Elderly patients are at increased risk for treatment failure in outpatient management of purulent skin infections

a b s t r a c t

Objective: Current Infectious Disease Society of America guidelines for the management of purulent skin or soft tissue infections do not account for patient age in treatment recommendations. The study objective was to determine if age was associated with outpatient treatment failure for purulent skin infection after adjusting for IDSA treatment guidelines.

Methods: We conducted a Multicenter retrospective study of adult patients treated for a purulent skin infection and discharged home from four emergency departments between April and September 2014. Patients were followed for one month to assess for treatment failure (defined as need for a change in antibiotics, surgical inter- vention, or hospitalization). We used multivariable logistic regression to examine the role of patient age on treat- ment failure adjusting for demographic variables (gender, race), comorbidities and severity of infection.

Results: A total of 467 patients met inclusion criteria (mean age 37.9 years [SD 14.0], 48.2% of whom were women). Overall, 12.4% failed initial therapy. Patients 65 years and older (n = 35) were almost 4 times more like- ly to fail initial ED therapy in follow-up compared with younger patients (adjusted Odds Ratio (OR) 3.87, 95% Confidence Interval (CI) 1.24-12.10). After adjustment, for every 10 years of Advancing age there was a 43% in- creased odds of failing initial treatment (OR 1.43 95% CI 1.09-1.88).

Conclusion: Elderly patients with purulent Skin infections, whose providers followed the 2014 IDSA guidelines, were more likely to fail initial treatment than younger patients. This study suggests that there is a need to re- evaluate treatment guidelines in elderly patients.

Introduction

The burden of annual visits and total hospital admissions for skin and soft tissue infections (SSTIs) has increased dramatically in the past

? Meetings: None.

?? Grant: This study was designed and carried out at the University of Massachusetts

Medical School and was supported by an intradepartmental grant through the Department of Emergency Medicine. PLH is supported by an NIH award 5K24AT003683- 09.

? Conflicts of Interest: None of the authors listed have any conflict of interest.

?? Author Contributions: JPH, JT, and PLH conceived the study, designed the trial,

and obtained research funding. JPH, EW, and TZ supervised the conduct of the trial and data collection. JPH, EW and TZ recruited participating centers and patients and managed the data, including collection and quality control. JPH and FLB provided sta- tistical advice on study design and analyzed the data; JPH drafted the manuscript, and all authors contributed substantially to its revision. JPH takes responsibility for the paper as a whole.

* Corresponding author at: 55 Lake Avenue North, Worcester, MA 01655, United States.

E-mail address: [email protected] (J.P. Haran).

decade [1,2]. Between 1993 and 2005, annual visits for SSTIs in U.S. emergency departments ED increased from 1.2 million to 3.4 million [3]. In response, the Infectious Disease Society of America (IDSA) recent- ly updated their guidelines for the management of skin and soft tissue infection [4]. The 2014 guidelines departed from previous versions by creating three SSTI treatment categories (mild, moderate, and severe) with specified Treatment regimens for both purulent and non- purulent Infection types. These categories of severity are defined mainly by the patient’s medical comorbidities (such as those with markedly impaired host defenses), recent antibiotic use, and severity of present- ing symptoms. Current treatment recommendations do not take a patient’s age into consideration. However, age-related biologic changes such as immune system dysregulation, and physiologic changes such as increased dryness and decreased blood flow to the skin can diminish the body’s innate ability to fight bacterial infections [5]. The objectives of this study were to: 1) describe the frequency with which outpatient treatment failure occurs among older and younger adults treated for a purulent skin infection while comparing the ED treatment to the

http://dx.doi.org/10.1016/j.ajem.2016.10.060

recommended IDSA guidelines and 2) evaluate whether age is an inde- pendent risk factor for treatment failure of purulent SSTI in patients treated in the ED and discharged to home.

Methods

Study Design

We conducted a multi-center, retrospective cohort study. This study was approved by the institutional review board (IRB docket H00007714).

