Incision and Drainage - Curbside
Incision and Drainage
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Skin abscess
Exclusion Criteria
  • Toxic appearance
  • Mycotic abscesses
  • Recurrent or extremely large abscess that would require the operating room
  • Complex medical problems related to drainage or sedation
  • Complex anatomical location (Breast abscess, perirectal abscess, Hand abscess, neck abscess likely involving a congenital cyst (thyroglossal, brachial, etc.), abscess in central triangle of face, other complex area (near vital artery, vein or other structure))
Consult surgeon or other advanced provider

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Evidence
Total Notes: 15
Evidence

1 Skin abscess

Most skin abscess (and large furuncles & carbuncles) should be drained to optimize healing. A majority of these procedures can be done outside the operating room however abscesses in complex anatomical locations, involving patients with high risk past medical history or extremely large abscess should be done in an OR setting.



References:
  1. Incision and Drainage. In: Clinical Procedures in Emergency Medicine, 5th ed
    Butler K
    Saunder Elsevier, Philadelphia 2010.p.657.
  2. Videos in clinical medicine. Abscess incision and drainage.
    Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M
    N Engl J Med. 2007;357(19):e20.
  3. Procedures for primary care physicians, 1st ed
    Derkson, DJ
    Mosby, St. Louis 1994.p.50.

2 I&D indication

Abscesses best heal with incision and drainage as many of these abscess contain loculated collections of infectious material. Needle aspiration should be reserved for specific complex situations as studies have shown that I&D has superior resolution at 7 days. In addition, very small abscess, furuncles and carbuncles that are spontaneously draining may not need incision and drainage.

If a patient is to be observed they should apply warm compresses to the area 3 - 4 times per day. In some of these observed cases antibiotics may promote resolution.

Bedside ultrasound has become an increasingly common way to identify abscesses which will require drainage. Ultrasound has the ability to identify fluid collections and determine the volume and depth of the collections to better inform the indication for I&D.



References:
  1. Management and microbiology of cutaneous abscesses.
    Meislin HW, McGehee MD, Rosen P
    JACEP. 1978;7(5):186.
  2. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus.
    Gaspari RJ, Resop D, Mendoza M, Kang T, Blehar D
    Ann Emerg Med. 2011 May;57(5):483-91
  3. Effect of bedside ultrasound on management of pediatric soft-tissue infection.
    Sivitz AB, Lam SH, Ramirez-Schrempp D, Valente JH, Nagdev AD
    J Emerg Med. 2010;39(5):637.

3 Antibiotic use without I&D

In patients with abscesses, furuncles or carbuncles who do not undergo I&D a majority of these lesions with self-resolve with warm compresses and no use of antibiotics. In high risk patients (immunocompromised, diabetes, etc.), patients with worsening lesions despite optimal supportive care or patients with large cellulitic component, the use of antibiotics may be warranted. If so, medications active against skin flora and MRSA should be considered.

Clindamycin, Vancomycin, Doxycycline, TMP-SMX and Linazolid are all commonly used antibiotics with activity against MRSA. Some Staphylococcus species possess inducible clindamycin resistance that is conferred by an mutation in the ERM gene (erythromycin ribosomal methylase), which can cause cross-resistance between macrolides and linacosamides (clindamycin). These are know as the macrolide-linacosamide-streptogramin B "MLSB" phenotype. To determine if a strain possesses this phenotype labs run a "D" test where they plate the strain with inoculums of both mediations (clinda & eryhro) to assess for a zone of growth next to the erythromycin area (implying inducible resistance). The lab will report these strains as clinda resistant in vitro. It should be noted however that, while these strains may actually have in vivo activity, there is evidence that iMLS strains may transform to constitutively resistant in the even in the absence of a macrolide, thus leading to treatment failure.

If TMP-SMX is used, an anti-streptococcus antibiotic (i.e. Cephalexin) should be considered in addition if there is concern for strep as the causative organism (TMP-SMX has limited activity against strep).



