Optimization of Antibiotic Selection in the Emergency Department for Adult Skin and Soft Tissue Infections

Abstract

Objectives: Emergency department (ED) order sets that include skin and soft tissue infections (SSTI) stratification and antimicrobial selection criteria may improve clinical outcomes and appropriateness of initial antibiotic selection. The purpose of this study was to optimize and evaluate antimicrobial prescribing for SSTI in the ED by implementing an institution specific Infectious Diseases Society of America (IDSA) guideline directed computerized provider order entry (CPOE) order set. The primary outcome was the rate of appropriate antibiotic prescribing for SSTI in the ED before and after order set revision. Secondary outcomes were length of hospital stay, rate of continuity of antibiotics from the ED to hospital admission orders, and frequency of order set utilization. Methods: This was a single-centered, retrospective, cohort study. The ED SSTI order set revision reflected current IDSA guidelines, institution formulary, and institution antibiogram. Results: A total of 180 patients were included in the study. The rate of appropriate antibiotic prescribing was 74.4% and 78.9% ( P = .60) in the pre-revision and post-revision groups, respectively. Length of hospital stay of admitted patients was 4.93 and 4.32 days ( P = .61). Rate of antibiotics continued from the ED to admission was 62.1% and 59.4% ( P = .99). Order set utilization was 17.8% and 24.4% ( P = .36). A subgroup analysis found appropriateness increased with order set use in admitted patients (50% vs 88.2%; P = .0382) and total patients (50% vs 81.8%; P = .037). Conclusion: An order set reflective of current IDSA guidelines and institution specific antibiogram showed a similar rate of appropriate antibiotic selection compared to provider’s clinical judgment. Provider awareness of SSTI management could have been a limitation to the study.

Antibiotic Management of Uncomplicated Skin and Soft Tissue Infections in the Real World

“…The clinical manifestations of patients with skin and soft tissue infections, as well as the location of infections predominantly in the lower limbs, were consistent with those reported in the literature [ 13 , 15 , 16 , 19 , 20 ]. Hypertension was the most prevalent comorbidity in this report, consistent with what was published in a multicenter study in six European countries, although in a lower proportion (19.8% vs. 48.4%) [ 14 ], and contrasts with other reports where diabetes mellitus predominated (10.0% vs. 18.5%–51.0%) [ 4 , 13 , 15 , 18 , 19 , 20 ].…”

“…The median age of the patients was lower than that found in other studies (38.0 vs. 41.1–61.6 years) [ 4 , 13 , 14 , 15 , 16 , 17 ], with a predominance of men, similar to previous studies (52.3% vs. 50.7–63.0%) [ 4 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. The clinical manifestations of patients with skin and soft tissue infections, as well as the location of infections predominantly in the lower limbs, were consistent with those reported in the literature [ 13 , 15 , 16 , 19 , 20 ].…”

“…The median age of the patients was lower than that found in other studies (38.0 vs. 41.1-61.6 years) [4,[13][14][15][16][17], with a predominance of men, similar to previous studies (52.3% vs. 50.7-63.0%) [4,[13][14][15][16][17][18][19]. The clinical manifestations of patients with skin and soft tissue infections, as well as the location of infections predominantly in the lower limbs, were consistent with those reported in the literature [13,15,16,19,20]. Hypertension was the most prevalent comorbidity in this report, consistent with what was published in a multicenter study in six European countries, although in a lower proportion (19.8% vs. 48.4%) [14], and contrasts with other reports where diabetes mellitus predominated (10.0% vs. 18.5%-51.0%) [4,13,15,[18][19][20].…”