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West J Emerg Med. 2014 Jul;15(4):491-8. doi: 10.5811/westjem.2014.4.20583.

Clinical management of skin and soft tissue infections in the U.S. Emergency Departments.

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University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.
University of California, San Francisco Medical Center, Department of Pediatrics, San Francisco, California.
George Washington University, Department of Emergency Medicine, Washington, District of Columbia.
Perelman School of Medicine at the University of Pennsylvania, Division of Infectious Diseases, Philadelphia, Pennsylvania.
University of California, San Francisco School of Medicine, Division of Infectious Diseases, San Francisco, California.
University of Utah School of Medicine, Division of Infectious Diseases, Salt Lake City, Utah.



Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation's emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).


Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007-09. Demographics, rates of I+D, and adjuvant antibiotic therapy were described. We used multivariable regression to identify factors independently associated with use of I+D and adjuvant antibiotics.


An estimated 6.8 million (95% CI: 5.9-7.8) ED visits for SSTI were derived from 1,806 sampled visits; 17% were for children <18 years of age and most visits were in the South (49%). I+D was performed in 27% (95% CI 24-31) of visits, and was less common in subjects <18 years compared to adults 19-49 years (p<0.001), and more common in the South. Antibiotics were prescribed for 85% of SSTI; there was no relationship to performance of I+D (p=0.72). MRSA-active agents were more frequently prescribed after I+D compared to non-drained lesions (70% versus 56%, p<0.001). After multivariable adjustment, I+D was associated with presentation in the South (OR 2.36; 95% CI 1.52-3.65 compared with Northeast), followed by West (OR 2.13; 1.31-3.45), and Midwest (OR 1.96; 1.96-3.22).


Clinical management of most SSTIs in the U.S. involves adjuvant antibiotics, regardless of I+D. Although not necessarily indicated, CA-MRSA effective therapy is being used for drained SSTI.

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