Blood Cultures in the Evaluation of Uncomplicated Skin and ...

Blood Cultures in the Evaluation of Uncomplicated Skin
and Soft Tissue Infections

WHAT’S KNOWN ON THIS SUBJECT: Blood cultures are a common AUTHORS: Jay R. Malone, MD, MS,a Sarah R. Durica, BA,b
investigation in children admitted to the hospital with skin and David M. Thompson, PhD,a Amanda Bogie, MD,c and
soft tissue infections. The yield of blood cultures in this condition Monique Naifeh, MD, MPHa
is unknown.
Sections of aGeneral and Community Pediatrics and cEmergency
WHAT THIS STUDY ADDS: Blood cultures are not useful in Medicine, Department of Pediatrics, The University of Oklahoma,
children admitted to the hospital with uncomplicated skin and Oklahoma City, Oklahoma; and bThe University of Oklahoma
soft tissue infections, and they may be associated with increased College of Medicine, Oklahoma City, Oklahoma
length of hospital stay.
KEY WORDS
abstract abscess, cellulitis, bacteremia, infant, child, adolescent, blood,
culture, blood specimen collection
BACKGROUND: Blood cultures are often obtained in children hospi-
talized with skin and soft tissue infections (SSTIs). Because little ABBREVIATIONS
evidence exists to validate this practice, we examined the yield of CA-MRSA—community-acquired methicillin-resistant Staphylococcus
blood cultures in the evaluation of immunocompetent children with aureus
SSTIs. CI—confidence interval
METHODS: Medical records were reviewed for all children admitted CRP—C-reactive protein
between January 1, 2007 and December 31, 2009 after emergency de- cSSTI—complicated skin and soft tissue infection
partment evaluation and diagnosis of cellulitis or abscess. We com- ED—emergency department
pared patients with SSTIs (n = 482) with those with complicated LOHS—length of hospital stay
SSTIs (cSSTIs; n = 98). A cSSTI was defined as surgical or traumatic MRSA—methicillin-resistant Staphylococcus aureus
wound infection, need for surgical intervention, or infected ulcers or SSTI—skin and soft tissue infection
burns. The SSTI group included patients without complicating factors. WBC—white blood cell
RESULTS: None of the patients in the SSTI group had a positive blood
culture. In the cSSTI group, 12.5% of blood cultures were positive. The Dr Malone conceptualized and designed the study, participated
mean length of hospital stay (LOHS) of children with SSTIs was shorter in data acquisition and initial data analysis, and drafted the
than that of those with cSSTIs (P , .001). In the SSTI group, obtaining initial manuscript; Ms Durica performed data acquisition; Dr
a blood culture was associated with a higher mean LOHS (P = .044). Thompson performed data analysis and interpretation; Dr Bogie
CONCLUSIONS: Blood cultures are not useful in evaluating immuno- contributed to the conceptualization and design of the study; Dr
competent children who are admitted to the hospital with uncompli- Naifeh contributed to study design and participated in data
cated SSTIs, and they are associated with a nearly 1-day increase in interpretation; Ms Durica and Drs Thompson, Bogie, and Naifeh
mean LOHS. Pediatrics 2013;132:454–459 critically revised the manuscript; and all authors approved the
final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1384

doi:10.1542/peds.2013-1384

Accepted for publication Jun 20, 2013

Address correspondence to Monique Naifeh, MD, MPH,
Department of Pediatrics, The University of Oklahoma, 1200
Children’s Ave, Suite 14000, Oklahoma City, OK 73104. E-mail:
[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no conflicts of interest to disclose.

454 MALONE et al

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ARTICLE

Skin and soft tissue infections (SSTIs) are admitted to The Children’s Hospital of a standard form. Data extracted in-
a common pediatric problem, accounting Oklahoma after diagnosis of SSTI dur- cluded demographics, length of hospi-
for 1 in 500 to 1 in 150 pediatric emer- ing initial ED evaluation. The Children’s tal stay (LOHS), clinical presentation,
gency department (ED) visits.1,2 Some Hospital of Oklahoma is an urban, past medical history, and laboratory
management guidelines1,3,4 suggest ob- university-affiliated pediatric hospital results obtained in the ED including
taining blood cultures to ensure early at a tertiary medical center. The ED blood and wound cultures, complete
identification of bacteremia and pre- treats ∼40 000 children annually, and blood count with differential, and C-
vention of subsequent sepsis. Obtaining during the study period, patients were reactive protein (CRP). A second re-
a blood culture during an episode of SSTI evaluated by residents in pediatrics, viewer independently checked 10% of
is common practice, particularly in chil- emergency medicine, and family med- the medical records to ensure accuracy
dren who are admitted to the hospital icine and attending physicians. This of data collection.
for treatment with intravenous anti- study was approved by the institutional
biotics.2,5 review board of the University of Okla- Protocol
homa Health Sciences Center.
The rate of bacteremia in immunocom- During the study period, blood cultures
petent children with SSTIs is not known. In A search of the hospital’s electronic were collected in BACTEC Peds Plus/F
the pre–Haemophilus influenzae vaccine medical records listed all children who culture vials (Becton, Dickinson and
era, the rate of SSTI-associated bacter- were seen in the ED between January 1, Company, Sparks, MD). One culture with
emia was ∼20%,6 but after introduction 2007 and December 31, 2009, diagnosed a volume of 1 to 3 mL was drawn from
of the H. influenzae vaccine, the rate with SSTIs using ICD-9-CM codes for cel- each patient and incubated for 120
decreased to 2%.7 In 1998, Sadow and lulitis and abscess (682.X), and admitted hours. Cultures were categorized as
Chamberlain reported that bacteremia to the hospital. Children who were dis- contaminated if they grew Staphylococ-
during SSTI was largely associated with charged from the hospital from the ED cus epidermidis, viridans streptococci,
superinfected lesions originating from were excluded. Other exclusion criteria diphtheroids, micrococcus, or propioni-
active varicella infection,7 which is now were immunocompromise, missing bacterium species. Cultures containing
much less common because of routine medical record, return ED visit for a sin- any other organism were categorized as
childhood vaccination.8 However, since gle episode of cellulitis, diagnoses that positive. Cultures were categorized as
that study was published, the widespread the primary reviewer judged to be mis- negative if no organism was found.
emergence of community-acquired coded upon detailed chart review, in-
methicillin-resistant Staphylococcus au- cidental diagnosis of cellulitis at the time The primary reviewer judged medical
reus (CA-MRSA) has been implicated in of admission for a reason other than records to be miscoded and excluded
invasive infections and now accounts SSTI, and development of cellulitis while themfrom the studyifthe clinical history,
for 45% to 75% of SSTIs.9–13 The number admitted to the hospital for a reason physical examination, and physician
of pediatric ED visits for SSTIs increased other than SSTI. assessment and plan made no mention
more than 170% between 1997 and 2005.14 of SSTI or symptoms of SSTI. All charts
It remains unclear how the introduction Eligible patients were stratified into excluded for this reason were reviewed
of varicella and pneumococcal vaccines groups that distinguished those with by a second reviewer. The primary re-
and the widespread emergence of CA- complicated skin and soft tissue in- viewer also excluded medical records
MRSA have affected rates of bacteremia fection (cSSTI) from those with un- from patients who were immunocom-
in SSTIs. complicated infections (SSTIs). The promised, as evidenced by information
cSSTI group included patients with that was available to the treating phy-
We determined the prevalence of bac- surgical or traumatic wound infection, sician in the ED that indicated primary or
teremia, defined as a blood culture that need for surgical intervention, and secondary immunodeficiency.
yields a positive result, among immu- infected ulcers or burns.4 Routine in-
nocompetent children admitted to the cision and drainage was not consid- Data Analysis
hospital after ED evaluation and di- ered surgical intervention. The SSTI
agnosis of SSTI. group included all children without Categorical variables are reported as
these complicating factors. counts and percentages. Intergroup
METHODS differences in percentages were tested
Measurements by using Fisher’s exact tests. Continu-
Subjects ous variables, including age, are
The primary reviewer evaluated medi- reported as means with SDs, and in-
This retrospective case series included cal records from eligible patients using tergroup differences in means were
children aged 0 to 18 years who were

