Skin and soft tissue infection management, outcomes, and follow-up in the emergency department of an urban academic hospital.

Article: AENJ-D-14-00004

Date: October 17, 2014

Time: 22:56

Advanced Emergency Nursing Journal Vol. 36, No. 4, pp. 348–359 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Skin and Soft Tissue Infection Management, Outcomes, and Follow-Up in the Emergency Department of an Urban Academic Hospital Kanokwan Seeleang, DNP, CRNP, FNP-BC Mary Lou Manning, CRNP, PhD, CIC, FAAN Mark Saks, MD, MPH, FAAEM Yvette Winstead, DNP, CRNP, FNP-BC, MBA

Abstract Skin and soft tissue infections (SSTIs) are among the most common infections treated by emergency department clinicians. The emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) as the cause of these infections prompted the Centers for Disease Control and Prevention and the Infectious Disease Society of America to publish guidelines for the outpatient management of SSTIs. This study describes the management and outcomes of emergency department patients treated for uncomplicated SSTIs who returned within 30 days of the initial visit. The study found that of 857 eligible patients, only 17.6% returned and of these, 80% had their wound checked or packing removed. The clinicians prescribed antibiotics for the majority of patients, and the selection of antibiotics typically was active against CA-MRSA. Of 91 lesions drained, 24 specimens were obtained for culture and sensitivity. The majority of the initial treatment of patients consisted of incision and drainage with antibiotic prescription. Key words: abscess, cellulitis, community-associated methicillin-resistant Staphylococcus aureus, emergency department, skin and soft tissue infection

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KIN AND SOFT TISSUE INFECTIONS (SSTIs) are among the most common bacterial infections managed by clinicians in the emergency department (ED; Abrahamian, Talan, & Moran, 2008; Winstead et al., 2010). A retrospective analysis of 2006–2010 data from the National Hospital

Author Affiliations: Emergency Department, Hahnemann University Hospital, Philadelphia, Pennsylvania (Dr Seeleang); Thomas Jefferson University, Jefferson School of Nursing, Philadelphia, Pennsylvania (Drs Seeleang, Manning, and Winstead); Department of Emergency Medicine, Crozer-Chester Medical Center, Chester, Pennsylvania (Dr Saks); Emergency Medicine Drexel University College of Medicine, Philadelphia, Pennsylvania (Dr Saks); and Aria Health, Philadelphia, Pennsylvania (Dr Winstead). The authors thank Dr. Hamilton Richard, Dr. Dunn Rosemary, McCloskey Elizabeth, Silverman Mary Kay, Heather Guiliano, Linda Celia, and Nancy Vanek for their many hours of consultation and support. Disclosure: The authors report no conflicts of interest.

Corresponding Author: Kanokwan Seeleang, DNP, CRNP, FNP-BC, Emergency Department, Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA 19102 ([email protected]). DOI: 10.1097/TME.0000000000000039

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Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS) estimated that there were 34.8 million ambulatory visits for SSTI and 33% of these were seen in EDs (May, Mullins, & Pines, 2014). During the past decades, there has been a change in the microbiology of SSTI. Prior to the 1990s, methicillin-sensitive Staphylococcus aureus (MSSA) was the most common cause of SSTIs (Abrahamian et al., 2008). However, several recent surveillance studies found that community-associated methicillinresistant S. aureus (CA-MRSA) has emerged as a major SSTI pathogen, largely supplanting MSSA as the causative agent, and ED visits for SSTIs have risen in direct correlation (Chen, Chastain, & Anderson, 2011; Moran et al., 2006; Ramsetty, Stuart, Blake, Parsons, & Salgado, 2010; Taira, Siner, Thode, & Lee, 2009). It is now estimated that nearly 80% of mild to moderate SSTIs are caused by CA-MRSA (NeVille-Swensen & Clayton, 2011) rather than health care–associated MRSA. This evolution obviously has significant implications for ED clinicians treating patients with SSTIs. SIGNIFICANCE OF THE PROBLEM Before the rise in CA-MRSA, uncomplicated SSTIs were largely managed in outpatient settings. Routine wound cultures, other pathogen-specific testing, or other laboratory analysis was not widely used. Simple incision and drainage (I&D) was considered the standard of care for the management of purulent SSTIs. However, the increased prevalence of CA-MRSA infection has increased the failure of traditional treatments, resulting in treatment failure, recurrent infections, local or generalized spread, and other complications. This has prompted clinicians to more frequently prescribe antibiotic therapy (Mistry, Scott, Zaoutis, & Alpern, 2011). Because the prevalence of CA-MRSA varies from region to region, the choice of initial empiric antimicrobial therapy should depend upon the most likely microbiologic etiology and local antimi-

