Hospitalizations with healthcare‐associated complicated skin and skin structure infections: Impact of inappropriate empiric therapy on outcomes

Abstract

OBJECTIVE:Inappropriate empiric therapy worsens outcomes in certain healthcare-associated infections (HCAI). We studied the association of inappropriate empiric therapy with outcomes in patients with HCA complicated skin and skin structure infections (cSSSI). DESIGN:A single-center retrospective cohort study. PATIENTS: Hospitalized with a culture-positive cSSSI. MEASUREMENTS: We defined HCA-cSSSI as having !1 of these risk factors: (1) recent hospitalization, (2) recent antibiotics, (3) hemodialysis, (4) transfer from a nursing home, and inappropriate treatment as no antimicrobial therapy active against the pathogen(s) within 24 hours of obtaining culture specimen. We performed descriptive and multivariate statistics to compute the impact of inappropriate empiric therapy on outcomes. Hospital length of stay (LOS) served as primary and mortality as secondary outcomes. RESULTS:Of the 717 patients with culture-positive cSSSI, 527 (73.5%) had HCAI, of whom 405 (76.9%) received appropriate treatment. A higher proportion of those receiving inappropriate than appropriate treatment had a decubitus ulcer (29.5% vs. 10.9%, P < 0.001), a device-associated infection (42.6% vs. 28.6%, P ¼ 0.004), or bacteremia (68.9% vs. 57.8%, P ¼ 0.028). The frequency of methicillin-resistant Staphylococcus aureus (MRSA) did not differ between the groups. The low overall unadjusted mortality rate did not vary based on initial treatment. In a multivariable analysis adjusting for potential confounders inappropriate therapy had an attributable increase in hospital LOS of 1.8 days (95% CI, 1.4-2.3).CONCLUSION: Similar to other populations with HCAI, HCA-cSSSI patients are likely to receive inappropriate empiric therapy for their infection. This early exposure is associated with a significant prolongation of the hospitalization by nearly 2 days.

Epidemiology and Outcomes of Complicated Skin and Soft Tissue Infections in Hospitalized Patients

“…Available results are contradictory, possibly because of differences in study methods, definitions, and sample sizes. Zilberberg et al (28) reported that inappropriate therapy was independently associated with an excess hospital LOS (attributable LOS, 1.8 days; 95% CI, 1.4 to 2.3; P Ͻ 0.001), but not excess mortality, in 527 patients with health care-associated cSSTI. When patients were stratified by the presence of bacteremia, however, LOS differences were observed only in those with bacteremia.…”

Risk Factors for Mixed Complicated Skin and Skin Structure Infections To Help Tailor Appropriate Empiric Therapy

“…In the same data set analyzed in the current study, in a generalized linear model with the log-transformed LOS as the dependent variable, adjusting for multiple potential confounders, inappropriate empiric therapy conferred an attributable incremental increase in the hospital LOS of 1.8 days (95% CI 1.4-2.3) [6]. Together with the concerns about resistance pressures stemming from unnecessarily broad empiric coverage, the concern about the most efficient use of healthcare resources is a compelling impetus for developing risk stratification algorithms to use at the bedside, which can help clinicians develop appropriate coverage decisions that align with the goals of both best clinical care and antibiotic stewardship.…”

“…In the case of cSSSI, although inappropriate empiric therapy does not appear to elevate the risk of in-hospital death, it does alter hospital resource utilization [6]. In the same data set analyzed in the current study, in a generalized linear model with the log-transformed LOS as the dependent variable, adjusting for multiple potential confounders, inappropriate empiric therapy conferred an attributable incremental increase in the hospital LOS of 1.8 days (95% CI 1.4-2.3) [6].…”

“…The study was approved by the Washington University School of Medicine Human Studies Committee, and informed consent was waived. This population has been described previously [5][6][7].…”

“…An HCA cSSSI was defined as any cSSSI in a patient with recent hospitalization (within the previous year [6]), antibiotics in the 90 d prior to admission, transfer from a nursing home, or need for dialysis. An MSI represented an infection with both a gram-positive and a gram-negative organism.…”