Skin and soft tissue infection management failure in the emergency department observation unit: a systematic review

Abstract

A higher rate of EDOU management failure in SSTIs than the generally accepted rate of 15% was observed in most studies identified by this review. Risk factors identified were varied, but presence of a fever and elevated inflammatory markers were commonly associated with failure of EDOU admission by multiple studies. Recognition of risk factors and the increased application of clinical decision tools may help to improve disposition of patients at high risk for clinical deterioration or management failure.

Risk factors associated with methicillin-resistant Staphylococcus aureus skin and soft tissue infections in hospitalized patients in Colombia

“…This finding is similar to those of studies performed in the Middle East and Asia (Chou et al, 2015;Al Jalaf et al, 2018) and in contrast to the findings of other studies in Europe and the USA (Lipsky et al, 2007;Macía-Rodríguez et al, 2017), where an increase in prescription of antibiotics active against MRSA (Szumowski et al, 2007;Hersh, 2008) was noted in emergency rooms in the last decades (Pallin et al, 2008). A systematic review by Abetz et al reported a frequency of treatment failure of 15-38% in SSTI, and an MRSA infection was implicated in this outcome (Abetz et al, 2018). Macía-Rodríguez et al reported that an inadequate empirical therapy of SSTI resulted in greater mortality (OR 44.74, 95% CI 5.40-370.73) (Macía-Rodríguez et al, 2017).…”

Transfer of care and overstay in the management of cellulitis in the emergency short stay unit: A retrospective cohort study

“…Following admission to an ESSU for management of cellulitis, a high proportion (34.8%) of patients either had their care transferred to an inpatient team, or overstayed the ESSU time limit. This high rate of transfer of care or overstay is consistent with findings from a recent systematic review on the topic (15–38%) . In contrast to previously documented risk factors for these occurrences that include high initial temperature, elevated WBC and known methicillin‐resistant Staphylococcus aureus exposure or positive culture – derived primarily from studies on patient populations in the USA, this study found obesity, IVDU, elevated WBC and an elevated CRP were independently associated with transfer of care or overstay.…”

“…This high rate of transfer of care or overstay is consistent with findings from a recent systematic review on the topic (15–38%) . In contrast to previously documented risk factors for these occurrences that include high initial temperature, elevated WBC and known methicillin‐resistant Staphylococcus aureus exposure or positive culture – derived primarily from studies on patient populations in the USA, this study found obesity, IVDU, elevated WBC and an elevated CRP were independently associated with transfer of care or overstay. Knowledge of such risk factors can inform appropriate guidelines for ESSU admission and thereby improve patient flow and reduce length of stay in the ED and hospital.…”

“…The objective of ESSU management is early discharge from hospital; however, patients with cellulitis often spend extended periods in the ESSU, displacing other potential ESSU candidates, who may be more appropriate for the unit. There are currently no evidence‐based guidelines informing admission criteria to ESSU for management of cellulitis, where up to 40% of patients require either transfer of care to an inpatient team, or overstay of the ESSU time period …”

“…There are currently no evidence-based guidelines informing admission criteria to ESSU for management of cellulitis, where up to 40% of patients require either transfer of care to an inpatient team, or overstay of the ESSU time period. 6 This study involved a population of patients admitted to the ESSU of a major metropolitan hospital in Melbourne, Australia, and aimed to quantify the rate of transfer of care or overstay of patients with cellulitis. The secondary objective was to identify risk factors associated with transfer of care or overstay that could be identified during initial patient assessment.…”