EPIDEMIOLOGY AND DISEASE BURDEN
- The overall incidence of skin and soft tissue infections (SSTIs) in the US is estimated to be higher than the incidence of other common infections including pneumonia.1
- The most common reason for hospital admission in a patient with an SSTI is for administration of intravenous antibiotics.2
- Hospital admissions for SSTI impose a substantial burden in the US, accounting for roughly 10% of all infection-related hospitalizations.3
Since the early 2000s, multiple studies have reported a dramatic rise in SSTI incidence across outpatient, emergency department (ED), and inpatient hospital settings.1,4,5 Between 1997 and 2005, the annual incidence in ambulatory visits for purulent SSTI increased from 4.6 million to 9.6 million.5 In the United States (US), this dramatic rise in SSTI incidence was largely driven by the epidemic of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) USA300 clone.1
Using nationally representative data, a recent study found a dramatic rise in ambulatory visit incidence (to EDs and physician offices) for purulent SSTIs, peaking in 2010–2013, followed by a plateau in recent years. The total annual number of visits for purulent SSTI-related visits to ambulatory physicians in the US increased from 5.4 million in 2000 to a peak of 11.35 million in 2013 and declined to 8.4 million in 2015. Moreover, by practice setting, in recent years the decline in overall SSTI visits was driven by a large reduction in office visits, while ED visits remained unchanged. Over the study period, prescriptions for antibiotics recommended for methicillin-resistant
S. aureus (MRSA) increased, while β-lactam monotherapy prescriptions decreased.4
While many patients with SSTI have no identifiable risk factors, a history of trauma and certain comorbid conditions increase the risk for developing SSTIs.6 Patients hospitalized with SSTI often have comorbid conditions, especially diabetes, have failed outpatient antibiotics, and have signs of systemic infection.2,7 Patients with SSTIs caused by community-associated MRSA (CA-MRSA) have unique risk factors including injection drug use, which is associated with 16-fold increased risk of invasive MRSA infections.8,9
Risk Factors for Developing SSTIs6,8,9
- Traumatic injury
- Peripheral vascular disease
- Lymphatic insufficiency
- Injection drug use
- HIV infection
- Household contacts of CA-MRSA infection
- Prior history of CA-MRSA infections
Patients with SSTI rarely suffer from serious complications or death,10,11 and the mortality rate has been estimated to be approximately 0.5% for patients hospitalized with SSTI.11 Approximately 10% of patients hospitalized with SSTI have an SSTI-related readmission within 30 days of discharge.10 Patients with an SSTI caused by CA-MRSA are at a high risk for recurrent infections.12
MRSA accounts for almost half of all SSTI involving S. aureus,14,15 and increases the risk of morbidity and mortality,14 as well as higher healthcare costs than infections of the skin caused by methicillin-sensitive S. aureus.16
Hospital admissions for SSTI impose a substantial burden in the US, with SSTIs accounting for roughly 10% of all infection-related hospitalizations.3 SSTIs are estimated to cause up to 870,000 hospital admissions, 6.3 million office visits, and approximately 3.4 million ED visits annually in the US, with higher rates of hospitalizations observed in older populations.17-19
Admissions for SSTI impose a substantial hospital cost in the US.20 An increase in S. aureus-associated SSTI has been a major contributor to the US burden of skin infections including hospitalizations,21 with methicillin-resistant isolates responsible for nearly half of S. aureus-associated SSTI.22
Key Epidemiological Data
- Incidence: 49.5 per 1000 person years1
- Common comorbidities include diabetes, obesity, peripheral vascular disease and immunocompromised condition6
- Most common reason for hospital admission, in over 40% of patients, is perceived need for intravenous antibiotics 2
- ~870,000 hospital admissions and ~3.4 million emergency department visits annually 17,18
- Risk of hospitalization increases with age 18
- Mortality: ~0.5% for patients hospitalized with SSTI 11
- Kaye KS, Petty LA, Shorr AF, et al. Current Epidemiology, Etiology, and Burden of Acute Skin Infections in the United States.
Clin Infect Dis. 2019;68(Suppl 3):S193-S199.
- Talan DA, Salhi BA, Moran GJ, et al. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. West J Emerg Med. 2015;16(1):89-97.
- Christensen KL, Holman RC, Steiner CA, et al. Infectious disease hospitalizations in the United States. Clin Infect Dis. 2009;49(7):1025-1035.
- Fritz SA, Shapiro DJ, Hersh AL. National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015. Clin Infect Dis. 2020;70(12):2715-2718.
- Hersh AL, Chambers HF, Maselli JH, et al. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(14):1585-1591.
- Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and Soft Tissue Infections. Am Fam Physician. 2015;92(6):474-483.
- Jenkins TC, Knepper BC, Moore SJ, et al. Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection. Infect Control Hosp Epidemiol. 2014;35(10):1241-1250.
- Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-390.
- Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States. Available from: https://www.cdc.gov/drugresistance/ pdf/threats-report/2019-ar-threats-report-508.pdf (accessed October 24 2020).
- Jenkins TC, Sabel AL, Sarcone EE, et al. Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship. Clin Infect Dis. 2010;51(8):895-903.
- Kaye KS, Patel DA, Stephens JM, et al. Rising United States Hospital Admissions for Acute Bacterial Skin and Skin Structure Infections: Recent Trends and Economic Impact. PLoS One. 2015;10(11):e0143276.
- Morgan E, Hohmann S, Ridgway JP, et al. Decreasing Incidence of Skin and Soft-tissue Infections in 86 US Emergency Departments, 2009-2014. Clin Infect Dis. 2019;68(3):453-459.
- Mistry RD, Shapiro DJ, Goyal MK, et al. Clinical management of skin and soft tissue infections in the U.S. Emergency Departments. West J Emerg Med. 2014;15(4):491-498.
- Esposito S, Noviello S, Leone S. Epidemiology and microbiology of skin and soft tissue infections. Curr Opin Infect Dis. 2016;29(2):109-115.
- Pulido-Cejudo A, Guzmán-Gutierrez M, Jalife-Montaño A, et al. Management of acute bacterial skin and skin structure infections with a focus on patients at high risk of treatment failure. Ther Adv Infect Dis. 2017;4(5):143-161.
- Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009;4(12):e8305.
- Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298.
- Edelsberg J, Taneja C, Zervos M, et al. Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516-1518.
- Pallin DJ, Espinola JA, Leung DY, et al. Jr. Epidemiology of dermatitis and skin infections in United States physicians’ offices, 1993-2005. Clin Infect Dis. 2009;49(6):901-907.
- Keyloun KR, Weber DJ, Gardstein BM, et al. Economic burden of hospital admissions for patients with acute bacterial skin and skin structure infections in the United States. Hosp Pract (1995). 2018;46(5):278-286.
- Keyloun K, Murphy B, Gillard P, et al. Utilization and Cost of Healthcare Services During Episodes of Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) Involving Admission to US Hospitals: A Retrospective Observational Analysis Using a Large Healthcare Claims Database. ISPOR; 2017.
- Ray GT, Suaya JA, Baxter R. Incidence, microbiology, and patient characteristics of skin and soft-tissue infections in a U.S. population: a retrospective population-based study. BMC Infect Dis. 2013;13:252.