Skin and soft tissue infections (SSTIs) are frequently treated in the emergency department (ED) setting. Recent studies provide critical new information that can guide new approaches to the diagnosis and treatment of SSTIs in the ED. Rapid polymerase chain reaction assays capable of detecting MRSA in approximately 1 h hold significant potential to improving antibiotic stewardship in SSTI care. Emergency ultrasound continues to demonstrate value in guiding appropriate management of SSTIs, including the early diagnosis of necrotizing infections. Since emerging in the 1990s, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) continues to increase in prevalence, and it represents a significant challenge to optimizing ED antibiotic use for SSTI management. Growing literature reinforces the current recommendation of incision and drainage without antibiotics for uncomplicated abscesses. Selecting antibiotics with CA-MRSA coverage is recommended when treating purulent SSTIs; however, it is generally not necessary in cases of nonpurulent cellulitis. Future advances in ED SSTI care may involve expansion of outpatient parenteral antimicrobial therapy protocols and the recent development of a novel, once weekly antibiotic with activity against MRSA.
PurposeIn the era of community-associated methicillin-resistant Staphylococcus aureus (MRSA), clinicians face a difficult challenge when selecting antibiotics to treat abscesses. The lack of rapid diagnostics capable of identifying the causative organism often results in suboptimal antibiotic stewardship practices. Although not fully elucidated, the association between MRSA colonization and subsequent infection represents an opportunity to enhance antibiotic selectivity. Our primary objective was to examine the feasibility of utilizing a rapid polymerase chain reaction (PCR) system (Cepheid’s GeneXpert®) to detect MRSA colonization prior to patient discharge in the emergency department (ED).MethodsThis feasibility study was conducted at a tertiary care, urban, academic ED. Patients presenting with a chief complaint related to a potential abscess during daytime hours over an 18-week period were screened for eligibility. Subjects were enrolled into either the PCR swab protocol group (two-thirds) or traditional care group (one-third). PCR swabs were obtained from known MRSA carriage sites (nasal, pharyngeal) and the superficial aspect of the wound.ResultsThe two groups were similar in terms of demographics, abscess location, and MRSA history. The PCR results were available prior to patient discharge in 100% of cases. The turnaround times in minutes for the PCR swabs were as follows: nasal 73 ± 7, pharyngeal 82 ± 14, and superficial wound 79 ± 17. No significant difference in length of stay was observed between the two groups. The observed ideal antibiotic selection rates improved by 45% in the PCR group, but this trend was not significant (P = 0.08).ConclusionWhen collected in triage, PCR swabs demonstrated turnaround times that were effective for use in the ED setting. Utilizing a rapid PCR MRSA colonization detection assay for ED patients with abscesses did not adversely impact the length of stay. Real-time determination of MRSA colonization may represent an opportunity to improve antibiotic selectivity in the treatment of abscesses.
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