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crobial susceptibility patterns (Merritt, Haran, Mintzer, Stricker, & Merchant, 2013). The role of blood and wound cultures and other testing aimed at identifying that a specific organism has also increased (Abrahamain et al., 2008). Thus, although SSTIs have long been among the most commonly treated infections in the ED, a number of clinical dilemmas in their management have recently emerged. For example, the utility of wound cultures, routine wound packing, the accuracy of the clinical assessment of the likelihood of CA-MRSA infections, the decision to prescribe antibiotics in conjunction with I&D, and whether special instructions for patient follow-up should be given have all been debated (Abrahamian et al., 2008; Schmitz, 2011). Despite the development of practice guidelines to help simplify and streamline management, adherence to them is highly inconsistent. Multiple studies have shown that providers vary widely in several areas including prescriptive practices, wound culturing, and their approach to outpatient follow-up (Baumann et al., 2011; Carman, Phipps, Raley, Li, & Thornlow, 2011; Moran et al., 2006). For example, despite neither the Infectious Diseases Society of America (IDSA) nor the Centers for Disease Control and Prevention (CDC) recommending antimicrobial therapy for simple skin abscesses, ED clinicians have been noted to frequently prescribe antibiotics in addition to performing I&D for patients with skin abscess (Talan et al., 2011). In fact, it has been estimated that antibiotics were prescribed for up to 78% of ED visits for SSTIs (Krucke, Grimes, Grimes, & Dang, 2009). For another, although wound cultures are recommended, ED clinicians often fail to order them; questioning their routine use and cost-effectiveness as the delay in obtaining results means that they will not impact their management decisions (Abrahamian et al., 2008). This belief is supported by several studies that demonstrate increased rate of successful treatment with I&D alone even in the era of CA-MRSA (Breen, 2010; Schmitz, 2011).




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MANAGEMENT AND FOLLOW-UP CARE

NATIONAL GUIDELINES

The CDC treatment guidelines recommend that patients prescribed antibiotics be instructed to follow up within 2 days to verify a clinical response or to confirm adequate response to therapy (Gorwitz, Jernigan, Powers, Jernigan, & Participants in the Centers for Disease Control and Prevention-Convened Experts Meeting on Management of MRSA in the Community, 2006; Popvich, Hota, & Weinstein, 2008). However, little is known about how often this occurs, and there have been few studies regarding the outcomes of SSTIs treated in the ED (Mistry et al., 2011). Most of the literature related to SSTIs in EDs has focused on CA-MRSA prevalence and risk factors for infection with the organism. Few studies have focused on returning and outcomes of patients treated in the ED.

The increasing prevalence of CA-MRSA combined with the variability of clinical practice prompted the CDC to publish Outpatient Management of Skin and Soft Tissue Infections in the Era of Community Associated MRSA in 2007 and IDSA to publish Management of Patients With Infections Caused by MRSA in 2011 (CDC, 2007; Liu et al., 2011; see Figure 1). In short, both the CDC and IDSA guidelines stress that simple abscesses, regardless of the causative agent, are effectively treated with I&D alone (Gorwitz et al., 2006; Liu et al., 2011). The CDC also recommends that wound cultures are sent and that followup wound care is arranged within 2 days (Gorwitz et al., 2006; Winstead et al., 2010). However, they recommend antibiotic therapy for abscesses associated with severe local

Figure 1. Outpatient management of skin and soft tissue infections in the era of CA-MRSA. CA-MRSA= community-associated methicillin-resistant Staphylococcus aureus; CDC = Centers for Disease Control and Prevention; I&D = incision and drainage; IDSA = Infectious Diseases Society of America; MRSA = methicillin-resistant S. aureus. Adapted from CDC and IDSA guidelines.





