List of Abbreviations
AT – antibacterial therapy
GI – gastrointestinal tract
RF – respiratory failure
CSG – clinical-statistical group
CT – computed tomography
MRI – magnetic resonance imaging
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs
OF – organ failure
ICU – intensive care unit
ESR – erythrocyte sedimentation rate
CRP – C-reactive protein
SIRS – systemic inflammatory response syndrome
US – ultrasound examination
SI – surgical infections
SOFA – Sequential Organ Failure Assessment
SIRS – Systemic Inflammatory Response Syndrome
Terms and Definitions
Cutaneous felon – acute inflammation of a finger where the lesion is located intracutaneously between the papillary dermis and the epidermis.
Lymphadenitis – inflammation of a lymph node.
Felon – acute purulent inflammation of the tissues of the fingers and toes.
Paronychia – inflammation of the fold surrounding the nail base.
Paratendinous felon – inflammatory process where the lesion is located in the folds at the lateral edges of the nail plate.
Subcutaneous felon – diffuse purulent inflammation of the subcutaneous tissue of the fingers.
Subungual felon – inflammatory process where the lesion is located beneath the nail plate.
Wound infection – an infectious process developing within a wound.
Sepsis – a pathological process based on the body's response in the form of a generalized (systemic) inflammation to an infection of various origins, leading to acute organ dysfunction.
Systemic inflammatory response syndrome (SIRS) – the systemic response of the body to local tissue injury.
Phlegmon (cellulitis) – acute diffuse purulent inflammation of cellular spaces.
Surgical infections – infectious processes in the treatment and prevention of which certain surgical procedures are or may prove necessary, as well as infectious processes complicating surgical diseases, surgical interventions, and trauma.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Skin and subcutaneous surgical infection – a group of acute infections of the skin, its appendages, and subcutaneous tissue, the treatment of which may require various surgical interventions, as well as infectious complications of already performed surgical interventions or trauma. Skin and subcutaneous surgical infections account for 85% – 85% [sic: 80% – 85%] of all surgical infection cases [2, 3, 7].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Soft tissue surgical infections are caused predominantly by the patient's own microflora; in 70 – 80% of cases, this is S. aureus. Considerably less frequently, skin and subcutaneous infections may be caused by St. pyogenes, other Gram-positive and Gram-negative bacteria, and their associations [2, 3].
Staphylococcus (Staphilicoccus) is the most common causative agent of surgical infections. There are three main species of staphylococci: S. aureus, S. epidermidis, and S. Saprophyticus. Methicillin-resistant strains of Staphylococcus aureus (MRSA) pose a particular problem, with such strains being increasingly isolated from patients who have no prior history of hospitalization or antibacterial therapy. Like other Gram-positive bacteria, staphylococci secrete exotoxins and a number of enzymes (staphylolysin, plasminogen activator/coagulase, hyaluronidase) that cause the destruction of erythrocytes and leukocytes, coagulate and degrade proteins, and facilitate the spread of microorganisms within tissues. Staphylococci are characterized by resistance to physical and chemical agents, and resistance to antimicrobial drugs develops very rapidly. Most S. aureus strains are capable of producing several classes of beta-lactamases, which determines their resistance to beta-lactam antibiotics (beta-lactam antibacterial drugs, penicillins, and other beta-lactam antibacterial drugs [2, 3].
The presence of potential pathogens is in most cases insufficient for the development of a surgical infection; in addition to the presence of the pathogen, predispositions are required. Many conditions predisposing to the development of surgical infections have been studied.
First and foremost, these are foci of chronic infection, such as chronic infections of the skin and its appendages, the oral cavity and respiratory system, and the urogenital organs. The prolonged existence of such foci triggers a number of pathological immune responses, often referred to as bodily sensitization. Furthermore, chronic infections are frequently treated with antimicrobial agents (systemic antibacterial drugs), which leads to the development of resistance to them and greatly complicates the selection of adequate therapy when an acute surgical infection develops.
Primary and secondary immunodeficiencies frequently lead to the development of infections, including surgical ones. Endocrine disorders, primarily diabetes mellitus, can be complicated by infections. Unfortunately, there is currently an increasing incidence of diabetes mellitus in children. Moreover, a growing number of new cases are being registered not only of type 1 diabetes mellitus, typical for childhood, but also of type 2 diabetes mellitus, which was previously considered a more typical adult disease. Protein glycation in diabetes mellitus leads to a number of alterations in various organs and tissues of the body, including immunocompetent cells. This results in secondary immunodeficiency, impaired tissue trophism, and consequently a high predisposition to the development of infections, including surgical ones [2, 3, 10].
Traumas are frequently complicated by the development of surgical infections. This may be related both to damage to the skin and mucous membranes, which serve as an entry gate, and to severe systemic disorders, primarily hemodynamic ones.
Nevertheless, in the overwhelming majority of patients with surgical infections, predisposing factors cannot be identified.
