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Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education

Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic... Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Open Forum Infectious Diseases MAJOR ARTICLE Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education 1,2 3 4 5 6 7 8 Safa S. Almarzoky Abuhussain, Michelle A. Burak, Danyel K. Adams, Kelsey N. Kohman, Serina B. Tart, Athena L. V. Hobbs, Gabrielle Jacknin, 3,a 9 1 1 Michael D. Nailor, Katelyn R. Keyloun, David P. Nicolau, and Joseph L. Kuti 1 2 3 Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut; Umm Al-Qura University, Makkah, Saudi Arabia; Department of Pharmacy, Hartford Hospital, 4 5 6 Hartford, Connecticut; Department of Pharmacy, Baystate Medical Center, Springfield, Massachusetts; Department of Pharmacy, Baylor University Medical Center, Dallas, Texas; Department 7 8 of Pharmacy, Cape Fear Valley Health, Fayetteville, North Carolina; Department of Pharmacy, Baptist Memorial Hospital-Memphis, Memphis, Tennessee; Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado; Allergan plc, Jersey City, New Jersey Background. Acute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions. Methods. An anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, partic- ipants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision. Results. e s Th urvey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses. Conclusions. Variability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment. Keywords. abscess; antibiotics; cellulitis; education. Acute bacterial skin and skin structure infections (ABSSSIs), total hospitalizations [2, 3]. Guidelines by the Infectious Diseases defined by erythema extending ≥ 75 cm , are frequent and chal- Society of America (IDSA) recommend that many patients with lenging infections associated with high direct and indirect costs ABSSSI can be successfully treated in the outpatient setting with to both the medical system and society [1]. These infections are either oral agents or outpatient parenteral antibiotic therapy responsible for a growing number of emergency department (OPAT) [4]. However, administration of intravenous antibiotics (ED) visits and hospital admissions. Between 2005 and 2010, in 1 study was the sole reason provided for admission in 41.5% more than 3 million patients annually received care for a skin of skin infection patients [5]. Other reported factors associated or skin structure infection in the ED; furthermore, during that with hospital admission include advanced age, fever or clinical time, ABSSSI-related admissions increased from 1.6% to 1.9% of instability on presentation, failure of previous antibiotic therapy, and presence of comorbidities [5–7]. That said, many patients with simple ABSSSI are still admitted to the hospital [8]. Received 8 May 2018; editorial decision 13 August 2018; accepted 16 August 2018. Present affiliation: St. Joseph’s Hospital and Medical Center, Phoenix, Arizona ABSSSIs are most oen c ft aused by Gram-positive cocci, Correspondence: J. L. Kuti, PharmD, FIDP, Center for Anti-Infective Research and Development, including Staphylococcus aureus and Streptococcus spp., and Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 (joseph.kuti@hhchealth.org). ® more rarely by Gram-negatives and anaerobes [1, 4, 9]. Despite Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases this limited list of likely pathogens, antibiotic therapy for Society of America. This is an Open Access article distributed under the terms of the Creative ABSSSIs frequently varies from narrow-spectrum oral agents to Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ empiric administration of a combination of intravenous agents by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work with activity against methicillin-resistant S. aureus (MRSA) and is properly cited. For commercial re-use, please contact journals.permissions@oup.com Pseudomonas aeruginosa (eg, piperacillin/tazobactam) [8, 10]. DOI: 10.1093/ofid/ofy206 Provider Variability in ABSSSI Care • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 As a result, ABSSSI treatment selection is an appropriate target nurses (APRNs) and physician assistants (PAs). Any students for an Antimicrobial Stewardship Program (ASP) intervention or other members of the clinical team (eg, pharmacists, nurses, in the hospital setting, including in the ED [11–14]. Given that etc.) were excluded, and providers who previously participated intravenous antibiotic administration in the ED can be a gateway were not permitted to retake the survey. to hospital admission [5], improved antibiotic choices in the ED Survey Tool for ABSSSI