Primary Care Clinicians’ Perspectives on Management of Skin and Soft Tissue Infections: An Iowa Research Network Study

Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to several commonly used antibiotics other than methicillin, such as oxacillin, penicillin, and amoxicillin. An estimated 95,000 people in the United States developed MRSA infections during 2005 of which 14% were community-associated and 85% were hospital or other health setting associated, and 19,000 Americans died from MRSA infections that year.¹ The prevalence of the community-acquired infections in persons without established risk factors for MRSA has increased rapidly over the past decade.^2,3 Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has the potential to develop quickly from a localized abscess into an invasive infection requiring hospital admission, and it can lead to severe complications such as sepsis and necrotizing pneumonia.^4,5

Antibiotic resistance to Staphylococcal infections has increased dramatically over the past 3 decades, from 2% in 1972,⁶ to 20%-25% in the early 1990s,⁷ to 63% by 2004.⁶ Staphylococcal infections, including MRSA, occur most frequently among persons in hospitals and health care facilities (such as nursing homes and dialysis centers) who have weakened immune systems. These are known as health care-associated (HA-MRSA). MRSA infections acquired by persons who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, catheters) are classified as CA-MRSA infections.⁸ CA-MRSA infections are usually manifested as skin infections, such as pustules and abscesses, and often occur in otherwise healthy people. A third type of MRSA, livestock-associated MRSA (LA-MRSA), has also been identified.⁹

Health care is often less available in rural areas than it is in urban areas. Although rural areas include approximately 25% of the US population, they include only 10% of the nation's physicians despite having more health problems per capita.¹⁰ Risk factors that may contribute to greater health problems in rural areas include old age, low income levels, less employer-provided health care coverage, and greater transportation difficulties reaching health care providers.¹¹ Rural residents tend to be poorer, which impacts on their receiving medical care.¹⁰ Recent data show that Americans visit physicians approximately 12 million times each year for suspected Staphylococcal skin infections.¹² Since most CA-MRSA infections are managed initially on an outpatient basis, it is challenging for primary care clinicians to recognize and appropriately treat patients suspected of having such infections. The purpose of this study was to explore health care providers’ perspectives on the management of skin and soft tissue infections to gain a better understanding of the problems faced by busy primary care providers. We completed a qualitative analysis of focus group discussions involving family physician providers and their office staff. This study was also designed to learn about the tools that might be helpful to clinicians dealing with possible CA-MRSA infections.

Methods

The research team implemented a qualitative study using focus group meetings with physicians and staff from 9 different Iowa family physician offices. All but one office were private family physician offices; one was a residency training site. The residency training site has 2 locations in an urban and rural setting. The Institutional Review Board of the University of Iowa approved the project.

Subject Recruitment

We invited 302 family physicians, members of the of the Iowa Research Network (IRENE), a practice-based research network, to submit letters of support indicating they were potentially interested in participating in this study. We received letters of support from 43 physicians. After the proposal was funded, we notified those 43 IRENE physicians, provided them with a description of the study, and invited them to participate. Of the 43 invited physicians, 21 physicians from 20 different offices indicated interest and we selected 9 offices for the final sample based on serving a rural community. Each office was contacted and a focus group meeting with clinician providers and office staff was arranged at the office's convenience. During this time when arrangements were being made, 1 rural office pulled out of the study and no other office accepting to participate was rural, so the Urbandale office offered to participate. All focus groups were led by 1 of the investigators using a prepared set of open- and closed-ended prompts. Two investigators (one a family physician) conducted and audio-taped the focus group meetings, which lasted an hour. The tapes were transcribed and 3 investigators (JD, JE, and BL) reviewed the transcripts and developed a taxonomy of issues raised during the sessions (See Table 1).

Focus Group Questions

To help facilitate the focus group discussions, the investigators generated 13 questions related to the epidemiology and office management of CA-MRSA (See Table 2). The questions were developed and refined by the investigators during a series of research team meetings. Once a near final set of questions was determined, these questions were pilot tested on a group of 5 family medicine faculty and research assistants at the University of Iowa. The questions were further revised following this pilot session.

Focus Group Meetings

Focus group meetings were arranged by a study investigator with the office administrator or physician interested in the study. A study physician and research assistant traveled to each site and conducted the meeting at a time convenient for the office, usually the noon hour, and lunch was provided. Two tape recorders were arranged at each end of the meeting place to record all conversations. Everyone seemed willing to participate and share information. Similar responses to the questions were noted from both the rural and urban sites.

