Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis

      Study objective

      Skin and soft tissue infections are a common chief complaint in the emergency department. Research has shown that clinical examination alone can be unreliable in distinguishing between cellulitis and abscesses, a distinction that is important because they each require different treatments. Point-of-care ultrasonography has been increasingly studied as a tool to improve the diagnostic accuracy for these skin and soft tissue infections. The primary objective of this systematic review is to evaluate the diagnostic accuracy of point-of-care ultrasonography for abscesses. Subgroup analyses are performed for adult versus pediatric patients and high suspicion versus clinically unclear cases. Secondary objectives include the percentage of correct versus incorrect changes in management and reduction in treatment failures because of point-of-care ultrasonography.


      PubMed, Scopus, Latin American and Caribbean Health Sciences Literature database, Cumulative Index of Nursing and Allied Health, Google Scholar, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were assessed from inception to July 26, 2019, for all prospective studies assessing the diagnostic accuracy of point-of-care ultrasonography for evaluation of skin and soft tissue abscesses. Data were dual extracted into a predefined work sheet and quality analysis was performed with the Quality Assessment of Diagnostic Accuracy Studies–2 tool. Diagnostic accuracy was reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR–), with 95% confidence intervals (CIs).


      We identified 14 studies comprising 2,656 total patients. Point-of-care ultrasonography was 94.6% sensitive (95% CI 89.4% to 97.4%) and 85.4% specific (95% CI 78.9% to 90.2%), with an LR+ of 6.5 (95% CI 4.4 to 9.6) and LR– of 0.06 (95% CI 0.03 to 0.13). Among cases with a high pretest suspicion for abscess or cellulitis, point-of-care ultrasonography was 93.5% sensitive (95% CI 90.4% to 95.7%) and 89.1% specific (95% CI 78.3% to 94.9%), with an LR+ of 8.6 (95% CI 4.1 to 18.1) and LR– of 0.07 (95% CI 0.05 to 0.12). Among cases that were clinically unclear, point-of-care ultrasonography was 91.9% sensitive (95% CI 77.5% to 97.4%) and 76.9% specific (95% CI 65.3% to 85.5%), with an LR+ of 4.0 (95% CI 2.5 to 6.3) and LR– of 0.11 (95% CI 0.03 to 0.32). Among adults, point-of-care ultrasonography was 98.7% sensitive (95% CI 95.3% to 99.8%) and 91.0% specific (95% CI 84.4% to 95.4%), with an LR+ of 10.9 (95% CI 6.2 to 19.2) and LR– of 0.01 (95% CI 0.001 to 0.06). Among pediatric patients, point-of-care ultrasonography was 89.9% sensitive (95% CI 81.8% to 94.6%) and 79.9% specific (95% CI 71.5% to 86.3%), with an LR+ of 4.5 (95% CI 3.1 to 6.4) and LR– of 0.13 (95% CI 0.07 to 0.23). Point-of-care ultrasonography led to a correct change in management in 10.3% of cases (95% CI 8.9% to 11.8%) and led to an incorrect change in management in 0.7% of cases (95% CI 0.3% to 1.1%).


