Diagnosis: Infectious Disease (Fever, Skin abscess) Treatment: Inpatient Hospital Summary: This patient presented to the Emergency Department (ED) for a chief complaint of an abscess of the left buttock. His parent reported there was fever the day prior to presentation. There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses. On arrival, his temperature was 102.9°F, pulse was 140 and respirations were 26. Bloodwork revealed 21.3 white blood cells (WBCs) and 68.2% neutrophils. A bedside ultrasound showed a deep pocket abscess. Blood cultures were drawn, and intravenous (IV) Vancomycin was started. Pediatric surgery was consulted, and the patient was admitted with concern for signs of systemic infection, likely Methicillin-resistant Staphylococcus aureus (MRSA) given the recent family history. Antibiotics were continued and an incision and drainage was performed. Wound cultures grew moderate staphylococcus aureus and few Citrobacter freundii. The patient spiked a temperature of 101.2°F and was medicated with Ibuprofen. He was switched to oral antibiotics and discharged home in stable condition with outpatient follow-up planned. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses. These are described in the notes as being due to MRSA, but there is no evidence of that in the records. In fact, the subsequent culture report yielded methicillin-susceptible Staphylococcus aureus. The patient was fussy but consolable and well hydrated. A left medical gluteal abscess with a 2 cm induration was described. There was no mention of erythema of signs that would indicate extensive cellulitis. The ED physician's medical decision making note does not adequately justify the reasons for choosing IV antibiotics and a need for treatment as an inpatient. Although febrile, his vital signs were stable. There were no abnormal laboratory criteria other than leukocytosis (21,300/cu.mm), which reflects the bacterial soft tissue infection. The abscess was small and was incised and drained. IV Vancomycin was probably unnecessary, and antibiotics could have been continued orally following an initial IV dose. The medical necessity is not substantiated.

1) Kaplan S, et al. "Suspected Staphylococcus aureus and streptococcal skin and soft tissue infections in children >28 days: Evaluation and management." Uptodate.com 2) Lawrence HS, Nopper AJ. "Superficial Bacterial Skin Infections and Cellulitis." In: Long SS, Ed. Principles and Practice of Pediatric Infectious Diseases, 4th edition, 70, 427-435.e2. 2012, Elsevier Inc. Philadelphia, PA