References:
  1. The role of ancillary antimicrobial therapy for treatment of uncomplicated skin infections in the era of community-associated methicillin-resistant Staphylococcus aureus.
    Gorwitz RJ
    Clin Infect Dis. 2007;44(6):785.
  2. Failure of clindamycin treatment of methicillin-resistant Staphylococcus aureus expressing inducible clindamycin resistance in vitro.
    Siberry GK, Tekle T, Carroll K, Dick J.
    Clin Infect Dis. 2003 Nov 1;37(9):1257-60.
  3. Detection of Inducible Clindamycin Resistance in Beta-Hemolytic Streptococci by Using the CLSI Broth Microdilution Test and Erythromycin-Clindamycin Combinations
    Bowling J, Owens A, McElmeel M, Fulcher L, Herrera M, Wickes B, Jorgensen J
    J Clin Microbiol. Jun 2010;48(6): 2275–2277.

4 Endocarditis prophylaxis

Patients at risk for endocarditis undergoing I&D should be prophylaxed since the procedure carries the risk of introducing bacteria into the blood stream. Some studies show that I&D is not associated with bacteremia, however coconscious guidelines still recommend prophylaxis for at risk individuals. Since MRSA is a common pathogen in abscesses, vancomycin is the preferred antibiotic of choice. Alternatives are possible if patient cannot tolerate vancomycin.



References:
  1. Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults.
    Bobrow BJ, Pollack CV Jr, Gamble S, Seligson RA
    Ann Emerg Med. 1997;29(3):404.
  2. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
    Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, American Heart Association Council on Cardiovascular Disease in the Young, American Heart Association Council on Clinical Cardiology, American Heart Association Council on Cardiovascular Surgery and Anesthesia, Quality of Care and Outcomes Research Interdisciplinary Working Group
    Circulation. 2007;116(15):1736.

5 Tetanus prophylaxis

Incision and drainage creates an open wound increasing the risk of tetanus. If a patient is not adequately vaccinated against tetanus they should receive the tetanus vaccine immediately. This should include the diphtheria vaccine (Td) or the pertussis as well if indicated (Tdap).



References:
  1. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: United States, 2014.
    Bridges CB, Coyne-Beasley T, Advisory Committee on Immunization Practices
    Ann Intern Med. 2014;160(3):190.
  2. Serologic immunity to diphtheria and tetanus in the United States.
    McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M
    Ann Intern Med. 2002;136(9):660.

6 Procedural sedation

Sedation has been shown to improve provider’s ability to adequately perform procedures in patients who otherwise would not be able to tolerate the procedure. There are no hard and fast indications for the use of procedural sedation. The providers should assess the patient's level of anxiety, behavioral status and ability to tolerate the procedure and weigh this against the risks inherent in sedation.



References:
  1. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.
  2. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.
    American Academy of Pediatrics, American Academy of Pediatric Dentistry, CotéCJ, Wilson S, Work Group on Sedation
    Pediatrics. 2006;118(6):2587.
  3. Relief of pain and anxiety in pediatric patients in emergency medical systems.
    Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
    Pediatrics. 2004;114(5):1348.

7 Anxiolysis

Incision and drainage can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the provider’s ability to perform the procedure and maximize cosmetic outcome. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.

Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrious oxide.

Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).



References:
  1. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.
    Annequin D, Carbajal R, Chauvin P, Gall O, Tourniaire B, Murat I
    Pediatrics. 2000 Apr;105(4):E47.
  2. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.
    Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM
    Ann Emerg Med. 2001;37(1):20.
  3. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents.
    Ekbom K, Kalman S, Jakobsson J, Marcus C
    Arch Pediatr Adolesc Med. 2011;165(9):785.
  4. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases.
    Zier JL, Liu M
    Pediatr Emerg Care. 2011 Dec;27(12):1107-12.
  5. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation.
    Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN
    Pediatrics. 2008 Mar;121(3):e528-32.
  6. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.

