title: 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.
abstract: OBJECTIVE
  Test the hypotheses that emergency department (ED) visits for skin and soft tissue infections became more frequent during the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA), and that antibiotics typically active against community-associated MRSA were chosen increasingly.
  
  
  METHODS
  From merged National Hospital Ambulatory Medical Care Survey data for 1993-2005, we identified ED visits with diagnosis of cellulitis, abscess, felon, impetigo, hidradenitis, folliculitis, infective mastitis, nonpurulent mastitis, breast abscess, or carbuncle and furuncle. Main outcomes were change over time in rate of ED visits with such a diagnosis and proportion of antibiotic regimens including an agent typically active against community-associated MRSA. We report national estimates derived from sample weights. We tested trends with least squares linear regression.
  
  
  RESULTS
  In 1993, infections of interest were diagnosed at 1.2 million visits (95% confidence interval [CI] 0.96 to 1.5 million) versus 3.4 million in 2005 (95% CI 2.8 to 4.1 million; P for trend <.001). As a proportion of all ED visits, such infections were diagnosed at 1.35% in 1993 (95% CI 1.07% to 1.64%) versus 2.98% in 2005 (95% CI 2.40% to 3.56%; P for trend <.001). When antibiotics were prescribed at such visits, an antibiotic typically active against community-associated MRSA was chosen rarely from 1993 to 2001 but increasingly thereafter, reaching 38% in 2005 (95% CI 30% to 45%; P for trend <.001). In 2005, trimethoprim-sulfamethoxazole was used in 51% of regimens active against community-associated MRSA.
  
  
  CONCLUSIONS
  US ED visits for skin and soft tissue infections increased markedly from 1993 to 2005, contemporaneously with the emergence of community-associated MRSA. ED clinicians prescribed more antibiotics typically active against community-associated MRSA, especially trimethoprim-sulfamethoxazole. Possible confounders are discussed, such as increasing diabetes or shifts in locus of care.
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA. dpallin@partners.org
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Pallin
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Egan
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Pelletier
authors.forename: Janice A
authors.initials: JA
authors.lastname: Espinola
authors.forename: David C
authors.initials: DC
authors.lastname: Hooper
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D021821:Communicable Diseases, Emerging / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D015994:Incidence; D008297:Male; D016106:Methicillin Resistance; D008875:Middle Aged; D018461:Soft Tissue Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D013207:Staphylococcal Skin Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D013211:Staphylococcus aureus; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents