title: Emergency management of pediatric skin and soft tissue infections in the community-associated methicillin-resistant Staphylococcus aureus era.
abstract: OBJECTIVE
  Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections.
  
  
  METHODS
  This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed.
  
  
  RESULTS
  In total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections.
  
  
  CONCLUSIONS
  Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.
authors.affiliation: Department of Pediatrics and the Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. mistryr@email.chop.edu
authors.forename: Rakesh D
authors.initials: RD
authors.lastname: Mistry
authors.forename: Keith
authors.initials: K
authors.lastname: Weisz
authors.forename: Halden F
authors.initials: HF
authors.lastname: Scott
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Alpern
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002481:Cellulitis / Q000628:therapy; D002981:Clindamycin / Q000627:therapeutic use; D017714:Community-Acquired Infections; D003430:Cross-Sectional Studies; D004632:Emergency Medical Services; D019538:Health Care Surveys; D006801:Humans; D055624:Methicillin-Resistant Staphylococcus aureus; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012874:Skin Diseases, Infectious / Q000188:drug therapy*; D018461:Soft Tissue Infections / Q000188:drug therapy*
chemical_list: D000900:Anti-Bacterial Agents; D002981:Clindamycin