Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review

Aim To generate a landscape of the current knowledge in the interventional management and outcomes of purulent skin and soft tissue infections. Design This study is a scoping review. Methods Electronic searches were undertaken using CINAHL, Medline, Cochrane Library, British Nursing Index, Science Direct, the National Health Service knowledge and library hub, ClinicalTrials.gov, and MedNar. The population, concept, context framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were utilised, supporting a rigorous appraisal and synthesis of literature. Data Sources. The initial search and synthesis of literature were completed in January 2022 with repeat searches completed in March 2022 and July 2023. There were no imposed chronological parameters placed on the returned literature. Results Nineteen papers were reviewed. Incision and drainage with primary closure, needle aspiration, loop drainage, catheter drainage, and suction drainage are viable adjuncts or alternatives to the traditional surgical management of skin and soft tissue abscesses. Conclusion Despite the empirically favourable alternatives to the incision and drainage technique demonstrated, this does not appear to be driving a change in clinical practice. Future research must now look to mixed and qualitative evidence to understand the causative mechanisms of incision and drainage and its ritualistic practice. Implications. Ritual surgical practices must be challenged if nurses are to improve the treatment and management of this patient group. This will lead to further practice innovation. Impact: This study explored the challenges posed to patients, clinicians, nurses, and stakeholders, resulting from the ritualistic practice of the incision and drainage technique in purulent skin or soft tissue abscesses. Empirically and holistically viable alternatives were identified, impacting all identified entities and recommending a wider holistic study. Reporting Method. Adherence to EQUATOR guidance was achieved through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.


Background
Acute purulent skin and soft tissue infections (SSTIs) also referred to as cutaneous abscesses or type II SSTIs [1] are a common global health complaint, accounting for a third of the most common admissions to the emergency department in the developing world, behind cardiac and respiratory complaints [2,3].
SSTIs are most prevalent in the male working-age population with other risk factors including obesity, smoking, immunosuppression, anatomical areas of heavy hair growth, and a sedentary lifestyle [2].SSTIs are considered an urgent surgical presentation requiring prompt intervention [4,5].
SSTIs are generally caused by an invasion of β-haemolytic streptococci, Staphylococcus aureus, or community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) within the cutaneous layers of the body, generating a localised cycle of pathogen vs immune response [6].
Tis cycle within the macroenvironment causes localised infammation, tissue destruction, and a resulting cavity comprised of pus which is a composition of live and expired neutrophils, bacteria, and debris [7,8].Symptoms can range wildly between patients and anatomical locations from localised pain to systemic sepsis and even death in the comorbid individual [9,10].
In England alone, emergency presentations with SSTIs trebled between 1989 and 2004 from 23,884 to 74,447 admissions per 100,000 population [11,12].Treatment failure, concomitant with the rise of CA-MRSA, is now a pivotal issue in this patient group and is a direct causative mechanism in the empirical failure of incision and drainage through proliferation of wound beds and persistent cellular damage [13].Studies from the United States of America (USA) quote a 47%-94% range of CA-MRSA prevalence within the SSTI patient population [14,15] with a dearth of contemporary research into this aspect in the United Kingdom (UK).
Te problem, and thereby the opportunity for research, arises when one considers that, since the Hippocratic era, the technique of incision and drainage has been the dominating preference of clinicians to achieve infective source control in this patient group [16,17].
Generally, the standard SSTI treatment pathway generates an admittance into a hospital bed, an acute operating demand, and general anaesthetic to facilitate the incision and drainage procedure, followed by an intensive regime of postoperative wound packing to facilitate healing by secondary intent [4,16].
Te driving premise is ofered that the formulaic familiarity with this surgical dogma has blinded clinicians and nurses to the intervention's progressive failure.Te efcacy of incision and drainage has been exclusively justifed by the narrow scope of empirical infective resolution [18].While this without doubt should be accepted as an essential outcome for any SSTI intervention, the efciency of incision and drainage continues to wane [18,19], likely secondary to the epidemic rise of CA-MRSA [14,15].Since 2010, there has been a concern that the technique is no longer sufcient within the contemporary treatment population [20].And yet, evidence suggests that the technique is practiced in over 90% of cases [21].Furthermore, when one considers beyond empirical outcomes, there is speculation that wider implications of incision and drainage experienced by the patient, clinicians, and National Health Service (NHS) have, up until now, been vastly overlooked.It is argued that workforce demands, institutional resources and, perhaps most importantly, the physical, psychological, and fnancial challenges imposed upon the recipient of the surgical intervention reveal an undertow of treatment failure [22,23].
While the surgical practice of incision and drainage has historic connotations for the medically trained clinician, surgically advanced clinical practitioners now have a contemporary role in performing this intervention [24].One postulates that the increasing concern and speculation about incision and drainage and its wider causative mechanisms have blossomed through the addition of diverse professions and philosophical outlooks now contributing to and exploring this phenomenon [25,26].

The Review
2.1.Aim.Te aim of this study is to provide a focused landscape of the current interventional management pathway and outcomes in purulent skin and soft tissue infections and to understand why incision and drainage have remained practiced without contemplation or challenge.Tis scoping review does not aim to answer a specifc question, but rather, to provide an overview of the current knowledge in the SSTI phenomenon.Tis was rationalised due to the speculation that empirical infective resolution of a SSTI exclusively populates the mainstream of this research landscape [15,19].Te driving force behind this research is to explore beyond the empirical [25].Seeking to address the postulation, there are unrecognised holistic mechanisms at play, distorting the empirical perception of success, relative to the management of this condition.Tis acknowledgment raised several objectives to be explored: (1) Why is I&D practiced without contemplation or challenge?(2) What are the interventional alternatives?(3) How is the success of SSTI management defned in the research?(4) Are there any decision-making processes to direct treatment away from I&D? (5) Is there SSTI research acknowledging levels of reality beyond the immediate outcome of infective source control?
It was supposed that there would be a wealth of available research evidence examining variable clinical treatment methods and outcomes for SSTIs and the resulting wounds following intervention.It was further considered that the philosophical stance of critical realism [25], with a supportive underlying nursing philosophy [26] would drive a review of not only the empirical (person) but also the actual (health and nursing) and real (health, nursing, and environmental) afects that current SSTI treatment practices and outcomes generate.

2.2.
Design.An evidenced and repeatable approach to the scoping review was chosen, as this supports the key aspects of rigor and appraisal as with the systematic review design [27].Te population, concept, context framework tool (PCC) was chosen in line with guidance from the Joanna Briggs Institute (JBI) for conducting scoping reviews [28][29][30].Te Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [31] was also utilised to demonstrate a repeatable appraisal and synthesis of the available evidence throughout the review.

Search Methods.
Keywords were explored to identify an acceptable saturation of any relevant literature.Trough the identifcation of seminal research papers [15,32,33], a multitude of keywords with Boolean operators and truncation [34] were tested to identify a focused return of available literature.Following six searches with keywords in multiple orders, the researchers identifed an efcient combination, settling on search term seven (Tables1 and 2): Abscess * AND (skin infection OR soft tissue infection) AND (Treatment OR therapy) AND (Drainage OR antibiotics OR aspiration OR suction OR negative pressure).

2
Nursing Research and Practice     In January 2022, fve databases were searched with the addition of three grey literature sources.Repeat searches were concluded in March 2022 and July 2023, ensuring the most up-to-date and relevant information.Te only exclusions applied to the search in support of the scoping view methodology were studies expressed in languages other than English and animal studies.Te advancing searches were focused towards identifying terms cited within the title, abstract, or subject term dependent upon the options ofered through each database and grey literature source (Tables 1  and 2).
Tere were no chronological restrictions placed upon the return of potential articles for review.Tis decision was taken as we speculated that there were viable yet underresearched and unadopted alternative SSTI management practices explored in both a historic and contemporary context.Terefore, to provide a competent and complete landscape of SSTI management knowledge in this scoping review, time of publication was not considered a restriction.
When considering the types of studies eligible for review, the critical realist stance supported the inclusion of all possible study types [25].Te PCC tool was utilised as the recommended framework to acknowledge the intended concepts and postulated outcomes of this scoping review process [30] (Table 3).

