Factors associated with emergency department methicillin-resistant Staphylococcus aureus coverage in patients with skin and soft tissue infections in an urban, tertiary care emergency department.

Abstract

Skin and soft tissue infections (SSTIs) are common and contribute significantly to morbidity and healthcare costs in emergency departments (EDs). The rise of antimicrobial resistance, particularly due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA), complicates treatment decisions. Objective physical examination findings suggesting need for empiric MRSA coverage are sometimes ignored. Improving initial antimicrobial selection in the ED, especially regarding MRSA, could enhance antimicrobial stewardship. We conducted a retrospective review of patient records for those who presented with SSTIs to an urban tertiary care ED between January 1, 2017, to December 31, 2019. Patients admitted during their initial visit were excluded. Data collected included demographics, vital signs, and laboratory results. Logistic regression was used to assess factors associated with the decision to provide MRSA coverage at presentation, reporting odds ratios with 95% confidence intervals. Among 1675 patients, 42.2% received empiric MRSA coverage. Factors associated with MRSA coverage included male gender, white race, intravenous drug use, immunocompromised status, systemic symptoms, tachycardia, presence of abscess, and surgical consultation. After adjusting for confounders, male gender, history of intravenous drug use, immunocompromised status, systemic symptoms, tachycardia, surgical consultation, and recent antibiotic use remained significantly associated. Several factors, not always aligned with clinical guidelines, influenced the decision to initiate MRSA coverage in the ED. Understanding these determinants may improve antimicrobial stewardship and reduce costs. Future research should focus on patient outcomes based on methicillin-sensitive S. aureus (MSSA) versus MRSA coverage decisions and educational initiatives to improve guideline compliance.