may also reduce unnecessary hospital admission. Eight case-based survey questions were designed to assess treat- ASP interventions in the ED could present unique challenges ment decisions based on the same patient presenting to the ED due to the variety of provider types, rapid patient turnover, and with various clinical scenarios escalating in severity (Table  1) the need for quick treatment decisions. In the absence of a clear from simple ABSSSI (Case 1)  to recurrent infection (Case 2), ABSSSI clinical pathway in the ED or hospital, an understand- concurrent controlled diabetes (Case 3), or sepsis (Case 4). ing of patient factors that influence emergency medicine (EM) Each case was then followed by the same questions pertaining providers to prescribe intravenous therapy or admit a patient to decisions on choice of intravenous vs oral antibiotic treat- with ABSSSI would help to streamline educational efforts as ment and hospital admission. Data were also collected on pro- part of ASP interventions. Herein, we surveyed EM providers vider type, years of experience, and ranking of the following from 6 US EDs using a case-based questionnaire to capture patient/antibiotic characteristics considered important in the their treatment decisions for patients with ABSSSI. treatment of ABSSSI: patient comorbidities, patient severity of METHODS presentation, patient adherence to antibiotic therapy, antibiotic microbiological spectrum of activity, antibiotic cost, antibiotic Study Design treatment schedule, antibiotic route of administration, and anti- This was a multicenter study conducted in 6 EDs across the biotic adverse event profile. Finally, providers were asked how United States. Participating centers included Hartford Hospital often they engaged patients directly and involved them in their (Hartford, CT), Cape Fear Valley Medical Center (Fayetteville, preferences for ABSSSI treatment. NC), Baylor University Medical Center at Dallas (Baylor, TX), University of Colorado Hospital (Aurora, CO), Baptist Analyses Memorial Hospital–Memphis (Memphis, TX), and Baystate Survey results were descriptively reported as the proportion Medical Center (Springfield, MA). The study was approved of participants selecting each response for each question. The by the institutional review board at each participating hospi- ranking of specific antibiotic/patient characteristic importance tal. A  short 12-item anonymous survey was administered to was based on the mode score from 1 (most important) to 8 local ED providers. By completing the survey, providers were (least important). Questions with no response were included giving permission to participate in the study. No Protected by adjusting the denominator of each individual question, as Health Information was collected. Questionnaires were distrib- required. Responses to cases were assessed by provider type uted by the clinical ED or ASP pharmacists at each institution (MD vs APP) and years of clinical practice experience (>5 years over a 6-month time period between December 2016 and May vs ≤ 5 years). Odds ratios with 95% confidence intervals (CIs) 2017; this was frequently done at monthly department meet- were generated to compare survey results by provider type and ings. Eligible providers included EM physicians, including MD/ years of clinical practice experience. All analyses were per- DO attendings, residents, or fellows, as well as advanced prac- formed in Sigma Plot, version 13.0 (Systat Software Inc., San tice providers (APPs), including advanced practice registered Jose, CA). Table 1. Case-Based Survey Questions to EM Providers Survey Questions and Answer Case Description Options How would you treat this patient? Case 1: Simple ABSSSI An adult patient presents to the ED with cellulitis on the lower leg, where a. An oral antibiotic the lesion size is ≥75 cm (larger than the average cell phone). The patient b. 1–2 doses of IV antibiotic followed is afebrile, has a normal white blood cell count, and has no comorbidities; by an oral antibiotic this is their first ABSSSI presentation. c. A full IV antibiotic course Case 2: Recurrent ABSSSI After completing treatment as outlined above, the patient returns to the ED Where would you send this patient? approximately 30 days later with a second ABSSSI episode at the same a. Admit to inpatient unit site. b. Admit to observation unit Case 3: Controlled diabetes Assume the patient described in Case 1, presenting with first episode of c. Discharge the patient home with ABSSSI, has insulin-dependent but controlled diabetes. further instructions Case 4: Septic patient Assume the patient described in Case 1 presenting with a first episode of ABSSSI is tachycardic, febrile, and has a white blood cell count of 15 000 cells/microliter. Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; ED, emergency department; EM, emergency medicine; IV, intravenous. 2 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 RESULTS (34.6%) of the remaining respondents. Participants reported less than 1 year (20, 15.4%), 1–5 years (58, 44.6%), >5–10 years Providers (16, 12.3%), and >10 years (36, 27.7%) of experience. Out of a total of 443 EM providers employed in the 6 partici- pating EDs at time of the study, 130 (29.3%) completed the sur- Survey Responses vey. The numbers of providers included by site were as follows: Participant choices for admission and intravenous vs oral anti- n = 30 (Hartford, CT), n = 26 (Baystate, MA), n = 23 (Baylor, biotic therapy for cases are presented in Figure  1. Variability TX), n  =  19 (Cape Fear, NC), n  =  17 (Baptist-Memphis, TN), in responses for recommended treatment and disposition was and n = 15 (Univ. Colorado, CO). All providers answered every observed for the recurrent ABSSSI and controlled diabetes survey question, except for Case 3 (n = 129), Case 4 (n = 128), cases, and less so for the septic patient. The least variability was and the question about engaging patients in antibiotic pref- observed for the simple ABSSSI case, with most providers dis- erence (n  =  125). Physicians accounted for the majority of charging the patient home on oral antibiotic therapy. Notably, respondents (85, 65.4%), with 51 (39.2%) listed as attendings 34 (40%) and 51 (60%) providers chose to give 1–2 intravenous and 34 (26.2%) as residents or fellows. APPs accounted for 45 doses in the ED and discharge the patient on oral therapy for the Recommended Antibiotic Treatment 4.7 29.7 48.5 53.5 93.1 32.2 65.6 38.8 5.4 10 19.2 7.8 1.5 Case 1: Simple ABSSSI Case 2: Recurrent ABSSSI Case 3: Controlled Case 4: Septic Patient Diabetes A full IV antibiotic course 1–2 doses of IV antibiotic followed by an oral antibiotic An oral antibiotic Recommended Patient Disposition 3.9 51.5 62.8 96.2 30.5 39.2 67.2 31.8 3.1 9.2 0.8 5.4 Case 1: Simple ABSSSI Case 2: Recurrent ABSSSI Case 3: Controlled Case 4: Septic Patient Diabetes Discharge the patient home with further instructions Admit to observation unit Admit to inpatient unit Figure 1. Percentage of providers selecting each response for the 4 cases. Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; IV, intravenous. Provider Variability in ABSSSI Care • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 recurrent ABSSSI and controlled diabetes cases, respectively. treatment decision-making process), 7 (5.6%), 36 (28.8%), 61 Comparisons in responses by type of provider and experience (48.8%), and 21 (16.8%) indicated always, frequently, rarely, and level are provided in Table 2. Compared with PHYs, APPs were never, respectively. The rank order of the 8 factors influencing 2.59 (95% CI, 1.23–5.47) times more likely to select 1–2 doses providers’ antibiotic treatment decisions is provided in Table 3. of IV antibiotic followed by oral therapy for the controlled dia- DISCUSSION betes case; APPs were also 56% (95% CI, 0.07–0.79) less likely to choose oral antibiotics for this case. For the septic case, APPs Despite guidelines supporting transitions of care to outpa- were 2.19 (95% CI, 1.01–4.74) times more likely to choose to tient treatment for low-risk patients with ABSSSI, observa- admit the septic patient to an inpatient unit. There was no dif- tional studies indicate that providers couple hospitalization ference in responses by years of experience. with administration of parenteral antibiotics, regardless of the When queried about how oen p ft roviders asked patients absence of need for other services that can only be provided in about their antibiotic preference (ie, involving patients in the the hospital and availability of outpatient intravenous antibiotic Table 2. Case Scenario Answers by EM Provider Type and Experience EM Provider Type Experience in Years PHY APP ≤5 >5 Cases and Answer Options n = 85 n = 45 OR (95% CI) n = 78 n = 52 OR (95% CI) Case 1: Simple ABSSSI Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 4 (4.7) 3 (6.7) 1.45 (0.31–6.76) 3 (3.8) 4 (7.7) 2.08 (0.45–9.72) A full IV antibiotic course 1 (1.2) 1 (2.2) 1.91 (0.12–31.26) 0 2 (3.9) N/A An oral antibiotic 80 (94.1) 41 (91.1) 0.64 (0.16–2.52) 75 (96.2) 46 (88.5) 0.31 (0.07–1.29) Patient disposition Admit to observation unit 3 (3.5) 1 (2.2) 0.62 (0.06–6.15) 3 (3.8) 1 (1.9) 0.49 (0.05–4.86) Admit to inpatient unit 0 1 (2.2) N/A 0 1 (1.9) N/A Discharge home 82 (96.5) 43 (95.6) 0.79 (0.13–4.89) 75 (96.2) 50 (96.2) 1.00 (0.16–6.20) Case 2: Recurrent ABSSSI Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 25 (29.4) 17 (37.8) 1.46 (0.68–3.12) 29 (37.2) 13 (25.0) 0.56 (0.26–1.23) A full IV antibiotic course 17 (20.0) 8 (17.8) 0.86 (0.34–2.19) 12 (15.4) 13 (25.0) 1.83 (0.76–4.41) An oral antibiotic 43 (50.6) 20 (44.4) 0.78 (0.38–1.61) 37 (47.4) 26 (50.0) 1.11 (0.55–2.24) Patient disposition Admit to observation unit 32 (37.7) 19 (42.2) 1.21 (0.58–2.53) 29 (37.2) 22 (42.3) 1.24 (0.61–2.54) Admit to inpatient unit 10 (11.8) 2 (4.4) 0.35 (0.07–1.67) 8 (10.3) 4 (7.7) 0.73 (0.21–2.56) Discharge home 43 (50.6) 24 (53.3) 1.12 (0.54–2.30) 41 (52.6) 26 (50.0) 0.90 (0.45–1.82) Case 3: Controlled diabetes Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 26 (30.6) 24 (54.6) 2.59 (1.23–5.47) 34 (43.6) 16 (31.4) 0.58 (0.27–1.21) A full IV antibiotic course 8 (9.4) 2 (4.6) 0.45 (0.09–2.20) 7 (9.0) 3 (5.9) 0.62 (0.15–2.52) An oral antibiotic 51 (60.0) 18 (40.9) 0.44 (0.21–0.93) 37 (47.4) 32 (62.8) 1.77 (0.87–3.62) Patient disposition Admit to observation unit 26 (30.6) 15 (34.1) 1.13 (0.52–2.46) 26 (33.8) 15 (28.9) 0.81 (0.38–1.74) Admit to inpatient unit 6 (7.1) 1 (2.3) 0.30 (0.03–2.57) 5 (6.5) 2 (3.9) 0.58 (0.11–3.13) Discharge home 53 (62.4) 28 (63.6) 0.99 (0.47–2.10) 46 (59.7) 35 (67.3) 1.43 (0.69–2.99) Case 4: Septic patient Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 28 (33.3) 10 (22.7) 0.58 (0.25–1.34) 20 (26.3) 18 (34.6) 1.54 (0.71–3.30) A full IV antibiotic course 50 (59.5) 34 (77.3) 2.16 (0.97–4.84) 54 (71.1) 30 (57.7) 0.61 (0.29–1.26) An oral antibiotic 6 (7.1) 0 N/A 2 (2.6) 4 (7.7) 3.17 (0.56–17.96) Patient disposition Admit to observation unit 27 (31.8) 12 (26.7) 0.78 (0.35–1.74) 20 (25.6) 19 (36.5) 1.67 (0.78–3.57) Admit to inpatient unit 54 (63.5) 32 (71.1) 2.19 (1.01–4.74) 56 (71.8) 30 (57.7) 0.54 (0.26–1.12) Discharge home 4 (4.7) 1 (2.2) 0.94 (0.17–5.35) 2 (2.6) 3 (5.8) 2.33 (0.38–14.43) All data are number (%) and odds ratio with 95% confidence interval of the difference between APP vs PHY and >5 years’ vs ≤5 years’ experience.  Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; APP, advanced practice provider; CI, confidence interval; EM, emergency medicine; IV, intravenous; OR, odds ratio; PHY, physician. 4 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Table  3. Rank Order of Factors Influencing Provider Decisions When intravenous followed by oral therapy, and full intravenous Selecting Antibiotics for Treatment of ABSSSI courses were selected by 48.5%, 32.2%, and 19.9% of providers, respectively. Discharge home was selected in 51.5%, followed by Factor Mode admission to an observation unit in 39.2%. The frequent selec- Severity of infection presentation 1 tion of the observation unit is supported by a growing trend Presence of patient comorbidities 2 in this strategy among Medicare beneficiaries [15]. However, Microbiological spectrum of activity 3 in practice, ABSSSI is not a common diagnosis in medical or Route of administration 4 Patient adherence 5 surgical observation units. In a single-center study of ABSSSI Adverse event profile 5 patients receiving intravenous antibiotics for less than 24 Antibiotic treatment schedule 6 hours, 28.7% were sent to the observational unit. Notably, these Antibiotic cost 8 patients more frequently had comorbid conditions and met cri- Ranked by mode (1 = most important; 8 = least important). teria for SIRS, which were not characteristics described in Case Abbreviation: ABSSSI, acute bacterial skin and skin structure infection. 2 in our study [16]. In the study by Talan and colleagues, failure of prior anti- strategies [5, 8, 10]. The purpose of this study was to identify biotic therapy was significantly associated with admission EM provider treatment hypothetical choices for hospital admis- to the hospital (present in 16% of admissions vs 6.0% of dis- sion and route of antibiotic administration based on escalating charges) but was not directly listed by physicians as a reason clinical scenarios commonly observed in patients with ABSSSI. for admission [7]. An important distinction here may be the In brief, we observed good agreement in treatment strategies difference between treatment “failure” and “recurrence/relapse.” for ABSSSI patients first presenting with simple cellulitis but Recurrence/relapse is generally accepted as cellulitis that has variability in provider selections when ABSSSI patients pre- improved aer ft completing a course of antibiotics but that sub- sented with infection recurrence, controlled diabetes, or sepsis. sequently reappeared, whereas treatment failure is clinically With few exceptions, the type of provider and experience level accepted as lack of improvement during the course of antibiot- did not significantly influence the choices. These observations ics. Treatment