Search Outcomes.
Adopting a systematic approach, the PRISMA tool [31] was used to identify research of relevance (Figure 1).A total of 1,811 results were obtained through all searches across all predefned platforms.Te Microsoft ™ program EndNote ™ was used to correlate the search returns into a designated library.Subgroups were created to correspond with the results from each database.
A total of 287 duplicates were removed by the EndNote ™ application.A human review of the initial results removed a further 43 duplications and excluded an additional 45 studies due to the predefned exclusion criteria (not written in the English language, n � 40; animal studies, n � 5).Tis left 1,428 items available for screening of titles and abstracts.
Tere were a further 430 papers excluded as the titles or abstracts were found to be at odds with the predefned PCC [30].Tere were also nine studies which were removed as they were either terminated (n � 5) or withdrawn before completion (n � 4).Tis left 120 papers which were sought for full retrieval and exploration for eligibility.
Of the 120 papers, 27 papers were researching the efects of SSTI diagnostic modality, choice, or duration of treatments in SSTI such as antibiotics, contrasting the PCC [30].Tere were 21 studies which turned out to be nonspecifc to purulent type II SSTIs or studying complex SSTIs [1].Tere were 15 studies which turned out to be personal reviews, commentary on a published study, or abstract/poster references to a published study.Seven papers were in fact clinical trial registrations, two papers were specifcally focused on CA-MRSA, and a fnal study was excluded due to the main body not being written in the English language.
Te remaining 47 articles were then screened throughout the full text and assessed for eligibility amongst two authors, with the third available to resolve any generated conficts.
Antibiotic therapy is highly researched within the SSTI phenomenon and has become an integral part of contemporary management due to the rise of CA-MRSA [15,19].It is, therefore, an important search term to include in this review.However, the driving aim was to acknowledge and landscape the surgical and interventional practices of SSTI management.It was therefore concluded that research explicitly examining the choice of antibiotic therapy postsurgical intervention was unsuitable for fnal inclusion.
A further four studies were found to be focused towards either the irrigation or dressing of a SSTI wound [3,[49][50][51] and therefore would not contribute to furthering knowledge relevant to the aims of this review.
Tree further returns were found to be clinical trial protocols of studies yet to be undertaken and questionable in their relevance to this review [52][53][54].As there was no experimentation or fndings to examine, these clinical trial protocols were excluded.
One study was found to be a survey of surgical opinion in traditional SSTI management and therefore would not contribute to new knowledge within this review [55].A study by Gottlieb and Peksa [56] was identifed as an older version of an updated study included in this review [57].A third study by Long and Gottlieb [58] was found not to be specifc in its aims to type II SSTIs [1], and it was felt that any fndings from this study could not be generalised to type II SSTI management outcomes nor be utilised in support of any recommendations generated from this review.A fnal excluded study [59] demonstrated a poor study design with ambiguous results.It is likely that this was due to a serious confict of interest, in that the primary investigator received

Quality Appraisal.
Although not a stipulation within the framework of a scoping review [60], it was felt necessary to clarify the academic quality of the research papers to be reviewed within the main body of this chapter.Tis was performed to demonstrate that highquality rigorous studies had not been favoured in isolation in support of this research, providing a clarity of clinical impact within each research paper examined and Nursing Research and Practice informing the reader with a deeper context when summarising the fndings of this review.In addition, as this review was being generated in partial fulflment of a doctoral research qualifcation, the guidance provided at this level of study demands that a systematic and rigorous appraisal be demonstrated [61].Te Hawker appraisal tool [62] was designed specifcally for assessing a wide range of literature from a broad research question of both a quantitative and qualitative nature.When considering the philosophy driving this work, the Hawker tool supports the critical realist perspective to acknowledge all possible levels of reality [25].Te tool seeks to classify each research paper through its relevance to a subject, data extraction, methodological rigor, and fndings which are then correlated and expressed numerically out of a possible score of 36 [62].Whilst credit should be aforded to Hawker et al. [62] for this recognition of healthcare study beyond the empirical, Williams et al. [63] argue that laboriously applying a positivist standard of rigor within a qualitative paradigm is counterproductive, given the polarising epistemologies of the two methods.It could further be argued that a conclusion of trustworthiness within a qualitative study is subjective, generated through the openness of interpretation in the absence of a framework.Te Hawker tool addresses this argument by including open-ended, descriptive evaluation in tandem with quantitative dimensions.It was for these reasons that this tool was utilised for the anticipated wide-ranging literature.As per advice from the JBI [28][29][30], two authors undertook the appraisal process with the third available to resolve any conficts.

