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Table of Contents
ORIGINAL ARTICLES
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 48-52

Pattern and etiological agents of superficial soft tissue abscesses in children


1 Sub-department of Pediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku/Ozalla, Enugu, Nigeria
2 Department of Surgery, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
3 Department of Surgery, Federal Medical Centre, Umuahia, Abia State, Nigeria

Date of Submission27-Oct-2019
Date of Decision22-Dec-2019
Date of Acceptance16-Jan-2020
Date of Web Publication03-Apr-2020

Correspondence Address:
Dr. Uchechukwu O Ezomike
Sub-department of Pediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku/Ozalla, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_34_19

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  Abstract 

Background: Superficial soft tissue abscesses (SSTAs) constitute a considerable proportion of the pediatric surgeon’s workload. SSTAs are abscesses involving skin, subcutaneous tissues, muscles superficial to bones, and deep body cavities such as pleural and peritoneal cavities. However, scientific publications assessing patterns of presentation in children, identifying the common bacterial etiological agents, and calculating multiple antibiotic resistance (MAR) index of positive abscess culture results in our environment are not common. Aims and Objectives: The aim of this study was to determine the pattern of presentation of SSTAs in children in our environment, determine their common bacterial etiological agents, and calculate MAR index. Materials and Methods: An observational study was conducted on children with SSTA over a 21-month period at the Federal Medical Center, Umuahia, Abia State, Nigeria. All patients had incision and drainage, packing of cavity with gauze drain, and a sample of the pus sent for aerobic culture and sensitivity. MAR index was calculated for each positive isolate after sensitivity testing. Data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20.0 (SPSS, Chicago, Illinois). Results were presented as mean values, ratios, percentages, and in tables. Results: There were 40 patients with 45 abscess sites: 22 males and 18 females aged 7 days to 14 years (median of 21 months). Symptom duration before presentation ranged from 2 to 14 days. The most common site of abscess was the lower limb (12 of 45, 26.7%). Blunt trauma was the most common predisposing factor to abscess formation (17 of 45, 38%). MAR index ranged from 0.25 to 1 with a mean of 0.49. Staphylococcus aureus was the most common organism grown in all positive cultures (23 of 25, 92%). Conclusion: In our environment, most SSTAs in children occur in the lower limbs; S. aureus is the most common etiological bacterial agent involved in SSTAs, and blunt trauma is the most prevalent predisposing factor in SSTAs. Mean MAR index is high in this study.

Keywords: Children, etiological agents, multiple antibiotic resistance index, pattern, superficial soft tissue abscesses


How to cite this article:
Ezomike UO, Akpabio IM, Ekpemo SC, Chukwu IS, Emehute JC. Pattern and etiological agents of superficial soft tissue abscesses in children. Int J Med Health Dev 2020;25:48-52

How to cite this URL:
Ezomike UO, Akpabio IM, Ekpemo SC, Chukwu IS, Emehute JC. Pattern and etiological agents of superficial soft tissue abscesses in children. Int J Med Health Dev [serial online] 2020 [cited 2020 Nov 29];25:48-52. Available from: https://www.ijmhdev.com/text.asp?2020/25/1/48/281889




  Introduction Top


Superficial soft tissue abscesses (SSTAs) in children are one of the common surgical problems, presented to the pediatric surgeons in our environment. Different parts of the body may be involved with one or multiple abscesses, and causative organisms from many studies are Staphylococcus aureus[1],[2],[3] with various antibiotic sensitivities. Determination of antibiotic sensitivity profile of abscess aspirate culture is important in assisting clinicians in empiric antibiotic therapy.[4] It is also necessary in the calculation of multiple antibiotic resistance (MAR) index, which is very important in bacteria source tracking.[5] MAR index is calculated by dividing the number of antibiotics to which a cultured organism is resistant to by the total number of antibiotics to which the organism has been tested for susceptibility. MAR index more than 0.2 is taken to be high and it indicates high-risk source of contamination where antibiotics are commonly used, and high risk of exposure of the bacteria to antibiotics and possible development of resistance to a high number of antibiotics. We therefore set out to study the patterns of and etiological agents involved in SSTAs in children and calculate the mean MAR index of the available positive cultures.