8 Local aesthetic field block

1 percent lidocaine is the infiltration anesthetic of choice for a field block. Concentrations greater than 1 percent have not been shown to improve the onset or duration of analgesia and increase the risk of toxicity. Onset time is usually 2 - 5 min and the duration lasts 30 - 120 minutes. Buffering lidocaine with sodium bicarbonate has been shown to decrease pain and may shorten the onset time.

The use of epinephrine has the benefit of decreasing local bleeding, decreasing systemic absorption of lidocaine and extending the duration of action up to 180 minutes. Max doses are 4mg/kg for lidocaine WITHOUT epinephrine and 7mg/kg for lidocaine WITH epinephrine.

Due to the low pH of infected tissue around abscesses, lidocaine is less effective. Performing a field block along the margins of the abscess in the subcutaneous layer through intact skin will optimize the analgesic effect. Care should be made not to inject directly into the abscess cavity as this will increase the pressure within the cavity and cause further pain.



References:
  1. Local and topical anesthesia. In: Clinical Procedures In Emergency Medicine, 5th edition
    McGee, DL.
    Saunders Elsevier, Philadelphia 2010.p.481.
  2. Toxicity of local anesthetics in infants and children.
    Berde CB
    J Pediatr. 1993;122(5 Pt 2):S14.
  3. Sedation and analgesia. In: Textbook of Pediatric Emergency Medicine, 5th
    Selbst SM, Fein JA
    Lippincott Williams and Wilkins, Philadelphia 2006.p.69.
  4. The ouchless emergency department. Getting closer: advances in decreasing distress during painful procedures in the emergency department.
    Kennedy RM, Luhmann JD
    Pediatr Clin North Am. 1999;46(6):1215.
  5. Anesthesia. In: Dermatology, Volume 2, 2nd
    Hruza, GJ
    Mosby Elsevier, Spain 2008.p.2173.

9 Antibiotic treatment

Prior to the arrival of community acquired MRSA several studies showed that antibiotic use for abscesses was not generally useful. However, there have been conflicting studies since the advent of MRSA, some showing benefit and some showing no benefit with the use of antibiotics. Currently, we advocate for the use of no antibiotics unless there are high risk situations where antibiotics may be beneficial (immunocompromised patient, diabetes, high risk past medical history, large surround cellulitis, systemic infection, incomplete resolution with I&D alone and abscesses larger than 5 cm.)

Clindamycin, Vancomycin, Doxycycline, TMP-SMX and Linazolid are all commonly used antibiotics with activity against MRSA. Some Staphylococcus species possess inducible clindamycin resistance that is conferred by an mutation in the ERM gene (erythromycin ribosomal methylase), which can cause cross-resistance between macrolides and linacosamides (clindamycin). These are know as the macrolide-linacosamide-streptogramin B "MLSB" phenotype. To determine if a strain possesses this phenotype labs run a "D" test where they plate the strain with inoculums of both mediations (clinda & eryhro) to assess for a zone of growth next to the erythromycin area (implying inducible resistance). The lab will report these strains as clinda resistant in vitro. It should be noted however that, while these strains may actually have in vivo activity, there is evidence that iMLS strains may transform to constitutively resistant in the even in the absence of a macrolide, thus leading to treatment failure.

If TMP-SMX is used, an anti-streptococcus antibiotic (i.e. Cephalexin) should be considered in addition if there is concern for strep as the causative organism (TMP-SMX has limited activity against strep).