Qualitative Analysis

A multistep process was used to identify the core themes that represented the perceptions of nurses, nurse practitioners, physicians, physician assistants, and family medicine residents (at the single residency training site) about the management of CA-MRSA.^13,14 All transcriptions were analyzed using ATLAS.ti (Scientific Software Development GmbH, Berlin, Germany, http://www.atlasti.com), a qualitative software program that allows for coding and systematic searching of data. After development of a preliminary codebook, initial coding was conducted by the investigators (JD, JE, and BL) to identify general themes in the transcripts. The 3 investigators added extensively to the original codebook as additional transcripts were reviewed until saturation was obtained. Codes were then grouped into underlying themes after discussion among the investigators.

Results

Focus group meetings were held with physicians and office staff from each of the 9 participating practices. A total of 78 clinicians (nurses, nurse practitioners, physicians, physician assistants, family practice residents, pharmacists) participated. The participating practices were mostly located in small Iowa towns: Bloomfield (2,601 population, 9 participants), Blue Grass (1,169 population), Davenport (98,359 population, 20 participants), Guttenberg (1,987 population, 6 participants), Le Mars (9,237 population, 5 participants), Lone Tree (1,151 population, 3 participants), Manchester (5,257 population, 24 participants), Sigourney (2,209 population, 6 participants), and Urbandale (29,072 population, 5 participants). The main themes that emerged from the focus groups were grouped into 7 broad categories: epidemiology, diagnosis, treatment, management, prevention, special populations, and public relations. Within these broad themes, the most frequently discussed items were the incidence of MRSA, initial antibiotic used, clinic protocol, and management strategy.

Epidemiology

The epidemiology category included incidence, risk factors, onset, infection site, and infection type. Overall, the participants agreed that the incidence of CA-MRSA is increasing, that they are seeing it in all age groups and especially those persons who are healthy.

The exact number of CA-MRSA infections was difficult to pinpoint across all offices.

Some risk factors were common across sites, such as participating in sports and sharing equipment, residing in a nursing home, impaired immune system, and recent hospitalization. However, most cases seemed to have none of the recognized risk factors.¹⁵

However, some risk factors were only described at 1 office, such as tattooing, wearing a CPAP mask, and sharing a makeup compact.

The infection site varied, such as under the arm or on the leg, no 1 infection site was apparent across offices. Infections were noted with either abscesses or cellulitis, or both. Onset varied from a few days to many days before a patient would present with symptoms.

Diagnosis

The diagnosis theme incorporated MRSA identification as well as signs and symptoms. Rapid testing for MRSA, cultures, differential diagnosis, and appearance were also discussed.

Physicians for the most part agreed if the abscess is fluctuant that a culture should be obtained and sent to the laboratory. At many offices, circumstances often prevented culturing and led to confusion about appropriate treatment. Problems encountered with culture included cultures not being taken when drainage was present, cultures not done because the patient had no insurance, no fluid present to take a culture, and cultures being taken after an antibiotic was prescribed and taken.

Discussion of the appearance of the infected site included many aspects, such as the size, color, presence of drainage, and inflammation. The participants noted that the more prominent the abscess as part of a cellulitis, the more likely they thought about it being CA-MRSA.

Treatment

This category included techniques or actions applied to infections or suspected infections. Participants discussed antibiotic treatment, incision and drainage, packing, follow-up care, seeking care, unresponsiveness to treatment, decolonization, and nonantibiotic local treatment.

Incising wounds was also commonly discussed.

Packing an incised wound varied depending on the size, fluctuance, and purulence. Plain gauze was commonly used, and iodoform gauze was used occasionally.

Participants had many doubts about whether and how to attempt decolonization in patients with MRSA infections.

Management

The management category addressed issues that included both diagnosis and treatment or issues where this distinction was not easily identified. Participants discussed clinic protocol, the patient's ability to pay for care, ethics, management strategies, patient education, suggestions for improving the treatment of MRSA infections in the future, and photographing wounds.

Among the 9 offices, only 1 had a protocol for skin and soft tissue infections. This protocol included items such as having 1 room designated for skin and soft tissue infections, and that a person presenting to the office with an infection be roomed immediately instead of waiting in the waiting room. There was concern that some of the guidelines for health care providers are too cumbersome to be used regularly in practice.

