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Failure of Emergency Department Observation Unit Treatment for Skin and Soft Tissue Infections
Rakesh D Mistry1, Alexander W Hirsch2, Ashley L Woodford3
1Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
Insights
Observation unit (OU) management of pediatric skin and soft tissue infections (SSTI) is effective, but children with fever are at higher risk for treatment failure and may require inpatient admission.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Clinical Management
Background:
- The effectiveness of observation unit (OU) management for pediatric skin and soft tissue infections (SSTI) requires further evaluation.
- SSTIs are common in children presenting to emergency departments.
Purpose of the Study:
- To determine the rate of treatment failure in pediatric patients with SSTI managed in an OU.
- To identify risk factors associated with OU treatment failure for pediatric SSTI.
Main Methods:
- Retrospective cohort study of children (2 months to 18 years) admitted to the OU for SSTI.
- Defined OU therapy failure by subsequent admission, re-admission, surgical intervention, or antibiotic change.
- Collected demographic, clinical, and lesion characteristics; analyzed factors associated with OU failure.
Main Results:
- Of 304 eligible subjects, 192 were included; mean age was 6.2 years.
- Treatment failure occurred in 22% of patients, primarily due to inpatient admission.
- Fever in the emergency department (ED) was significantly associated with OU failure (OR 2.02).
Conclusions:
- Observation unit management is a viable option for pediatric SSTI.
- Febrile children with SSTI are at increased risk for OU treatment failure.
- Consideration for inpatient admission is recommended for febrile pediatric SSTI patients.
Background:
The effectiveness of observation unit (OU) management of skin and soft tissue infections (SSTI) has not been fully evaluated.
Objective:
This study was performed to determine the rate and risk factors.
Methods:
Retrospective cohort study of children ages 2 months to 18 years admitted to the OU for an SSTI between 2007 and 2010 from a pediatric emergency department (ED). Failure of OU therapy was defined as subsequent inpatient ward admission, re-admission after discharge from OU, initial or repeat incision and drainage after OU admission, or change in antibiotic therapy. Demographic, clinical, and lesion characteristics were collected. Comparative analyses were conducted to determine factors associated with OU failure; prolonged OU admission, defined as length of stay ≥ 36 h was evaluated.
Results:
One hundred ninety-two (63.2%) of 304 subjects with SSTI were eligible; mean age was 6.2 ± 5.3 years, and 52% were male. Fever (≥38°C) in the ED was present for 77 (40%). Most lesions were skin abscesses (53%) and were located on the lower extremity (36%) and buttock/genitourinary (21%). OU treatment failure occurred in 22% (95% confidence interval [CI] 16.5-28.3), primarily due to inpatient admission. Fever on ED presentation was significantly associated with OU failure (odds ratio 2.02; 95% CI 1.02-4.02). Demographics, body site, presence of abscess, and methicillin-resistant Staphylococcus aureus were not associated with OU failure. Prolonged OU admission occurred in 18 subjects (9.4%).
Conclusion:
SSTI can be successfully treated in the OU, though febrile children with SSTI are at risk for OU treatment failure and should be considered for inpatient admission.
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