Data Abstraction.
Te nineteen studies reviewed were almost entirely of an empirical nature, with a focus on the study of SSTI interventional management relative to infective resolution (n � 16).Six studies incorporated some quantitative measurements of lived experiences such as pain, daily activities, procedural satisfaction, and experiences with antibiotics [32,33,[64][65][66][67].
Te studies were expressed as a collective relative to the geographical focus of study/location, Hawker score [62], intervention, sample size, study design and duration, outcome measurements, and authors conclusions (Table 4).Te data was extracted by the lead author and reviewed by the supporting authors as the review progressed.

Synthesis.
Te identifcation, categorisation, and expressions of the reviewed studies were performed to generate a narrative relative to the aims and objectives of this scoping review.Te synthesis of the evidence was also performed to identify gaps in the current SSTI knowledge.
Pertinent information synthesised from the literature examined was then developed and expressed in visualisation formats (Tables 4-6; Figure 2).

Efciency of SSTI Management. Te variability of the papers reviewed revealed a comprehensive collection of alternative SSTI management practices with evidenced empirical outcome measurements.
A 75% empirical success rate of the traditional incision and drainage procedure in the resolution of SSTI infection was accepted based on the median historic and contemporary evidence [18,19,68,72].Taking the median percentile, where available across the relative studies, the empirical efciency of each SSTI management option can be ranked as follows: (1) Modifed incision and drainage with primary closure and suction therapy: 96% [33,77]   Nursing Research and Practice 13

Defning SSTIs.
Troughout the reviewed literature, there were several reoccurring characteristics which were expressed as a diagnostic interpretation of an SSTI. Figure 3 demonstrates the repeating terms used and how many studies these descriptors were cited in when defning an SSTI.Interestingly, the presence of a "visible or palpable mass" was one of the least used descriptors, utilised only in the earliest studies reviewed [68,69].One could argue that a palpable mass is of unique importance for confrming the presence of a purulent SSTI as opposed to the most used descriptors of "pain" and "induration" which could be seen as rather nonspecifc.Te term "fuctuance" was a common theme throughout the studies which could be accepted as a clinical indication of purulence, potentially demonstrating an advancement in descriptive terms over time from the generic term "mass".Of further interest was the use of the terms, "erythema" and "redness" which were frequently used throughout the literature.Whilst one can assume that such presentations are easily observable in lighter skin tones, this has been a speculated causative mechanism in this review, leading to insufcient diagnosis and determination of SSTI progression for individuals with darker skin tones [37,78].Finally, although diagnostic criteria were evident throughout this review, twelve out of the nineteen papers made no attempt to defne a diagnosis of an SSTI in their studies [21,32,57,64,65,67,70,71,[73][74][75][76].4).One of the least utilised descriptive terms for treatment failure was "SSTI recurrence."Two research teams [68,69] classifed a repeat SSTI at the original site of intervention or within less than fve centimetres of the initial SSTI as a treatment failure.Whilst this may seem sensible, this term lacks the required specifcs, like the challenges analysed in the SSTI defnition.Interestingly, the most common descriptors used to defne treatment failure were the presence of "pain or tenderness" and "cellulitis".It is countered that these terms could be seen as nonspecifc to the recurrence of a purulent SSTI but potentially support the speculation of descriptive progression over time.It is noted that perhaps the most appropriate descriptors of treatment failure would be the presence of "purulence" and "fuctuance".Tese descriptors were, however, only used in three of the studies examined [21,66,70] with nine further research articles failing to clarify SSTI treatment failure in any capacity [32,57,64,67,[71][72][73][74]77].

Patient Outcomes.
It is clear from this review that little credence was aforded to the patient's lived experience, as the recipient of SSTI interventions, and this is a notable theme throughout the review.Although seven of the nineteen included papers did explore some elements of patient experiences such as pain, aesthetics, and use of antibiotics, this was examined in an entirely quantitative capacity [21,32,33,[64][65][66][67].Patient experiences formed part of the primary outcome measurements in only one study [33], otherwise demonstrating a scarcity of research recommendations utilising this paradigm in the progression of SSTI research.
Empirical outcomes dominated the design and implementation of the studies reviewed and demonstrated an overwhelming positivist stance towards the resolution of the SSTI infective process [25].As there is little information available, one can speculate that the priorities of the patient, relative to their SSTI management, may be in stark contrast to those of empirical infective resolution.For example, pain and quality of life may be valued most by recipients of SSTI interventions [23] which are not exclusively paralleled with the empirical focus of the studies synthesised.
3.6.Clinical Outcomes.Surgical clinicians made up fve of the lead authors across the literature examined throughout this review with the remaining studies led by ffteen physicians and only one nurse (Table 5).
Te review has identifed a theme that despite a recognised need for new diverse treatment options [64,72], the evolution of SSTI intervention has been slow to progress due to a persistent culture of clinical resistance.Alternative

