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Failure of outpatient antibiotics among patients hospitalized for acute bacterial skin infections: What is the clinical relevance?

Published:February 11, 2016DOI:https://doi.org/10.1016/j.ajem.2016.02.013

      Abstract

      Background

      Infectious Diseases Society of America guidelines recommend that patients hospitalized for acute bacterial skin infections after failure of outpatient antibiotic therapy be managed as “severe” infections; however, the clinical relevance of apparent failure of outpatient therapy is not clear.

      Methods

      This was a secondary analysis of a multicenter, retrospective cohort of adults and children hospitalized for cellulitis, abscess, or wound infection. We compared clinical features, laboratory and microbiology findings, antibiotic treatment, and outcomes among patients who received outpatient antibiotics prior to admission and those who did not.

      Results

      Of 533 patients, 179 (34%) received outpatient antibiotics prior to admission. Compared with those who did not, patients who received antibiotics prior to admission less frequently had fever (18% vs 26%, P = .04) and leukocytosis (33% vs 51%, P < .001). In the 202 cases where a microorganism was identified, Staphylococcus aureus was more common among those who received antibiotics prior to admission (75% vs 58%, P = .02), particularly methicillin-resistant S aureus (41% vs 27%, P = .049), whereas aerobic gram-negative bacilli were less common (3% vs 13%, P = .03). After hospitalization, clinical failure occurred with similar frequency between the 2 groups (12% vs 11%, P = .73).

      Conclusions

      Patients hospitalized with skin infections after apparently failing outpatient therapy had clinical features suggestive of less severe infection and similar outcomes compared with patients who did not receive antibiotics prior to admission. Our results suggest that inpatient treatment for patients not responding to outpatient therapy should focus on methicillin-resistant S aureus, not gram-negative pathogens.
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      References

        • Hersh A.L.
        • Chambers H.F.
        • Maselli J.H.
        • Gonzales R.
        National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.
        Arch Intern Med. 2008; 168: 1585-1591
        • Edelsberg J.
        • Taneja C.
        • Zervos M.
        • Haque N.
        • Moore C.
        • Reyes K.
        • et al.
        Trends in US hospital admissions for skin and soft tissue infections.
        Emerg Infect Dis. 2009; 15: 1516-1518
        • Magill S.S.
        • Edwards J.R.
        • Beldavs Z.G.
        • Dumyati G.
        • Janelle S.J.
        • Kainer M.A.
        • et al.
        Prevalence of antimicrobial use in US acute care hospitals, May-September 2011.
        JAMA. 2014; 312: 1438-1446
        • Jenkins T.C.
        • Knepper B.C.
        • Sabel A.L.
        • Sarcone E.E.
        • Long J.A.
        • Haukoos J.S.
        • et al.
        Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess.
        Arch Intern Med. 2011; 171: 1072-1079
        • Wargo K.A.
        • McCreary E.K.
        • English T.M.
        Vancomycin combined with clindamycin for the treatment of acute bacterial skin and skin-structure infections.
        Clin Infect Dis. 2015; 61: 1148-1154
        • Stevens D.L.
        • Bisno A.L.
        • Chambers H.F.
        • Dellinger E.P.
        • Goldstein E.J.
        • Gorbach S.L.
        • et al.
        Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2014; 59: e10-e52
        • Jenkins T.C.
        • Knepper B.C.
        • Moore S.J.
        • O'Leary S.T.
        • Brooke C.
        • Saveli C.C.
        • et al.
        Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection.
        Infect Control Hosp Epi. 2014; 35: 1241-1250
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Wong C.H.
        • Khin L.W.
        • Heng K.S.
        • Tan K.C.
        • Low C.O.
        The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.
        Crit Care Med. 2004; 32: 1535-1541
        • Jenkins T.C.
        • Sabel A.L.
        • Sarcone E.E.
        • Price C.S.
        • Mehler P.S.
        • Burman W.J.
        Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship.
        Clin Infect Dis. 2010; 51: 895-903
        • Moran G.J.
        • Krishnadasan A.
        • Gorwitz R.J.
        • Fosheim G.E.
        • McDougal L.K.
        • Carey R.B.
        • et al.
        Methicillin-resistant S. aureus Infections among patients in the emergency department.
        N Engl J Med. 2006; 355: 666-674