However, some office staff were aware of MRSA problems and had the following comments:

Participants were given copies of the Centers for Disease Control (CDC) and UpToDate^® algorithms for the management of skin and soft tissue infections.^16,17 After reviewing the algorithms, some clinicians indicated this is what they are currently doing and others remained confused about the guidelines:

Ethical issues were discussed mainly concerning the patients’ ability to pay for services. Those services discussed were obtaining a culture or filling a prescription for antibiotics.

A few doctors mentioned the cost of culturing being prohibitive for uninsured patients. Some treated patients without insurance differently, so there is a variation and lack of agreement on culturing.

Prevention

The prevention category included overuse of antibiotics and cleaning athletic equipment and does overlap some of the management issues.

Special Populations

The special populations category addressed aspects of MRSA management related to children, low socioeconomic status patients, and patients with dark skin.

Public Relations

The public relations category dealt with any aspect of public relations including the media. Only 1 office discussed this issue.

Discussion

Most patients presenting to these physicians with CA-MRSA had none of the risk factors that have been noted,^18,19 leading to the confusion of providers regarding treating patients without the known risk factor. In some cases, however, risk factors were noted, such as athletics, especially wrestling, and farm exposures. Physicians expressed frustration with the absence of clear guidelines on diagnosis and treatment. They noted that in many patients, there was no wound drainage to culture and wondered whether to initially treat for MRSA without the benefit of culture results. Physicians also found themselves deviating from usual practice in patients who could not afford cultures and in children who may be less tolerant of incision and drainage procedures.

Infections with MRSA have increased in community practices over the past decade.^6-8 The prevalence of CA-MRSA nationwide is unknown since we know of no states that track this. Diagnosis and treatment protocols for physicians outside of the hospital have lagged behind institutional protocols, and no commonly accepted diagnostic or treatment algorithms were used by the physicians in our focus groups. The CDC published a report that summarizes 16 strategies for the clinical management of MRSA in the community. This report is accessible on the web, but for a busy clinician it would be difficult to find, time consuming to read in its entirety, and does not have an algorithm or easy to use page with treatment strategies.²⁰ The clinicians freely admitted confusion about the best management and treatment of skin and soft tissue infections.

Management and treatment of skin and soft tissue infections were found to be different across primary care offices. However, similar themes across offices included the lack of an explanation for the cause of the infection, the common practice of incising and draining abscesses, and the lack of written instructions for wound care. The initial antibiotic choice varied across offices, and dedicated rooms for examination or treatment were infrequently employed. Concern by the clinicians was voiced that many recommended practices are simply not practical in the community setting.

Physicians and nurses expressed interest in using standard algorithms to help guide management of skin and soft tissue infections, but they were typically unaware of the existence of the algorithms released by the Centers for Disease Control and UpToDate.^16,17 Additional education of physicians and ongoing research to develop diagnosis and treatment algorithms that take into account local antibiotic susceptibilities may help guide treatment of MRSA infections and prevent future infections in the community. The clinicians in this study acknowledged that liberal use of antibiotics may have contributed to the increased incidence of MRSA infections. Our findings are supported by previous studies that found that most patients with CA-MRSA have no identifiable risk factors, although potential risk factors include working in health care, having a previous MRSA infection, and being recently hospitalized.^18,19 For example, in a study of New York high school football players, those who shared towels were at higher risk for MRSA infections.²¹ Our participants also felt that high school wrestlers and football players were at increased risk.

Limitations of this study include that a relatively small group of physicians from practices in a rural state were studied and the results may not be generalizable to other settings. The Davenport and Urbandale offices were located in fairly large towns rather than small office settings. Although our focus group questions were developed using an iterative process with faculty physicians actively involved in clinical care, some of the questions were closed-ended. However, participating physicians did not seem restricted by our questions and offered many opinions that were unrelated to our questions. For example, several physicians brought up the problems associated with decolonization, which we did not anticipate.

In conclusion, we found that practicing physicians face several issues that have been inadequately addressed by current guidelines:

Physicians in this study expressed an interest in following guidelines that address these issues more comprehensively, and they were open to standardization of practice in relation to MRSA, provided these guidelines accounted for practical issues that arise in the community. We recognize the lack of definitive evidence to support recommendations related to these practice-based problems and that more research may be needed. But in the absence of such research, physicians need better advice now to help them manage patients with skin and soft tissue infections. A guideline source that is easy to implement within the context of a busy practice setting would be appropriate, such as the CDC Treatment Algorithm for Skin and Soft Tissue Infections.¹⁶