Two types of bacterial SSTIs predominate among ED patients: cellulitis, typically a non-purulent bacterial skin infection; and abscesses, characterized by collections of purulent fluid. Though the current epidemiology of cellulitis is understudied, the most common circulating strains of CA-MRSA have a well-described predilection for causing abscesses, and are the primary pathogens in these purulent

SSTIs in many areas [5]. Prevalence Inhibitors,research,lifescience,medical of CA-MRSA varies from region to region. Most hospitals publish antibiotic susceptibility data from their own microbiology laboratories. Commonly called “antibiograms”, these documents are important tools for use by front-line clinicians in making educated treatment decisions. However, they typically report aggregate data based on bacterial Inhibitors,research,lifescience,medical isolates from all sources (blood, skin, sputum, etc.), and infrequently delineate pathogens based on the age of the patient or the source of the infection. Although healthcare exposure appears to remain a risk factor for drug-resistant

infections, Inhibitors,research,lifescience,medical ED clinicians are left with few additional demographic or clinical clues to the likelihood of resistant organisms in SSTI patients without exposures. Investigators have also noted differences in microbiology and treatment of pediatric and adult SSTIs [6]. Children beyond the neonatal period have been considered high-risk for CA-MRSA SSTIs relative to adults, though as the CA-MRSA epidemic Inhibitors,research,lifescience,medical has matured, this distinction has become

less clear [7]. Current guidelines for treatment of CA-MRSA infections do not call for routine antibiotics for adequately drained, uncomplicated abscesses [8]. Nonetheless, while incision and drainage (I&D) remains the primary treatment for abscesses, clinicians prescribe antibiotics for the majority of these patients Inhibitors,research,lifescience,medical and empiric prescription of antibiotics typically active against CA-MRSA has become routine [9-13]. In addition, many clinicians provide “double coverage”, which we define as using two or more antibiotics with the intention of effectively find more treating MRSA, methicillin-sensitive S. aureus (MSSA) else and β-hemolytic Streptococcus[14,15]. Because antibiotics increase the cost of treatment, the incidence of adverse medication effects, and – importantly – the selective pressure leading to further antibiotic resistance, their precise role continues to be debated [16-21]. Given the inability to predict resistance based on clinical factors, some discordance between empiric treatment and pathogen is inevitable. Factors related to this discordance have not been well studied. If antibiotic choices are not well targeted, ED patients with purulent SSTIs may represent a population in whom antibiotic use could effectively be reduced, decreasing the selective pressures, cost burdens, and unintended side effects of these medications.

The patient must have appropriate expectations of a procedure or intervention with appropriate informed consent. Appropriate outcome measures must also be considered and these should include measures from several domains that will include a range of pain scores (eg, worst pain, average pain, frequency), emotional measures, behavioral scores, and, where appropriate, more specific questions around sexual activity Inhibitors,research,lifescience,medical and end-organ functional disorders (eg, bowel and urinary dysfunction). This translates into

clinical Stattic cost practice that the patient needs to be treated as a whole and as an individual through an integrated care team approach. Subsequent intervention should be decided in the context of the biopsychosocial model. There is no doubt about the importance of evaluating and treating UCPPS patients as individuals using

a team approach with comprehensive assessments, expectations, and explanations to optimize outcome. [Andrew Paul Baranowski, BSc Hons, MBBS, FRCA, MD, FFPMRCA] Inhibitors,research,lifescience,medical Optimizing Clinical Outcome Clinical outcome for patients suffering from UCPPS and physicians managing it will depend on multiple factors that can best be described by the biopsychosocial rather Inhibitors,research,lifescience,medical than a pure biomedical model of disease. These factors include antecedent premorbid conditions, associated medical conditions, various etiologic mechanisms, and multiple pathogenic

pathways leading to very heterogenous clinical phenotypic presentations. A comprehensive assessment of all these factors, including diagnosis of all possible pain generators (Table 3), allowing a phenotypic classification (UPOINT is recommended; Figure 3) is therefore required prior Inhibitors,research,lifescience,medical to intervention (Table 4 and Figure 3). Patient and physician expectations must be realistic and patient-oriented goals of therapy must be mutually agreed upon. These should include a clinical meaningful amelioration of symptoms, improvement Inhibitors,research,lifescience,medical in QoL and activities, and reduction in the level of disability. This will only be accomplished not by proper diagnosis and phenotyping (sources of pain, associated conditions, impacting factors) and appropriate therapy (treat all pain sources, all associated conditions, and all impacting factors). A multidisciplinary team approach with comprehensive assessment and individually directed therapy will ultimately optimize outcome. Figure 3 UPOINT domains and associated therapies. CPPS, chronic pelvic pain syndrome; IC, interstitial cystitis; PBS, painful bladder syndrome. Table 3 Pain Generators That May Be Operative in Chronic Pelvic Pain Table 4 The Five Steps of UCPPS Management Main Points Urologic Chronic Pelvic Pain Syndromes (UCPPS) are one of the most difficult conditions to manage in urologic practice.