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Pus Plus Old Equals Fail

December 20, 2016

Short Attention Span Summary

Pus + Old = Fail
There is a push to treat more skin infections on an outpatient basis.  These authors found that for each decade of life, the odds of treatment failure for purulent skin infections increased by 43%.  Patients over age 65 had nearly 4 times the odds of failure of initial ED treatment than younger patients.

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Have a lower admission threshold for elderly patients with purulent skin infection.  Journal Watch has a free summary.


Am J Emerg Med. 2016 Oct 29. pii: S0735-6757(16)30776-8. doi: 10.1016/j.ajem.2016.10.060. [Epub ahead of print]

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

Haran JP1, Wilsterman E2, Zeoli T2, Beaudoin FL3, Tjia J4, Hibberd PL5.

Author information:

1Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, United States. Electronic address: john.haran@umassmed.edu.

2Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, United States.

3Department of Emergency Medicine, Alpert School of Medicine, Brown University, Providence, RI, United States.

4Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.

5Department of Pediatrics and Division of Global Health, Massachusetts General Hospital, Boston, MA, United States.



Current Infectious Disease Society of America (IDSA) 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.


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 intervention, or hospitalization). We used multivariable logistic regression to examine the role of patient age on treatment failure adjusting for demographic variables (gender, race), comorbidities and severity of infection.


A total of 467 patients met inclusion criteria (mean age 37.9years [SD 14.0], 48.2% of whom were women). Overall, 12.4% failed initial therapy. Patients 65years and older (n=35) were almost 4 times more likely 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 10years of advancing age there was a 43% increased odds of failing initial treatment (OR 1.43 95% CI 1.09-1.88).


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.

Copyright © 2016. Published by Elsevier Inc.

PMID: 27836315 [PubMed – as supplied by publisher]

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