      According to the current data, point-of-care ultrasonography has good diagnostic accuracy for differentiating abscesses from cellulitis and led to a correct change in management in 10% of cases. Future studies should determine the ideal training and image acquisition protocols.
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        • Taira B.R.
        • Singer A.J.
        • Thode Jr., H.C.
        • et al.
        National epidemiology of cutaneous abscesses: 1996 to 2005.
        Am J Emerg Med. 2009; 27: 289-292
        • Hersh A.L.
        • Chambers H.F.
        • Maselli J.H.
        • et al.
        National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.
        Arch Intern Med. 2008; 168: 1585-1591
        • Singer A.J.
        • Talan D.A.
        Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus.
        N Engl J Med. 2014; 370: 1039-1047
        • Berger T.
        • Garrido F.
        • Green J.
        • et al.
        Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections.
        Am J Emerg Med. 2012; 30: 1569-1573
        • Marin J.R.
        • Dean A.J.
        • Bilker W.B.
        • et al.
        Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department.
        Acad Emerg Med. 2013; 20: 545-553
        • Marin J.R.
        • Bilker W.
        • Lautenbach E.
        • et al.
        Reliability of clinical examinations for pediatric skin and soft-tissue infections.
        Pediatrics. 2010; 126: 925-930
        • Giovanni J.E.
        • Dowd M.D.
        • Kennedy C.
        • et al.
        Interexaminer agreement in physical examination for children with suspected soft tissue abscesses.
        Pediatr Emerg Care. 2011; 27: 475-478
        • Page-Wills C.
        • Simon B.C.
        • Christy D.
        • et al.
        Utility of ultrasonography on emergency department management of suspected cutaneous abscess.
        Acad Emerg Med. 2000; 7: 493
        • Squire B.T.
        • Fox J.C.
        • Anderson C.
        ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections.
        Acad Emerg Med. 2005; 12: 601-606
        • Tayal V.S.
        • Hasan N.
        • Norton H.J.
        • et al.
        The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.
        Acad Emerg Med. 2006; 13: 384-388
        • Sivitz A.B.
        • Lam S.H.
        • Ramirez-Schrempp D.
        • et al.
        Effect of bedside ultrasound on management of pediatric soft-tissue infection.
        J Emerg Med. 2010; 39: 637-643
        • Iverson K.
        • Haritos D.
        • Thomas R.
        • et al.
        The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED.
        Am J Emerg Med. 2012; 30: 1347-1351
        • Adams C.M.
        • Neuman M.I.
        • Levy J.A.
        Point-of-care ultrasonography for the diagnosis of pediatric soft tissue infection.
        J Pediatr. 2016; 169: 122-127
        • Greenlund L.J.S.
        • Merry S.P.
        • Thacher T.D.
        • et al.
        Primary care management of skin abscesses guided by ultrasound.
        Am J Med. 2017; 130: e191-e193
        • Lam S.H.F.
        • Sivitz A.
        • Alade K.
        • et al.
        Comparison of ultrasound guidance vs clinical assessment alone for management of pediatric skin and soft tissue infections.
        J Emerg Med. 2018; 55: 693-701
        • Gaspari R.J.
        • Sanseverino A.
        • Gleeson T.
        Abscess incision and drainage with or without ultrasonography: a randomized controlled trial.
        Ann Emerg Med. 2019; 73: 1-7
        • Mower W.R.
        • Crisp J.G.
        • Krishnadasan A.
        • et al.
        Effect of initial bedside ultrasonography on emergency department skin and soft tissue infection management.
        Ann Emerg Med. 2019; 74: 372-380
        • Levine M.C.
        • Arroyo A.
        • Likourezos A.
        • et al.
        The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses.
        Am J Emerg Med. 2019; 37: 1466-1469
        • Quraishi M.S.
        • O'Halpin D.R.
        • Blayney A.W.
        Ultrasonography in the evaluation of neck abscesses in children.
        Clin Otolaryngol Allied Sci. 1997; 22: 30-33
        • Subramaniam S.
        • Bober J.
        • Chao J.
        • et al.
        Point-of-care ultrasound for diagnosis of abscess in skin and soft tissue infections.
        Acad Emerg Med. 2016; 23: 1298-1306
        • Barbic D.
        • Chenkin J.
        • Cho D.D.
        • et al.
        In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? a systematic review and meta-analysis.
        BMJ Open. 2017; 7e013688
        • McInnes M.D.F.
        • Moher D.
        • Thombs B.D.
        • et al.
        Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy studies: the PRISMA-DTA statement.
        JAMA. 2018; 319: 388-396
        • Whiting P.F.
        • Rutjes A.W.
        • Westwood M.E.
        • et al.
        QUADAS- 2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.
        Ann Intern Med. 2011; 155: 529-536
      1. Higgins JPT, Altman DG, Sterne JAC, eds. Assessing risk of bias in included studies. In: Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (Updated March 2011). Cochrane Collaboration; 2011. Available at: Accessed November 2, 2019.

        • Wells G.A.
        • Shea B.
        • O’Connell D.
        • et al.
        The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
        (Available at:)
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • et al.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Bramer W.M.
        • Rethlefsen M.L.
        • Kleijnen J.
        • et al.
        Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study.
        Syst Rev. 2017; 6: 245
        • Blehar D.J.
        • Barton B.
        • Gaspari R.J.
        Learning curves in emergency ultrasound education.
        Acad Emerg Med. 2015; 22: 574-582
        • Chamberlain M.C.
        • Reid S.R.
        • Madhok M.
        Utilization of emergency ultrasound in pediatric emergency departments.
        Pediatr Emerg Care. 2011; 27: 628-632
        • Gold D.L.
        • Marin J.R.
        • Haritos D.
        • et al.
        Pediatric emergency medicine physicians' use of point-of-care ultrasound and barriers to implementation: a regional pilot study.
        AEM Educ Train. 2017; 1: 325-333
        • Talan D.A.
        • Mower W.R.
        • Krishnadasan A.
        • et al.
        Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess.
        N Engl J Med. 2016; 374: 823-832
        • Moran G.J.
        • Krishnadasan A.
        • Mower W.R.
        • et al.
        Effect of cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of uncomplicated cellulitis: a randomized clinical trial.
        JAMA. 2017; 317: 2088-2096
        • Gottlieb M.
        • DeMott J.M.
        • Hallock M.
        • et al.
        Systemic antibiotics for the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis.
        Ann Emerg Med. 2019; 73: 8-16
        • Lin M.J.
        • Neuman M.
        • Rempell R.
        • et al.
        Point-of-care ultrasound is associated with decreased length of stay in children presenting to the emergency department with soft tissue infection.
        J Emerg Med. 2018; 54: 96-101

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        Annals of Emergency MedicineVol. 79Issue 1
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          Correction to “Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis”
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