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Research ArticleOriginal Research

Treatment Failure and Costs in Patients With Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections: A South Texas Ambulatory Research Network (STARNet) Study

Matthew J. Labreche, Grace C. Lee, Russell T. Attridge, Eric M. Mortensen, Jim Koeller, Liem C. Du, Natalie R. Nyren, Lucina B. Treviño, Sylvia B. Treviño, Joel Peña, Michael W. Mann, Abilio Muñoz, Yolanda Marcos, Guillermo Rocha, Stella Koretsky, Sandra Esparza, Mitchell Finnie, Steven D. Dallas, Michael L. Parchman and Christopher R. Frei
The Journal of the American Board of Family Medicine September 2013, 26 (5) 508-517; DOI: https://doi.org/10.3122/jabfm.2013.05.120247
Matthew J. Labreche
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Grace C. Lee
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Russell T. Attridge
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Eric M. Mortensen
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Jim Koeller
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Liem C. Du
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Natalie R. Nyren
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Lucina B. Treviño
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Sylvia B. Treviño
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Joel Peña
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Michael W. Mann
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Abilio Muñoz
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Yolanda Marcos
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Guillermo Rocha
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Stella Koretsky
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Sandra Esparza
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Mitchell Finnie
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Steven D. Dallas
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Michael L. Parchman
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Christopher R. Frei
the Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin (MJL, GCL, JK, CRF); the Pharmacotherapy Education and Research Center, School of Medicine (MJL, GCL, JK, CRF); the South Texas Ambulatory Research Network (LCD, NRN, LBT, SBT, JP, MWM, AM, YM, GR, SK, SE, MF); the School of Health Professions, Clinical Laboratory Sciences (SDD), University of Texas Health Science Center, San Antonio; the Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX (RTA); the Division of General Internal Medicine, VA North Texas Health Care System, Dallas (EMM); the Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas (EMM); and the MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, WA (MLP).
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Article Figures & Data

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    Figure 1.

    Severity classification and qualifying characteristics of methicillin-resistant Staphylococcus aureus skin and soft tissue infections (n=98).

  • Figure 2.
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    Figure 2.

    Type of treatment failure.*

    *There were no significant differences in the types of treatment failure between the two severity groups (p > 0.05 for all comparisons). I&D, incision and drainage; SSTI, skin and soft tissue infections.

  • Figure 3.
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    Figure 3.

    Initial antibiotic choice (n=98).*

    *There was no statistically significant difference in the initial antibiotic choice between patients with Mild or Uncomplicated infections as compared to patients with Moderate or Complicated infections (Chi-square test for homogeneity, p = 0.71). TMP/SMX, trimethoprim-sulfamethoxazole.

  • Figure 4.
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    Figure 4.

    Proportion of patients with treatment failure: patients receiving incision and drainage (n=62).*

    There was a statistically significant difference in the rate of treatment failure between patients with Mild or Uncomplicated infections as compared to patients with Moderate or Complicated infections (p = 0.04).

Tables

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    Table 1. Estimated Additional Costs of Treatment Failure
    InterventionCost (2011 US$)*
    Hospital admission1717,591.07
    Outpatient incision and drainage202,130.96
    Emergency department visit18754.84
    Antibiotics34
        Bacitracin ointment5.23/tube
        Mupirocin ointment0.31/25 g
        Cephalexin 500-mg capsules0.11/capsule
        Ciprofloxacin 500-mg tablets0.15/tablet
        Clindamycin 300-mg capsules0.20/capsule
        Clindamycin 150-mg capsules0.07/capsule
        Doxycycline 100-mg capsules0.04/capsule
        Trimethoprim-sulfamethoxazole double-strength tablets0.04/tablet
        Clindamycin 600 mg intravenous solution2.24/600 mg
    • ↵* All costs were discounted to 2011 U.S. dollars using National Medical Consumer Price Index inflation rates.21

    • View popup
    Table 2. Initial Treatment Strategy (n=98)*
    Treatment RegimenTotal (n=98)Mild or Uncomplicated (n=35)Moderate or Complicated (n=63)
    I&D alone6 (6)1 (3)5 (8)
    I&D + antibiotics56 (57)19 (54)37 (58)
    Antibiotics alone33 (34)14 (40)19 (30)
    Follow-up alone2 (2)1 (3)1 (2)
    Surgery1 (1)0 (0)1 (2)
    • Data are shown as n (%).

    • ↵* There was no statistically significant difference in the initial treatment strategy between patients with mild or uncomplicated infections compared with patients with moderate or complicated infections (P=.66, χ2 test for homogeneity).

    • I&D, incision and drainage.

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The Journal of the American Board of Family     Medicine: 26 (5)
The Journal of the American Board of Family Medicine
Vol. 26, Issue 5
September-October 2013
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Treatment Failure and Costs in Patients With Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections: A South Texas Ambulatory Research Network (STARNet) Study
Matthew J. Labreche, Grace C. Lee, Russell T. Attridge, Eric M. Mortensen, Jim Koeller, Liem C. Du, Natalie R. Nyren, Lucina B. Treviño, Sylvia B. Treviño, Joel Peña, Michael W. Mann, Abilio Muñoz, Yolanda Marcos, Guillermo Rocha, Stella Koretsky, Sandra Esparza, Mitchell Finnie, Steven D. Dallas, Michael L. Parchman, Christopher R. Frei
The Journal of the American Board of Family Medicine Sep 2013, 26 (5) 508-517; DOI: 10.3122/jabfm.2013.05.120247

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Treatment Failure and Costs in Patients With Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections: A South Texas Ambulatory Research Network (STARNet) Study
Matthew J. Labreche, Grace C. Lee, Russell T. Attridge, Eric M. Mortensen, Jim Koeller, Liem C. Du, Natalie R. Nyren, Lucina B. Treviño, Sylvia B. Treviño, Joel Peña, Michael W. Mann, Abilio Muñoz, Yolanda Marcos, Guillermo Rocha, Stella Koretsky, Sandra Esparza, Mitchell Finnie, Steven D. Dallas, Michael L. Parchman, Christopher R. Frei
The Journal of the American Board of Family Medicine Sep 2013, 26 (5) 508-517; DOI: 10.3122/jabfm.2013.05.120247
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