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symptoms, extensive disease, or rapid progression with the presence of associated cellulitis, signs and symptoms of systemic illness, associated comorbidities or immunosuppression, extremes of age, abscess in an area difficult to drain, or associated septic phlebitis (CDC, 2007; Liu et al., 2011). They also recommend the initiation of antibiotic following a lack of response to I&D alone (CDC, 2007; File, 2011; Liu et al., 2011; Stevens et al., 2005). PURPOSE The purpose of this study was to describe the management and outcomes of ED patients treated for uncomplicated abscess and cellulitis who returned to the same ED within 30 days of the initial visit. The objectives were to (1) determine the prevalence and characteristics of uncomplicated skin abscesses and cellulitis in the ED of an urban teaching hospital, (2) describe the management and outcomes of ED patients returning to the same ED within 30 days of the initial visit, and (3) describe clinician adherence to IDSA and CDC guidelines for SSTI management.

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umented, easily extractable proxy for diagnosis, and were the standard for coding skin abscess and cellulitis in this setting during the study period. It is important to note that International Classification of Diseases, Ninth Revision (ICD-9) codes combine cellulitis and abscess, making it difficult to identify patients with cellulitis from patients with abscess. In 2011, the ED staff consisted of 16 physicians, 7 nurse practitioners, 45 resident physicians, and 60 registered nurses. The institutional review board approved this study on January 17, 2012. Data were extracted between February 29 and May 25, 2012. Eligible patient’s charts were reviewed and the following data were extracted: patient’s age, gender, race, lesion site, wound culture results, treatment (I&D, wound packing, antimicrobial therapy, follow-up instruction), and reason for return ED visit and treatment outcome. The descriptive statistics including frequency distribution, central tendency, dispersion, and summary statistics with means ± standard deviation were analyzed using SPSS version 18.0. RESULTS

STUDY DESIGN AND METHODOLOGY This retrospective medical chart review was conducted at a 31-bed ED of an urban tertiary care academic medical center in Philadelphia. Eligible subjects included all patients 18 years of age or older who were evaluated and discharged from the ED for uncomplicated skin abscess or cellulitis between January 1, 2011, and December 31, 2011, and who returned to the same ED within 30 days of initial visit. Exclusion criteria included all patients younger than 18 years, patients who returned to the ED after 30 days of initial visit, and patients who were admitted. Patients were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of cellulitis/abscess (681.0–685.0). A total of 13 ICD-9-CM codes were used to extract patient data. These ICD9-CM codes were the most consistently doc-

Objective 1. Determine the prevalence and characteristics of uncomplicated skin abscesses and cellulitis. There were 45,411 ED patient visits between January 1 and December 31, 2011. A total of 1,124 patients or 2.48% were diagnosed and treated for both complicated and uncomplicated skin abscesses and/or cellulitis in 2011. Of these, 857 patients (76%) were treated for uncomplicated skin abscess and cellulitis, and 151 patients (17.6%) returned to the ED within 30 days after the initial visits. This group was the population of interest. Eighty-eight patients were male (58.3%) and 104 (68.9%) were Black. The average age was 40.6 years, with a range from 18 to 80 years. Characteristics of patients returning to the ED are presented in Table 1. The 151 patients initially visited the ED for skin abscess and cellulitis on the upper arm and forearm





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Table 1. Characteristic of patients’ returning to the emergency department within 30 days after initial treatment for uncomplicated skin abscess/cellulitis (n = 151) Characteristic Gender Male Female Race White Black Asian Other Age (years) 18–29 30–39 40–49 50–59 ≥60

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Frequency

%

88 63

58.3 41.7

29 104 3 15

19.2 68.9 2.0 9.9

45 32 24 35 15

29.8 21.2 15.9 23.2 9.9

(25%), leg (22%), trunk (16%), and buttock (10%). The frequency data for ICD-9 codes are presented in Figure 2.

