Acute Bacterial Skin and Skin Structure Infections (ABSSSI)

Practice Guidelines for Management and Care Transitions in the Emergency Department and Hospital

Charles V. Pollack Jr., MA, MD; Alpesh Amin, MD, MBA; William T. Ford Jr., MD, SFHM; Richard Finley, MD; Keith S. Kaye, MD, MPH; Hien H. Nguyen, MD, MS; Michael J. Rybak, PHARMD, MPH; David Talan, MD


J Emerg Med. 2015;48(4):508-519. 

In This Article


Infectious agents such as MRSA are increasing in incidence and have led to higher rates of complications and hospitalization for ABSSSI. According to the National Hospital Ambulatory Medical Care Survey, the number of ED visits for skin infections almost tripled from the late 1990s until 2005, and continues to increase at an alarming rate. MRSA is prevalent in ABSSSI with high rates of morbidity and other associated medical conditions.

Patients who develop CA-MRSA are at significantly greater risk of mortality during the year after diagnosis compared with patients who did not contract it, 21.8% vs. 5.0%, respectively. Diabetes, cardiovascular disease and stroke, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, and cancer are all more common in patients with MRSA infections than in disease-free patients. The highest rate of MRSA hospitalization is among the elderly—360.8 MRSA stays per 100,000 patients over 65 years of age. This is more than three times higher than for any other age group.

Inadequate treatment of MRSA due to antibiotic resistance is a factor in relapse of ABSSSI. More effective outpatient treatment is needed to reduce hospitalization. These management strategies should include programs that evaluate and limit the use of relatively low-yield diagnostic tests. Use of ED ultrasound instead of CT scans in ABSSSI to evaluate for deep abscesses can save time and resources. Use of MRI should be reserved for situations in which the result will importantly impact management. Standard antimicrobial regimens for empiric therapy (based on local resistance patterns), standard approaches to bacteriologic testing, and uniform patient follow-up procedures increases consistency and quality of care. Finally, emergency physicians and hospitalists must remain current with the availability of new antimicrobial options (such as long-acting agents with activity against MRSA) and with local capabilities for home infusion services and close follow-up.