration.
Key words: cellulitis, cutaneous abscess, necrotizing fasciitis, point-of-care ultrasound (POCUS),
skin and soft-tissue infections (SSTIs)
S
KIN AND SOFT-TISSUE INFECTIONS
(SSTIs) represent a diverse group of in
fections that vary in clinical presenta
tion and degree of severity. They are one
of the most common infections in both the
community and hospital settings and account
for nearly 4.8 million emergency department
(ED) visits annually (Amin et al., 2014; Pallin
et al., 2008; Pollack et al., 2015; Rui, Kang,
& Ashman, 2016). Rui et al. (2016) indicated
that 3.5% of all ED visits are for SSTIs, and the
Agency for Healthcare Research and Quality
Author Affiliation: University of San Diego Hahn
School of Nursing and Health Science San Diego,
California.
Disclosure: The author reports no conflict of interest.
Corresponding Author: Nicole Martinez, PhD, RN,
FNP-BC, ENP-C, PHN, University of San Diego Hahn
School of Nursing and Health Science, 5998 Alcala Park,
San Diego, CA 92110 (nicolemartinez@sandiego.edu).
DOI: 10.1097/TME.0000000000000312
(Moore, Stocks, & Owen, 2017) assert that
SSTIs are the fifth most common medical com
plaint for ED patients in the United States.
There is a range of SSTIs and distinguish
ing one infection from another leads to ap
propriate treatment and management. For
this reason, it is essential for all emergency
care providers, including advanced practice
nurses (APRNs), to have a comprehensive un
derstanding of the physical examination find
ings, clinical practice guidelines, diagnostics,
and management. This article reviews the
definition, clinical presentation, and manage
ment for abscesses, cellulitis, and necrotizing
fasciitis and presents a common case study
for consideration.
BACKGROUND AND SIGNIFICANCE
Infections of the skin and soft tissue are
encountered in community and health care
196
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SSTI It's More Than Just Skin Deep
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settings and may commonly result in ED
Abscesses
visits. The overall incidence of SSTIs has
steadily increased over the last few decades.
In fact, according to the National Hospital
Ambulatory Medical Care Survey (Rui et al.,
2016), U.S. ED visits for SSTIs increased
from 1.2 million in 1993 to 3.4 million in
2005, whereas hospitalizations for SSTIs have
increased similarly (Edelsberg et al., 2009;
Pallin et al., 2008; Talan et al., 2015). This dra
matic increase coincides with the emergence
of community-associated methicillin-resistant
Staphylococcus aureus (CA-MRSA) and can
be attributed to the increase in incidence of
SSTIs, in particular cellulitis and abscesses.
These common clinical condition infections
can have mild to potentially life-threatening
clinical outcomes and complications. There
fore, it is prudent to understand the intrica
cies of disease recognition, treatment, and
management.
CLINICAL FEATURES AND ASSESSMENT
Skin and soft-tissue infections represent a col
lection of diagnoses that are reflective of
an inflammatory microbial invasion of the
epidermis, dermis, and subcutaneous tissues
(Dryden, 2009). When the skin barrier is
compromised, pathogens can cause infec
tions as they gain access from a break in the
skin, ulcer,  burn, or trauma/surgical  wounds
(Dryden, 2009). The vast majority of SSTIs are
commonly managed on an outpatient basis.
However, some cases require hospitalization
for parenteral antibiotic coverage and surgi
cal management.
Cellulitis
Cellulitis is a potentially serious SSTI that
may spread to the blood and lymphatic sys
tems, causing a potentially life-threatening sit
uation. It is characterized by erythematous ar
eas of skin that are edematous, indurated, and
poorly demarcated (see Table 1). The area
may be tender and warm but not fluctuant
(see Figure 1).
Abscesses are characterized by purulent
drainage from an erythematous wound that
is indurated and/or edematous. This collec
tion of pus is within the dermis or deeper
and is accompanied by redness, edema, and
induration (Center for Drug Evaluation and
Research, Food and Drug Administration,
United States Department of Health and Hu
man Services [HHS], 2013; see Figure 2).
Common bacterial pathogens causing SSTIs
are Streptococcus pyogenes and Staphylococ
cus aureus including MRSA (see Table 1).
Less common causes include other Strepto
coccus species, Enterococcus faecalis, Kleb
siella pneumoniae, or gram-negative bacte
ria (Center for Drug Evaluation and Research,
Food and Drug Administration, HHS, 2013;
Talan et al., 2011; Yadav, Gatien, Corrales-
Medina, & Stiell, 2017).