Patients returned to the ED within 30 days for multiple reasons, including wound check (63%), packing removal (17%), complications (9%), and new and recurring lesions (6%). Five percent of patients returned for reasons unrelated to the initial visits. Within the same 30-day period, 31 of 151 patients (20.5%) made more than one abscess- and cellulitisrelated ED visit. Patients returned a second time for wound check (n = 22), packing removal (n = 5), complications (n = 1), recurrent lesion (n = 2), and other reason (n = 1). Two patients returned a third time for wound check. Table 2 describes the reasons for patients’ returns to the ED within 30 days. INITIAL PATIENT MANAGEMENT Incision and Drainage Ninety-one patients (60.3%) who returned to the ED were treated with I&D, and in 76 of 91 patients (83.5%), wounds were packed. These lesions occurred most frequently on the upper arm (21%), buttock (19%), and leg (17%),

Figure 2. Initial International Classification of Diseases, Ninth Revision (ICD-9) codes and frequency of patients’ returning to the emergency department within 30 days after initial treatment for uncomplicated skin abscess and cellulitis (n = 151). ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification.





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Table 2. Reason for patients’ returning to the emergency department within 30 days after initial treatment for uncomplicated skin abscess/cellulitis (n = 151) Reason for patients’ return Visit 1 Wound check Packing removed Complication/worsening New skin lesion Recurrent lesions Other Visit 2 Wound check Packing removed Complication/worsening New skin lesion Recurrent lesions Other Visit 3 Wound check

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Frequency % 95 26 13 6 3 8

62.9 17.2 8.6 4.0 2.0 5.3

22 5 1 0 2 1

71.0 16.1 3.2

2

6.5 3.2 100

most frequently. See Table 3 for antibiotic frequency and distribution. The four MSSA culture–positive patients received the following antibiotics: clindamycin (n = 2), trimethoprim–sulfamethoxazole (n = 1), and doxycycline (n = 1). The 10 MRSA culture–positive patients were prescribed the following antibiotics: trimethoprim– sulfamethoxazole (n = 2), cephalexin (n = 2), clindamycin (n = 2), vancomycin intravenously (n = 2), cephalexin and trimethoprim–sulfamethoxazole (n = 1), and cephalexin and doxycycline (n = 1). In summary, the initial treatment of patients with an uncomplicated skin abscess and cellulitis returning to the ED within 30 days consisted primarily of I&D with antibiotics (57.6%) and antibiotics only Table 3. Antibiotic distribution and frequency for initial ED patient visit (n = 151) Antibiotics

and lesions tended to be 3 cm in size. On the contrary, small lesions’ description accounted for the majority of patient treated without I&D. No lesions described as being on the foot or the toe were treated by I&D. Microbiology Culture Of 91 lesions drained, 24 samples were sent to the laboratory for culture and susceptibility testing. Ten cultures (42%) failed to isolate an organism and 14 (58%) were positive. The positive cultures grew MRSA (71%) and MSSA (29%). The majority of MRSA-positive cultures (90%) were most frequently isolated from the arm (30%), buttock (30%), or leg (30%). Antimicrobial Treatment One hundred forty-six of the 151 (96.7%) patients returning to the ED received at least one antibiotic prescription. Sulfonamides (n = 47, 32%), cephalosporins (n = 20, 14%), a combination of both (n = 32, 22%), and clindamycin (n = 19, 13%) were prescribed

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Trimethoprim/ Sulfamethoxazole Cephalexin and Trimethoprim/ Sulfamethoxazole Cephalexin Clindamycin Doxycycline Cephalexin and Doxycycline Unasyn intravenous and Augmentin Trimethoprim/ Sulfamethoxazole and Clindamycin Bactroban ointment Levofloxacin Vancomycin intravenous Augmentin Augmenin and Methonidazole Other No antibiotic Total

Frequency

%

47

31.1

32

21.2

20 19 5 5

13.2 12.6 3.3 3.3

2

1.3

1

0.7

2 1 6

1.3 0.7 4.0

3 1

2.0 0.7

2 5 151

1.3 3.3 100




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(39.1%). The distribution of initial patient management data is presented in Table 4. The diagnosis of the146 patients receiving antibiotics represented all 13 of the ICD-9 codes. Patients with cellulitis and abscess of the upper arm, forearm, leg, and trunk were most frequently prescribed antibiotics. Data are depicted in Table 5. Of the patients receiving antibiotic prescriptions, 21% had worsening lesions during the first follow-up visit. The data indicated that 94% of patients with worsening lesions and 96.5% of patients with improved lesions received at least one antibiotic prescription. However, it is unclear what role the prescribed antibiotics Table 4. Distribution of initial patient management Management I&D only I&D with antibiotics Antibiotics only None Total

