Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation

Abstract

Background Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. Methods A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5–10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Results Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. Conclusions We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments

“…The provision of appropriate antibiotics in a critically ill patient population may be important to optimise patient outcome and minimise antibiotic‐associated harms. Previous studies have identified that guideline‐concordant antibiotic prescribing reduces mortality in patients with community‐acquired pneumonia, 22,23 intra‐abdominal infections 24 but not skin and soft tissue infections 25 . The current study did not replicate these findings whereby inappropriate antibiotics did not increase patient mortality, which may be due to the heterogeneity in patient comorbidities as we demonstrated, as well as the site of infection 26–28 and microbiological factors 29 that each influence mortality outcomes.…”

“…Previous studies have identified that guideline-concordant antibiotic prescribing reduces mortality in patients with community-acquired pneumonia, 22,23 intra-abdominal infections 24 but not skin and soft tissue infections. 25 The current study did not replicate these findings whereby inappropriate antibiotics did not increase patient mortality, which may be due to the heterogeneity in patient comorbidities as we demonstrated, as well as the site of infection [26][27][28] and microbiological factors 29 that each influence mortality outcomes. Additionally, patient outcomes may also be influenced by antibiotic adverse events.…”

International Validation of a Methicillin-Resistant Staphylococcus aureus Risk Assessment Tool for Skin and Soft Tissue Infections

“…The majority of patients in this and similar studies are at low MRSA risk and this could greatly reduce the number of patients receiving unnecessary MRSA coverage. [ 16 , 36 ] Such an approach would prevent unnecessary MRSA coverage in approximately 25% of the patients in this study. It would only result in failure to cover MRSA when necessary in 3% of the patients in this study.…”

“…With approximately 50% MRSA prevalence in many regions, local surveillance data and antibiograms become less useful for clinical decisionmaking. Consequently, SSTI prescribing practices vary widely, whereby both under-and over-prescribing of MRSA-active antibiotics occurs frequently [5,[14][15][16][17]. This antibiotic misuse has important implications for both patient outcomes and public health.…”

Implementation of a Cellulitis Management Plan in Three Australian Regional Health Services to Address an Evidence–Practice Gap in Antibiotic Prescribing

“…A recent study of antibiotic prescribing for patients admitted with cellulitis to an Irish district general hospital concluded that there was a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis [ 3 ]. A study in 34 Veterans Affairs Medical Centers in the USA that evaluated antibiotic prescribing for skin and soft tissue infections (cellulitis and abscess) reported that only 14% of patients received guideline-concordant empiric therapy and an appropriate duration of therapy [ 4 ]. In Australia, the National Antimicrobial Prescribing Survey (NAPS, a point prevalence survey of Australian hospitals) indicated that cellulitis/erysipelas was the fifth most common indication for prescribing an antibiotic in public and private hospitals, with an appropriateness of antibiotic choice at 75.3% [ 5 ].…”