Cellulitis and abscesses are the most com
mon SSTIs in the community and hospital set
tings. Ray, Suaya, and Baxter (2013) exam
ined the incidence, microbiology, and patient
characteristics of SSTIs from patients enrolled
in the Kaiser Permanente program in North
ern California and noted that 376,262 individ
uals experienced 471,550 SSTIs over a 2-year
time period. Of those who had a culture per
formed, Staphylococcus aureus was isolated
in 81% of the specimens, of which 46% were
MRSA.
Necrotizing Soft-Tissue Infections
Necrotizing soft-tissue infections span a spec
trum of diseases characterized by high mor
tality rates, extensive soft-tissue necrosis,
and systemic toxicity (Kelly & Magilner,
2016). Terms utilized to describe necrotiz
ing soft-tissue infections include "necrotiz
ing fasciitis," "Fournier's gangrene," or "gas
gangrene." The rapid necrotizing process
commences with a direct invasion of subcuta
neous tissue from external trauma, including
intravenous injection, abscess, insect bite)
or direct spread from a perforated viscus.
The bacteria will proliferate with invasion
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198
Table 1. Skin and soft-tissue infections
Clinical
Ultrasound
Common
SSTI
Definition
presentation
findings
pathogens
Abscess
A collection of pus
Erythematous, fluctuant, and tender
Anechoic or hypoechoic
Streptococcus pyogenes and
within the dermis or
area within the dermis and deeper
oblong or spherical
Staphylococcus aureus,
deeper that is
tissues
collection of echogenic
including
accompanied by
fluid representative of a
methicillin-resistant
edema, redness,
purulent collection
Staphylococcus aureus
and/or induration
Cellulitis
A diffuse skin infection
Erythematous, indurated, and tender
Increased echogenicity with
Streptococcus species,
characterized by areas
area to the skin that is superficial
progression to
Staphylococcus aureus, dog
of erythema, edema,
hyperechoic fat lobules
bite-Pasteurella
or induration
that are separated by
multocida, human
hyperechoic fluid-filled
bite-Eikenella corrodens,
areas producing a
salt water exposure-Vibrio
cobblestone appearance
vulnificus
Necrotizing
Skin infection
Constitutional symptoms: fever,
Positive subcutaneous
Staphylococcus aureus,
fasciitis
characterized by rapid
tachycardia, AMS, DKA,
thickening, air, and fascial
Streptococcus pyogenes, and
destruction of tissue
with/without evidence of skin
fluid (STAFF)
enterococci; Escherichia
and system toxicity
inflammation
coli and Pseudomonas
Skin changes: Patchy discoloration
species; and anaerobic
and swelling
organisms, such as
Progressive disease: Development
Bacteroides or Clostridium
of tense edematous tissue,
grayish-brown "dishwater"
discharge, bullae, necrosis, and
crepitus
Advanced Emergency Nursing Journal
Copyright (c) 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Note. AMS  = altered mental status; DKA = diabetic ketoacidosis. Content derived from Castleberg et al. (2014); Comer (2018); Thom and Warlaumont (2016); Center for
Drug Evaluation and Research, Food and Drug Administration, HHS (2013).

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SSTI It's More Than Just Skin Deep
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Figure 1. Cellulitis. Photo credit: bigyahu on Visu
alHunt.com / CC BY.
into the subcutaneous tissue and deep fascia.
Ultimately, exotoxin release leads to tissue
ischemia, liquefaction necrosis, and systemic
toxicity (Kelly & Magilner, 2016). Classic
symptoms of necrotizing soft-tissue infec
tions include severe pain, diaphoresis, and
anxiety. Physical examination oftentimes re
veals cutaneous inflammation, edema, discol
oration, and induration of the subcutaneous
tissues that is wooden-hard (see Table 1).
With necrotizing fasciitis, the underlying tis
sues are firm and the fascial planes and vari
ous muscle groups are undiscernible (Stevens
et al., 2014). These deep infections are poten
tially devastating due to major tissue destruc
tion that ultimately leads to death (Stevens
et al., 2014).