Frequency

%

4 87 59 1 151

2.6 57.6 39.1 0.7 100

played in patients’ improving or worsening clinical status, for it is unknown whether the patients filled the prescription(s) or took the antibiotics as prescribed. The 3-cm size accounted for the majority (20%) of trimethoprim–sulfamethoxazole prescribed and (25%) of trimethoprim–sulfamethoxazole and cephalexin prescribed. The 2-cm size accounted for the majority (27%) of cephalexin prescribed. Objective 2. Determine the treatment outcomes of patients returning to the ED after initial visits. PATIENT OUTCOMES AFTER INITIAL TREATMENT The majority of patients returned to the ED within 2 days (37.75%) after the initial treatment (see Figure 3). The mean number of days for patients’ return visits was as follows: visit 1 (3.94 days), visit 2 (4.48 days), and visit 3 (4.5 days). Return Visit 1 Ninety-five patients returned for a wound check, and more than 50% had clinically

Note. I&D = incision and drainage.

Table 5. Initial International Classification of Diseases, Ninth Revision codes and frequency of prescribed antibiotics ICD-9-CM 681.0 681.10 682.0 682.1 682.2 682.3 682.4 682.5 682.6 682.7 682.8 682.9 685.0 Total

ICD description

Antibiotic frequency

%

Cellulitis/abscess of finger Cellulitis/abscess of toe Cellulitis/abscess of face Cellulitis/abscess of neck Cellulitis/abscess of trunk Cellulitis/abscess of upper arm/forearm Cellulitis/abscess of hand Cellulitis/abscess of buttocks Cellulitis/abscess of leg Cellulitis/abscess of foot Cellulitis/abscess of other specified sites Cellulitis/abscess of unspecified sites Pilonidal cyst with abscess

7 1 8 4 24 35 4 15 33 3 4 1 7 146

4.8 0.7 5.5 2.7 16.4 24.0 2.7 10.3 22.6 2.1 2.7 0.7 4.8 100

Note. ICD = International Classification of Diseases; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification.





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antibiotics of which clindamycin (3/9) and cephalexin (3/9) were prescribed most frequently. Table 6 provides a summary of the disposition of patients returning within 30 days of initial visit. Of the patients that returned, 49% showed improvement in their clinical status and 2.6% showed resolution of their symptoms. Return Visits 2 and 3

Figure 3. Distribution of number of days for the return visits after the initial treatment. ED = emergency department.

improved. However, 16 (16.8%) patients were found to have a worsening condition as evidenced by failure to respond to initial treatment (increased size, pain, redness, swelling, and cellulitis). Of these, four patients were initially treated with I&D and drainage, and one patient was sent to the laboratory for culture and susceptibility testing. The culture was positive for MRSA, and the patient was treated with a combination of cephalexin and doxycycline. All 16 patients with worsening conditions were treated with antibiotics, and trimethoprim–sulfamethoxazole was the most frequency prescribed (6/16), followed by a combination of cephalexin and trimethoprim–sulfamethoxazole (3/16), clindamycin (2/16), and cephalexin alone (2/16). Twenty-six patients returned for packing removal, of which 24 had clinically improved and two had worsened as evidenced by failure to respond to initial treatment. Both patients with worsening lesions were treated with repeat I&D, but no drainage was collected for culture and sensitivity testing and/or antibiotics prescribed. Thirteen returning patients (8.6%) had complication/worsening of which 9 were hospitalized. Of these, two were treated with I&D without sending wound drainage for culture and sensitivity. All nine hospitalized patients were treated with

Of the 31 patients returning a second time, almost 75% showed resolution of their symptoms or improvement in their clinical status (n = 23), and three patients (9.7%) had recurrence or worsening of their condition. Those patients received repeat drainage and/or a change in oral antibiotics treatment. Two patients returned for a third time and both had improvement and continued to take oral antibiotics. Objective 3. Determine the clinician adherence to IDSA and CDC guidelines for SSTI management. Table 6. Disposition of patients’ returning to the emergency department within 30 days after initial treatment (n = 151) Reason for patients’ return and status Wound check Resolution Improved Worsening No change Increase drainage Missing document Other Packing removed Resolution Improved Worsening Complication/worsening Hospitalized New skin lesion Recurrent lesions Hospitalized Other

