Subramaniam Sathyaseelan, Bober Jacqueline, Chao Jennifer, Zehtabchi Shahriar
Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY.
Acad Emerg Med. 2016 Nov;23(11):1298-1306. doi: 10.1111/acem.13049. Epub 2016 Nov 1.
Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections (SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy.
The objective was to describe the operating characteristics of point-of-care ultrasound (POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI.
We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with their respective 95% confidence intervals (CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic (HSROC) model.
Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR- of 0.04 (95% CI = 0.02 to 0.08).
Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis.
传统上，急诊科（ED）医生在评估皮肤和软组织感染（SSTI）时，依靠临床检查来区分蜂窝织炎和脓肿。脓肿的治疗需要切开引流，而蜂窝织炎通常需要一个疗程的抗生素治疗。误诊往往导致不必要的侵入性操作、镇静（用于儿科患者的切开引流），或因抗生素治疗失败而再次就诊于急诊科。
目的是描述在急诊科SSTI患者中，与临床检查相比，床旁超声（POCUS）识别脓肿的操作特征。
我们系统检索了从数据库建立至2015年5月的Medline、Web of Science、EMBASE、CINAHL和Cochrane图书馆数据库。纳入了在急诊科评估SSTI时，比较POCUS与临床检查以识别脓肿的试验。排除包括口腔内脓肿或手术室脓肿引流的试验。脓肿的存在通过脓液引流来定义。无脓肿定义为切开引流时无脓液引流，或随访时SSTI消退且无脓液引流。使用QUADAS - 2工具评估试验质量。操作特征报告为敏感性、特异性、阳性似然比（LR +）和阴性似然比（LR -），以及它们各自的95%置信区间（CI）。通过生成分层汇总接受者操作特征（HSROC）模型计算汇总指标。
在识别出的3203篇参考文献中，纳入了6项观察性研究（4项儿科试验和2项成人试验），共800例患者。2项试验比较了临床检查与临床检查加POCUS。其他4项试验直接比较了临床检查与POCUS。POCUS的HSROC显示敏感性为97%（95%CI = 94%至98%），特异性为83%（95%CI = 75%至88%），LR +为5.5（95%CI = 3.7至8.2），LR -为0.04（95%CI = 0.02至0.08）。
现有证据表明，POCUS有助于识别急诊科SSTI患者中的脓肿。在体格检查不明确的情况下，POCUS可协助医生区分脓肿与蜂窝织炎。
