February 28, 2011 — A guideline for the management of inpatient cellulitis and cutaneous abscess has led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes, a new study has found.
Timothy C. Jenkins, MD, from the Denver Health Medical Center Colorado, and colleagues reported their findings online today in the Archives of Internal Medicine.
According to the researchers, cellulitis and cutaneous abscess are the second most common infections leading to hospitalization in the United States and result in nearly 600,000 admissions annually, but "evaluation and treatment strategies for severe cases warranting hospitalization have not been well studied."
The current study, conducted in a Denver Healthcare System, sought to determine whether implementation of a clinical practice guideline for inpatient cellulitis and cutaneous abscess would decrease unnecessary antibiotic exposure through shorter durations of narrower-spectrum antimicrobial therapy.
The practice guidelines included strategies for diagnostic evaluation and recommended transition to oral doxycycline, clindamycin, or trimethoprim-sulfamethoxazole, in many cases, for 7 days or longer if needed. Use of antimicrobial agents with broad aerobic gram-negative or anaerobic activity was discouraged. Over a 12-month intervention period, an education campaign and other methods for disseminating and assessing the guideline were employed.
A group of patients was assessed before and after the implementation of the guideline; 169 patients (66 with cellulitis, 103 with abscess) were included in the preguideline cohort, and 175 patients (82 with cellulitis, 93 with abscess) were included in the postguideline cohort.
The intervention decreased the use of microbiological cultures (80% vs 66%; P = .003) and resulted in fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased by 3 days, from 13 days (interquartile range [IQR], 10 - 15 days) to 10 days (IQR, 9 - 12 days; P < .001).
Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases, respectively (P = .93).
"Implementation of a clinical practice guideline for inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of health care resources without adversely affecting clinical outcomes," Dr. Jenkins and colleagues concluded.
"This broadly applicable intervention should be considered by hospitals and antibiotic stewardship programs to improve patient safety and decrease use of finite health care resources," the authors suggest.
Limitations of the trial include single-center study design, exclusion of nearly 50% of participants because of complications, retrospective design, and potential for reviewer bias.
In a related editorial, Brad Spellberg, MD, from the University of California–Los Angeles Medical Center, notes that the current study follows up on a previous observational study that found an "alarming frequency of prolonged, inappropriately broad antibiotic therapy in hospitalized patients with skin and soft-tissue infections." "They subsequently assembled a multidisciplinary group to create a clinical guideline for the management of [skin and soft-tissue infections]," he writes.
According to Dr. Spellberg, the findings are "good news" and indicate that "a comprehensive, well-advertised clinical guideline can positively affect antibiotic prescribing behavior for a common infection at a major medical center." However, he also points out that about a third of patients continued to receive therapy with agents with broad gram-negative bacilli activity even after the guideline, and nearly 20% of patients received therapy with an antipseudomonal agent.
"Our goal should be to have these numbers approach zero," he writes.
The study was supported by the Department of Patient Safety and Quality, Denver Health Medical Center. One author received an Independent Scientist Award from the Agency for Healthcare Research and Quality. The authors and editorialist have disclosed no relevant financial relationships.
Arch Intern Med. Published online February 28, 2011.
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