A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

Barriers to Admission

Barriers to Admission

Wait time is lost time

Nearly half the time a patient spends in ED is spent waiting for a bed.

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

Strapped for Care

Strapped for Care

The changing definition of prudence

High deductible healthcare plans are altering EMTALA’s “prudent layperson standard” as patients triage themselves away from the ED based on…

That Ain't My ED

That Ain't My ED

"The Night Shift" is an embarrassment to us all

Having now watched the first two episodes, the only thing I can honestly do is beat my head into a…

Grace Under Fire

Grace Under Fire

EPM Reviews NBC's The Night Shift, Episode 4

This is the 4th episode of “The Night Shift” that I’ve endured watched. If you’ve seen it and you work in an…

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Review by Evan Schwarz
Column arranged by Evan Schwarz
Division of Emergency Medicine
Washington University in St. Louis
 
Frazee BW, LynnJ, Charlebois ED, et al.  High prevalence of Methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections.  Ann Emerg Med. 2005; 45: 311-320.
 
In this study a convenience sample consisting of 137 patients presenting to a northern California ED was prospectively enrolled.  Any patient with cellulitis, wound infection, ulcer, septic bursitis, an abscess, or a necrotizing soft tissue infection was eligible.  Patients with odontogenic infections and Bartholin gland abscess were excluded as were children.  A nasal swab was taken from all patients (to detect MRSA colonization) as well as a culture from the wound site if possible.  MRSA is also known to colonize the axilla or groin but these areas were not cultured.  Organisms that grew were then identified and tested for antimicrobial resistance.
 
Nearly 75% of all Staphylococcus aureus isolates were MRSA.  Overall 50% of the enrolled patients had a culture that grew MRSA.  While many of the nasal swabs were negative for Staph (71%), 40 samples were positive with 28 (70%) being MRSA.  Also 31 subjects had Staph identified on both their nasal swab and wound infection.  Of these 26 (84%) were concordant for methicillin susceptibility.  Streptococcal species and Proteus species were also commonly isolated from wound cultures.  All Staph isolates were susceptible to vancomycin and bactrim.  However for the MRSA isolates, oxacillin (or its equivalent) were completely ineffective just as would be a first generation cephalosporin such as keflex.
 
(IMAGE)
Antibiotic MSSA (N=30) MRSA (N=89)
Vancomycin 100 100
Bactrim 100 100
Clindamycin
Oxacillin 93
100 94
0
Tetracycline 96 85
Levofloxacin 97 57
Erythromycin 58 4
(END IMAGE)
 
Demographic data was also collected from all the patients that were enrolled.  Surprisingly, white race and furuncles were the only characteristics associated with MRSA colonization and infection.  Other risk factors such as homelessness and a history of multiple abscesses were only associated with colonization.  Other studies did not find the same demographic data as presented by these authors. 
 
While concerning because of the large amount of Staphylococcal isolates, this data may not be generalizable as all participants came from a single population.  Most importantly it may be difficult to use the demographic results to try to predict which patients are at the highest risk for MRSA infections as the results may not have external validity.   Also since only patients with soft tissue infection had nasal swabs done, the actual MRSA colonization rate is unknown since patients with colonization and without infection would not have been enrolled.  However if the prevalence of MRSA is found to be this high in future studies, the authors conclude that there may be very little utility in identifying predictor variables.   Of note, no follow up was done concerning antibiotic efficacy.  Of the patients that received antibiotics in this study, seventy-eight percent were given an ineffective (BETA)-lactam! 
 
Since these patients were not followed, it is not known if their infections got worse as they were on an inadequate antibiotic regimen or if there was a difference between in vitro and in vivo antibiotic susceptibilities.  Also of note in this study is that more than 98% of MRSA isolates possessed the SCCmecIV allele on genetic testing.  This allele is considered a marker for community acquired MRSA.  Also 94% of the MRSA isolates tested positive for the Panton-Valentine leukocidin gene that is also associated with community acquired MRSA.  This gene is also associated with spontaneous soft tissue infections.
 
In summary these authors find community-acquired MRSA to be a highly prevalent pathogen in skin and soft tissue infections.  They also question the usage of predictors to identify MRSA infections as the prevalence is so high.  When starting empiric therapy, the authors recommend antibiotics that cover community-acquired MRSA as well as Streptococcus pyogenes:  triimethoprim/sulfamethoxazole + cephalexin for moderate to severe skin infections or doxycycline (non-pregnant adults) or clindamycin (pediatrics) for minor skin infections. 
 

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