Emergency Medicine Expert Opines on Inadequate Testing of Suspected MRSA

This case involves a middle aged female patient who presented to the ER with a sore on her arm. The patient’s husband had had a similar sore on his leg a few weeks prior to her presentation at the ER. The Plaintiff’s husband had his sore cultured and diagnosed as MRSA and was successfully treated. The Plaintiff was seen by a physician assistant during her visit to the ER who, despite being aware of the Plaintiff’s husband’s MRSA infection, did not order any tests. Subsequently, she was discharged from the hospital with a prescription for antibiotics. The Plaintiff’s sore continued to worsen despite the antibiotics over the course of the next few days. She returned to the ER for a second time, where she was again seen by a physician assistant instead of a physician. Again, no culture or additional testing was done and the patient was discharged. A few days later, she returned to the ER again, now with pain in her shoulder. She was seen by a physician assistant again, who advised her that the pain was just inflammation and she was again discharged. A few days later, the patient collapsed while at work and was taken to the hospital, where it was discovered that she was suffering from massive sepsis. Despite efforts by hospital staff to save her life, the patient expired shortly after arrival at the hospital. It was alleged that the patient’s sore should have been tested during her visit to the emergency room, and that she would have had a better outcome had her MRSA been identified sooner.

Question(s) For Expert Witness

1. Do you treat patients with the presentation described in this case?

2. What is the standard work up for a patient presenting with a sore?

3. What is the differential diagnosis for such a presentation?

4. Given the patient's history of her husband having an MRSA infection recently should MRSA have been entertained as a diagnosis sooner?

Expert Witness Response E-000755

MRSA is currently the most commonly identified bacteria in community-acquired skin abscesses. Given the frequency of this infection, emergency medicine physicians typically treat MRSA (or suspected MRSA) on a frequent basis. The prevalence of MRSA also affects medical decision-making in emergency medicine, since the bacteria itself is widespread, highly contagious, aggressive, and prone to causing complex patterns of disease. In my emergency medicine practice, I am either treating MRSA cases, or at least considering MRSA within a differential diagnosis, on a daily basis. The prevalence of MRSA, combined with the fact that it is the prime suspect in nearly all cutaneous abscesses, has changed the practice of emergency medicine in that routine abscess cultures are no longer mandated. This is because clinicians treat simple abscesses with incision and drainage. When antibiotics are required, coverage for MRSA is always provided. In the present case, with the patient's husband having a recent MRSA infection, an active MRSA infection in the patient would have been an even more obvious concern. This is critically relevant since, in a vast majority of cases, early and appropriate treatment of MRSA is effective in averting nearly all subsequent complications. Consequently, the key to this case is to determine whether the treatment of the infection was compliant with the standard of care, and whether any deviation from the standard either caused or contributed to the patient's catastrophic outcome. At present, it seems like the patient did experience a lapse in the standard of care for suspected MRSA.