We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics.

We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method.

The survey response rate was 36.9% (n=391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10.

The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.

The prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization among Emergency Medical Services (EMS) personnel is not well studied. Methicillin-resistant Staphylococcus aureus colonization can be a health hazard for both EMS personnel and patients. The aim of this study was to quantify the prevalence of MRSA colonization among EMS personnel. This study will help the scientific community understand the extent of this condition so that further protocols and policies can be developed to support the health and wellbeing of EMS personnel.

The hypothesis of this study was that the prevalence of MRSA colonization among EMS personnel is significantly higher than among the general population.

This was a cross-sectional study. A total of 110 subjects were selected from two major US Mid-Atlantic fire departments. Methicillin-resistant Staphylococcus aureus colonization was detected by nasal swabbing. Nasal swabs were inoculated onto a special agar medium (C-MRSAgar) with polymerase chain reaction testing performed. One-sided binomial distribution at the StudySize 2.0 Web calculator was used. Using the Web calculator, p (H0 proportion) = 1.5%; a difference (H1-H0) ‘Δ’ = 4.53% can be detected at α = 5% and power = 80% with N = 110.

Samples were collected from 110 volunteers. Seven samples were positive for MRSA, resulting in a prevalence of 7/110 or 6.4% (95% CI, 1.8%-11%; P < .0003) compared with a 1.5% prevalence of MRSA colonization among the general population.

There is evidence that EMS personnel have a higher prevalence of MRSA colonization than the general population. This can be a risk to patients and can be recognized as an occupational hazard.

Al AmiryA, BissellRA, MaguireBJ, AlvesDW. Methicillin-Resistant Staphylococcus Aureus Nasal Colonization Prevalence among Emergency Medical Services Personnel. Prehosp Disaster Med. 2013;28(4):1-5.

The objective of this study was to determine whether skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) in patients presenting to The Ottawa Hospital emergency departments (TOHEDs) differed from SSTIs caused by methicillin-susceptible Staphylococcus aureus (MSSA) with regard to risk factors, management, and outcomes.

All patients seen at TOHEDs in 2006 and 2007 with SSTIs who yielded MRSA or MSSA in cultures from the site of infection were eligible for inclusion. We excluded patients with decubitus ulcers and infections related to diabetes or peripheral vascular disease. We used an unmatched case-control design. Cases were defined as patients with MRSA isolated from the infection site, and controls were defined as patients with MSSA isolated from the infection site. Data were collected retrospectively from health records and laboratory and hospital information systems.

A total of 153 patients were included in the study (81 cases and 72 controls). The mean age of cases was 37 years, compared to 47 years for the controls (p < 0.001). Cases were more likely to have transient residence (31% v. 3% [OR 15.6, 95% CI 3.9–61.8, p < 0.001]), present with abscesses (64% v. 15% [OR 9.9, 95% CI 4.3–23.7, p < .001]), have a documented history of hepatitis C infection (28% v. 3% [OR 13.9, 95% CI 3.9–55.0, p < 0.001]), and have a history of substance abuse (53% v. 10% [OR 10.5, 95% CI 4.4–25.1, p < 0.001]). Cases most commonly used crack cocaine and injection drugs.

SSTIs caused by MRSA at TOHEDs mainly occur in a population that is young and transient with comorbidities such as hepatitis C and substance abuse.

To identify the rate of treatment failure in emergency department patients with cellulitis.

This prospective observational convenience study enrolled adult patients with uncomplicated cellulitis. Physicians performed a standardized assessment prior to treatment. To calculate the interrater reliability of the assessment, duplicate data collection forms were completed on a small subsample of patients. Treatment failure was defined as the occurrence of any one of the following events after the initial emergency department visit: incision and drainage of abscess; change in antibiotics (not due to allergy/intolerance); specialist consultation; or, hospital admission. Comparison of means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate.

Seventy-five patients were enrolled; 57% were male, the mean age was 48 (standard deviation 19), 71 (95%) patients had extremity cellulitis and 10 (13%) had abscess with cellulitis. Fourteen episodes (18.7%, 95% confidence interval [CI] 11%–28%) were classified as treatment failures, with an oral antibiotic failure rate of 6.8% (95% CI 2%–22%) and an emergency department-based intravenous antibiotic failure rate of 26.1% (95% CI 16%–40%). Patients with treatment failure were older (mean age 59 yr v. 46 yr, p = 0.02) and more likely to have been taking oral antibiotics at enrolment (50% v. 16.4%, p = 0.01). Patients with a larger surface area of infection were also more likely to fail treatment (465.1 cm2 v. 101.5 cm2, p < 0.01). Interrater agreement was high for the presence of fever (kappa 1.0) and the size of surface area of infection (intraclass correlation coefficient 0.98), but low for assessments of both severity (kappa 0.35) and need for admission (kappa 0.46).

The treatment of cellulitis with daily emergency department–based intravenous antibiotics has a failure rate of more than 25% in our centre. Cellulitis patients with a larger surface area of infection and previous (failed) oral therapy are more likely to fail treatment. Further research should focus on defining eligibility for treatment with emergency department-based intravenous antibiotics.