Skin Infections and Antibiotic Stewardship: Analysis of Emergency Department Prescribing Practices, 2007-2010

Abstract

Introduction: National guidelines suggest that most skin abscesses do not require antibiotics, and that cellulitis antibiotics should target streptococci, not community-associated MRSA (CA-MRSA). The objective of this study is to describe antimicrobial treatment of skin infections in U.S. emergency departments (EDs) and analyze potential quality measures.Methods: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a 4-stage probability sample of all non-federal U.S. ED visits. In 2007 NHAMCS started recording whether incision and drainage was performed at ED visits. We conducted a retrospective analysis, pooling 2007–2010 data, identified skin infections using diagnostic codes, and identified abscesses by performance of incision and drainage. We generated national estimates and 95% confidence intervals using weighted analyses; quantified frequencies and proportions; and evaluated antibiotic prescribing practices. We evaluated 4 parameters that might serve as quality measures of antibiotic stewardship, and present 2 of them as potentially robust enough for implementation.Results: Of all ED visits, 3.2% (95% confidence interval 3.1–3.4%) were for skin infection, and 2.7% (2.6–2.9%) were first visits for skin infection, with no increase over time (p=0.80). However, anti-CA-MRSA antibiotic use increased, from 61% (56–66%) to 74% (71–78%) of antibiotic regimens (p<0.001). Twenty-two percent of visits were for abscess, with a non-significant increase (p=0.06). Potential quality measures: Among discharged abscess patients, 87% were prescribed antibiotics (84–90%, overuse). Among antibiotic regimens for abscess patients, 84% included anti-CA-MRSA agents (81–89%, underuse).Conclusion: From 2007–2010, use of anti-CA-MRSA agents for skin infections increased significantly, despite stable visit frequencies. Antibiotics were over-used for discharged abscess cases, and CA-MRSA-active antibiotics were underused among regimens when antibiotics were used for abscess. [West J Emerg Med. 2014;15(3):282–289.]

Cellulitis of the Knee in a 16-Month-Old Boy: A Case Report

“…In the United States, about 3.2% of all ED visits between 2007 and 2010 were related to skin infection, and 68% were treated with anti-MRSA agent antibiotics. 7,9,10,19,[23][24][25]27,28,30 About 10% of cellulitis cases are reported to be related to invasive MRSA 4. Because of the increased number of abscesses that turn into NF, cellulitis, and/or MRSA, hospitals are currently taking a more aggressive approach in treatment.…”

“…Clindamycin is considered the most effective agent against group A streptococci and is frequently used in the treatment of severe infections such as NF to prevent streptococcal toxic shock syndrome. [7][8][9][10][15][16][17][18][19][20][21][26][27][28][29] Methicillin-resistant S aureus has been talked about since the mid-20th century, when it was first discovered in humans. In the United States, about 3.2% of all ED visits between 2007 and 2010 were related to skin infection, and 68% were treated with anti-MRSA agent antibiotics.…”

“…They all have similar initial presentation, and their outcome could vary from antibiotic treatment, surgical debridement, toxic shock, or death. 9,10,[15][16][17][18] Taking into consideration the fast progression of the erythematous reaction, irregular margins, striations, and nonpurulent presentation, the patient was diagnosed with acute cellulitis. The importance of immediate care was explained to the parents, and the patient was referred to the local emergency department (ED).…”

“…These are the conventional guideline medications used for severe skin infections when considering the possibility of NF or MRSA. 10,[15][16][17][18][19][20][21][22][23][24] The rapid spreading of the patient's rash showed pathognomonic markings similar to the presentation of NF, which has a higher potential to induce shock, especially in a young child.…”

“…Other common presentations are seen among patients with a body mass index higher than 31, geriatric patients, and patients with a history of diabetes or immune compromise. 6,[9][10][11][12][13][14] The presentation of cellulitis to a chiropractic clinic is not commonly reported in the literature. At present, only 1 case report exists which describes the www.journalchiromed.com presentation in an adolescent.…”