Frequency 95 3 51 16 17 3 4 1 26 1 23 2 13 9 6 3 1 8




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CLINICIAN ADHERENCE TO IDSA AND CDC GUIDELINES FOR SSTI MANAGEMENT Despite recommendations for I&D to be the primary treatment of uncomplicated SSTI, few clinicians seemed to adhere to it. Of the 151 patients returning to the ED within 30 days, 91 (60%) were initially treated with I&D procedures. Of the 91 patients treated with I&D, only four (4%) were treated with I&D only. Although CDC recommends that clinicians collect specimens for culture and antimicrobial susceptibility testing from all patients with abscess or purulent skin lesions, it is unclear how many patients had purulent lesions and how many patients had cellulitis. We found that only 24 samples (26%) were collected and sent to the laboratory for culture and susceptibility testing. According to the CDC and IDSA guidelines, cellulitis and I&D treatment failure should be managed with antimicrobial therapy with MRSA coverage (CDC, 2007; Liu et al., 2011). Doxycycline, clindamycin, and trimethoprim–sulfamethoxazole are considered the appropriate antimicrobial treatment of skin infection associated with CA-MRSA. In our study, trimethoprim–sulfamethoxazole was most frequently prescribed antibiotic either as a single agent (31.1%) or in combination with cephalexin (21.2%). The prescription of trimethoprim–sulfamethoxazole is considered appropriate treatment of skin abscesses and/or cellulitis involving CA-MRSA. However, for the MRSA-positive microorganism, cephalexin was prescribed alone 20%, which according to guidelines is inappropriate treatment of MRSA coverage. We found that cephalexin was the second most frequently prescribed antibiotic either alone (13.2%) or in combination with trimethoprim–sulfamethoxazole (as noted previously). Cephalexin was also the most frequently prescribed antibiotic for the lack of response to I&D only category, which is inappropriate management for I&D treatment failure. For nonpurulent cellulitis or cellulitis without abscess, IDSA guideline recommends

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empirical therapy for infection because of βhemolytic streptococci and considers adding antibiotic coverage for MRSA if patients fail the first treatment (Liu et al., 2011). This study found that 50% of the lesions worsened after cephalexin treatment; consequently, trimethoprim–sulfamethoxazole was added to the plan. This is considered an appropriate treatment and supports the recommendation of the guidelines that cephalexin is inappropriate as a single-agent treatment of CA-MRSA coverage. Antibiotic therapy is recommended for abscesses associated with severe or extensive disease (e.g., involving multiple sites of infection) or rapid progression in the presence of associated cellulitis, signs and symptoms of systemic illness, associated comorbidities or immunosuppression, extremes of age, abscess in an area difficult to drain (e.g., face, hand, and genitalia), and associated septic phlebitis (Liu et al., 2011). We found that cellulitis and abscess of the face and hand were universally treated with antibiotics 8/8 and 4/4, respectively. Although it is a small number, these clinical presentations represented only 5.3% and 2.6% of the uncomplicated skin abscess/cellulitis of the return visits; it is significant finding because of its high risk for complication. If coverage for both β-hemolytic streptococci and CA-MRSA is desired, options include the following: clindamycin alone or trimethoprim–sulfamethoxazole or a tetracycline in combination with β-lactam (e.g., amoxicillin) or linezolid alone (Liu et al., 2011). Clindamycin alone was prescribed 12.6%, a combination of cephalexin and trimethoprim–sulfamethoxazole was prescribed 21.2%, and doxycycline and cephalexin was prescribed 3.3%. Trimethoprim– sulfamethoxazole alone was prescribed 31.1% and cephalexin (β-lactam) 13.2%, which according to IDSA guideline does not provide coverage for both β-hemolytic streptococci and CA-MRSA, a common cause of cellulitis and abscess. As a result, 37% followed β-hemolytic streptococci and CA-MRSA antibiotic selection guidelines.





