Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting

Abstract

Background Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. Methods This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines. Results 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%. Conclusions Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic.

Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients

“…Other studies of uncomplicated SSTIs have focused upon antibiotic appropriateness in pediatric patients [17, 20] and in adult patients in ambulatory care settings [19]. Our current evaluation adds to the growing body of evidence demonstrating that the management of hospitalized adult patients with uncomplicated SSTIs represents an opportunity to significantly reduce antimicrobial use by reducing the duration of therapy in addition to promoting the use of narrow spectrum therapy targeting aerobic gram-positive organisms only.…”

The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

“…Finally, antibiotic use for respiratory tract infections has received extensive attention from ASPs, which might have led to less inappropriate prescriptions [7,8,23,24]. In previous studies it was already shown that antimicrobial treatment of uncomplicated SSTI had a low guideline adherence rate, 11-20.2%, due to an inappropriate length of treatment and due to an inappropriate choice of broad spectrum antibiotic agents [9,26,27]. Altogether, these findings suggest that there is considerable room for quality improvement for SSTI prescriptions and emphasize the need of information on antibiotic use per clinical care setting to direct ASP efforts [10,24].…”

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis

“…16 Large-scale studies suggest that hospitalized patients with uncomplicated SSTIs should not receive 10 or more days of antibiotics. 16 Other studies posit that 5 to 7-day courses are sufficient and no less effective than longer treatment courses. [17][18][19] By these standards, 101 (57.7%) of the 175 study patients received longer treatment courses (≥10 days) than what is recommended by expert guidelines (eFigure 1 in Supplement 2), suggesting that additional measures are needed to overcome perceptions that excessive courses of antibiotics cannot be harmful.…”