PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2012 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
18(12)
SUBMITTED BY:
California Chapter
SUBJECT:
Opposition to Routine Abscess Culturing
PURPOSE: Develop a policy stating the treating physician can best determine the necessity of antibiotic therapy
and cultures. Directs ACEP to oppose requirements that all abscesses with cellulitis treated with antibiotics be
cultured and oppose federal or state legislation and/or regulation requiring an attending physician to contact and
notify patients of positive cultures.
FISCAL IMPACT: Budgeted committee work and staff time to create a policy statement. Additional staff time for
advocacy efforts to oppose federal or state legislation or regulation
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WHEREAS, Emergency departments see a significant number of patients with abscesses with some
degree of cellulitis which therefore require antibiotics; and
WHEREAS, In January 2011 the Infectious Diseases Society of America released guidelines for
treatment of MRSA Infections that the IDSA reported “was reviewed and endorsed by ACEP;” and
WHEREAS, These guidelines recommend obtaining cultures from all patients with abscesses that are also
treated with antibiotic therapy; and
WHEREAS, Since January 2009, model legislation signed into California law requires the attending
physician to contact the patient and report results of a positive MRSA culture result; and
WHEREAS, Guidelines and statutes related to reporting MRSA cultures has placed a significant financial
and time burden on emergency physicians affected by this legislation; therefore be it
RESOLVED, That ACEP develop a position statement that states the treating physician can best
determine the necessity of antibiotic therapy and cultures; and be it further
RESOLVED, That ACEP oppose the recommendation and/or requirement that all abscesses with
cellulitis treated with antibiotics be cultured; and be it further
RESOLVED, That ACEP oppose federal or state legislation and/or regulation that require an attending
physician to be the person who contacts and notifies patients of positive cultures.
Background
This resolution directs ACEP to develop a policy stating the treating physician can best determine the necessity of
antibiotic therapy and cultures, that ACEP oppose the recommendation and/or requirement that all abscesses with
cellulitis treated with antibiotics be cultured, and oppose federal or state legislation and/or regulation that requires
an attending physician to contact and notify patients of positive cultures.
The 2011 “Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of
Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children” states that “cultures from
abscesses and other purulent SSTIs are recommended in patients treated with antibiotic therapy, patients with
Resolution 18(12) Opposition to Routine Abscess Culturing
Page 2
severe local infection or signs of systemic illness, patients who have not responded adequately to initial treatment,
and if there is concern for a cluster or outbreak. Antibiotic therapy is recommended for abscesses associated with
the following conditions: severe or extensive disease (e.g., involving multiple sites of infection) or rapid
progression in presence of associated cellulitis, signs and symptoms of systemic illness, associated comorbidities
or immunosuppression, extremes of age, abscess in an area difficult to drain (eg, face, hand, and genitalia),
associated septic phlebitis, and lack of response to incision and drainage alone.” There is also guidance for
empirical therapy for outpatients with purulent and nonpurulent cellulitis.
The guidelines state that it “is not intended to supplant physician judgment with respect to particular patients or
special clinical situations. The Infectious Diseases Society of America (IDSA) considers adherence to these
guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician
in light of each patient’s individual circumstances.”
An ACEP member served on the development panel for these guidelines. Members of ACEP’s Public Health
Committee and Clinical Policies Committee reviewed and provided comments on an earlier draft of the
document, then reviewed the final document for endorsement recommendation to the ACEP President, who
approved ACEP endorsement on November 24, 2010.
The Centers for Disease Control and Prevention (CDC) states: “In general, a culture should be obtained from the
infection site and sent to the microbiology laboratory. If S. aureus is isolated, the organism should be tested as
follows to determine which antibiotics will be effective for treating the infection. Skin Infection Culturing: Obtain
either a small biopsy of skin or drainage from the infected site. A culture of a skin lesion is especially useful in
recurrent or persistent cases of skin infection, in cases of antibiotic failure, and in cases that present with advanced
or aggressive infections.” Also, “MRSA is reportable in several states. The decision to make a particular disease
reportable to public health authorities is made by each state, based on the needs of that individual state.”
The CDC also states: “Incision and drainage constitutes the primary therapy for these purulent (MRSA) skin
infections. Empiric antimicrobial coverage for MRSA may be warranted in addition to incision and drainage
based on clinical assessment (eg, presence of systemic symptoms, severe local symptoms, immune suppression,
extremes of patient age, infections in a difficult to drain area, or lack of response to incision and drainage alone).
Antibiotic treatment, if indicated, should be guided by the susceptibility profile of the organism. Obtaining
specimens for culture and susceptibility testing is useful to guide therapy, particularly for those with more severe
infections and those who fail to respond adequately to initial management. MRSA skin infections can develop
into more serious infections. It is important to discuss a follow-up plan with your patients in case they develop
systemic symptoms or worsening local symptoms, or if symptoms do not improve within 48 hours.” A reference
and link to the IDSA MRSA guidelines is included on the CDC Website.
According to RID (Reduce Infection Deaths), a not-for-profit educational campaign regarding hospital infections,
as of October 2011, twelve states have laws requiring the screening and/or reporting of hospital-acquired MRSA
rates, and three states have legislation pending on this matter. Numerous educational sessions at ACEP meetings
have addressed wound management and antibiotic use. EMRA continues to publish the Antibiotic Guide.
ACEP Strategic Plan Reference
Enhance emergency care through federal and state policy initiatives.
Fiscal Impact
Budgeted committee work and staff time to create a policy statement. Additional staff time for advocacy efforts to
oppose federal or state legislation or regulation.
Resolution 18(12) Opposition to Routine Abscess Culturing
Page 3
Prior Council Action
Substitute Resolution 23(98) Appropriate Use of Antibiotics adopted. Directed ACEP to explore working
collaboratively with other organizations to develop educational materials for physicians and the general public on
the consequences of the unnecessary use of antibiotics.
Prior Board Action
October 1998, adopted Substitute Resolution 23(98).
Background Information Prepared By: Rhonda Whitson, RHIA
Clinical Practice Manager
Reviewed by: Marco Coppola, DO, FACEP, Speaker
Kevin Klauer, DO, EJD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director