Halden F. Scott

Emergency Management of Pediatric Skin and Soft Tissue Infections in the Community‐associated Methicillin‐resistant Staphylococcus aureus Era

OBJECTIVESnSkin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections.nnnMETHODSnThis was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed.nnnRESULTSnIn total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections.nnnCONCLUSIONSnPractice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.

Emergency department treatment failures for skin infections in the era of community-acquired methicillin-resistant Staphylococcus aureus.

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.

Prevalence of Proteus mirabilis in Skin Abscesses of the Axilla

Gram-positive organisms are the most common infectious etiologic agents in skin abscesses. Empiric antimicrobial treatment choices are influenced by this knowledge. In this report, we describe a high prevalence of Proteus mirabilis, a Gram-negative bacillus, in skin abscesses of the axilla, which has potential implications for selection of antimicrobial therapy.

1371: USING LACTATE AND BLOOD PRESSURE TO CLASSIFY SHOCK IN PEDIATRIC SEPSIS: AN EHR-BASED APPROACH.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) COPD (P = 0.039), and had lower APACHE scores at presentation (P = 0.002). Per kg, obese patients received the lowest volume of fluid at 3 and 6 hours (30.4, 36.0), followed by overweight patients (35.5, 43.2), and normal/underweight patients (44.9, 54.3; P < 0.001, P < 0.001). There was no difference in mortality among the groups (P=0.11). Conclusions: The obesity paradox was not observed in patients with severe sepsis in the era of protocolized sepsis care. Despite implementation of a standardized weight-based volume administration protocol, obese patients received significantly less fluid per kg than did overweight or normal/ underweight patients, similar to findings from earlier studies that did show an obesity paradox. These results argue against the theory that “under-resuscitation” is a contributor to lower mortality in obese patients.