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STUDY LIMITATIONS The primary limitation to our study is the inclusion of only the patients receiving care in one ED for uncomplicated SSTIs and returning to the same ED within 30 days. No attempt was made to follow patient seeking follow-up care at another institution or with another provider (e.g., primary care provider or another ED). Second, data were collected retrospectively from an electronic medical record system. No information was collected regarding detailed medical histories, comorbidities, or risk factors (e.g., recent hospitalization). Third, ICD-9-CM codes combined cellulitis and abscesses into one code, so we were unable to determine whether a patient had an abscess and/or cellulitis. Fourth, neither local nor hospital antibiotic susceptibility patterns (antibiograms) were considered when determining appropriate clinician prescribing. Finally, our data are purely descriptive and have no correlation with clinical outcomes.

DISCUSSION In the past decade, ED visits in the United States for acute bacterial SSTI have rapidly increased, and CA-MRSA is now the predominant cause of purulent SSTI (Moran, Abrahamian, LoVecchio, & Talan, 2013). In this study, 2.48% (n = 1,124) of ED patients were diagnosed and treated for skin abscess and/or cellulitis in the year 2011. Although similar to the rate found by Winstead et al. (2010), who conducted an ED study in the same geographic region of the United States, the finding is higher than that in a previous study of SSTI visits in the ED during 1993–2005 (Pallin et al., 2008). Little is known about patients discharged from the ED following initial SSTI treatment. We were particularly interested in patients’ response to treatment and clinician adherence to the IDSA and CDC SSTI management guidelines. To begin to describe this phenomenon, we used a convenience sample of patients returning to the same ED within 30 days of SSTI treatment.

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Of the 857 patients treated for uncomplicated skin abscess and cellulitis, only 151 patients (17.6%) returned to the same ED within 30 days after initial treatment. This was surprising, since according to the CDC (2007) and others (Gorwitz et al., 2006; Popvich et al., 2008; Schmitz, 2011), patients should be instructed to return within 2 days of initial treatment for a wound check. Of concern is that less than 18% of patients returned, leaving one to question the following: (1) Were patients instructed to return within 48 hours?; (2) Were patients instructed and did not return to this ED?; or (3) Were they instructed to return and returned to another ED or their primary care provider? This warrants further study. Of the 151 returning patients, 91 patients (60.3%) had an I&D of their lesion during their initial ED visit. Surprisingly, only 24 samples were obtained for microbiologic culture and susceptibility testing. It may be that culture results would not alter the clinician’s management of the patient and thus deemed unnecessary. Of these, 14 were positive either for MRSA (n = 10) or for MSSA (n = 4). So, despite current recommendations for I&D to be the primary treatment of uncomplicated SSTIs, there was substantial variation in the use of I&D among clinicians. Because of the small number of cultures obtained, it is also difficult to ascertain the CA-MRSA prevalence in this population. The IDSA and CDC guidelines for the treatment of SSTI do not call for routine antibiotics for adequately drained uncomplicated abscesses. However, of the 151 returning ED patients, more than 96% were prescribed at least one antibiotic, mostly for suspected CA-MRSA. These results mirror national trends, indicating that clinicians routinely prescribe antibiotics for the majority of patients with SSTI, and the empiric prescription of antibiotics typically is active against CA-MRSA (Merritt et al., 2013). This is concerning, for it is known that the misuse and overuse of antibiotics can lead to antimicrobial resistance, as well as development of secondary antibiotic-associated infections such as Clostridium difficile infections.