References:
  1. The role of ancillary antimicrobial therapy for treatment of uncomplicated skin infections in the era of community-associated methicillin-resistant Staphylococcus aureus.
    Gorwitz RJ
    Clin Infect Dis. 2007;44(6):785.
  2. Treatment of cutaneous abscess: a double-blind clinical study.
    Llera JL, Levy RC
    Ann Emerg Med. 1985;14(1):15.
  3. The treatment of acute superficial abscesses: a prospective clinical trial.
    Macfie J, Harvey J
    Br J Surg. 1977;64(4):264.
  4. Methicillin-resistant Staphylococcus aureus disease in three communities.
    Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, Harriman K, Harrison LH, Lynfield R, Farley MM, Active Bacterial Core Surveillance Program of the Emerging Infections Program Network
    N Engl J Med. 2005;352(14):1436.
  5. Randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection.
    Rajendran PM, Young D, Maurer T, Chambers H, Perdreau-Remington F, Ro P, Harris H
    Antimicrob Agents Chemother. 2007;51(11):4044.
  6. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus.
    Lee MC, Rios AM, Aten MF, Mejias A, Cavuoti D, McCracken GH Jr, Hardy RD
    Pediatr Infect Dis J. 2004;23(2):123.
  7. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome.
    Ruhe JJ, Smith N, Bradsher RW, Menon A
    Clin Infect Dis. 2007;44(6):777.
  8. Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus aureus infection.
    Davis SL, Perri MB, Donabedian SM, Manierski C, Singh A, Vager D, Haque NZ, Speirs K, Muder RR, Robinson-Dunn B, Hayden MK, Zervos MJ
    J Clin Microbiol. 2007;45(6):1705.
  9. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection.
    Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J, Huebner K, Lightfoot J, Ritz B, Bates C, Schmitz M, Mete M, Deye G
    Ann Emerg Med. 2010;56(3):283.
  10. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient.
    Duong M, Markwell S, Peter J, Barenkamp S
    Ann Emerg Med. 2010;55(5):401.
  11. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america.
    Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC
    Clin Infect Dis. 2014;59(2):e10.
  12. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.
    Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF, Infectious Diseases Society of America
    Clin Infect Dis. 2011;52(3):e18.
  13. Failure of clindamycin treatment of methicillin-resistant Staphylococcus aureus expressing inducible clindamycin resistance in vitro.
    Siberry GK, Tekle T, Carroll K, Dick J.
    Clin Infect Dis. 2003 Nov 1;37(9):1257-60.
  14. Detection of Inducible Clindamycin Resistance in Beta-Hemolytic Streptococci by Using the CLSI Broth Microdilution Test and Erythromycin-Clindamycin Combinations
    Bowling J, Owens A, McElmeel M, Fulcher L, Herrera M, Wickes B, Jorgensen J
    J Clin Microbiol. Jun 2010;48(6): 2275–2277.

10 Culture

Routine wound culture is often not helpful unless antibiotics are started or there are specific circumstances (immunocompromised, history of failed treatment or reoccurrence, complex patient histories, systemic or severe local infection).



References:
  1. Use of routine wound cultures to evaluate cutaneous abscesses for community-associated methicillin-resistant Staphylococcus aureus.
    Abrahamian FM, Shroff SD
    Ann Emerg Med. 2007;50(1):66.

11 Probing loculations and irrigation

Many abscesses will have loculated areas that if not sufficiently opened, will not resolve. Probing should be done judiciously as extreme force may cause damage to underlying tissues. Blind probing should always be done with an instrument as foreign bodies may cause harm if a gloved finger is used.

Irrigation with tap water assists in removal of pus and debrided tissue.

 



References:
  1. Evidence-based approach to abscess management.
    Korownyk C, Allan GM
    Can Fam Physician. 2007;53(10):1680.

12 Packing

Packing may be useful in ceratin situations, especially large abscesses > 5 cm. Studies have shown that packing wounds less than 5 cm is not nessessary in most routine situations. Care should be made to leave packing loose as oversue may lead to tissue necrossis.



References:
  1. Routine packing of simple cutaneous abscesses is painful and probably unnecessary.
    O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E
    Acad Emerg Med. 2009;16(5):470.
  2. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department.
    Kessler DO, Krantz A, Mojica M
    Pediatr Emerg Care. 2012 Jun;28(6):514-7.
  3. Clinical Procedures in Emergency Medicine, 5th ed
    Butler K.
    Saunder Elsevier, Philadelphia 2010.p.657.

13 Repacking and wound checks

Packing does not help wound closure once purulent drainage has ceased. If copious drainage continues the wound should be repacked and checked again in 2 days. Once it ceases, the packing should be removed and allow the wound to heal by secondary closure with warm water soaks several times per day.