16
Nursing Research and Practice methods of drainage remain largely unadopted by the surgical community and are a persisting factor in modern research, with 90% of SSTIs still being treated with a traditional incision and drainage technique [21].When considering why this resistance exists and why almost all SSTI lead researchers have a medical background (95%), the exploration for causative mechanisms and the will to extend knowledge beyond the empirical were severely hampered by a dearth of qualitative or mixed method enquiries.Te opinions and values of the surgical team were only acknowledged within one of the studies examined and relative only to an education process during a change to clinical practice [74].Tis absence of knowledge often generated a theme of surgical discretion when choosing to undertake a traditional or novel SSTI management practice during research, demonstrating a lack of sociocultural understanding and competent research protocols, outside of randomised controlled trials [64,70,74,75].When left to the discretion of the surgical clinician, research demonstrated that incision and drainage remained favoured over all treatment methods, despite an available body of evidence [19,21,64].A pertinent demonstration of this was seen in the study by Alder et al. [64] when only 19% of 400 pediatric patients underwent a novel treatment method, having been left to the free choice of an intervening clinician.

Nursing Outcomes.
Tere was only one nurse who took on the role of the lead author in a nonexperimental SSTI research article [71].When considering the role of supporting author, limited to four of the nineteen studies examined, only four individuals from the nursing profession were acknowledged out of a total of 89 recognised researchers the literature [21,64,70,71].
As with the theme of patient outcomes, evidenced experiences of nurses treating or managing SSTIs was barren throughout this review.Mahida et al. [74] were the only research team to undertake some form of investigation into the experiences of nurses within this phenomenon, limited to the education of the nursing team during a period of clinical practice change.When challenging historic or ritualistic surgical practices, the limited evidence synthesised indicated that the afected entities of healthcare professionals and institutions should be consulted, educated, and utilised [74].Tere was also a complete absence of enquiry into the values and opinions of the nursing team undertaking SSTI management which could help in identifying the nursing and institutional [26] gaps in current management practices during a recognised need for change [21].

