Objectives: Treatment failure rates for incision and drainage (I&D) of skin abscesses have increased in recent years and may be attributable to an increased prevalence of community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA). Previous authors have described sonographic features of abscesses, such as the presence of interstitial fluid, characteristics of abscess debris, and depth of abscess cavity. It is possible that the sonographic features are associated with MRSA and can be used to predict the presence of MRSA. The authors describe a potential clinical decision rule (CDR) using sonographic images to predict the presence of CA-MRSA.Methods: This was a pilot CDR derivation study using databases from two emergency departments (EDs) of patients presenting to the ED with uncomplicated skin abscesses who underwent I&D and culture of the abscess contents. Patients underwent ultrasound (US) imaging of the abscesses prior to I&D. Abscess contents were sent for culture and sensitivity. Two independent physicians experienced in soft tissue US blinded to the culture results and clinical data reviewed the images in a standardized fashion for the presence or absence of the predetermined image characteristics. In the instance of a disagreement between the initial two investigators, a third reviewer adjudicated the findings prior to analysis. The association between the primary outcome (presence of MRSA) and each sonographic feature was assessed using univariate and multivariate analysis. The reliability of each sonographic feature was measured by calculating the kappa (j) coefficient of interobserver agreement. The decision tree model for the CDR was created with recursive partitioning using variables that were both reliable and strongly associated with MRSA.Results: Of the total of 2,167 patients who presented with skin and soft tissue infections during the study period, 605 patients met inclusion criteria with US imaging and culture and sensitivity of purulence. Among the pathogenic organisms, MRSA was the most frequently isolated, representing 50.1% of all patients. Six of the sonographic features were associated with the presence of MRSA, but only four of these features were reliable using the kappa analysis. Recursive partitioning identified three independent variables that were both associated with MRSA and reliable: 1) the lack of a well-defined edge, 2) small volume, and 3) irregular or indistinct shape. This decision rule demonstrates a sensitivity of 89.2% (95% confidence interval [CI] = 84.7% to 92.7%), a specificity of 44.7% (95% CI = 40.9% to 47.8%), a positive predictive value of 57.9 (95% CI = 55.0 to 60.2), a negative predictive value of 82.9 (95% CI = 75.9 to 88.5), and an odds ratio (OR) of 7.0 (95% CI = 4.0 to 12.2).Conclusions: According to our putative CDR, patients with skin abscesses that are small, irregularly shaped, or indistinct, with ill-defined edges, are seven times more likely to demonstrate MRSA on culture.ACADEMIC EMERGENCY MEDICINE 2014;21:558-567