CLINICAL PRACTICE GUIDELINES
The Infectious Disease Society of America
(IDSA) established practice guidelines for the
diagnosis and management of SSTIs. These
recommendations focus on the diagnosis and
treatment of all SSTIs from minor infections,
for example, impetigo, to life-threatening in
fections such as necrotizing fasciitis (Liu
et al., 2011; Stevens et al., 2014). The guide-
Figure 2. Abscess. Retrieved from https://phil.cdc
.gov/Details.aspx?pid=7826.
lines facilitate prompt diagnosis, identifica
tion of pathogen, and efficient treatment.
Abscess Management
According to the IDSA guidelines, the rec
ommended treatment of an abscess is an in
cision and drainage. Gram stain and culture
of pus from abscesses are recommended, but
treatment without obtaining these studies is
reasonable. The utilization of antibiotics in
addition to the incision and drainage is rec
ommended with the presence of systemic
inflammatory response syndrome (SIRS), in
cluding a temperature of more than 38  degC
or less than 36  degC, tachypnea, tachycardia, a
white blood cell count of more than 12,000
or fewer than 400 cells/microL, or evidence
of failed initial outpatient treatment (Miller
et al., 2015; Stevens et al., 2014).
Cellulitis Management
Cellulitis without signs of systemic illness
in the general population should be treated
with an antimicrobial agent that is active
against streptococci. Parenteral antibiotics
are indicated in patients who do present
with systemic symptoms. For patients who
present with a history of MRSA, penetrating
trauma, including intravenous drug use, or
SIRS, antimicrobial treatment against MRSA
is recommended in addition to the cover
age for streptococci (Stevens et al., 2014).
Broad-spectrum coverage may be considered
in patients who are immunocompromised.
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Advanced Emergency Nursing Journal
Cultures are not routinely recommended
unless the patient is neutropenic, has severe
cell-mediated immunodeficiency, has a ma
lignancy and is undergoing chemotherapy,
has failed outpatient treatment and taking
another agent, or has sustained an animal
bite (Stevens et al., 2014). In addition to
pharmacological management, elevation of
the affected extremity is indicated.
Outpatient therapy for SSTIs is recom
mended for all patients who do not have SIRS,
hemodynamic instability, or an altered men
tal state, whereas hospitalization is recom
mended if the infection is severe, if there is
concern for a deeper infection or necrotiz
ing fasciitis, if the patient is failing outpatient
treatment, or if there is a concern for poor ad
herence to therapy (Cranendonk, Lavrijsen,
Prins, & Wiersinga, 2017; Gunderson, Cherry,
& Fisher, 2018; Kamath et al., 2018; Stevens
et al., 2014).
Necrotizing Fasciitis Management
Prompt surgical consultation is recom
mended for patients with aggressive in
fections,
including
necrotizing
fasciitis.
Empirical antibiotic treatment should in
clude broad coverage (i.e., vancomycin or
linezolid plus piperacillin-tazobactam or a
carbapenem; plus ceftriaxone and metronida
zole; Stevens et al., 2014). Early recognition
is key with necrotizing infections as time is
of the essence. In fact, necrotizing soft-tissue
infections can spread as fast as 1 inch per
hour. Surgery is considered the gold standard
for diagnosis and treatment and may include
fasciotomy, debridement, or amputation
(Kelly & Magilner, 2016).
Community-Associated Methicillin-Resistant
Staphylococcus aureus
Staphlococcus aureus is a major cause of
both purulent and nonpurulent SSTIs (Moran,
Gorwitz, & McDougal, 2006; Stevens et al.,
2014). Methicillin-resistant Staphylococcus
aureus is associated with health care infec
tions, as well as community-associated infec
tion. Since the early 1900s, there has been
a steady increase in incidence of the disease
from 1.2 million ED visits to 3.4 million ED
visits in just 10 years (Pallin et al., 2008; Rui
et al., 2016). This influx of disease has con
tributed to a notable public health problem
and has resulted in an increase in invasive in
fections nationwide among patients seeking
treatment in the ED (Edelsberg et al., 2009;
Pollack et al., 2015). For patients with cuta
neous abscess, the primary treatment is an
incision and drainage alone. Per the clinical
practice guidelines for the treatment of MRSA
from the IDSA, antibiotic therapy is indicated
for patients with the following:
r Signs and symptoms of systemic illness;
r Severe or extensive disease, including in
fections with multiple sites;
r History suggestive of a rapid progression
with associated cellulitis;
r Abscess in a high-risk and complicated area
to drain, including the face, genitalia, and
hands/feet;
r Associated septic phlebitis;
r Comorbidities;
r Immunosuppression;
r Extremes of age from the very young to the
very old; and
r Failure to respond to incision and drainage
alone. (Liu et al., 2011)
Patients who have purulent cellulitis
should
receive
empirical
coverage
for
CA-MRSA. In contrast, those who have
nonpurulent cellulitis should receive empir
ical therapy for infection due to -hemolytic
streptococci. Only patients who do not re
spond to treatment of nonpurulent cellulitis
with a -lactam should receive empirical
coverage for CA-MRSA (Liu et al., 2011). Hos
pitalized patients with a complicated SSTI,
including those that involve major abscesses,
infected burns or ulcers, deeper soft tissue,
and surgical/traumatic wounds, should be
treated with surgical debridement and broad-
spectrum antibiotics with consideration for
empirical therapy for MRSA. Wound cul
tures should be obtained from patients who
present with systemic illness, patients who
have failed initial treatment, or patients with
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severe infection (Liu et al., 2011; Moran et al.,
2006; Singer & Talan, 2014).