Two main routes of infection are described: exogenous and endogenous. Although often both mechanisms to varying degrees can lead to the development of an infectious process in the same patient. Exogenous infection is associated with damage to the skin or mucous membranes, as well as deeper tissues. Infections most frequently develop from accidental injuries, especially extensive and crushed wounds, and their contamination. Concomitant blood loss leads to hemodynamic disorders, which also contributes to the development of the infectious process. Infections can complicate surgical interventions and various invasive procedures, frequently leading to the development of infection caused by nosocomial flora resistant to many antimicrobial agents.
In endogenous infection, microorganisms enter the sterile environments of the macroorganism from foci of chronic infection or natural reservoirs of potential pathogens in the body, primarily the gastrointestinal tract. This mechanism is termed translocation, i.e., the migration of microorganisms, and is most commonly realized in patients with severe hemodynamic disorders. Ischemia of the GI mucosa develops, its barrier function decreases, and microorganisms penetrate into deeper layers and the vascular bed.
The development of a surgical infection consists of interrelated and sequentially developing phases.
Upon tissue alteration by various damaging agents and invading microorganisms, the mediator (biochemical) phase is triggered, associated with the release of inflammatory mediators and the action of histamine, serotonin, prostaglandins, the complement system, etc. Hyperemia develops.
This is followed by the exudative phase, marked by the escape of the liquid portion and blood plasma proteins into the intercellular spaces, which is associated with damage to the endothelium of blood vessels, increased capillary permeability, and a decrease in their ability to retain water and large molecules within the vascular lumen. This leads to edema, increased interstitial pressure, tissue ischemia, and their further damage.
This phase is followed by the infiltrative phase, characterized by tissue infiltration with lymphocytes, macrophages, and other cells. Tissue infiltration leads to a further increase in interstitial pressure, impairing tissue viability and their resistance to the aggressive action of microorganisms. Soon, an immunological phase develops with manifestations of cellular and humoral immune response.
If the inflammatory process does not stop at these stages, necrotic changes develop in the tissues due to both the direct pathogenic action of microorganisms and the host's response reactions. This leads to the formation of pus, and depending on the anatomical and physiological characteristics of the damaged area, an abscess or phlegmon (cellulitis) is formed. In the case of early thrombus formation, necrotic processes predominate in the inflammatory process, and the formation of pus as such may not occur.
With a favorable course or adequate treatment, the phase of repair begins.
When local defense mechanisms fail, a generalized (systemic) inflammation develops, which can ultimately lead to sepsis.
Sepsis is a pathological process based on generalized (systemic) inflammation (systemic inflammatory response syndrome, SIRS) in response to an infection of various origins (bacterial, viral, fungal, or parasitic), leading to acute organ dysfunction. The fundamental difference between sepsis and a local uncomplicated infection is the development of acute organ dysfunction due to dysregulation of the host response. The development of systemic organ dysfunction is assessed using the SOFA (Sepsis-related Organ Failure Assessment) score, with a score of 2 or more. This scale allows for the quantitative determination of the severity of systemic disorders and currently has the most robust clinical validation. A zero value on the SOFA scale indicates the absence of organ dysfunction.
1.3 Epidemiology of the Disease or Condition
Surgical soft tissue infections account for a significant proportion of surgical patients, comprising 80% – 85% of all surgical infection cases. The number of skin and subcutaneous tissue surgical infections increases in the summer and decreases during the cold season.
1.4 Features of Coding the Disease or Condition
Infections of the skin and subcutaneous tissue (L00-L08):
Phlegmon (L03):
L03.0 – Phlegmon of finger and toe
L03.1 – Phlegmon of other parts of limbs
L03.3 – Phlegmon of trunk
L03.8 – Phlegmon of other sites
Acute lymphadenitis (L04):
L04.1 – Acute lymphadenitis of trunk
L04.2 – Acute lymphadenitis of upper limb
L04.3 – Acute lymphadenitis of lower limb
L04.8 – Acute lymphadenitis of other sites
L08.8 – Other specified local infections of skin and subcutaneous tissue
L98.6 – Other infiltrative disorders of skin and subcutaneous tissue
T79.3 – Posttraumatic wound infection, not elsewhere classified
1.5 Classification of the disease or condition
Skin and subcutaneous tissue infections are classified according to their location, the stage of the inflammatory process, and the presence of complications.
Infections of the skin and subcutaneous tissue:
- skin infections (folliculitis, furuncle, pyoderma, cutaneous whitlow);
- subcutaneous tissue infections (carbuncle, abscess, phlegmon, subcutaneous whitlow).
Stages of the inflammatory process:
- infiltration stage;
- abscess formation stage.
Complications:
- sepsis;
- septic shock.