PEDIATRICS Volume 132, Number 3, September 2013 455

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tested by using 2-sample t tests. Sta- Table 1 lists patient demographics and blood cell (WBC) count (17.7 vs 15.5,
tistical significance was determined by clinical features. In the SSTI group (n = P = .15). Patients with a blood culture
using a critical a of .05. 482), the mean age was 3.4 years (SD: were more likely to have a CRP drawn
3.8) with a range of 4 days to 16 years. (97.8% vs 74.1%, P , .001).
A sample of 340 patients was needed to Of these, 50% were male, and 56.2%
ensure, with 90% certainty, that the had received at least 1 dose of anti- Patients with uncomplicated SSTIs most
width of the confidence interval (CI) on biotics before ED presentation. The often presented with infections located
the estimated rate of bacteremia in mean temperature was 37.5°C (SD: 1.2), ontheextremities(32.3%)or thebuttocks
patients with SSTI would be no more and 26.6% had temperatures .37.9°C. or perineum (26.8%) (Table 2). The most
than 2%. The sample size estimate common site of infection in the cSSTI
assumes that 2% is the true preva- In the cSSTI group (n = 98), the mean group was the face or neck (39%), and
lence of bacteremia in children with age of 5.8 years (SD: 4.7), with a range no children in the cSSTI group had
SSTIs.7 of 6 days to 16 years, was significantly infections of the buttocks or perineum
older than the uncomplicated group (P , .001). The cSSTI group also had
RESULTS (P , .001). The cSSTI group also had a higher number of periorbital infections
more males (64.2%; P = .011). Forty-nine than the SSTI group (11 vs 0, P , .001).
The initial database search identified percent received at least 1 dose of
1812 children who were seen in the ED antibiotics before ED presentation, and Laboratory investigations were per-
for SSTI during the 3-year study period mean temperature was 37.5°C (SD: 1.0) formed in the majority of cases (Table 3).
(Fig 1). Of those, 657 were admitted to with 24.5% of temperatures .37.9°C. Blood cultures were performed in 94.4%
the hospital. Exclusion criteria were of uncomplicated and 81.6% of compli-
met by 77 patients. The primary in- In the uncomplicated SSTI group, cated cases. No positive blood cultures
vestigator reviewed the remaining 580 patients with and without a blood cul- were detected in the SSTI group, which
charts and judged 482 patients to have ture had similar presenting tempera- suggests that the chance of obtaining
uncomplicated SSTIs and 98 to meet ture (37.5°C vs 37.1°C, P = .095), CRP a positive blood culture during an epi-
criteria for cSSTIs. (60 mg/L vs 47 mg/L, P = .39), and white sode of uncomplicated SSTI is ,1%

FIGURE 1
Study design diagram.

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(95% CI: 0%–0.81%). In the cSSTI group, DISCUSSION preponderance of contaminated cultures
10 positive cultures were observed parallels the findings of 2 recent studies
(12.5%; 95% CI: 6.2%–22.0%; P , .001). SSTIs are an increasingly common of antibiotic choice in SSTIs, both of which
cause of outpatient visits and pediatric noted false-positive to true-positive cul-
In the SSTI group, 75.7% of patients (365/ ED visits. This is the first study in the tures in a ratio of 3:1.2,15 Similar false-
482) had a wound culture, of which CA-MRSA era to specifically examine positive blood culture rates were also
68.4% (250/365) grew MRSA. In the cSSTI the prevalence of bacteremia in chil- noted in the 1998 study by Sadow and
group, 67.3% of patients (66/98) had a dren with SSTIs. More than 90% of Chamberlain, who examined the utility of
wound culture, and 37.9% (25/66) of children admitted to the hospital for blood cultures in the post–Haemophilus
those grew MRSA. SSTIs undergo laboratory investigations, influenzae vaccination era.7 They col-
including blood cultures. However, our lected data in 1994–1995, before the in-
Mean LOHS differed significantly be- study found that blood cultures are troduction of the varicella vaccine in
tween the 2 groups (P , .001, Table 4). positive in ,1% of patients with un- 1995 and the pneumococcal conjugate
Children admitted with SSTIs had complicated SSTIs and so do not im- vaccine in 2000. They detected 5 cases of
a mean LOHS of 3.2 days (SD: 2.3, range prove patient management. bacteremia, of which 3 were associated
1–21 days), whereas children with with varicella and one was Streptococ-
cSSTIs had a mean LOHS of 6.6 days (SD: In our cohort, 83% of patients were cus pneumoniae. Routine vaccination
10.9, range 1–72 days). In the SSTI judged to have uncomplicated SSTIs, against both of these pathogens is now
group (Table 4), patients in whom and 94% of those had blood cultures common practice.
a blood culture was obtained had obtained. Among those with uncom-
a mean LOHS that was 0.91 days longer plicated SSTIs, there were no positive but Additionally, Sadow and Chamberlain’s
than patients without a blood culture 3 contaminated blood cultures. This study was performed just as CA-MRSA
(95% CI: 0.026–1.8 days; P = .044). infections were beginning to increase
in incidence. Although CA-MRSA has
TABLE 1 Patient Demographics and Clinical Features (N = 580) been implicated in a wide range of se-
vere infections, including bacteremia
SSTI (n = 482) cSSTI (n = 98) P and sepsis, it remains unclear wheth-
er CA-MRSA causes bacteremia in
Age, mean (SD) 3.4 (3.8) 5.8 (4.7) ,.001 a higher percentage of cases than
Male gender, n (%) 241 (50) 63 (64.2) .011 methicillin-sensitive Staphylococcus
Temperature (°C), mean (SD) 37.5 (1.2) 37.5 (1.0) .99 aureus. Despite a high prevalence of
128 (26.6) 24 (24.5) .9 MRSA (68.4%) detected in wound cul-
Fever (.37.9°C), n (%) 138 (30) 133 (31) .1353 tures in children with uncomplicated
Heart rate, mean (SD) 271 (56.2) 48 (49.0) .22 SSTI, no cases of bacteremia were
Prior antibiotics (yes), n (%) detected. In the cSSTI group, 60% of the
detected cases of bacteremia were
TABLE 2 Location of Cellulitis (N = 580) MRSA, although this figure should be
viewed cautiously because there were
SSTI (n = 482), n (%) cSSTI (n = 98), n (%) P only 10 isolates.

