Diagnostic Stewardship: A Clinical Decision Rule for Blood Cultures in Community-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections

Abstract

Introduction: The emergence, spread and persistence of methicillin-resistant Staphylococcus aureus (MRSA) as a causative pathogen in community-onset (CO) skin and soft tissue infections (SSTIs) have resulted in substantial changes in the management of these infections. The indications for obtaining blood cultures in patients with CO-MRSA SSTIs remain poorly defined. The objectives of this study were to derive and validate a clinical decision rule that predicts the probability of MRSA bacteremia in CO-MRSA SSTIs and to identify a low-risk population for whom blood cultures may be safely omitted. Methods: This was a retrospective, case-control study with an internal temporal validation cohort conducted at two large urban academic medical centers. Hospitalized adults with CO-MRSA SSTI between 2010 and 2018 were included. Independent predictors of MRSA bacteremia were identified through multivariable logistic regression. A decision rule was derived using weighted coefficient-based scoring. The decision rule was validated in an internal temporal validation cohort. Results: A total of 307 patients (155 cases and 152 controls) were included in the derivation cohort. A decision rule was created with a “major criterion” defined as purulent cellulitis and “minor criteria” defined as abnormal temperature, intravenous drug use, leukocytosis, tachycardia, body mass index < 25 kg/m2 and non-upper extremity infection site. A blood culture is indicated by this rule for patients with one major or at least two minor criteria. Otherwise patients are classified as low risk, and blood cultures may be omitted. The sensitivity of the decision rule in the derivation and validation cohorts was 98.71% (95% CI 95.42%, 99.84%) and 95.65% (78.05%, 99.89%), respectively. The specificity was 23.03% (95% CI 16.59%, 30.54%) and 30.77% (95% CI 24.15%, 38.02%), respectively. Conclusion: The decision rule developed and validated in this study provides a standardized, evidenced-based approach to determine the need for blood cultures based on bacteremia risk.