1.6 Clinical presentation of the disease or condition
The clinical presentation of skin and subcutaneous tissue infections is quite characteristic. In the infiltration stage, edema, hyperemia, and tenderness of the inflammation zone are determined. There is no fluctuation or discharge at this stage. When an abscess forms, fluctuation is added to these symptoms. The systemic response is variable, but as a rule, fever, malaise, in some cases a picture of systemic inflammatory response syndrome (SIRS), and even signs of organ dysfunction develop, indicating the development of sepsis (the SOFA scale).
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis of surgical infections of the skin and subcutaneous tissue is established on the basis of:
- clinical data (fever, edema, hyperemia, tenderness on palpation, possible presence of fluctuation, impaired function of the affected segment);
- laboratory findings (leukocytosis with a predominance of neutrophils, elevated ESR, increased C-reactive protein level);
- instrumental findings (characteristic ultrasound signs: edema and tissue infiltration; in case of abscess formation, the presence of cavity lesions filled with heterogeneous fluid content).
2.1 Complaints and Anamnesis
All presenting patients and/or their legal representatives are recommended to undergo complaint evaluation and medical history taking [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comment. Skin and subcutaneous tissue infections are often preceded by various injuries associated with a breach of skin integrity. Typical complaints include pain, edema, and hyperemia in the area of infection development. Fever and malaise are frequently noted. When an infection develops in the limb area, especially around joints, restriction of movement of the affected segment and a forced position are noted. In younger patients, behavior changes, the child becomes lethargic, appetite decreases, sleep is disturbed, and vomiting may occur.
Acute lymphadenitis is in most cases a secondary disease and often develops against the background of prior infections. Patients or their parents note the appearance of a painful mass in the area of the lymph nodes, with skin hyperemia over it [2].
2.2 Physical Examination
Phlegmon (cellulitis) manifests as pronounced diffuse tissue edema, hyperemia, and usually severe pain. Fluctuation is not detected in most cases. When fairly large cavities filled with pus are formed, fluctuation may be determined. When an inflammatory process develops in the area of the fingers and large joints of the limbs, restriction of mobility and sharp pain upon attempts at flexion and extension are noted.
In cutaneous whitlow, bright skin hyperemia appears with epidermal detachment in the form of a blister in the center. Serous, purulent, or hemorrhagic exudate shines through the epidermis.
The superficial form of paronychia is characterized by the formation of a subepidermal abscess, manifesting as edema, hyperemia, and tenderness; an accumulation of pus may be visible beneath the epidermis. The deep form of paronychia is characterized by the spread of pus under the base of the nail plate, between the nail and its bed, which can lead to detachment of the nail along its length and the formation of a subungual whitlow. Pressure on the nail fold causes sharp pain and the appearance of droplets of pus.
In paronychia of the nail fold, edema, hyperemia, and sharp tenderness upon pressure in the area of the nail fold located at the lateral edges of the nail plate are noted.
In subcutaneous whitlow, edema, hyperemia, and pronounced tenderness of one or more phalanges are noted; fluctuation may also be determined in the same area.
The clinical picture of lymphadenitis depends on the stage of inflammation. In the infiltration stage, skin hyperemia and soft tissue edema are determined, the lymph nodes are sharply painful, moderately adherent to each other and surrounding tissues. In case of abscess formation and the development of adenophlegmon, fluctuation is clearly defined.
When an infection develops in a wound, the appearance of pain, edema, and hyperemia of the wound edges is noted. Wound discharge becomes purulent or seropurulent, and a characteristic unpleasant odor may appear [2].
All children with surgical skin and soft tissue infections are recommended an examination of the affected area, both during the initial examination to establish a diagnosis and subsequently on a daily basis to assess the course of the pathological process [2, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Patients with surgical skin and soft tissue infections are recommended to undergo palpation to determine infiltration, edema, and possible fluctuation of the affected area, both during the initial examination to establish a diagnosis and subsequently on a daily basis to assess the course of the pathological process [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
2.3 Laboratory Diagnostics
All patients with suspected skin and subcutaneous tissue infection are recommended to undergo a complete blood count with differential leukocyte count (leukocyte formula) and erythrocyte sedimentation rate determination upon admission, and subsequently at least once every 5 days or before discharge from the hospital [2, 7, 10].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
In children with signs of SIRS and/or infection-induced organ dysfunction (sepsis), it is recommended to additionally test the blood level of C-reactive protein and procalcitonin [2, 10].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
If indicated (suspected sepsis), in consultation with an anesthesiologist-resuscitologist, it is recommended to perform additional laboratory tests: a coagulogram (screening hemostasis test) determining the international normalized ratio (INR), prothrombin time (thromboplastin) in blood or plasma, and activated partial thromboplastin time (APTT); general clinical biochemical blood test (total protein, total bilirubin, conjugated (direct) bilirubin, creatinine, urea, glucose, sodium, potassium, and chlorides in the blood) [2, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Microbiological testing of wound discharge and/or blood is recommended for patients with severe surgical skin and subcutaneous soft tissue infections (development of SIRS/sepsis), prolonged or atypical inflammatory process, suspected presence of resistant bacterial strains (primarily MRSA), as well as in cases of treatment failure [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
For patients with surgical skin and subcutaneous soft tissue infections presenting with an unclear clinical picture, it is recommended to perform soft tissue ultrasound (US) for diagnostic purposes [2, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
When limb segments, particularly the fingers and toes, are affected, patients with surgical skin and subcutaneous soft tissue infections are recommended to undergo radiography of the hand or foot in two projections to rule out bone involvement [2, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
If the above studies are insufficiently informative, patients with surgical skin and subcutaneous soft tissue infections are recommended to undergo computed tomography (CT) of the upper or lower extremity, or magnetic resonance imaging (MRI) of soft tissues; such a need typically arises when soft tissue ultrasound is uninformative or in cases of complex localizations of the inflammatory process [2, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comment. Characteristic signs of soft tissue infection in the infiltration stage include the presence of infiltrated, edematous tissues without clear margins, and increased local blood flow. In case of abscess formation, cystic cavities filled with heterogeneous fluid contents are added to the above picture.