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IMPLICATIONS FOR PRACTICE There is significant evidence that cellulitis, abscess, and other infections of the skin and soft tissue are among the most common infections evaluated and treated by ED clinicians. Regardless of initial ED treatment, a follow-up plan for the patient is imperative. This study showed that a remarkably low rate of patients returned to the same ED within 30 days after the initial treatment. Because of the nature of the ED setting, the inability to follow up with patients, patients choosing to follow up with their primary care providers, or the inconsistency of the follow-up instruction could be the cause of the low rate of return. This warrants further study. Clinical practice guidelines are developed to reduce inappropriate health care variations by assisting with clinicians’ and patients’ decisions. Guidelines are developed on the basis of the best evidence at the time. They should be considered when managing all patients. However, guidelines do have limitations. Patients, especially patients being seen in the ED, seldom have one single clinical problem, and few guidelines are designed to help clinicians manage patients with complications. However, studies repeatedly find ED provider’s adherence to the SSTI clinical management guidelines inconsistent, but there are limited data on how this lack of adherence affects patients’ outcomes. The results of this study begin to scratch the surface of this issue; additional research is needed in this area. REFERENCES Abrahamian, F., Talan, D., & Moran, G. (2008). Management of skin and soft-tissue infections in the emergency department. Infection Disease Clinic North America, 22, 89–116. doi:10.1016/j.idc.2007.12.001 Baumann, B. M., Russo, C. J., Pavlik, D., Cassidy-Smith, T., Brown, N., Sacchetti, A., . . . Mistry, R. D. (2011). Management of pediatric skin abscesses in pediatric, general academic and community emergency departments. Western Journal of Emergency Medicine, 12(2), 159–167. Breen, J. O. (2010). Skin and soft-tissue infections in immunocompetent patients. American Family Physician, 81(7), 893–899.

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Mistry, R. D., Scott, H. F., Zaoutis, T. E., & Alpern, E. R. (2011). Emergency department treatment failures for skin infections in the era of communityacquired methicillin-resistant staphylococcus aureus. Pediatric Emergency Care, 27, 21–26. doi:10.1097/PEC.0b013e318203ca1c Moran, G. J, Abrahamian, F. M, LoVecchio, F., & Talan, D. A. (2013). Acute bacterial skin infections: developments since the 2005 Infectious Diseases Society of America (IDSA) guidelines. The Journal of Emergency Medicine, 44, e397–e411. doi:10.1016/j.jemermed.2012.11.050 Moran, G. J., Krishnadasan, A., Gorwitz, R. J., Fosheim, G. E., McDougal, L. K., Carey, R. B, . . . Talan, D. (2006). Methicillin-resistant S. aureus infections among patients in the emergency department. The New England Journal of Medicine, 355(7), 666– 674. NeVille-Swensen, M., & Clayton, M. (2011). Outpatient management of community-associated methicillinresistant Staphylococcus aureus skin and soft-tissue infection. Journal of Pediatric Health Care, 25, 308– 315. doi:10.1016/j.pedhc.2010.05.005 Pallin, D. J., Egan, D. J., Pelletier, A. J., Espinola, J. A., Hooper, D. C., & Camargo, C. A. (2008). Increased US emergency department visits for skin and soft-tissue infections, and changes in antibiotic choices, during the emergence of communityassociated methicillin-resistant Staphylococcus aureus. Annals of Emergency Medicine, 51, 291–298. doi:10.1016/j.annemergmed.2007.12.004 Popvich, K. J., Hota, B., & Weinstein, R. A. (2008). Treatment of community-associated methicillin-resistant

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Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections.

Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection.

All purulence is local - epidemiology and management of skin and soft tissue infections in three urban emergency departments.

Patterns in computed tomography utilization among emergency physicians in an urban, academic emergency department.

Developments in skin and soft tissue infection.

Clinical management of skin and soft tissue infections in the U.S. Emergency Departments.

An academic emergency department: residents' perspective.

Improving the quality of cancer pain management in an academic medical center emergency department.

A day in the life of an urban emergency department.

Epidemiology and outcomes of dental trauma cases from an urban pediatric emergency department.

Patients with acute poisoning presenting to an urban emergency department of a tertiary hospital in Tanzania.

HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department.

Trends in emergency department management of skin abscesses.

Diagnosis, management and outcomes of necrotising soft tissue infection within a Plastic and Reconstructive Surgery unit.

Emergency department discharge prescription errors in an academic medical center.

Posttraumatic Skin and Soft-Tissue Infection due to Pseudomonas fulva.

Emergency Department Crowding and Outcomes After Emergency Department Discharge.

Bacteremic skin and soft tissue infection caused by Prevotella loescheii.

Improving the assessment and treatment of pelvic inflammatory disease among adolescents in an urban children's hospital emergency department.

An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department.

Outcomes in the management of adult soft tissue sarcomas.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes.

Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus among skin and soft tissue infections in an emergency department in Guyana.

An outcomes analysis of anterior epistaxis management in the emergency department.