We found that the emergence of CA-MRSA has influenced multiple factors related to the diagnosis and clinical management of SSTIs in ambulatory pediatrics. Additionally, we found that there were both internal and external barriers [13
] to adoption of recommended therapies for SSTIs and opportunities to improve care. Our findings highlight the complex issues facing physicians when a new disease emerges that generates public attention, affects a large number of patients and requires changes in practice.
This is the first study to explore the significance of CA-MRSA in primary care pediatrics in terms of the impact it has had on clinical practice. The qualitative design of our study enabled us to probe with great depth around issues faced by primary care physicians and their practice patterns. Similar to national trends, our participants reported increased patient visits due to SSTIs caused by CA-MRSA [4
]. As a consequence, some of the challenges identified related to increased time demands in terms of changes in how pediatricians manage children with SSTIs in the CA-MRSA era. This includes time for more follow-up visits, following up on culture results and time requirements for explaining decolonization regimens to families. Additionally, non-medical burdens were noted such as frustration about the lack of evidence-based strategies for preventing recurrences and household transmission as well as time demands to address questions and concerns about CA-MRSA among patients and their families.
Addressing these challenges faced by primary care pediatricians is crucial to informing the design of future interventions focused on treatment and prevention of CA-MRSA.
Participants in our study believe that fear induced by media coverage of CA-MRSA caused increased visits for mild skin problems. We did not directly ascertain from our participants whether they felt pressure to prescribe antibiotics for mild infections, however, participants reported using antibiotics frequently and substantially increasing the number of cultures they performed. The potential for media to influence physician behavior was highlighted in a prior study showing a strong association between media reports of invasive group A streptococcus infection and testing for GAS in a pediatric ED [14
The potential for "disease mongering" (expansion of the market for a disease) exists because of the broad spectrum of severity for CA-MRSA ranging from life-threatening (invasive infections) to mild (most SSTIs) to none (asymptomatic colonization). Media reports prompted by severe infections may "blur the distinction between mild and severe," which is a key component of this phenomenon [15
]. Determining whether the observations noted by our participants are representative of national trends will further our understanding of how the media can influence patient use of ambulatory services and subsequent physician behavior. Gaining more direct insight into how communication from schools to parents about CA-MRSA influences office visits is important since our participants noted that schools also contributed to parental fears and concerns. Additionally, the impact of new legislation mandating MRSA screening for hospital admissions in many states (including California) on public perceptions about MRSA remains unknown.
Our participants felt strongly about prescribing antibiotics for SSTIs, independent of whether or not I&D is performed. Although current recommendations suggest that some patients can be treated with I&D alone, our results indicate reluctance among primary care pediatricians to adopt this practice. Some of the reluctance to limit antibiotic use may stem from the challenges faced by primary care pediatricians to performing adequate I&D in office settings including internal barriers such as a lack of self-efficacy and guideline agreement. Additionally, external barriers such as inadequate time and supplies and inability to provide adequate pain control or sedation also seem to influence their practice. Our participants did not explicitly cite reimbursement as a barrier to performing I&D, however, reimbursement has been previously shown to be a barrier to guideline adherence [16
]. Participants were concerned about the time and supplies that are required, issues that could impact reimbursement by increasing overhead or decreasing patient flow in a busy office practice. Designing interventions to increase use of I&Ds for purulent SSTIs is important because for some patients, failure to perform a prompt I&D may delay resolution of the infection.
Some participants in our study did not target CA-MRSA with their initial empiric antibiotic. Although the optimal antibiotic therapy for purulent SSTIs is unknown, experts have suggested using a 10% community prevalence as a threshold above which to empirically treat with an antibiotic active against CA-MRSA and this was validated using a decision-analytic model [11
]. Our prior work [4
] has shown that cephalexin remains commonly prescribed for SSTIs despite the fact that CA-MRSA prevalence in most communities is >10%. Participants in our study felt that they did not have access to epidemiologic data about bacterial infections and antibiotic resistance patterns in their community. Because physician education has been shown to improve antibiotic selection [18
], it is possible that direct dissemination of epidemiologic data about SSTIs to pediatricians would address this barrier and could influence their prescribing.
Most of the participants in our study were unaware of recent SSTI treatment recommendations. Since guidelines are more credible to physicians when developed by their own specialty organization [19
] and the AAP recently published SSTI treatment recommendations, this is especially concerning. The lack of awareness among our participants of guidelines about a condition that significantly impacts on their practice suggests that more effective methods of dissemination must be identified.
The practice patterns reported by our participants are similar to prior studies of patterns of care for SSTIs showing high rates of antibiotic prescribing, including increased use of antibiotics active against CA-MRSA. In a study using nationally representative office visit data, >75% of children with SSTIs received an antibiotic and use of antibiotics active against CA-MRSA had increased substantially by 2005 [4
]. On the other hand, studies examining I&D use have shown low utilization in ambulatory settings [20
]. A recent survey of pediatric infectious disease specialists reported that 100% recommended antibiotics for SSTIs and many used decolonization regimens, although there was significant variability in antibiotic selection and decolonization methods [22
]. Although this variability is an area of concern for our participants, it is notable that the primary prevention strategy recommended by the CDC which emphasizes personal hygiene including hand washing and not sharing personal items was only mentioned by a small number of participants. The CDC recently launched an MRSA Education Campaign (available at http://www.cdc.gov/MRSA/
) which will hopefully increase awareness among both health care providers and parents about recognition and prevention of SSTIs caused by CA-MRSA by providing educational materials.
There are several limitations to our study. First, our participants were selected from one urban geographic region and their experiences and opinions may not be generalizable to other communities, including rural areas or those where CA-MRSA is not endemic. Although we used purposive sampling to enhance generalizability and to minimize response bias, it is possible that the study participants' experiences differed from other pediatricians in the region. Although pediatricians provide the majority of pediatric primary care in the United States [23
], because we did not include family physicians and emergency department physicians in the study it is unknown whether our findings are applicable to these specialties. Despite these potential limitations, we believe these findings are relevant to primary care physicians nationwide since we included participants from a variety of clinical settings and recent data indicates that SSTIs have increased throughout the country and present most frequently to primary care offices [4