2.5 Other Procedures
Other diagnostic examinations are not required.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment of skin and subcutaneous infections depends on the stage of inflammation and the presence or absence of complications.
For small lesions that are not localized on the head and face and are not accompanied by SIRS, as well as in children older than 1 year, outpatient treatment is possible. In all other cases, patients with skin and subcutaneous infections require hospitalization.
3.1 Conservative Treatment
Antibacterial therapy
Patients with surgical skin and subcutaneous soft tissue infections are recommended to be prescribed systemic antibacterial drugs [2, 3].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comment. Exceptions may include small superficial skin abscesses without signs of SIRS [7, 9].
The choice of a systemic antibacterial drug depends on the localization of the infection, its severity, and patient-specific contraindications or limitations. The intravenous route of administration should be preferred. If intravenous administration is not feasible, intramuscular administration is acceptable. For outpatients, oral administration is preferred [2, 3, 9].
For patients with mild to moderate surgical skin and subcutaneous soft tissue infections, it is recommended to prescribe:
- beta-lactamase-resistant penicillins: oxacillin** intravenously or intramuscularly for children over 6 years old 2–4 g/day, children under 3 months 60–80 mg/kg/day, 3 months to 2 years 1 g/day, 2 to 6 years 2 g/day, newborns and premature infants 20–40 mg/kg/day; frequency of administration 4 times a day [1, 2, 5].
- second-generation cephalosporins: cefuroxime** 30–100 mg/kg/day, divided into 3–4 administrations. For most infections, the optimal dose is 60 mg/kg/day. Neonates: 30–100 mg/kg/day, divided into 2–3 administrations [1, 2, 5].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
If parenteral administration is not feasible or necessary, patients with surgical skin and subcutaneous soft tissue infections are recommended to receive systemic antibacterial drugs orally:
- cefuroxime** for children 3–6 months (4–6 kg) 40–60 mg every 12 hours, 6 months – 2 years (6–12 kg) 60–120 mg every 12 hours, 2–12 years (from 12 and over 20 kg) 125 mg every 12 hours, over 12 years 250 mg every 12 hours [1, 2, 5].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
In case of intolerance to beta-lactamase-resistant penicillins and cephalosporins, patients with surgical skin and subcutaneous soft tissue infections are recommended to be prescribed lincosamides:
- clindamycin** by intravenous infusion or intramuscularly (in children over 3 years old) 20–40 mg/kg/day; frequency of administration 3 times a day [1, 2, 5].
- lincomycin** by intravenous infusion or intramuscularly (in children over 1 month old) 10–20 mg/kg/day; frequency of administration 3 times a day [1, 2, 5].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
In case of a high risk or confirmation of methicillin-resistant staphylococcal strains, as well as in the presence of signs of sepsis, patients with surgical skin and subcutaneous soft tissue infections are recommended to receive:
- daptomycin**: children 12–17 years old 5 mg/kg once every 24 hours by intravenous infusion lasting at least 30 minutes; children 7–11 years old 7 mg/kg once every 24 hours by intravenous infusion lasting at least 30 minutes; children 2–6 years old 9 mg/kg once every 24 hours by intravenous infusion lasting at least 60 minutes; children 1–2 years old 10 mg/kg once every 24 hours by intravenous infusion lasting at least 60 minutes [1, 2, 5];
- linezolid** by intravenous infusion for children over 12 years old 600 mg every 12 hours, newborns and children under 12 years old 10 mg/kg every 12 hours [1, 2, 5].
- vancomycin** by intravenous infusion for children over 12 years old 2 g per day, every 6 or 12 hours, for children aged 1 month to 12 years 40 mg/kg per day, administered every 6 hours, for newborns a starting dose of 15 mg/kg, then 10 mg/kg every 12 hours during the first week of life [1, 2, 5].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
In other cases, antibacterial therapy regimens based on the Antimicrobial Stewardship Program (AMSP) guidelines are used [5].
The effectiveness of antibacterial therapy is evaluated 48 hours after its initiation based on clinical, instrumental, and laboratory data [5].
Detoxification therapy
Detoxification therapy is recommended for patients with surgical skin and subcutaneous soft tissue infections presenting with pronounced SIRS/sepsis and fluid-electrolyte disturbances. When sepsis develops, the patient is treated in the intensive care unit, which, in addition to antibacterial therapy, includes infusion-transfusion therapy and a complex of intensive care measures aimed at correcting organ dysfunction and/or replacement therapy [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Infusion therapy is recommended for patients with surgical skin and subcutaneous soft tissue infections showing signs of SIRS and fluid-electrolyte disturbances. The volume is calculated based on water deficit using the following formula: water deficit (in liters) = (actual hematocrit – normal hematocrit) / (100 – normal hematocrit) × body weight (kg) × k, where k = 0.33 in the first year of life and 0.25 in children older than one year [2]. As an infusion medium, it is recommended to use isotonic sodium chloride solution**, compound sodium chloride solution [potassium chloride + calcium chloride + sodium chloride]**, potassium chloride + calcium chloride + magnesium chloride + sodium acetate + sodium chloride, compound sodium lactate solution [potassium chloride + calcium chloride + sodium chloride + sodium lactate]**; for children under 3 years of age, 5% or 10% dextrose solution** must be added due to the risk of ketoacidosis [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Local conservative treatment
During the infiltration stage of inflammation, all children with surgical skin and subcutaneous soft tissue infections are recommended to undergo physiotherapy procedures prescribed by a physical therapy physician [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
3.2 Surgical Treatment
In the abscess stage, surgical treatment is recommended for patients with surgical infections of the skin and subcutaneous tissue. The main goals of surgical treatment are removal of pus and necrotic tissue, as well as drainage of the purulent focus. For formed abscesses, when technically feasible, it is recommended to use puncture treatment methods, which allow adequate drainage with less tissue trauma compared to traditional methods of abscess incision and drainage. In addition, this significantly reduces the risk of wound infection in the postoperative period. For diffuse purulent inflammation of the subcutaneous tissue (phlegmon/cellulitis), it is recommended to perform wide incision of the phlegmon [2, 3, 7].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
The choice of anesthesia method depends on the location and extent of the lesion, as well as the child's age. In older children with a superficial lesion, its debridement under local anesthesia is recommended; for lesions located in the fingers, Oberst nerve block recommended (lidocaine** 10 mg/ml) is indicated, and infiltration anesthesia is recommended for other locations. In all other cases, general anesthesia is recommended [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
For cutaneous and parungual felon (whitlow) and paronychia, opening the abscess over the area of maximum fluctuation, removing the exudate, and applying a dressing with ointments containing antiseptics and disinfectants or topical antibiotics (povidone-iodine** local and topical solution 10% or povidone-iodine ointment 10% for topical use in children over 1 month of age, chloramphenicol + dioxomethyltetrahydropyrimidine in children over 1 year of age) are recommended [2, 3, 10].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
For subcutaneous felon, incisions along the lateral surfaces of the affected phalanges are recommended, and a through-and-through Penrose drain is placed through these incisions. Dressings containing antiseptics and disinfectants or topical antibiotics are also applied [2, 3, 10].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
When phlegmon (cellulitis) is walled off and a purulent focus has formed, it is recommended to open it via one or more incisions dissecting the skin and subcutaneous tissue. Pus and necrotic tissue are removed. It is important to perform a thorough wound exploration to avoid missing pockets and tracking tracts, which must also be debrided. The wound is left unclosed. After opening the phlegmon, the wound is managed with dressings containing antiseptics and disinfectants or topical antibiotics [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
For extensive phlegmons, the application of a negative pressure wound therapy system is recommended. In case of a favorable clinical course, early secondary sutures are applied [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Abscessing forms of lymphadenitis are treated similarly to phlegmons; patients with skin and subcutaneous soft tissue infections are recommended to undergo an incision over the site of maximum fluctuation, evacuation of pus, and drain placement [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Patients with skin and subcutaneous soft tissue infections are recommended to undergo ultrasound and laser debridement. For large wounds, the application of negative pressure wound therapy systems is recommended. The decision on wound closure is always made individually and can be achieved through secondary suturing or various plastic surgery techniques (pedicle flaps, split-thickness skin grafts, etc.) [2, 4].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comment. Treatment of infected wounds is a rather complex task and includes the removal of all necrotic tissue, pus, and foreign bodies (if present), as well as treatment of the wound surface with antiseptics and disinfectants.
3.3 Postoperative management
The postoperative period includes antibacterial therapy, pain management, local treatment, and symptomatic treatment [2, 9, 10].
Antibacterial therapy is carried out according to the principles outlined above.
Pain management.
Pain management is recommended for all children in the postoperative period [2, 3].
LoE CGoE 5Level of Evidence C (Grade of Recommendation – 5)
Non-opioid analgesics (other analgesics and antipyretics) and NSAIDs.
