title: Emergency department treatment failures for skin infections in the era of community-acquired methicillin-resistant Staphylococcus aureus.
abstract: BACKGROUND
  Despite rapidly increasing incidence of skin and soft tissue infections (SSTIs) presenting to emergency departments (EDs), outcome data for these infections are limited.
  
  
  METHODS
  This is a retrospective cohort study of children with culture-positive SSTI, managed as outpatients from a large pediatric ED in the year 2006. The primary outcome was treatment failure, defined as presence of 1 or more of the following: (1) change in antibiotic owing to poor clinical response, (2) subsequent incision and drainage, or (3) hospitalization. Demographics, isolated pathogens, and therapeutics were also assessed. To accurately capture the outcome of interest, only children who are observed in the hospital-based primary care network were included.
  
  
  RESULTS
  Among 148 eligible subjects, there were 158 SSTIs including 131 abscesses, 19 folliculitis, and 8 cellulitis. Mean age was 9.1 ± 6.2 years, 41.2% were male, and 94.6% were African American. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 66%, methicillin-sensitive S. aureus (MSSA) in 21%, and others in 13%. Outcome data were available for 144 subjects (97.2%). Emergency department treatment failure rate was 7.6% (95% confidence interval, 3.3%-12.0%); 10 of 11 failures were abscesses. Only S. aureus produced treatment failure and occurred in 13.3% of MSSA and 6.4% MRSA infections (odds ratio, 1.9; 95% CI, 0.5-7.1). An antibiotic to which the organism was sensitive was prescribed for 9 (81.8%) of 11 treatment failures and did not differ between MRSA and MSSA; appropriate antibiotics were used in 91.5% of treatment successes.
  
  
  CONCLUSIONS
  The rate of ED treatment failure for SSTI is low and is more likely to occur with S. aureus infection, irrespective of methicillin resistance or appropriate antibiotic therapy.
authors.affiliation: Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. mistryr@email.chop.edu
authors.forename: Rakesh D
authors.initials: RD
authors.lastname: Mistry
authors.forename: Halden F
authors.initials: HF
authors.lastname: Scott
authors.forename: Theoklis E
authors.initials: TE
authors.lastname: Zaoutis
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Alpern
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D013207:Staphylococcal Skin Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents