Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections

Abstract

A B S T R A C TOBJECTIVES: To describe variation in empirical antibiotic selection in infants ,60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost. METHODS:Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models. RESULTS:A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns.CONCLUSIONS: Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.

Antibiotic Regimens and Associated Outcomes in Children Hospitalized With Staphylococcal Scalded Skin Syndrome

“…Our study cohort included relatively few neonates, and thus our findings may not be applicable to this population subgroup. We chose not to include regimens with third‐generation cephalosporins or ampicillin, which may have limited the number of included neonates, because these antibiotics are frequently administered during evaluation for invasive bacterial infections 23 . We found a very low occurrence of treatment failure in our study cohort across all three groups, which is consistent with other studies of SSSS that report an overall good prognosis and low recurrence and/or readmission rates 6,16,24 .…”

Staphylococcal Infections and Neonatal Skin: Data from Literature and Suggestions for the Clinical Management from Four Challenging Patients

“…The first was a retrospective study by Markham et al of infants hospitalized with skin and soft-tissue infections (SSTI), in which a wide variation in empirical antibiotic selection has been noted: clindamycin was the most commonly used staphylococcal antibiotic, whereas 21.4% of patients received vancomycin. However, they did not discuss the management of different conditions because the aim of the study was to describe empirical antibiotic selection in infants with SSTI across 36 children’s hospitals and investigate the association of different empirical antibiotic regimens with the length of hospital stay, readmission rates, and costs [ 9 ].…”

Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study

“…The frequency of treatment failure in this study falls within the range of treatment failure rates described by several retrospective studies of young infants less than 60 days of age with SSTIs (0%-9.3%). 3,[15][16][17] Two of the studies with lower treatment failure rates (0%-0.8%) included only culture-proven S aureus SSTIs and a large proportion of neonates with pustulosis, which can often be treated solely with topical antibiotics and likely contributed to the lower rate of treatment failure. 15,16,18,19 The other 2 larger retrospective multicenter studies based on administrative billing data in children's hospitals found a similar occurrence of treatment failure in neonates with SSTIs of 9.2% to 9.3%.…”

“…13,14 Prior studies report that clindamycin is commonly used for treatment as a component of therapy for SSTIs in neonates, making SSTIs an ideal condition for further study of enteral antibiotic use in this population. [15][16][17] The Infectious Diseases Society of America recommendations for neonates with Staphylococcus aureus SSTIs are extrapolated from adults and children, with no specific recommendations regarding oral therapies, indicating the need for further evidence. 18 The purpose of this study is to determine the frequency of treatment failure in neonates receiving IV and oral antibiotic therapy for uncomplicated SSTIs and explore patient and SSTI-related characteristics associated with treatment failure, including the oral antibiotic regimen and factors that may influence enteral absorption of oral antibiotics.…”