In the postoperative period, the administration of non-opioid analgesics (other analgesics and antipyretics) and NSAIDs is recommended [2]:
- paracetamol** orally in children over 12 years of age 500 mg every 6 hours (in tablets), from 3 months to 12 years of age 15 mg/kg every 6 hours (in suspension or tablets), from 2 to 3 months 15 mg/kg every 12 hours (in suspension); intravenously in children over 1 month of age via infusion: for children weighing more than 50 kg, 1 g every 6 hours; less than 50 kg, 15 mg/kg every 6 hours; less than 10 kg, 7.5 mg/kg every 6 hours.
- ibuprofen** orally in children over 12 years of age 200 mg every 6 hours (tablets),
Children aged 3-6 months (child weight 5 to 7.6 kg): 2.5 ml (50 mg) up to 3 times per 24 hours, not exceeding 7.5 ml (150 mg) per day. Children aged 6-12 months (child weight 7.7 – 9 kg): 2.5 ml (50 mg) up to 3-4 times per 24 hours, not exceeding 10 ml (200 mg) per day. Children aged 1 – 3 years (child weight 10 – 16 kg): 5.0 ml (100 mg) up to 3 times per 24 hours, not exceeding 15 ml (300 mg) per day. Children aged 4 - 6 years (child weight 17 – 20 kg): 7.5 ml (150 mg) up to 3 times per 24 hours, not exceeding 22.5 ml (450 mg) per day. Children aged 7 – 9 years (child weight 21 – 30 kg): 10 ml (200 mg) up to 3 times per 24 hours, not exceeding 30 ml (600 mg) per day. Children aged 10 – 12 years (child weight 31 – 40 kg): 15 ml (300 mg) up to 3 times per 24 hours, not exceeding 45 ml (900 mg) per day. Duration of treatment is no more than 3 days (oral suspension).
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Opioids.
For widespread processes following traumatic surgical interventions, as well as in cases of ineffectiveness of non-opioid analgesics and NSAIDs, the administration of opioids is recommended [2]:
- tramadol** intravenously or intramuscularly in children over 12 years of age 50 – 100 mg every 6 hours, in children from 1 year to 12 years of age 1 – 2 mg/kg every 6 hours.
- trimeperidine** intramuscularly in children over 2 years of age 3 – 10 mg depending on age.
- morphine** intramuscularly 0.05 – 0.2 mg/kg every 6 hours.
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Local treatment in the postoperative period.
It is recommended to treat postoperative wounds with antiseptic and disinfectant solutions (povidone-iodine** as a 10% solution in children over 1 month of age, chlorhexidine** 0.05%; other antiseptics and disinfectants approved for topical use in children may be used) 1 – 2 times a day. Then the wounds are covered with atraumatic ointment dressings containing antiseptics or antibiotics, or dressings applied with solutions or ointments containing antiseptics or antibiotics [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to remove single-channel silicone drainage tubes in all patients when exudate discharge through them ceases, and rubber drains after 24 hours [2].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
When applying a vacuum-assisted closure system, it is recommended to change it every 2 – 3 days in all patients [4].
GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)
The issue of secondary wound closure is decided on an individual basis, guided by the absence of fibrin and purulent discharge in the wound, the presence of granulation tissue, and negative microbiological test results.
Physiotherapy treatment is prescribed by a physical therapy physician.
Discharge from the inpatient facility is carried out after achieving clinical recovery.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Medical rehabilitation services are recommended for patients who have suffered from surgical infections complicated by sepsis, multiple organ dysfunction syndrome, or septic shock [2, 3].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
5. Prevention and Dispensary Observation
As prevention of surgical infections, the timely elimination of causes that may lead to their occurrence is recommended [2, 5].
GCR CLoE 5Grade of Recommendation C (Level of Evidence – 5)
6. Organization of Medical Care
Stages of medical care delivery
1. Medical evacuation of patients with skin and subcutaneous soft tissue infections to medical organizations is carried out based on a three-tier system of specialized medical care in emergency and urgent forms established in a constituent entity of the Russian Federation, in order to provide a differentiated scope of medical examination and treatment depending on the severity of acute pancreatitis, the degree of risk of complications, taking into account the structure, bed capacity, level of equipment, and provision of qualified personnel in these medical organizations.
Depending on bed capacity, equipment, and staffing, medical organizations providing specialized, including high-tech, medical care in emergency and urgent forms to patients with skin and subcutaneous soft tissue infections are divided into three groups according to the feasibility of providing such medical care within the framework of the three-tier system of specialized medical care in emergency and urgent forms:
a) first tier – district medical organizations for the provision of specialized medical care in emergency and urgent forms;
b) second tier – inter-district medical organizations for the provision of specialized medical care in emergency and urgent forms;
c) third tier – regional medical organizations for the provision of specialized, including high-tech, emergency and urgent medical care.