failure, from a clinical perspective, is unlikely to could prove useful in targeting ASP education efforts to EM occur 30 days out from presentation as antibiotic therapy would providers or when developing a clinical pathway in the ED for have been completed well before then. Patients with previous treatment of patients with ABSSSI. cellulitis may have annual recurrence rates as high as 20% [17, As noted previously, common reasons for hospital admission 18]. A number of factors including edema, venous insufficiency, of patients with ABSSSI include advanced age, clinical instability, tinea pedis, unresolved or past trauma, obesity, tobacco use, the presence of certain comorbidities, recurrence or reinfection, cancer, and homelessness can all contribute to infection recur- and provider perception that these infections require intrave- rence; therefore, IDSA guidelines recommend evaluation of nous therapy [5–7]. We are not aware of any other studies in the risks and resolution of these factors in addition to oral penicillin literature that have directly measured EM provider hypothet- or monthly injections with intramuscular penicillin [4]. These ical decisions in the treatment of ABSSSI. Beginning with the treatments can be accomplished in the outpatient setting for a simple cellulitis case scenario (Case 1: Simple ABSSSI), 93.1% patient with no signs of systemic infection. Consistent with the and 96.2% of providers selected an oral antibiotic and discharge guidelines, physicians surveyed in our study most commonly home with further instructions, respectively. This case was writ- selected oral therapy in the outpatient setting overall, yet >50% ten to explicitly state that the patient presented with their first of providers chose a regimen that included IV antibiotics for ABSSSI, no systemic inflammatory response syndrome (SIRS), Case 2. Further ASP education, along with implementation of a and no comorbidities. Age was not noted, nor was the pre- clinical pathway, may be helpful to identify appropriate candi- cise size of the lesion, only that it was ≥75 cm . Although both dates for either oral therapy or OPAT (including the use of sin- ≥65  years of age and larger lesion size (ie, 313–367  cm ) were gle-dose, long-acting lipoglycopeptides) and avoid unnecessary significantly associated with hospital admission in 1 study, nei- observation use or hospital admission in these scenarios. ther of these patient factors was listed as a reason for admission Diabetes is among the most common underlying comor- [5]. IDSA guidelines recommend oral therapy in the outpatient bidities present in patients with ABSSSI, existing in 10% of setting for the treatment of a simple skin infection in patients patients presenting with an episode [19]. Patients with diabetes such as Case 1, and it appears that most EM providers surveyed are 3-fold more likely to acquire infection and oen ft have lower would have followed these recommendations [4]. clinical success rates [20]. However, a recent comparison of Case 2 portrayed the same ABSSSI patient described earlier, patients with and without diabetes in the ABSSSI clinical tri- only with a recurrent infection or relapse approximately 30 days als for dalbavancin, a long-acting lipoglycopeptide antibiotic, later. In contrast to Case 1, there was significant variance in observed similarly high success rates aer 14 a ft nd 30 days [21]. treatment strategies for this patient. Oral antibiotic therapy, Case 3 portrayed a patient with stable, controlled diabetes, as Provider Variability in ABSSSI Care • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 opposed to diabetic ketoacidosis or hyperglycemic hyperosmo- use of the most expensive agents to infectious diseases consult lar syndrome, the latter 2 requiring immediate medical inter- service or ASP approval. Treatment schedule and patient adher- vention. Thirty-nine percent of providers chose to administer ence go hand in hand; less frequent dosing increases adherence 1–2 doses of an intravenous antibiotic followed by an oral agent and has been linked to improved outcomes in skin infections to complete therapy; furthermore, roughly half of the provid- [28, 29]. Following patient characteristics (severity of infection, ers selected an oral-only antibiotic regimen. Sixty-three percent comorbidities) and microbiological spectrum of activity (ie, were comfortable discharging the patient home, followed by getting the right antibiotic), the next most important consid- 31.8% admitting the patient to an observation unit. Very few eration was route of administration. Historical practices have providers selected hospital admission with a full intravenous primarily reserved intravenous