Over half of skin infections in EDs are drug-resistant

Simple practices can stop spread of infection

If you are seeing increased numbers of patients with skin infections resistant to antibiotics in your ED, know that this jump reflects a nationwide trend.

"We are seeing an increased number of these skin infections," reports Bill Raines, RN, assistant manager of the pediatric ED at Vanderbilt Children's Hospital in Nashville, TN. "This past summer, we probably saw eight to 10 per week."

National research data indicate the increase is widespread. When researchers analyzed 422 cases of skin infections in adult ED patients in 11 cities, they found that 59% were caused by methicillin-resistant Staphylococcus aureus (MRSA).1

Only a decade ago, MRSA was hardly ever seen outside of hospitals and nursing homes, but EDs now are reporting dramatic surges in these cases. These skin infections can be life-threatening if bacteria get into the bloodstream, and drug-resistant strains can cause pneumonia and "flesh-eating" wounds, says Gregory Moran, MD, the study's lead author and clinical professor in the Department of Emergency Medicine at University of California Los Angeles-Olive View Medical Center in Sylmar.

Signs that a skin infection may be life threatening include rapid progression, gas formation in the tissues, systemic toxicity such as high fever, or signs of organ dysfunction such as elevated creatinine levels, altered mental status, hypoxia, or acidosis, says Moran.

"We have had a number of cases of necrotizing fasciitis in our emergency department, but most of these were not due to MRSA," reports Moran. "MRSA-related necrotizing fasciitis cases have been described at several sites, but they are a small minority of cases of MRSA skin infections."

The study also reported some good news: Researchers found that several antibiotics were effective against MRSA infections, which suggests that infections contracted outside a hospital are easier to treat.

To improve care of MRSA infections in your ED, do the following:

Educate patients on wound care and how to avoid spreading the infection to others.

Instruct patients not to share towels, razors, or other objects that could spread MRSA, says Moran. At Vanderbilt Children's ED, discharge instructions were improved for patients with MRSA who are treated and released. Patients are given the following instructions:

— Hand washing or use of an alcohol hand rub is the No. 1 method of defense against any type of infection, and is important in helping to prevent the spread of the bacteria to other family members.

— Keep cuts and scrapes clean and covered with a bandage until healed.

— Avoid sharing personal items such as towels, washcloths, or clothing that may have had contact with the infected wound or bandage.

— Wash sheets, towels, and clothes that may have become soiled with laundry detergent, and dry in a hot dryer. Clean household and personal items with a commercial disinfectant or a fresh solution of one part bleach and 100 parts water (1 tablespoon of bleach in 1 quart of water).

Be extra vigilant about hand washing and infection control.

Community strains of MRSA can be spread in health care settings, warns Moran. Since MRSA typically is spread by direct contact, it is important to cover any infected areas, and use careful hand washing when changing dressings, he says.

"We have increased awareness at patient intake for contact precautions on any patient with skin lesions," reports Raines. When a patient presents to Vanderbilt's ED with any type of skin infection complaint, these steps occur:

— The triage nurse assesses the patient and notifies the charge nurse of the potential need for increased precautions.

— The patient is placed on contact precautions and given gown and gloves on arrival to a treatment room. "If the wound turns out to be 'just a bug bite,' that's good," says Raines. "If it turns into an incision and drainage, we have an early start on protecting staff and other patients from possible cross-contamination."

The ED is trying to identify the potential need for isolation precautions at intake, instead of after treatment has begun and staff potentially have already been exposed to an infectious agent, adds Raines.

Incision and drainage of an abscess usually is done with local anesthetic, sometimes supplemented by systemic analgesia, or even procedural sedation for large abscesses, says Moran. The abscess is incised with an 11 blade, sometimes irrigated, then packed with gauze, he says.

It's important for nurses who handle dressings for potential MRSA infections to use vigilant infection control techniques, wearing gowns and gloves, to avoid spreading MRSA to other patients, says Moran. At Vanderbilt Children's, ED nurses are encouraged to say "I didn't see you wash your hands" to their colleagues if needed, says Raines. "Our staff are pretty good at checking each other as they assist with procedures and treatments," he says.

In addition, formal Environment of Care surveys are done quarterly in the ED, and the reviewers watch for instances in which staff members don't use an alcohol gel or wash hands before contact with the patient. "This is reported to the management team," Raines says. If a nurse is noncompliant, counseling takes place. Also, as we do manager rounds, we ask patients if they witnessed their caregivers wash their hands before touching the patient," Raines says.


  1. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Eng J Med 2006; 355:666-674.