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A retrospective electronic-chart review to determine if cultures should be routinely utilized for skin and soft tissue infections in the Emergency Department at Legacy Emmanuel Hospital

1 August 2005


Background. Soft tissue skin infections rank among the most common diagnosis in hospitalized patients in America, yet attempts to culture these infections often demonstrates no definitive pathogen. Low yields for positive cultures is often demonstrated when culturing cellulitis, however, the yield is much greater with abscess cultures. Over the past decade, several clinical trials have shown etiologic organisms in less than 26% of cellulitis cultures, discouraging an attempt by many practitioners to utilize tissue and blood cultures for other soft tissue infections, like skin abscesses. Instead, practitioners often commence empiric B-Iactam antibiotics for more common" organisms, like Streptococcus and Staphylococcus aureus (S. aureus). However, when empiric B-lactams are given to treat a resistant form of S. aureus, community associated methicillin-resistant Staphylococcus aur~us (MRSA), therapy often fails and is considered inappropriate. The result of not routinely culturing skin abscesses to, grow out community associated MRSA for susceptible antibiotic therapy may result in progressive infections and increased costs.

Methods. A retrospective electronic-chart review of skin and soft tissue ' infections on patients seen in the Emergency Department between February 1, 2005 and April 30, 2005 was conducted on patients identified by ICD-9 code. Skin and soft tissue infections (SSTI's) include cellulitis, skin abscesses, carbuncles, impetigo, and erysipelas. Patients,were excluded if they were less than 16 years of age.

Results. Of the 100 patient charts reviewed, there were none who received a culture on the,initial visit. Therefore, determining community-associated ME-SA (CA-MRSA) prevalence at Legacy Emmanuel Emergency Department in this review was not possible. There were 26 (26%) patients who returned with a progressing SSTI, all of which were initially started on Cephalexin. One patient developed septic bacteremia secondary to a progressed knee abscess following Cephalexin therapy (later determined as MRSA) incurred medical bills of at least $20,000. An abscess fluid culture costs approximately $80 and would have cost $8,000 had all 100 patients received cultures, and even less if only the skin and soft tissue abscesses had been cultured. All twenty-six patients who returned with progressing SSTI's either didn't return to LEED for follow-up or demonstrated resolving infections at the next follow-up when started on a second antibiotic.

Conclusions. Due to progressing infections in Cephalexin therapy patients alone, it is likely there was some degree of resistance to this medication. This is especially supported by the fact that all of these patients improved or did not return for follow-up when a second, more MRSA selective antibiotic, was commenced. This study also suggests that culturing skin and soft tissue abscesses may prove cost effective for patients, in addition to providing the hospital with· CA-MRSA prevalence data. The dichotomy between culture costs and hospital bills may warrant cultures of at least abscesses. Cultures may also prevent some unnecessary patient volume in the LEED. Though all of these conclusions may be suggestive in this study, none by any means is definitive. Especially, since there was no MRSA prevalence determined through cultures in the LEED.


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