  Materials and Methods Top


This was a cross-sectional observational study of patients aged 15 years and younger who presented with SSTAs involving various parts of the body to the pediatric surgical team at the Federal Medical Centre Umuahia, Abia State, Nigeria, over a 21-month period from November 1, 2014 to December 1, 2015 and then from August 1, 2017 to February 28, 2018. For the purpose of this study, SSTAs involving skin, subcutaneous tissues, muscles superficial to bones, and superficial to deep body cavities such as pleural and peritoneal cavities were included. Surgical site infections and non-purulent superficial soft tissue infections were excluded. Aspirates obtained from the lesion using suction with needle and syringe, before incision and drainage, were sent to the laboratory for aerobic culture and sensitivity, as it is not routinely carried out in our environment. All patients had incision and drainage of abscess with breaking of any loculi within the abscess cavity and packing of the resultant cavity with saline-soaked gauze drain. Subsequent dressings were carried out pro re nata till the wound healed. Patients were all placed on various empirical antibiotics following incision and drainage. We did not influence the sensitivity disc used as this was an observational study, and the choice of the disc was left to the discretion of the laboratory. MAR index was calculated using the method developed by Krumperman.[6] This was carried out for each positive culture and sensitivity result by dividing the number of antibiotics to which the organism was resistant to the total number of antibiotics tested. The mean MAR index was then calculated by dividing the sum of the individual MAR indices with the total number of positive cultures for which MAR indices were calculated. Data were entered and analyzed using the Statistical Package for the Social Sciences software, version 20.0 (SPSS, Chicago, Illinois). Results were presented as means, ratios, percentages, and in tables.


  Results Top


There were 40 patients [Table 1] with 45 abscess sites (three patients had two abscess sites and one patient had three abscess sites). The most common age-group involved was between 1 and 5 years [Table 1]. There were 22 males and 18 females aged 7 days to 14 years (median of 21 months). The symptom duration before presentation ranged from 2 to 14 days (mean, 7.7 ± 4.5 days). These manifested mainly as localized tenderness of an erythematous, warm, and fluctuant swellings with essentially no evidence of systemic illness. Blunt trauma was the most common predisposing factor to abscess formation (17 of 40, 42.5%), followed by intramuscular injections in 17.5% (7 of 40), whereas 14 of 40 (35%) had no obvious predisposing factor [Table 2]. The most common anatomical site of abscess was the lower limb (12 of 45, 26.7%) followed by the upper limb (7 of 45, 15.6%), and head/neck region (7 of 45, 15.6%) [Table 3]. S. aureus (coagulase-positive Staphylococcus spp.) was the most common organism grown in all positive cultures (23 of 25, 92%) [Table 4]. Coagulase-negative Staphylococcus spp. was grown from one breast abscess and Klebsiella pneumoniae was grown in one culture of neck abscess. Four had previous abscesses at different sites before the index presentation (4 of 40, 10%). Ofloxacin was the most common antibiotic to which the cultured organisms were sensitive to (17 of 25, 68%), followed by genticin (14 of 25, 56%), ciprofloxacin (12 of 25, 48%), amoxicillin/clavulanic acid (9 of 25, 36%), cetriaxone (8 of 24, 33%), and cefuroxime (6 of 25, 24%). MAR index values ranged from 0.25 to 1 with a high mean value of 0.49 [Table 5].
Table 1: Age distribution of patients

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Table 2: Predisposing factors to abscess formation

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Table 3: Site distribution of abscesses

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Table 4: Bacterial growth from culture

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Table 5: Multiple antibiotic resistance index

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  Discussion Top


This study revealed that S. aureus is the most common cultured bacteria from SSTAs. This finding is in agreement with other research results from many other studies.[1],[2],[3] As found in this study and corroborated by other literature, coagulase-negative Staphylococcus spp.[4] and Klebsiella pneumoniae[7],[8] are uncommon causes of SSTAs. All positive cultures were monomicrobial, and this is in agreement with the findings by Ramakrishnan et al.[9]

From our findings, SSTAs were more in males with a male:female ratio of 1.2:1. This is similar to the findings by Khan et al.[1] with a male:female ratio of 1.4:1 and less than the male:female ratio of 2.2:1 found in a study by El Shallaly et al.[8]

In this study, the lower limb is the most common site for abscess, followed by upper limb/head and neck region. In some other studies, upper limbs[8] were the most common site, whereas in others, they were found more in head and neck[3],[10] and gluteal[11] regions. This shows that there is a wide variation in anatomical site predilection for SSTA formation in different environments and age-groups.

Mean duration of symptoms before presentation was 7.7 days. This is comparable to the symptom duration recorded by Mahdi et al.,[3] where mean duration of symptoms was 6 days. Also 15 of 40 patients took various antibiotics before coming to hospital. This may have led to delay in presentation as also recorded in another study.[3]

In our study, as conducted traditionally, physical examination was used to diagnose all superficial abscesses. All were palpated to assess for fluctuance and had needle aspiration through the fluctuant part to confirm pus within the lesion before incision and drainage was carried out. As corroborated by another study,[9] there was no need for imaging to diagnose the abscesses. Ultrasound imaging, however, assists in detection and localization of superficial abscesses where clinical examination is equivocal.[12],[13],[14]

The incisions in our study were not sutured, but the abscess cavities were packed with gauze as drain and covered with dressing, which was subsequently changed pro re nata till they healed. This method of not suturing surgical wound created for an incision, and drainage was also recorded by Mahdi et al.[3] and El Shallaly et al.[8] This is unlike Abraham et al.[15] and Edino et al.[16] who performed and encouraged primary closure of incisions following drainage of abscesses.