Study Setting and Population

We identified patients 18 years and older who presented to one urban tertiary care academic center with an annual ED census of 132 000 visits and three community emergency departments with a combined annual ED census of 100 000 visits for treatment of a purulent skin infection between April and September in 2014. Patients were eli- gible for participation if they were discharged from the ED or the ED ob- servation unit with a diagnosis of a skin or soft tissue purulent infection pulled from the electronic medical records. All patients were classified as having a suspected purulent infection based on discharge diagnoses of abscess. Patients were further classified as having a confirmed puru- lent infection if they underwent an incision and drainage in the ED with document purulent material. Patients were excluded if their purulent skin infection had undergone an incision and drainage within the previ- ous month in the ED, if they were admitted to the hospital for this prob- lem on their initial visit, or if they did not have follow-up visit data. Additionally, we excluded patients with: a post-surgical infection, a pu- rulent skin infection of the oral cavity, hidradenitis suppurativa, or a Bartholins gland abscess. Both patients with hidradenitis or a Bartholins abscess were excluded because they are not expected to improve with- out further surgical intervention.

Data Collection

In order to reduce the potential for systematic error and to mitigate bias, we followed protocols for the optimal conduct of retrospective studies [6]. Prior to data abstraction activities, we a priori defined the pertinent predictor and outcome variables to be collected in a standard- ized manner. Abstractors were uniformly trained by the investigators and blinded to the Study objectives and hypotheses. We utilized two dif- ferent abstractors for each patient enrolled, the first one collecting data on the initial ED visit, recording demographic, historical and clinical data, while the second abstractor collected all follow-up visit data that included the principal study outcome variables. Abstractors met regu- larly with the investigators to review the coding rules. The investigators performed an interrater reliability assessment on a 10% random sample of charts.

Variable Measurement

Baseline variables were extracted from the initial ED visit including: sociodemographic characteristics, medical history, chief complaint, and previous antibiotic use. Patients already on antibiotics from a source outside of the ED were included (e.g., primary care office). The Charlson Comorbidity Index (CCI) was calculated and used to rank patient’s med- ical comorbidities [7,8]. Information pertaining to initial ED presenta- tion, ED course, surgical, and antibiotic treatments used were recorded. Starting from this initial visit, all subsequent medical visits pertaining to this index infection were reviewed to assess for outcomes including: 1) change in antibiotic treatments, 2) unplanned surgical in- tervention to further treat the purulent skin infection, and 3) Inpatient hospitalization or admission to ED observation unit for continued infec- tion treatment. We created a Composite outcome of ED treatment

failure based on these three outcomes. Follow-up chart review was per- formed by a different abstractor using electronic medical records re- cording treatment failure one month after the initial visit. We did not include routine follow-up visits (e.g. wick removal, wound checks with- out a change in care) in the outcome measurement. All patients without documentation of treatment failure but with continued documentation or repeat visits in the medical record were classified as clinically cured.

Infectious Disease Society of America Classification

We used IDSA guidelines to classify the severity of each patient’s pu- rulent skin infection clinical presentation and the observed ED treat- ments. Each case was categorized into one of 3 treatment categories of purulent SSTIs: mild, moderate, or severe. In brief, these guidelines de- fine mild as an uncomplicated infection, a moderate infection as one where the patient has signs of a systemic inflammatory response (SIRS), and a severe infection when patients have either an impaired host defense, have failed previous antibiotic therapy, or have had SIRS plus hypotension [4,9]. We defined SIRS as the presence of one of the following: heart rate N 90 beats/min, respiratory rate N 20 breaths/ min, temperature N 38.0 ?C, white blood count N 12 000 cells/mm³ or presence of greater than 10% immature neutrophils. The presence or ab- sence of antibiotics and the class of antibiotics prescribed were used to categorize treatment into mild, moderate, or severe therapy class ac- cording to IDSA treatment recommendations [4]. We used the 2014 IDSA guidelines to compare the observed antibiotic treatment regimens to the expected according to these guidelines. Incision and drainage was recommended for all purulent skin infections regardless of class. Ac- cordingly, each patient received a score of 1 for mild, 2 for moderate, and 3 for severe for that initial ED visit presentation and a second score for the type of treatments rendered. We then compared the clini- cal presentation and treatment scores with each other to determine if the observed matched the anticipated treatment class. We categorized patients into expected treatment when the scores equaled each other, under-treated if the observed score was lower than the anticipated score, and over-treated when the observed score was higher than the anticipated score. This scoring system has been reported on previously [10].