Discussion
While SSTI research has evolved, this has been found to be exclusively in a quantitative capacity.Tere remains a distinct absence of holistic enquiry despite researchers acknowledging that such studies are required if nurses are to generate new data in the feld [32,64].Tis narrow spectrum of SSTI research refects an overriding realist mentality [25], acknowledging only the empirical aspect of SSTI management and infective resolution.Te identifed gaps in knowledge generated within this review reveal that empirical outcomes of SSTI management are but a layer of a greater encompassing reality.While empiricism has been the principal focus of SSTI research, the fndings of this review have generated a recommendation for a mixed-method or qualitative study, recognising the distinct lack of groundwork previously undertaken when attempting to promote SSTI management innovation.
Te fndings of this scoping review have revealed that there are many knowledge gaps to address before clinical modernisation in the treatment and management of SSTIs comes to fruition.Without accepting these opportunities, one concedes the likelihood that future research and practice innovation will simply repeat what has gone before, generating the same voids in knowledge and resistance to change that SSTI research needs to explore and address.From the philosophical foundations of nursing [26] and critical realism [25], nurses must now acknowledge and explore evidence-based innovations in SSTI management and utilise the values and opinions of patients, clinical staf, and stakeholders relative to these innovations, addressing the need for qualitative evidence to support alternative SSTI management into clinical practice and professional aceptance.Without these considerations, future SSTI innovation will persist under the theme of empirically constrictive study.Although empirical outcomes are recognised as vital in justifying the efciency of any SSTI intervention, one counters that we, as nurses, must frst acknowledge and direct our innovation in support of the entities directly afected.
From the fndings of this scoping review, one could conclude that the healthcare community has a greater understanding of what an SSTI is not, rather than what a SSTI is (Figures 3 and 4).Tere has been evidence-based focus on the absence of clinical features to determine SSTI resolution rather than actual diagnostic criteria.Tere remains a varied and sometimes absent consensus within the SSTI research community as to what defnes the phenomenon we are exploring.It could be argued further that these variabilities in SSTI description have, collectively, not altered since the frst documented incision and drainage procedures in the Hippocratic era [79].For example, although infrequently used, the terms "erythema" and "redness" appeared to remain a contemporary diagnostic tool in SSTI assessment [21].Trough the critical analysis of the research papers Nursing Research and Practice examined [37], one concludes that within today's multiracial societies, less importance should be placed upon these physiological paradigms [78], and we must gain a consensus that supports the entirety of the SSTI patient group.Te apparent clinical resistance to alternative SSTI management practices could be simply a by-product of historical familiarity and the fact that incision and drainage have always been the primary interventions.Terefore, as described by Wallis [80], because we have always done it this way, why should we change our practice?Te resistance of the healthcare professionals evidenced within this review is ultimately denying the improvement of patient care and goes against our ethos as nurses and clinicians [26].
Te scoping review has yielded evidence that provides founding principles upon which new management pathways can be evidenced for the inclusion of current alternative SSTI management practices.For example, if an objectively healthy patient presents with a pilonidal SSTI, then evidence suggests that needle aspiration with prophylactic antibiotics is a favourable treatment option [32], avoiding the incision and drainage procedure with wound packing.In contrast, there was no evidence found to suggest that needle aspiration would be a suitable option for a patient with a breast abscess [69].One would therefore consider a more favourable option such as loop drainage [21] or a modifed incision and drainage approach with catheter or suction drainage [33,64].Evidence also suggests that while an approach using local anaesthetic is a viable option for the adult SSTI population, potentially relieving the institutional demands of historic SSTI practices [25,26], it is unlikely to be appropriate for pediatric patients [65].Perhaps surprisingly, the fndings from this review suggest that empirical evidence alone does not facilitate a practice change.Tis recognition has generated some profound unanswered questions which should now be undertaken with clinicians, nurses, patients, and stakeholders to understand why infective resolution and empiricism alone are not driving widespread change in the phenomenon of SSTI treatment and management.
As research continues in its attempts to achieve innovation in SSTI management practices, it is countered, from the perspective of a nurse clinician [26] and a critical realist [25], that the relevant sociocultural groups should be held at the centre of these investigations.Without a deeper context of experiences, one attests that there is no way of understanding the areas of importance and personal value placed upon SSTI management from the required contextual perspectives.For example, infective resolution, ease of use of novel equipment, dexterity, efciency, training, follow-up demand, and cost efectiveness will all likely play a part in the professional acceptance of alternative SSTIclinical practices.Te values and opinions of the patient, however, will likely be in stark contrast and must all be taken into consideration.
If one is to improve upon the interventional management of SSTI patients, it be argued that the act of traditional incision and drainage currently perpetuates failure.Tere needs to be a defnitive change to surgical practice with credence aforded to the unrecognised holistic paradigm in the SSTI phenomenon.It is postulated that only then will contemporary management innovation be achieved and accepted within this feld.

Limitations of Tis Study.
Te main limitation of this study is in its methodology as a scoping review and the inherent risk of bias generated through this type of review [60].However, the work was undertaken using a systematic clear approach to minimise a lack of rigor in the study selection, utilising the PRISMA-ScR and PPC tools [30,31].Due to our chosen approach to this review, we speculate that additional relevant literature could have been missed due to the predefned search strategy developed by the authors.We further recognise the limitations upon our synthesis of the evidence both as a collective and within the SSTI intervention subgroupings.Te ranging methods, aims, objectives, and patient populations used within each study are recognised as a confounding variable in our fndings and recommendations.

Figure 2 :
Figure 2: Evolution of SSTI management over time.
[59]e equipment was used to conduct the study.It was contested that any results from the work of Brody et al.[59]would be tenuous and would add very little to the landscaping of SSTI treatment.With the exclusion of this research, this left fnal 19 papers to be included within this review.Details of all searches and extractions can be provided by the lead author upon reasonable request.

Table 5 :
Authors' professions in SSTI research over time.