References:
  1. Clinical Procedures in Emergency Medicine, 5th ed
    Butler K
    Saunder Elsevier, Philadelphia 2010.p.657.
  2. Abscess incision and drainage in the emergency department--Part I.
    Halvorson GD, Halvorson JE, Iserson KV
    J Emerg Med. 1985;3(3):227.

14 Loop I&D

Classic I&Ds have the dissadvantage of requiring a large incision that often causes marked scaring as the wound heals by secondary intention. They also tend to cause significant pain during the procedure. Loop I&Ds have been shown to be an effective and cost-effective (require less follow up care) alternative to traditional methods and are becoming a common technique in many acute care centers.

Loop I&Ds are less useful for very large or deep abscess that likely will need extensive debrietment. Also in complex anatomic locations such as ear, nose, perineal, palmar space or near neurovascular structures.



References:
  1. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children.
    Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK.
    J Pediatr Surg. 2010 Mar;45(3):606-9.
  2. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children.
    Ladd AP, Levy MS, Quilty J.
    J Pediatr Surg. 2010 Jul;45(7):1562-6.

15 Probiotics

Large systemic reviews have shown that probiotics are efficacious and safe for the treatment and prevention of antibiotic associated diarrhea in children and adults. The largest trial showed a 42 percent lower risk of diarrhea with a number needed to treat of 13. However, given the heterogeneity of the data, optimal dosing and probiotic organism is not possible (Bacillus, Bifidobacterium, Enterococcus, Lactobacillus, Saccharomyces, Streptococcus) although no significant difference in effectiveness was found between organisms used.

Since up to 10 percent of patients treated with antibiotics will develop diarrhea routine use of probiotics is recommended as long as there are no contraindications.



References:
  1. Efficacy of probiotics in prevention of acute diarrhoea: a meta-analysis of masked, randomised, placebo-controlled trials.
    Sazawal S, Hiremath G, Dhingra U, Malik P, Deb S, Black RE
    Lancet Infect Dis. 2006;6(6):374.
  2. Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis.
    D'Souza AL, Rajkumar C, Cooke J, Bulpitt CJ
    BMJ. 2002;324(7350):1361.
  3. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis.
    Van Niel CW, Feudtner C, Garrison MM, Christakis DA
    Pediatrics. 2002;109(4):678.
  4. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.
    McFarland LV
    Am J Gastroenterol. 2006;101(4):812.
  5. Probiotics for the prevention of pediatric antibiotic-associated diarrhea.
    Johnston BC, Supina AL, Ospina M, Vohra S
    Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004827.
  6. Probiotics in the prevention of antibiotic-associated diarrhea in children: a meta-analysis of randomized controlled trials.
    Szajewska H, Ruszczyński M, Radzikowski A
    J Pediatr. 2006;149(3):367.
  7. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis.
    Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B, Shekelle PG
    JAMA. 2012 May;307(18):1959-69.
  8. Meta-analysis: probiotics in antibiotic-associated diarrhoea.
    Videlock EJ, Cremonini F
    Aliment Pharmacol Ther. 2012;35(12):1355.
  9. Saccharomyces boulardii for the prevention of antibiotic-associated diarrhea in adult hospitalized patients: a single-center, randomized, double-blind, placebo-controlled trial.
    Pozzoni P, Riva A, Bellatorre AG, Amigoni M, Redaelli E, Ronchetti A, Stefani M, Tironi R, Molteni EE, Conte D, Casazza G, Colli A
    Am J Gastroenterol. 2012;107(6):922.
  10. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial.
    Allen SJ, Wareham K, Wang D, Bradley C, Hutchings H, Harris W, Dhar A, Brown H, Foden A, Gravenor MB, Mack D
    Lancet. 2013;382(9900):1249.
  11. Probiotics have clinical, microbiologic, and immunologic efficacy in acute infectious diarrhea.
    Chen CC, Kong MS, Lai MW, Chao HC, Chang KW, Chen SY, Huang YC, Chiu CH, Li WC, Lin PY, Chen CJ, Li TY
    Pediatr Infect Dis J. 2010;29(2):135.