Data Analysis

We used chi-square tests to compare categorical variables, and the Student’s t-test for continuous variables, between patients with clinical cure and those that failed therapy. Given the large sample size, data were assumed to be normally distributed. We used multivariable logis- tic regression analysis to test whether or not increasing age (the main exposure variable) was associated with treatment failure. To select the set of covariates for the multivariable model, we first determined im- portant a priori covariates that we thought would have clinical rele- vance. Patient age was the main variable of interest. Patient demographics including gender and race, patient comorbidities (CCI), and IDSA infection severity class (mild, moderate, or severe), Provider adherence to IDSA guidelines as described above (or if they did not by either over or under-treating the patient), and treatment variables such as if an incision and drainage was performed or if they received any antibiotics were also included. Finally, any covariates with a p b 0.10 from our unadjusted bivariate analysis were included. IDSA treatment was categorized into either matched, over, or under-treated while age was categorized into elderly or non-elderly using the cutoff of age >= 65 years. We then performed analysis stratified in cases of suspected versus confirmed purulent infection to examine whether or not this modified the effect estimate. To analyze the affect of patients lost to follow-up we performed a sensitivity analysis using best-case and worst-case scenarios where we reran the model with the patients that were lost were coded as either none having failed therapy or all

of them failing therapy. We used Stata Version 13.1 (StataCorp LP, Col- lege Station, TX) for all analyses.

Results

Characteristics of the Study Subjects

During the 6-month study period over the four ED sites, there were a total of 2190 ED visits for a complaint of a skin or soft tissue infection of which 33.1% were diagnosed with a purulent skin infection and 13.5% were admitted (Fig. 1). Among the this cohort there were a total of 627 patients with a diagnosis of purulent skin infection who were discharged home from the ED. We excluded 28 patients (4.5%) with an abscess related to a dental infection, 9 patients (1.4%) with a bartholins gland abscess, 6 patients (1.0%) with hidradenitis suppurativa, and 12 patients (1.9%) with a post-surgical infection. There were 105 patients (18.4%) with an average age of 34.4 years who did not have follow-up data available. The average age of the study sample was 37.9 years, 48.2% were women, with 59.5% of patients seen at the community sites. Among the cohort 362 (77.5%) patients had an incision and drainage performed confirming purulent material and thus were labeled as confirmed cases. We had a interrater reliability kappa for all variables used in this analysis of 0.92.

Among all 2190 ED visits for a SSTI (included both abscess and cellu- litis patients), patients 65 years and older had significantly lower prev- alence of purulent skin infection diagnosis (11.4% vs. 39.3%, p b 0.001) and higher prevalence of admission to the hospital (42.7% vs. 20.5%, p b 0.001) for a cutaneous infection. Elderly patients presenting to the ED were 5 times more likely to be diagnosed with a non-purulent bac- terial skin infection rather than purulent infection (unadjusted OR 5.0, 95% CI 3.8, 6.8).

Our final study cohort consisted of 467 patients of which 58 (12.4%) patients had a failure of initial ED therapy upon follow-up. A low per- centage of patients presented already on antibiotics (15.4%) from a pre- vious non-ED healthcare visit. Patients that failed therapy after their ED visit were older in age, had higher CCI scores, and had a purulent skin infection involving the structures of the hand (Table 1). For every 10- year increase in patient age, the odds of failing therapy increased by 22% (OR 1.22, 95% CI 1.01-1.47). With regard to the CCI score, patients with scores of 4 or greater had 13 times the odds of failing therapy (OR 13.62, 95% CI 1.21-153.12) compared to those with scores of 0.

Fig. 1. Study enrollment flow chart. SSTI, skin and soft tissue infections; Confirmed Cases, those patients with and incision and drainage done confirming a purulent infection.

Table 1

Characteristics of study patients.^a

Demographics Clinical cure Therapy failure p value

	n	%	n	%
Age (SD)	37.4	(13.4)	41.5	(14.2)	0.03
Female	201	(49.1)	24	(41.4)	0.27
White	208	(82.9)	24	(41.4)	0.18
Hispanic	69	(16.9)	9	(15.5)	0.80
African American	26	(6.4)	6	(10.3)	0.26
Asian	5	(1.2)	0	(0.0)	0.40
Medical history CCI 0	320	(78.2)	47	(81.0)	0.63
CCI 1	60	(14.7)	3	(5.2)	0.05
CCI 2	24	(5.8)	3	(5.2)	0.01
CCI 3 or more	5	(1.2)	5	(8.6)	b0.001
IVDA	33	(8.1)	2	(3.4)	0.21
Current Abx.	62	(15.2)	10	(17.2)	0.68
Infection characteristics Face	49	(12.5)	8	(13.8)	0.53
Trunk	86	(21.0)	9	(15.5)	0.35
Hand	27	(6.6)	8	(13.8)	0.05
Extremity	127	(31.1)	20	(34.5)	0.60
Buttocks	70	(17.1)	10	(17.2)	0.98
Genitals	38	(9.3)	6	(10.3)	0.80
Fever	42	(10.3)	8	(13.8)	0.42
Proximal streaking	14	(3.4)	3	(5.2)	0.51

Abx, antibiotics; CCI, Charlson comorbidity index; IVDA, intravenous drug abuse.

^a Data is presented as n (percentages) unless otherwise indicated.

Purulent skin infection involving the hand were 2.3 increased odds to fail (OR 2.26, 95% CI 1.00-5.26).

Characteristics of Initial ED Treatment Therapies Comparing Those With Treatment Failure

During the course of their initial ED visit, patients with a purulent in- fection did not receive an incision and drainage 22.5% of the time and re- ceived antibiotics 72.6% of the time. Intravenous antibiotics were used in 12.8% of patients with 2.6% receiving only one intravenous dose in the ED without being sent home with a prescription. ED providers used antibiotic coverage for Methicillin-resistant Staphylococcus aureus (MRSA) only 72.6% of the time.

In comparing the treatment options among patients that went on to fail therapy compared to those did not (Table 2), there was no signifi- cant difference in the rates of treatment failure among the difference an- tibiotic classes with the exception of those that received intravenous vancomycin. Patient that received an intravenous dose of vancomycin were at a 3.2 increased odds of failing ED therapy that those that did not receive this antibiotic (OR 3.20, 95% CI 1.45-7.07). Patients that re- ceived vancomycin within the ED went home without MRSA antibiotic coverage 31.0% of the time. There was also no difference in Treatment failure rates if the ED provider gave intravenous antibiotics before dis- charge or if the antibiotic class selection included MRSA coverage.

Comparison With National Guidelines

Physicians followed the IDSA guidelines for treatment of purulent infections only 40.0% of the time; patients were over-treated 40.9% of the time and under-treated 20.1% of the time. Among patients classified by IDSA as having a mild infection requiring only an incision and drain- age, they received unnecessary antibiotics 69.9% of the time; while not undergoing and incision and drainage in 23.0% of cases. The majority of patients had a mild infection according to IDSA guidelines; however, we did not detect any differences in treatment Failure rates among the three IDSA classes (Table 2). Additionally, we did not see any differences in treatment failure rates if the provider either followed the IDSA guide- lines or if they over or under-treated the patient according to these guidelines.

Table 2

ED treatment characteristics.

Type Clinical cure Therapy failure p value

	n	%	n	%			Odds ratio	95% CI	Odds ratio	95% CI
I&D not done	94	(23.0)	11	(19.0)	0.49	Age (10 years)	1.43	(1.09-1.88)	1.62	(1.20-2.20)
IV Abx in ED	47	(11.5)	13	(22.4)	0.02	CCI score >= 3^a	6.67	(1.42-31.31)	5.09	(0.85-30.59)
IV Abx only	10	(2.4)	2	(3.4)	0.65	Vancomycin	6.78	(2.15-21.33)	7.83	(1.99-30.82)

Table 3

Factors affecting the risk of treatment failure from multivariable logistic regression.

suspected cases Confirmed cases

MRSA coverage ED IV antibiotics	215	(52.6)	31	(53.4)	0.90	After adjusting for gender, race, Charlson comorbidity index, proximal streaking, severity of infection, location of infection in the hand, severity of infection by IDSA guidelines, if
Cephalosporin	3	(0.7)	0	(0.0)	0.51	treatment followed IDSA treatment guidelines, if an incision and drainage was performed,
Clindamycin	4	(1.0)	1	(1.7)	0.61	and if any antibiotics were given.
Fluoroquinolone	6	(1.5)	1	(1.7)	0.88	^a Compared to CCI score = 0 as reference; CCI, Charlson comorbidity index.
Penicillin/I	3	(7.3)	7	(9.7)	0.51
Vancomycin	25	(6.1)	10	(17.2)	0.003	odds of failure of initial ED treatment (OR 8.38, 95% CI 2.30-30.49)
Home antibiotics						after adjusting for the other covariates in the model which included

IDSA treatment classification. The significance of elderly patients having greater odds of failing treatment did not change in our sensitivity

Clindamycin	37	(9.0)	5	(8.6)	0.92	analysis.
Doxycycline	26	(6.4)	3	(5.2)	0.73
Flagyl	2	(0.5)	0	(0.0)	0.59	3.6. Study Strengths and Limitations
Fluoroquinolone	4	(1.0)	0	(0.0)	0.45

Azithromycin	1	(0.2)	0	(0.0)	0.71
Bactrim	152	(37.2)	24	(41.4)	0.54
Cephalosporin	110	(27.0)	17	(29.3)	0.70

To our knowledge this is the first study to provide evidence for poorer outcomes in elderly patients with purulent skin infections after adjustment for initial treatment guideline adherence. This study builds on prior study demonstrating poor adherence to IDSA guidelines by

Moderate	137	(33.5)	16	(27.6)	0.37	ED providers [10]. The strengths of this study include the quality of
Severe	76	(18.6)	12	(20.7)	0.70	the data extractions from multiple ED sites. There are, however, several

Home Abx none	128	(31.3)	17	(29.3)	0.76
Home Abx 1	203	(49.6)	33	(56.9)	0.30
Home Abx 2	156	(19.1)	8	(13.8)	0.33
IDSA guidelines Mild	196	(47.9)	30	(51.7)	0.59

Followed guidelines	164	(40.1)	18	(31.0)	0.19
Over-treated	163	(39.9)	28	(48.3)	0.22
Under-treated	82	(20.0)	12	(20.7)	0.91

Data are presented as n (percentages) unless otherwise indicated.

I&D, incision and drainage; Abx, antibiotics; Penicillin/I, penicillin inhibitor combination.

Characteristics of Elderly Patients

Elderly patients did not differ from their younger counterparts with regard to the infection location, if they received an incision and drain- age, or if they were placed on antibiotics, either within the ED or at home, as part of their care. Fewer elderly patients had a CCI score of 0 (57.1%) than younger patients, whereas a greater proportion of older patients had a score of >= 3 (11.4%) than their younger counterparts (80.3% and 1.4% respectively). A greater proportion of elderly patients failed ED Outpatient therapy upon follow up (25% versus 11.7%, p = 0.03). Elderly patients had a 2.5 increased odds for failed initial ED treat- ment than persons less than 65 years old (OR 2.51, 95% CI 1.06-5.92). Even though patients with higher CCI scores were older we did not ob- serve any significant difference in treatment failure rates with an age CCI score interaction.

Logistic Regression Model

In our multivariable logistic regression, patient’s age was significant- ly associated with treatment failure among both suspected and con- firmed cases after adjustment for baseline demographic and clinical variables that could have affected treatment choice and related out- comes (Table 3). Higher CCI scores and ED use of intravenous vancomy- cin were also significantly associated with ED treatment failure. For each increase of patient age by 10 years, the odds of treatment failure in- creased by 43% to 62% with patients in their 20s having a 7.0% chance of treatment failure that rose to 27.2% in patients in their 70s or older (Fig. 2). We reran this model changing the continuous age covariate into elderly (age >= 65 years) and non-elderly patients. Elderly patients of suspected cases had almost 4 times greater odds of failure of initial ED treatment (OR 3.87, 95% CI 1.24-12.10) than non-elderly patients while elderly patients among confirmed cases had 8 times greater

limitations that must be kept in mind in interpreting our study results. There exists the possibility of selection bias from loss to follow-up how- ever the main affect of age on the outcome did not change during our sensitivity analysis. For example, if the majority of cases lost to follow- up were patients who failed treatment, the true effect would still be sta- tistically significant (there still would exist a difference between elderly and non-elderly patients). This study was also limited by reliance of dis- charge diagnosis coding of purulent skin infection to identify the study cohort. This may partially explain why 1 in 5 patients did not receive an incision and drainage of their diagnosed purulent skin infection. Pro- viders may have been limited in localizing the purulent skin infection by ultrasound or unsure of their diagnosis. We did not have a confirmatory test to ensure all patients in the cohort did in fact have a purulent infec- tion however we observed the same association of age and treatment failure among the cases with suspected and confirmed purulent infec- tions in our stratified analysis. Further, factors such as purulent skin in- fection size could not be evaluated due to the low number of charts that

20 30 40 50 60 70

Percentage of Patients Failing ED Treatment

Patient’s Age (years)

Fig. 2. Predictive probability of failing ED treatment by age. Data is the predicted probability from the multivariable logistic regression model and is presented as means with 95% confidence intervals.

had this information recorded. Abscess size may have been a factor in the clinical decision making however size is not part of any guidelines on treatment. Finally, since our outcome was common (N 10% preva- lence) the OR may overestimate the risk.

Discussion

Treatment failure of ED patients that present with a purulent skin in- fection was significantly associated with advanced age with elderly pa- tients having almost 4 times the increased risk of treatment failure compared to their younger counterparts. This risk increased to more than 8 times among patients with confirmed purulent skin infections. There was no difference in failures across the three IDSA classifications (mild, moderate, and severe) nor if the patient was treated following IDSA guidelines or either over or under-treated. The IDSA developed these practice guidelines in order to diagnose and administer effective treatments in a timely fashion. By not including age in their treatment algorithm, the IDSA might be under-treating older adults who carry greater risk of morbidity from bacterial infections. Even though elderly patients presented less frequently to the ED with a purulent skin infec- tion their high treatment failure rate raises concerns for not basing an- tibiotic adjunct therapy off of age.

In our study, there was a high prevalence of deviation from national

guidelines with nearly 1 in 5 patients not receiving an incision and drainage and almost 1 in 4 patients with an uncomplicated mild puru- lent skin infection as defined by the IDSA guidelines, receiving unneces- sary antibiotics. The IDSA gives a strong recommendation with level 1 evidence for incision and drainage of any purulent skin infection [4, 11]. The high prevalence of purulent skin infections being diagnosed without a procedure to open up the infection pocket is concerning. Inci- sion and drainage either with or without packing is a painful procedure that ED physicians might avoid in an attempt to improve patient care [12]. The increase in overuse of antibiotics for discharged purulent skin infection cases from the ED has been a worrisome trend over the past decade [13]. We did not see any association of antibiotic use and treatment failure among all patients. Antibiotics have been shown un- necessary in the treatment of uncomplicated purulent infections [14-16]. Seeing how antibiotic resistance patterns are strongly correlat- ed with antibiotic use patterns, reducing unnecessary outpatient antibi- otics among patients with uncomplicated purulent infections would be a critical modality to combat antibiotic resistance [17,18].

Many widely used clinical decision rules incorporate age into their decision algorithms, such as those used for the treatment of pneumonia [19,20] and critically injured adults [21]. Age is an impor- tant consideration seeing that elderly patients are more susceptible to many types of bacterial infections compared to young adults due to a decline in the host immune defense mechanisms [5]. This com- bined with the fact that skin and soft tissue infections are common in the elderly [22] makes defining differential Treatment decisions by age essential to reducing treatment failure rates. In our study the failure rates ballooned to almost 30% in patients 70 years and older compared to 6.5% in patients in their 20s. The recommenda- tions for mild purulent infections are for an incision and drainage alone without adjunct antibiotic therapy. Recent data from a ran- domized control trial using trimethoprim-sulfamethoxazole demon- strated a minimal increase in cure rates for outpatient treatment of uncomplicated skin purulent skin infections [23]. Lacking any sub- group or adjusted analysis, elderly adults may have been one of the groups that benefited the most from adjunct therapy. Instead of widespread antibiotic therapy maybe targeted therapies to those at greatest risk would reduce the risk/reward of antibiotic use.

Vancomycin as a one-time dose in the ED was also associated with worse patient outcomes. This may be in part due to the high frequency with which vancomycin is under-dosed within the ED [24]. Additionally vancomycin was not followed with MRSA antibiotics for home in almost 1 out of 3 patients treated. In fact when antibiotics were given, MRSA

antibiotic coverage occurred in less than 3 out of 4 patients. Given the increased risk of treatment failure seen here with vancomycin use and its association with increased incidence of vancomycin resistant entero- cocci and Clostridium Difficile infection [25], we would recommend ED providers avoid its use as an adjunct in treating patients with a purulent skin infection.

Conclusions

Based on our findings, we recommend that in outpatient treatment of purulent skin infections elderly patients may warrant adjuvant ther- apy with antibiotics. Further work is needed determine the best treat- ment modalities for our elderly patients with a purulent skin infection. Treatment guidelines should take the age of the patient into consider- ation to improve cure rates and possibly target antibiotic therapy to those at increased risk of treatment failure.

References

AJEM