CASE REPORT
A 28-year-old homeless man presented to
the ED with a 2-day history of left lower ex
tremity pain. The patient was well known to
the ED for frequent visits related to chronic
methamphetamine use, multiple abscesses,
and cellulitis. The patient had been evaluated
2 days earlier at a sister hospital for an inci
sion and drainage of a right lower extremity
abscess related to intravenous drug use and
skin popping. No antibiotics were prescribed
at that time. The patient presented to this ED
with increased pain to his left leg and was
under the influence of methamphetamine.
Clinical findings included initial vital signs
revealed an afebrile (37.6  degC), mildly hyper
tensive (148/78) patient with tachycardia
(128 beats per minute) and mild tachypnea
(22 breaths per minute). On physical exam
ination, the patient was mildly somnolent
but when prompted would answer questions
appropriately. The bilateral lower extremities
of the patient revealed chronic skin changes
related to SSTIs secondary to drug use, with
various hyperpigmented areas and numerous
scars (see Figure 3). No crepitus or fluctu
ance was appreciated. A bedside ultrasound
scan was performed, which revealed sub-
Figure 3. Skin changes secondary to metham
phetamine use. Courtesy of archives.zinester.com.
cutaneous thickening, air, and fascial fluid
(STAFF) (Castleberg, Jenson, & Dinh, 2014).
The surgeon was immediately consulted, and
the patient received intravenous antibiotics
perioperatively.
POINT-OF-CARE ULTRASOUND
Point-of-care ultrasound (POCUS) has proven
to be a valuable tool for emergency providers
to help guide the diagnosis of many disorders
in the ED, including SSTIs (Comer, 2018).
The utilization of POCUS can help the clini
cian differentiate between cellulitis, abscess,
and even necrotizing fasciitis and will guide
clinical management of these cases. It serves
as an adjunct to assist in early diagnosis of
each disorder as the presentations of abscess,
cellulitis, and necrotizing fasciitis have dis
tinct characteristics via ultrasound (Thom &
Warlaumont, 2016; see Table 1).
The case previously discussed presented
a commonly seen ED patient and certainly
one who may have been overlooked. The pa
tient was a high-risk frequent ED user who
was under the influence of multiple sub
stances. His altered mental state may have eas
ily been attributed to drug utilization, though
the true cause was likely related to the sys
temic toxicity secondary to the necrotizing
skin infection. Ultimately, the identification of
irregularly thickened fascia with fluid track
ing along deep fascial planes aided in the clin
ical diagnosis of necrotizing fasciitis and was
an invaluable tool that contributed to the ex
peditious care for this patient.
DISCUSSION
Skin and soft-tissue infection is one of the
most common complaints in the ED. As emer
gency medicine providers, APRNs are aware
that early recognition and diagnosis of the
disease are key with SSTIs. These infections
can vary in presentation, treatment, manage
ment, and potential for complication. Health
care providers play an important role in mit
igating these variances in care through the
implementation and adherence to national
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Advanced Emergency Nursing Journal
guidelines that address not only the physical
examination findings and treatment of the
patient but also the sociodemographic char
acteristics of the patient that may predispose
him or her to a higher risk of complication
and poor health outcomes. In combination
with the guidelines, POCUS is an invaluable
tool and asset to emergency clinicians as it
will allow for an expeditious evaluation of
the disease with ultimate guidance of clinical
management.
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