Gillian Schmitz

Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection

STUDY OBJECTIVE Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days. METHODS In this multicenter, double-blind, randomized, placebo-controlled trial, we randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage. Using emergency department rechecks at 2 and 7 days and telephone follow-up, we assessed treatment failure within 7 days, and using clinical follow-up, telephone follow-up, and medical record review, we recorded the development of new lesions within 30 days. RESULTS We randomized 212 patients, and 190 (90%) were available for 7-day follow-up. We observed a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval -2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02. CONCLUSION After the incision and drainage of uncomplicated abscesses in adults, treatment with trimethoprim-sulfamethoxazole does not reduce treatment failure but may decrease the formation of subsequent lesions.

A study of the workforce in emergency medicine: 2007

INTRODUCTION This study was undertaken to describe the current status of the emergency medicine workforce in the United States. METHODS Surveys were distributed in 2008 to 2619 emergency department (ED) medical directors and nurse managers in hospitals in the 2006 American Hospital Association database. RESULTS Among ED medical directors, 713 responded, for a 27.2% response rate. Currently, 65% of practicing emergency physicians are board certified by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine. Among those leaving the practice, the most common reasons cited for departure include geographic relocation (46%) and better pay (29%). Approximately 12% of the ED physician workforce is expected to retire in the next 5 years. Among nurse managers, 548 responded, for a 21% response rate. Many nurses (46%) have an associate degree as their highest level of education, 28% have a BSN, and 3% have a graduate degree (MSN or higher). Geographic relocation (44%) is the leading reason for changing employment. Emergency department annual volumes have increased by 49% since 1997, with a mean ED volume of 32 281 in 2007. The average reported ED length of stay is 158 minutes from registration to discharge and 208 minutes from registration to admission. Emergency department spent an average of 49 hours per month in ambulance diversion in 2007. Boarding is common practice, with an average of 318 hours of patient boarding per month. CONCLUSIONS In the past 10 years, the number of practicing emergency physicians has grown to more than 42 000. The number of board-certified emergency physicians has increased. The number of annual ED visits has risen significantly.

Strategies for coping with stress in emergency medicine: Early education is vital

Introduction: Physician burnout has received considerable attention in the literature and impacts a large number of emergency medicine physicians, but there is no standardized curriculum for wellness in resident education. A culture change is needed to educate about wellness, adopt a preventative and proactive approach, and focus on resiliency. Discussion: We describe a novel approach to wellness education by focusing on resiliency rather than the unintended endpoint of physician burnout. One barrier to adoption of wellness education has been establishing legitimacy among emergency medicine (EM) residents and educators. We discuss a change in the language of wellness education and provide several specific topics to facilitate the incorporation of these topics in resident education. Conclusion: Wellness education and a culture of training that promotes well-being will benefit EM residents. Demonstrating the impact of several factors that positively affect emergency physicians may help to facilitate alert residents to the importance of practicing activities that will result in wellness. A change in culture and focus on resiliency is needed to adequately address and optimize physician self-care.

The Treatment of Cutaneous Abscesses: Comparison of Emergency Medicine Providers' Practice Patterns

Introduction Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting. Methods: Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED. Results: In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation. Conclusion: Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies.

Primary Versus Secondary Closure of Cutaneous Abscesses in the Emergency Department: A Randomized Controlled Trial

OBJECTIVES Cutaneous abscesses have traditionally been treated with incision and drainage (I&D) and left to heal by secondary closure. The objective was to compare the healing rates of cutaneous abscesses following I&D after primary or secondary closure. METHODS This was a randomized, controlled, trial, balanced by center, with blocked randomization created by a random-number generator. One urban and one suburban academic emergency department (ED) participated. Subjects were randomized to primary or secondary wound closure following I&D of the abscess. Main outcome measures were the percentage of healed wounds (wound was completely closed by visual inspection; a 40% difference in wound healing was sought) and overall failure rate (need for additional intervention including suture removal, additional drainage, antibiotics, or admission within 7 days after drainage). RESULTS Fifty-six adult patients with simple localized cutaneous abscesses were included; 29 were randomized to primary closure, and 27 were randomized to secondary closure. Healing rates at 7 days were similar between the primary and secondary closure groups (69.6%, 95% confidence interval [CI] = 49.1% to 84.4% vs. 59.3%, 95% CI = 40.7% to 75.5%; difference 10.3%, 95% CI = -15.8% to 34.1%). Overall failure rates at 7 days were also similar between the primary and secondary closure groups (30.4%, 95% CI = 15.6% to 50.9% vs. 28.6%, 95% CI = 15.2% to 47.1%; difference 1.8%, 95% CI = -24.2% to 28.8%). CONCLUSIONS The rates of wound healing and treatment failure following I&D of simple abscesses in the ED are similar after primary or secondary closure. The authors did not detect a difference of at least 40% in healing rates between primary and secondary closure.

Genitourinary Emergencies in the Nonpregnant Woman

Lower abdominal and pelvic pains are common symptoms in women who present to the emergency department (ED). Once pregnancy has been ruled out, attention should focus on other potential life or fertility threats. Ultrasound remains the most helpful initial diagnostic modality. Time-sensitive and serious conditions, such as large ovarian masses or abnormal vaginal bleeding, need gynecologic consultation. Because many patients do not have access to primary care, ED physicians should be familiar with the treatment of sexually transmitted diseases. However, most nonpregnant women with pelvic complaints can safely be managed in the outpatient setting after ED evaluation.