2. Hospitalization is indicated for all patients:
- who show signs of systemic inflammatory response syndrome;
- who require intensive care;
- who require surgery under general anesthesia;
- who have skin and soft tissue surgical infections located in the head and scalp region;
- under one year of age;
- who may require staged treatment;
- who have severe comorbid conditions (the decision is made jointly with a relevant specialist);
- if it is difficult or impossible to assess the patient's condition and disease prognosis during the initial examination.
3. Patient discharge is indicated:
- upon improvement/recovery, when further treatment can be provided on an outpatient basis;
- in the absence of signs of systemic inflammatory response syndrome;
- upon cessation of wound exudate, absence of signs of ongoing infection, and onset of epithelialization;
- in the absence of further indications for parenteral systemic antibacterial therapy.
7. Additional Information
The outcome of the disease or condition may be influenced by:
Polyvalent allergy (including a history of allergic reactions to the administration of horse serum (anti-diphtheria, anti-tetanus, etc.);
Infectious and parasitic diseases and/or suspected infection, food-borne toxicoinfections, dysentery, viral hepatitis, influenza, malaria, brucellosis, pseudotuberculosis, yersiniosis, etc.);
History of leukemia, oncological diseases, tuberculosis, or positive test results for HIV infection, hepatitis B and C);
Severe congenital defects confirmed by history and/or objective examination, leading to impaired normal functioning and requiring correction (congenital heart defects, gastrointestinal tract, urogenital system, skeleton, Marfan syndrome, Klinefelter syndrome, Edwards syndrome, Opitz syndrome, Goldenhar syndrome, and others);
Systemic connective tissue diseases according to medical history (systemic sclerosis, systemic lupus erythematosus, systemic vasculitis, antiphospholipid syndrome, dermatomyositis, sarcoidosis, rheumatism, and others);
Type I and type II diabetes mellitus;
Obesity with a body mass index greater than 40;
Acute renal failure;
Chronic renal failure with a glomerular filtration rate of less than 30 mL/min.;
Multiple sclerosis and other demyelinating diseases;
Any psychiatric disorders according to medical history;
History of hematological disorders.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1 | Collection of complaints and medical history was performed | Yes/no |
2 | An examination of the affected area was performed during the initial assessment to establish a diagnosis | Yes/no |
3 | A daily examination of the affected area was performed to evaluate the course of the pathological process | Yes/no |
4 | A complete blood count (CBC) with differential leukocyte count (leukocyte formula) and erythrocyte sedimentation rate (ESR) measurement was performed upon admission | Yes/no |
5 | A complete blood count (CBC) with differential leukocyte count (leukocyte formula) and erythrocyte sedimentation rate (ESR) measurement was performed at least once every 5 days or prior to hospital discharge | Yes/no |
6 | Children with signs of SIRS and/or infection-induced organ dysfunction (sepsis) underwent additional blood tests for C-reactive protein and procalcitonin levels | Yes/no |
7 | Patients with skin and soft tissue surgical infections and an unclear clinical picture underwent soft tissue ultrasound (ultrasonography) | Yes/no |
8 | In cases involving limb segments, particularly the fingers and toes, patients with skin and soft tissue surgical infections underwent radiography of the hand or foot in two projections | Yes/no |
9 | When soft tissue ultrasound has low diagnostic value or in complex localizations of the inflammatory process, computed tomography (CT) of the upper or lower extremity or magnetic resonance imaging (MRI) of the soft tissues was performed | Yes/no |
10 | Systemic antibacterial drugs were prescribed | Yes/no |
11 | Surgical treatment was performed at the abscess formation stage | Yes/no |
12 | Pain management was performed in the postoperative period | Yes/no |
13 | Medical rehabilitation services were prescribed to patients who suffered from surgical infections complicated by sepsis, multiple organ dysfunction, or septic shock | Yes/no |
References
Show references
State Register of Medicines. https://grls.rosminzdrav.ru
Pediatric Surgery: National Guidelines / ed. by A.Yu. Razumovsky. - 2nd ed., rev. and supp. – Moscow: GEOTAR-Media, 2021.
Infections in Surgery: A Guide for Physicians. V.K. Gostishchev. GEOTAR-Media Publishing House, 2007.
Kozlov Yu.A., Novozhilov V.A. Vacuum wound therapy in children. Russian Journal of Pediatric Surgery, Anesthesiology and Intensive Care. Volume 4, No. 3, 2014.
AMR Control Strategy (SKAT) Program in Inpatient Medical Care: Russian Clinical Guidelines / Ed. by S.V. Yakovlev, N.I. Briko, S.V. Sidorenko et al. - M.: Pero Publishing House, 2018.
Savenkova M.S., Afanasyeva A.A., Abdulaev A.K., Neizhko L.Yu. Lymphadenopathy and lymphadenitis in children: diagnosis and treatment. Trudny Patsient. No. 12. Volume 6, 2008.
