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Skin and Soft-Tissue Infections on the Rise

The incidence of SSTIs has increased rapidly in the U.S., coinciding with the rise in community-associated MRSA infections.

We are now several years into a global epidemic of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections. To determine the effects of this epidemic on the rate of visits to U.S. ambulatory clinics and emergency departments for skin and soft-tissue infections (SSTIs), and on antibiotic prescribing for SSTIs, investigators analyzed data from the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care surveys for 1997 through 2005.

The rate of SSTI-related ambulatory physician visits increased from 1997 to 2005 (from 32 to 48 visits per 1000 population; P=0.003). Most of this increase occurred from 2001 through 2004, and 95% of the rise was attributable to visits for abscess/cellulitis. The increase in the visit rate for abscess/cellulitis was most pronounced among patients aged <18 years (from 10 to 28 visits per 1000 population; P<0.001). Antibiotics were prescribed for most patients who visited for abscess/cellulitis, with β-lactams (primarily cephalosporins) the most commonly prescribed agents. The prescription of agents recommended for management of CA-MRSA SSTIs (tetracyclines, clindamycin, trimethoprim-sulfamethoxazole, vancomycin, and linezolid) increased from 7% of visits to 28% of visits during the study period, with most of the increase occurring in 2004–2005. By 2005, trimethoprim-sulfamethoxazole was the most commonly used agent among those recommended for CA-MRSA.

Comment: Although limited by reliance on ICD-9-CM codes for diagnostic information, this study confirms that the U.S. is experiencing a nationwide epidemic of SSTIs. This epidemic is almost certainly being driven by the emergence of CA-MRSA, which is now the most common cause of SSTIs treated in emergency departments in the U.S. (JW Infect Dis Aug 16 2006). The frequency with which cephalosporins and other β-lactams are still prescribed for outpatient SSTI treatment indicates a need for better education — first, to emphasize that many such infections can be managed with incision and drainage alone, without antibiotics, and second, to increase the likelihood that an antimicrobial agent (if needed) is active against CA-MRSA.

— Daniel J. Diekema, MD, MS

Published in Journal Watch Infectious Diseases August 20, 2008

Citation(s):

Hersh AL et al. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med 2008 Jul 28; 168:1585.

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