Also in some studies,[17] non-packing of the cavity was not noted to have an inferior outcome to packing but we packed the cavity in all our patients.

The fact that none of the 15 patients, who took various antibiotics before presentation, received ofloxacin and ciprofloxacin, which were, respectively, the most common and third most common antibiotic to which the cultured organisms were sensitive, was notable. This may be related to the fact that fluoroquinolones have been noted to cause degenerative changes in cartilage from animal studies,[18],[19] and hence in human children, most prescribers recommend them mainly for severe life-threatening infections where safer effective alternatives are lacking.[18],[20] They also should not be used off-label.[21] Only one patient took genticin despite being the second most common antibiotic the organisms were sensitive to. This may be due to the fact that genticin has only parenteral formulations, and hence will not likely be the first-line over-the-counter antibiotics for many patients.

All our patients received various antibiotics following incision and drainage. This is the practice in our hospital and observed in other studies,[3],[4] though others[14],[22],[23] propose incision and drainage alone as adequate treatment in non-methicillin resistant infections in immunocompetent patients.

In this study, as is our practice, all pus specimens aspirated from the abscess cavity were sent for microscopy, culture, and sensitivity to identify the offending organisms and their antimicrobial sensitivity patterns. This practice of routinely sending abscess aspirate for microscopy, culture, and sensitivity is supported by studies conducted by Garcea et al.[2] and Hsiao et al.[24] However, Seow-En and Ngu,[25] Khan et al.,[1] and Korownyk and Allan[26] noted that routine sending of aspirate for microbiology, culture and sensitivity was not important. Khan et al.[1] argued that cultured organisms were predictable, sensitive to empirical antibiotics used, and where cultured bacteria were resistant to prescribed empirical antibiotics, patient outcomes were not affected.

We sent all aspirates for microscopy, culture, and sensitivity to determine the common organisms and their antibiotic sensitivities. This will guide future therapeutic and empirical use of antibiotics. When this is carried out on a continuous basis, it will help to detect and monitor changing trends in bacterial agents and antibiotic sensitivities. Positive culture in 86.2% (25 of 29) of all available cultures is comparable to 93% observed in Mahdi et al.[3] and higher than 70.9% and 55.9% recorded by Khan et al.[1] and Garcea et al.,[2] respectively.

Ofloxacin and ciprofloxacin (both fluoroquinolones) were, respectively, the most common and third most common antibiotic to which the cultured organisms were sensitive. This high rate of sensitivity of bacterial isolates to fluoroquinolones is corroborated by some other studies where high susceptibility of their cultured organisms to quinolones and aminoglycosides was noted.[5],[27]

Calculated MAR index ranged from 0.25 to 1 with only two patients having MAR index of 0.25 (8%) in this study. This high MAR index is comparable to findings by Osundiya et al.,[5] where 91.2% of isolates had MAR index higher than 0.2. From a study conducted by Udobi et al.,[28] MAR index of greater than 0.25 suggests that the isolates originated from a high-risk source of contamination where antibiotics are often used and possibly abused and suggests the need for antibiotic surveillance program. This is the situation in this study where 92% had high MAR index. High MAR index suggests that organisms are from high-risk source.[5] It also shows previous exposure to antibiotics and development of resistance to commonly prescribed antibiotics; hence, antimicrobial susceptibility testing is imperative in selecting therapeutic options.[29]

In this study, risk factors for superficial abscess are mainly blunt trauma just as in the studies by El Shallaly et al.[8] and Anatol.[30] In a substantial proportion of our patients, no obvious predisposing factors were observed, and similar findings were made by Mahdi et al.[3]

Limitations of the study: This study was limited by the fact that it is an observational study, and hence there was no uniformity of discs used for all the sensitivity tests, and they were carried out by different people. No anaerobic cultures were found as this was not carried out routinely in our clinical setting. Some patients failed to return with microscopy, culture, and sensitivity results, making such results unavailable for analysis.


  Conclusion Top


In our environment, blunt trauma is the most prevalent predisposing factor for the development of SSTAs in children. The most common region of the body where SSTAs occur in children is the lower limbs. S. aureus is the most common etiological bacterial organism, and ofloxacin the most common antibiotic to which the positive bacterial isolates are sensitive to. Mean MAR index is high in this study.

Recommendations: We hereby recommend that future prospective studies should include standardization of sensitivity discs so that the cultured bacterial isolates are exposed to the same spectrum of antibiotics for sensitivity tests carried out for all cultured organisms. Furthermore, comparison of incision and drainage alone versus incision and drainage and antibiotics in superficial abscess patients without systemic symptoms is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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