Extremity 155 (32.3) 23 (23.5) .09 Children with uncomplicated versus
Buttock or perineum 129 (26.8) 0 (0) ,.001 complicated SSTI differed with regard to
Face or necka 93 (19.3) 38 (38.8) ,.001 several demographic and laboratory
Hand or foot 36 (7.5) 9 (9.2) measures. Mean age was higher in
Trunk 35 (7.3) 13 (13.3) .41 children with cSSTIs (5.8 vs 3.4 years; P ,
Genitals 25 (5.2) 2 (2.0) .07 .001), possibly because of the inclusion
Scalp 2 (2.0) .29 of infection secondary to traumatic in-
Periorbital 9 (1.9) 11 (11.2) .99 jury in the definition of complicated in-
0 (0) ,.001 fection. Blood cultures were performed
a Excluding periorbital. more frequently in children with un-
P complicated infection (94.4% vs 81.6%;
TABLE 3 Laboratory Investigations (N = 580) P , .001). This could be a result of
,.001
SSTI (n = 482) cSSTI (n = 98) ,.001

Blood culture performed, n (%) 455 (94.4) 80 (81.6) .11
Blood culture positive, n (%) 0 (0) 10 (12.5) .1
Blood culture contaminant, n (%) 3 (0.7) 1 (1.3) .0024
Complete blood count performed, n (%) 96 (98.0) .26
WBC count 3109/L, mean (SD) 477 (99.0) 15.2 (7.6) .052
Neutrophils, mean (SD) 17.6 (6.9) 9.9 (6.5) .015
Bands, mean (SD) 10.6 (5.3) 0.37 (1.1) ,.001
Band/neutrophil ratio, mean (SD) 0.2 (0.7) 0.05 (0.2) .0011
CRP performed, n (%) 0.02 (0.08) 83 (84.7)
CRP, mean (SD) 465 (96.5) 87.1 (101.1)
59.4 (64.2)

