Failure of Emergency Department Observation Unit Treatment for Skin and Soft Tissue Infections.
BACKGROUND
The effectiveness of observation unit (OU) management of skin and soft tissue infections (SSTI) has not been fully evaluated.


OBJECTIVE
This study was performed to determine the rate and risk factors.


METHODS
Retrospective cohort study of children ages 2 months to 18 years admitted to the OU for an SSTI between 2007 and 2010 from a pediatric emergency department (ED). Failure of OU therapy was defined as subsequent inpatient ward admission, re-admission after discharge from OU, initial or repeat incision and drainage after OU admission, or change in antibiotic therapy. Demographic, clinical, and lesion characteristics were collected. Comparative analyses were conducted to determine factors associated with OU failure; prolonged OU admission, defined as length of stay ≥ 36 h was evaluated.


RESULTS
One hundred ninety-two (63.2%) of 304 subjects with SSTI were eligible; mean age was 6.2 ± 5.3 years, and 52% were male. Fever (≥38°C) in the ED was present for 77 (40%). Most lesions were skin abscesses (53%) and were located on the lower extremity (36%) and buttock/genitourinary (21%). OU treatment failure occurred in 22% (95% confidence interval [CI] 16.5-28.3), primarily due to inpatient admission. Fever on ED presentation was significantly associated with OU failure (odds ratio 2.02; 95% CI 1.02-4.02). Demographics, body site, presence of abscess, and methicillin-resistant Staphylococcus aureus were not associated with OU failure. Prolonged OU admission occurred in 18 subjects (9.4%).


CONCLUSIONS
SSTI can be successfully treated in the OU, though febrile children with SSTI are at risk for OU treatment failure and should be considered for inpatient admission.
Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
Rakesh D
RD
Mistry
Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
Alexander W
AW
Hirsch
Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Ashley L
AL
Woodford
Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Megan
M
Lundy
D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D004322:Drainage; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007223:Infant; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D012874:Skin Diseases, Infectious / Q000628:therapy*; D018461:Soft Tissue Infections / Q000628:therapy*; D017211:Treatment Failure
D000900:Anti-Bacterial Agents
emergency medicine; observation medicine; skin infections