Segment description: Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, provide insight on how to determine the severity of an acute bacterial skin and skin structure infection based on location and extent of lesions, purulent versus nonpurulent, pain, fever, and lymph node enlargement, as well as signs of necrotizing fasciitis.
Peter L. Salgo, MD: Let’s talk again about risk stratification, because we have to now pick those patients who are going to do best and then decide that those are the ones we’re going to triage to this new system. If you want to determine the severity of the infection, how do you do that? What are the laboratory tools you’re going to use? How do you set about stratifying these folks?
Yoav Golan, MD: People with abscesses sometimes don’t have any systemic symptoms or signs. As I mentioned earlier, just drainage is fine. If they have a huge abscess, some of those patients may need to be admitted, because there needs to be a surgical procedure that’s more than just bedside. Most of those can be drained in the emergency department, and they are fine. People with cellulitis very often have fever and they have some leukocytosis, and I would expect that. But when they become hemodynamically unstable, for example, they have slight hypotension—and if this is in an older person, even 110/80 could be a slight hypotension; tachycardic—that is out of the usual and would make me a little concerned, and I would admit them. The general cases—fever, leukocytosis, a patch of erythema and tenderness—would be considered to be a normal routine presentation.
Peter L. Salgo, MD: None of those is a stand-alone, live-or-die, I’m going to admit you; fever, leukocytosis, patch of skin, even purulence, if I heard you correctly—you could drain this, yes?
Yoav Golan, MD: Of course.
Bruce M. Jones, PharmD: Right. I think it has to be some combination. There is some subjectivity that obviously comes into play when you’re choosing these patients.
Peter L. Salgo, MD: What about lymph nodes? Does lymph node enlargement per se mean you’re coming “in the house”?
Yoav Golan, MD: No, of course not. Most patients with lymphadenopathy or lymphadenitis we actually are very successful in treating in the community. With skin infections, particularly with Streptococcus, you can see some lymph nodes, but these by themselves are not a reason to admit the person.
Peter L. Salgo, MD: If you start to parse this out, those things that if you were to almost by knee-jerk reaction say, “We’ve got to bring you in,” I think we’ve begun to exclude. In other words, erythema, no, not going to come in; purulence, no, not going to come in; lymph nodes, you don’t need to come in; pain, don’t really need to come in all the time. What am I missing? Nothing much. Clearly size, sepsis, and necrotizing fasciitis, but that’s a small group, isn’t it?
Yoav Golan, MD: Well, also exacerbated comorbidities. Infection causes a fever, causing tachycardia, and then your ischemic heart disease is out of control. Those are obviously reasons to be concerned.
Peter L. Salgo, MD: Somebody coming in with tachycardia, fever, ST elevations and chest pains, he’s coming in because he has about a million things to come in for.
Yoav Golan, MD: Yes.
Peter L. Salgo, MD: Not necessarily a priority because of the infection.
Yoav Golan, MD: I would agree. Again, as this survey found, almost half of the patients who actually get admitted are admitted for the sole reason of the need for IV therapy and not for monitoring.
Peter L. Salgo, MD: Let me ask you an unfair question then. When we peel the onion skin back, we’re left with a very small core of patients who have to come in. What percent of all-comers to the ED with a skin infection actually need to come in for something that can only be done in the hospital and can’t be done on an outpatient basis?
Yoav Golan, MD: It’s hard for me to say. I would say half.
Peter L. Salgo, MD: Half?
Yoav Golan, MD: I would say half.
Bruce M. Jones, PharmD: I would be even more aggressive than that. I think it’s a pretty small number, I really do. I think when you really, as you said, peel back that onion, you evaluate those patients—small amounts of comorbidities, mainly IV therapy. I think you’d find that it’s a small number that truly needs to be there.
Yoav Golan, MD: I think it depends on the setting. We are more of a tertiary care, so we see very complicated patients. The more you move into community settings, there is a bigger proportion of patients who could be treated as outpatients.
Peter L. Salgo, MD: Not specifically you or your setting; I’m at a quaternary care hospital, as well, but our ED treats a catchment area, and that catchment area is all-comers, not necessarily referred in. Again, my sense of what you told me is that it’s a lot less than half that have to come in. I think I’m going to side with this guy. It sounds like a much smaller group, but the caveat is that you have to be set up to take care of them.
Yoav Golan, MD: That’s right.
Peter L. Salgo, MD: In other words, if you don’t have an outpatient treatment center, you don’t have an ED that’s ready to do this, and you don’t have some sort of infusion center, then you’re out of luck. You have to bring them in, because what else are you going to do?
Yoav Golan, MD: You need 2 capabilities, that’s all. You need the ability to infuse without being an inpatient—which every ED has, by the way—and you need the ability to follow-up. You already have resources for follow-up, because many patients have primary care physicians, they come from institutions, and so forth. You have outpatient clinics, walk-in clinics, and so forth. These are the 2 components that are required in order to not admit a patient in a way that’s not going to concern the ED doctor, and he’s going to participate in it.
Bruce M. Jones, PharmD: We struggle, too, with one of the things we see, and that is a fairly large indigent population, where they’re using the ED physician as their primary care provider—so making sure to take care of especially that subset of patients.
Peter L. Salgo, MD: Again, that may cut 2 ways; it’s expensive, yes, but also because if you are their physician, you see them. Maybe that’s a good thing in terms of this specific entity.