PEDIATRICS Volume 132, Number 3, September 2013 457

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TABLE 4 LOHS (N = 580) SSTI (n = 482) cSSTI (n = 98) P may have been initially bacteremic.
3.18 (2.3) 6.62 (10.9) ,.001 Though unlikely, this possibility limits
LOHS (days), our ability to determine with certainty
mean (SD) the true incidence of bacteremia dur-
ing SSTI. Therefore, the applicability of
Blood Culture No Blood Culture P Blood Culture No Blood Culture P our study is limited to hospitalized
Drawn Drawn patients.
(n = 27) Drawn Drawn
(n = 455) Despite these limitations, several find-
(n = 80) (n = 18) ings of this large case series are
important. First, blood cultures per-
LOHS (days), 3.24 (2.31) 2.33 (1.47) .044 7.30 (11.89) 3.61 (2.17) .194 formed in patients admitted to the
mean (SD) hospital with uncomplicated SSTIs yield
an extremely low number of positive
a greater percentage of children with Our study had several limitations. First, results. Second, although some labo-
cSSTI being admitted to surgical services its retrospective study design limited ratory findings differ between patients
that may perform laboratory investiga- our interpretation of history and clini- with uncomplicated and complicated
tions less often than medical services. cal appearance to clinician reports in SSTIs, these differences do not provide
Differences between the 2 groups in the medical record. Therefore, we may useful clinical predictive value. Given
WBC, band/neutrophil ratio, and CRP, have incorrectly assigned some the limited value of these tests, physi-
though statistically significant, were not patients to the SSTI or cSSTI groups. cians might reasonably limit their use
large enough to be clinically meaningful. Second, 56.2% of patients in the SSTI to children with complicated infections.
group had received at least 1 dose of Third, patients with cSSTIs have a high
Mean LOHS differed significantly be- antibiotics before their blood culture. rate of bacteremia, and blood cultures
tween the SSTI and cSSTI groups and This may have caused some blood are important in treating those pati-
also differed within the SSTI group. cultures to be negative in children ents. However, obtaining blood cultures
Among patients with SSTI, those who who were bacteremic before receiving in children with uncomplicated SSTI
underwent blood cultures stayed in the antibiotics. Third, blood cultures were is seldom useful and may be harmful,
hospital nearly 1 day longer (3.2 days) not obtained in 5.6% of the SSTI group or as we found that obtaining a blood cul-
than those who did not (2.3 days; P , 18.4% of the cSSTI group, which limits ture is associated with a longer mean
.044). It is possible that patients with- our ability to determine the precise LOHS.
out a blood culture were initially less ill incidence of bacteremia during SSTIs.
appearing than those who did receive Fourth, although our cohort included This is the first study to examine the
a blood culture. However, no differ- infants ,60 days old, we did not study yield of blood cultures in patients with
ences were detected in presenting enough patients in this age range to SSTIs since the introduction of the
temperature, CRP, or WBC. Blood cul- extend our conclusions to this high-risk varicella and pneumococcal vaccines,
tures were obtained in a large pro- group. Dedicated research is needed to and it is the first to do so in the CA-MRSA
portion of patients whose initial determine the bacteremia risk in era. We agree with recent research on
clinical appearance seems unlikely to young infants with SSTIs. Finally, our pediatric SSTIs that has called for ad-
have affected the decision to obtain study examined only the 36.3% of chil- ditional prospective research to define
a culture and therefore the LOHS. dren presenting to the ED with SSTIs criteria for hospitalization. We conclude
Rather, it is more likely that the longer who were admitted to the hospital. Al- that blood cultures are not useful in the
mean LOHS was a result of blood cul- though this allowed us to select for management of uncomplicated SSTI in
ture monitoring. Although a case se- children who were presumably more ill hospitalized children, and clinicians
ries design cannot prove causality, this appearing and had a greater number should discontinue their use in this
conclusion is clinically logical, because of laboratory examinations performed, setting.
care providers are most comfortable some of the children who were dis-
declaring a culture negative after 48 charged from the hospital from the ED
hours.

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TRADE WINDS: My wife and I lived in Hawaii for several years. We loved everything
about the islands, including the weather. Other than a short period early each fall,
we could always count on the trade winds to keep the sky clear and the tem-
perature and humidity perfect for outdoor activities. We even had an expression
about living in Hawaii: that there were “trade winds and tradeoffs.” Alas, the
trade winds, such a constant in island life, may be diminishing. As reported in the
Honolulu Star-Advertiser (News: June 4, 2013), researchers using data from four
airports and four ocean buoys have concluded that there has been a 28% drop in
northeast trade wind days since the early 1970s. Why the trade winds have di-
minished is not known. While the weather remains lovely and the humidity still
comfortable, other effects have been seen. Without the winds to generate waves,
outrigger paddlers can no longer ride the waves and now need to prepare to race
over flat water. If the winds are weak, sulfur dioxide from the Kilauea volcano on
the island of Hawaii is no longer blown out to sea, leaving a haze hanging over
Honolulu. The biggest issue, however, is decreased rainfall. The trade winds bring
rain clouds that bump into the mountains and release their water. It is this
rainfall, along with the rain associated with winter storms, which supplies the
islands with water. Residents report less water in streams fed by the rains, and
several parts of Hawaii are even reporting drought conditions. If the trends
continue, farmers may have to change when they plant or use more drought-
tolerant crops. While it is unclear if the trade winds will continue to diminish, I am
trying to convince my wife that we should visit and conduct our own investigation
for a week or two.

Noted by WVR, MD

PEDIATRICS Volume 132, Number 3, September 2013 459

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Blood Cultures in the Evaluation of Uncomplicated Skin and Soft Tissue
Infections

Jay R. Malone, Sarah R. Durica, David M. Thompson, Amanda Bogie and Monique
Naifeh

Pediatrics 2013;132;454; originally published online August 5, 2013;
DOI: 10.1542/peds.2013-1384

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
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Blood Cultures in the Evaluation of Uncomplicated Skin and Soft Tissue
Infections

Jay R. Malone, Sarah R. Durica, David M. Thompson, Amanda Bogie and Monique
Naifeh

Pediatrics 2013;132;454; originally published online August 5, 2013;
DOI: 10.1542/peds.2013-1384

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/132/3/454.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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