HIGHLIGHTS d Skin and soft tissue infections ( SSTIs ) caused by methicillin-resistant

The prevalence of skin and soft tissue infections (SSTIs) has been increasing in the United States. These infections are associated with an increase in hospital admissions. Hospitalists play an increasingly important role in the management of these infections and need to use hospital resources efficiently and effectively. When available, observation units are useful for treating low-risk patients who do not require hospital admission. Imaging tools may help to exclude abscesses and necrotizing soft tissue infections; however, surgical exploration remains the principal means of diagnosing necrotizing soft tissue infections. The most common pathogens that cause SSTIs are streptococci and Staphylococcus aureus.Methicillin-resistant S aureus (MRSA) is a prevalent pathogen, and concerns are increasing regarding the unclear distinctions between community-acquired and hospital-acquired MRSA. Other less frequent pathogens that cause SSTIs include Enterococcus species, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa. Cephalexin and clindamycin are suitable options for infections caused by streptococcal species and methicillin-susceptible S aureus. The increasing resistance of S aureus and Streptococcus pyogenes to erythromycin limits its use in these infections, and better alternatives are available. Parenteral cefazolin, nafcillin, or oxacillin can be used in hospitalized patients with nonpurulent cellulitis caused by streptococci and methicillin-susceptible S aureus. When oral MRSA therapy is indicated, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, or linezolid is appropriate. Vancomycin, linezolid, daptomycin, tigecycline, telavancin, and ceftaroline fosamil are intravenous options that should be used in MRSA infections that require patient hospitalization. In the treatment of patients with SSTIs, hospitalists are at the forefront of providing proper patient care that reduces hospital costs, duration of therapy, and therapeutic failures. This review updates guidelines on the management of SSTIs with a focus on infections caused by S aureus, particularly MRSA, and outlines the role of the hospitalist in the effective management of SSTIs. a 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;nn(n):1-16 From the Department of Medicine, University of California at Irvine, Irvine (A.N.A.); Department of Hospital Medicine, Cooper University Health Care, Camden, NJ (E.A.C.); Ochsner Clinic Foundation, New Orleans, LA (S.B.D.); Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH (J.C.P.); Department of Medicine, Hofstra North ShoreeLIJ School of Medicine, Manhasset, NY (D.J.R.); and Department of Medicine, Glen Cove Hospital, North ShoreeLIJ University Health System, Oyster Bay, NY (B.M.S.). S kin and soft tissue infections (SSTIs) are common, encompassing a wide range of clinical presentations and definitions, and have increased significantly since the mid1990s. Ambulatory visits for abscess and cellulitis have tripled from 1993 to 2005, with visits for all SSTIs reaching 14.2 million in 2005. Using data from the Healthcare Cost and Utilization Project National Inpatient sample, Edelsberg et al found a 29% increase in hospital admissions for SSTIs during a 5-year period (2000-2004). In a study that assessed the incremental clinical and economic burden of hospitalized patients with a secondary diagnosis of SSTIs compared with matched controls without SSTIs, patients with SSTIs had a mean of 3.8 additional days of hospitalization, $14,794 excess hospital charges, and an increased risk of mortality (odds ratio, 1.32). The most Mayo Clin Proc. n XXX 2014;nn(n):1-16 n http://dx.doi. org/10.1016 www.mayoclinicproceedings. org n a 2014 Mayo Foundation for M common organisms that cause SSTIs are Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus (MRSA) is a predominant pathogen that causes SSTIs, is associated with increased length of hospitalization, and is an independent risk factor for increased mortality and hospital charges compared with methicillin-susceptible S aureus (MSSA). The increasing incidence of SSTIs in both ambulatory and hospital settings, coupled with the increase of MRSA as a causative pathogen, demands optimal management of these infections to improve outcomes. This review outlines the role of the hospitalist in the effective management of SSTIs, with a focus on infections caused by S aureus, particularly MRSA. A PubMed search was performed from 2000 to the present using the search terms SSTI, MRSA, surveillance, resistance, clinical /j.mayocp. 2014.04. 018 edical Education and Research 1