Surgical Infections: Guidelines / Ed. by I.A. Eрюхин, B.R. Gelfand, S.A. Shlyapnikov. – St. Petersburg: Piter, 2003.
K B Santosa, M Keller, M O, A M Keane, E D Sears, A K Snyder-Warwick. Negative Pressure Wound Therapy in Infants and Children: A Population-Based Study. J Surg Res. 2018 Nov 30;235:560–568.
Y Gillet, M Lorrot, P Minodier, A Ouziel, H Haas, R Cohen. Antimicrobial treatment of skin and soft tissue infections. Infect Dis Now. 2023 Nov; 53(8S): 104787.
S Swartz, L Cotter, A Nelson, J Zhang, K Yan, M L Pickett. Skin and Soft Tissue Infections in Young Infants. WMJ. 2023 May; 122(2): 105-109.
Appendix A1. Working Group Composition
Golovanev Maxim Alekseevich – Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Surgery, Pirogov Russian National Research Medical University.
Razumovsky Alexander Yurievich – Corresponding Member of the RAS, Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Surgery, Pirogov Russian National Research Medical University.
Smirnov Alexey Nikolaevich – Doctor of Medical Sciences, Professor of the Department of Pediatric Surgery, Pirogov Russian National Research Medical University.
Chundokova Madina Arsenovna – Doctor of Medical Sciences, Professor of the Department of Pediatric Surgery, Pirogov Russian National Research Medical University.
Conflict of interest: All members of the Working Group confirmed the absence of financial support / conflicts of interest that need to be reported.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines
1. Pediatric surgeon;
2. Pediatrician;
4. District pediatrician;
5. City (district) pediatrician;
4. General practitioner (family physician);
5. Neonatologist;
7. Anesthesiologist-intensivist;
8. Surgeon;
9. General practitioner / Internist;
11. Adolescent physician;
12. District internist;
11. Functional diagnostics physician.
Methods used for collecting/selecting evidence: electronic database search.
Description of methods used to assess the quality and strength of evidence: the evidentiary base for the recommendations includes publications from the Cochrane Library, EMBASE, MEDLINE, and PubMed databases. Search depth – 7 years.
Methods used for assessing the quality and strength of evidence:
● expert consensus;
● significance assessment according to the grading scheme.
Methods used for analyzing evidence:
● reviews of published meta-analyses;
● systematic reviews with evidence tables.
Description of methods used for analyzing evidence
When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations.
To minimize potential bias, each study was evaluated independently. Any discrepancies in evaluations were discussed by the full panel of authors. If a consensus could not be reached, an independent expert was involved.
Evidence tables: compiled by the authors of the clinical guidelines.
Methods used for formulating recommendations: expert consensus.
Good Practice Points (GPPs)
Recommended good clinical practice is based on the clinical experience of the authors of these guidelines.
Economic analysis
Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.
Method of recommendation validation
● External peer review.
● Internal peer review.
Description of the recommendation validation method
The draft of these recommendations was reviewed by independent experts who were primarily asked to comment on how comprehensible the interpretation of the evidence underlying the recommendations is.
All comments received from the experts were thoroughly systematized and discussed by the members of the working group (authors of the recommendations). Each item was discussed individually.
Consultation and peer review
The draft recommendations were reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.
Working group
For the final revision and quality control, the recommendations were re-evaluated by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account and the risk of bias in the development of the recommendations was minimized.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading the levels of recommendation trustworthiness (LRT) for preventive, diagnostic, therapeutic, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
1. Clinical practice guidelines of the European Association of Pediatric Surgeons, 2024.
2. Order of the Russian Ministry of Health No. 562n dated October 31, 2012, "On approval of the procedure for providing medical care to the pediatric population in the profile 'pediatric surgery'."
4. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical practice guidelines, their revision, standard template of clinical practice guidelines, and requirements for their structure, composition, and scientific validity of the information included in clinical practice guidelines."
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Acute inflammatory processes developing in the subcutaneous tissue, muscles, and other soft tissues. They may manifest as abscesses (localized purulent inflammations), phlegmons (diffuse inflammation), or infected wounds.
Diagnosis of soft tissue surgical infections includes a general physical examination of the patient, examination of the affected area, as well as a number of laboratory and instrumental diagnostic methods. The choice of specific methods is determined by the physician based on the patient's examination data and previous test results.
Treatment includes mandatory prescription of antibiotics, which can be administered orally or via injection in more severe cases. Additionally, the physician may prescribe medications to relieve pain and reduce swelling in the affected area. In cases of infected wounds, regular dressings with antiseptic agents are performed.
Surgical treatment. In the presence of abscesses, surgical treatment involves opening and draining the purulent cavity. In cases of phlegmon, a more extensive surgery with the removal of non-viable tissue may be required. Infected wounds may also require surgical debridement, especially if the infection spreads deep into the tissues. This may include the removal of non-viable tissue (necrectomy) and cleaning of the wound surface.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable within the scope of these clinical practice guidelines.