Update on Management of Skin and Soft Tissue Infections in the Emergency Department
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Skin and soft tissue infections (SSTIs) are frequently treated in the emergency department (ED) setting. Recent studies provide critical new information that can guide new approaches to the diagnosis and treatment of SSTIs in the ED. Rapid polymerase chain reaction assays capable of detecting MRSA in approximately 1 h hold significant potential to improving antibiotic stewardship in SSTI care. Emergency ultrasound continues to demonstrate value in guiding appropriate management of SSTIs, including the early diagnosis of necrotizing infections. Since emerging in the 1990s, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) continues to increase in prevalence, and it represents a significant challenge to optimizing ED antibiotic use for SSTI management. Growing literature reinforces the current recommendation of incision and drainage without antibiotics for uncomplicated abscesses. Selecting antibiotics with CA-MRSA coverage is recommended when treating purulent SSTIs; however, it is generally not necessary in cases of nonpurulent cellulitis. Future advances in ED SSTI care may involve expansion of outpatient parenteral antimicrobial therapy protocols and the recent development of a novel, once weekly antibiotic with activity against MRSA.
KeywordsAbscess Cellulitis Skin and soft tissue infection CA-MRSA Antimicrobial Infection Antibiotic stewardship PCR Necrotizing fasciitis Blood cultures Emergency ultrasound Incision and drainage ABSSSI Home infusion therapy
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Conflict of Interest
Mary Calderone, Jamie Santistevan and John Meister declare no conflicts of interest. Larissa May has served as a consultant for Durata Therapeutics and has received payment for educational presentation from Cepheid and research support from Cepheid. Michael Pulia received payment for educational presentations and research support from Cepheid.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by the authors.
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- 1.Pallin D, Egan D, Pelletier A, Espinola J, Hooper D, Camargojr C. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291–8.PubMedCrossRefGoogle Scholar
- 3.Qualls ML, Mooney MM, Camargo Jr CA, Zucconi T, Hooper DC, Pallin DJ. Emergency department visit rates for abscess versus other skin infections during the emergence of community-associated methicillin-resistant Staphylococcus aureus, 1997–2007. Clin Infect Dis. 2012;55(1):103–5.PubMedCrossRefGoogle Scholar
- 11.Bassetti M, Baguneid M, Bouza E, Dryden M, Nathwani D, Wilcox M. European perspective and update on the management of complicated skin and soft tissue infections due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid. Clin Microbiol Infect. 2014;20 Suppl 4:3–18.PubMedCrossRefGoogle Scholar
- 16.Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Infectious Diseases Society of America. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18–55.PubMedCrossRefGoogle Scholar
- 19.Rossney AS, Herra CM, Brennan GI, Morgan PM, O’Connell B. Evaluation of the Xpert Methicillin-Resistant Staphylococcus Aureus (MRSA) assay using the GeneXpert real-time PCR platform for rapid detection of MRSA from screening specimens. J Clin Microbiol. 2008;46(10):3285–90.PubMedCentralPubMedCrossRefGoogle Scholar
- 20.Wassenberg MWM, Kluytmans JAJW, Box ATA, Bosboom RW, Buiting AGM, van Elzakker EPM, et al. Rapid screening of methicillin-resistant Staphylococcus aureus using PCR and chromogenic agar: a prospective study to evaluate costs and effects. Clin Microbiol Infect. 2010;16(12):1754–61.PubMedCrossRefGoogle Scholar
- 21.•Pulia M, Calderone M, Hansen B, Stake C, Cichon L, et al. Feasibility of rapid polymerase chain reaction for detection of methicillin-resistant Staphylococcus aureus colonization among emergency department patients with abscesses. Open Access Emerg Med. 2013;5:17–22. This study established the feasibility of deploying a rapid PCR assay for MRSA for patients with abscess during emergency department triage. Utilization of rapid MRSA diagnostics has the potential to improve antibiotic stewardship in the ED care of abscesses.CrossRefGoogle Scholar
- 35.•Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med. 2012;30(8):1347–51. This study is a useful addition to the growing body of evidence indicating that emergency ultrasound improves diagnostic accuracy and appropriate treatment for patients with skin and soft tissue infections.Google Scholar
- 38.Coyne C, Perera P, Mailhot T. Diagnosis of Fournier’s Gangres on Bedside Ultrasound. West J Emerg Med. 2014;15(2). http://escholarship.org/uc/item/7zm202hx. Published Feb 28, 2014. Accessed 1 Apr 2014.
- 49.Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant staphylococcus aureus infection. Ann Emerg Med. 2010;56(3):283–7.PubMedCrossRefGoogle Scholar
- 50.••Singer AJ, Thode HC Jr. Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis [published online ahead of print May 18 2013]. Emerg Med J. 2013. This systemic review provides further support for guidelines that emphasize the lack of benefit for antibiotics after incision and drainage of uncomplicated abscesses. Google Scholar
- 51.••Pallin DJ, Binder WD, Allen MB, Lederman M, Parmar S, Filbin MR, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis. 2013;56(12):1754–62. This randomized controlled trial represents the best evidence to date that the addition of a CA- MRSA active antibiotic does not improve outcomes in uncomplicated cellulitis.PubMedCrossRefGoogle Scholar
- 55.Chua K, Laurent F, Coombs G, Grayson ML, Howden BP. Not community-associated methicillin-resistant staphylococcus aureus (CA-MRSA)! A clinician’s guide to community MRSA - its evolving antimicrobial resistance and implications for therapy. Clin Infect Dis. 2011;52(1):99–114.PubMedCrossRefGoogle Scholar
- 56.McDougal LK, Fosheim GE, Nicholson A, Bulens SN, Limbago BM, Shearer JES, et al. Emergence of resistance among USA300 methicillin-resistant staphylococcus aureus isolates causing invasive disease in the United States. Antimicrob Agents Chemother. 2010;54(9):3804–11.PubMedCentralPubMedCrossRefGoogle Scholar
- 62.Levy ER, Swami S, Dubois SG, Wendt R, Banerjee R. Rates and appropriateness of antimicrobial prescribing at an academic children’s hospital, 2007–2010. Infect Control Hosp Epidemiol Off J Soc Hosp Epidemiol Am. 2012;33(4):346–53.Google Scholar
- 63.Rybak MJ, Lomaestro BM, Rotschafer JC, Moellering RC, Craig WA, Billeter M, et al. Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis Off Publ Infect Dis Soc Am. 2009;49(3):325–7.CrossRefGoogle Scholar
- 69.Pallin DJ, Camargo CA, Schuur JD. Skin Infections as Targets for Antibiotic Stewardship: Analysis of Emergency Department Prescribing Practices, 2007–2010. West J Emerg Med. 2014;0(0). http://escholarship.org/uc/item/5f16c3zs. Published Jan 6, 2014. Accessed 31 Mar 2014.
- 74.Itani KMF, Biswas P, Reisman A, Bhattacharyya H, Baruch AM. Clinical efficacy of oral linezolid compared with intravenous vancomycin for the treatment of methicillin-resistant Staphylococcus aureus-complicated skin and soft tissue infections: a retrospective, propensity score-matched, case–control analysis. Clin Ther. 2012;34(8):1667–73. e1.PubMedCrossRefGoogle Scholar
- 76.Puzniak LA, Capitano B, Biswas P, Lodise TP. Impact of patient characteristics and infection type on clinical outcomes of patients who received linezolid or vancomycin for complicated skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus: a pooled data analysis. Diagn Microbiol Infect Dis. 2014;78(3):295–301.PubMedCrossRefGoogle Scholar