therapy for patients who were course. We found APPs to be less likely than EM physicians to admitted while utilizing oral therapy in the outpatient setting. prescribe a full oral course for patients with diabetes. Like Case However, the availability of oral antibiotics with excellent bio- 2, further ASP educational efforts could focus on identifying availability, as well as the long-acting, single-dose lipoglyco- appropriate candidates for oral therapy vs OPAT. Furthermore, peptides, clearly defines a paradigm shift in how ABSSSI can be improvements in appropriate antibiotic therapy could have a managed in the ED [26]. beneficial downstream effect on reducing observation status er Th e are several limitations to our study. First, the study use in patients with stable comorbidities who could complete was conducted at 6 EDs throughout the United States; how- therapy as an outpatient. ever, some regional differences in antibiotic use or admission e fin Th al case introduced a patient presenting with 3 of 4 SIRS practices may not be accounted for. Our study was also not criteria, thereby meeting the 2012 Surviving Sepsis Campaign large enough to analyze any site effects for the participating (SSC) definition of sepsis [22]. It should be noted that the providers. Second, our survey questions were not validated in updated 2017 SSC guidelines no longer include SIRS but rather advance, and we did not ask any open-ended questions to iden- add other clinical/laboratory requirements; however, the opti- tify reasons for selections. Although the latter may have helped mal definition of sepsis is under debate, with many practitioners us understand selections, it also may have reduced the number still using SIRS criteria to guide treatment decisions [23–25]. of participants as EM provider time is scarce. As a result, we Based on SIRS alone, the majority of EM providers chose to attempted to encourage participation by balancing collection administer a full intravenous course of antibiotics and admit to of data that broadly reflects influences on treatment decisions an inpatient unit. These responses are largely in agreement with with survey burden. That said, a strength of the abbreviated the providers’ documented highest priority of infection severity case design was that it focused providers’ decisions on what was for influencing factors (Table  3); they are also concordant with different between cases (ie, infection recurrence, diabetes, sep- the IDSA guidelines, which recommend admission for patients sis). Finally, our questions on antibiotic therapy selection did who present with clinical instability [4]. However, 30.5% did not query specific generic drug names or treatment with 1 vs select an observation unit. This may reflect differences in sep- 2 agents (eg, vancomycin plus piperacillin/tazobactam or tri- sis definitions, as well as the aforementioned trend in increased methoprim-sulfamethoxazole plus cephalexin). Nonetheless, admissions to these units. It should be noted that there are mul- we acknowledge that these would be important topics to be tiple noninfectious etiologies of fever, tachycardia, tachypnea, covered in ASP education while expanding on appropriateness and leukocytosis, and a patient may still be a suitable candi- of oral vs intravenous therapies. date for outpatient therapy if he or she has cellulitis, along with known noninfectious causes for positive SIRS criteria with no CONCLUSIONS other signs of organ dysfunction [26]. In the recent, multicenter, This survey study revealed variability in EM provider hypo- double-blind randomized controlled trial comparing single dose thetical decisions for admission and selected route of antibiotic with weekly dalbavancin for ABSSSI, 42.4%–44.4% of partici- therapy in patients presenting with different ABSSSI scenarios. pants had SIRS on presentation, and approximately half of the ASP education efforts should specifically address antibiotic patients were successfully treated completely in the outpatient selection for patients presenting with comorbidities, infec- setting [27]. The identification of OPAT candidates for this sce- tion recurrence/relapse, or sepsis, as there are many treatment nario has the most potential to reduce unnecessary observation strategies that can be considered for an individual patient. The or admission. development of an ABSSSI clinical pathway may also be justi- An interesting observation among the antibiotic characteris- fied to align patient treatment plans and provide decision sup- tics influencing treatment decision was the lower priority given port for ED disposition. to antibiotic cost, treatment schedule (how many times per day the drug is administered), patient adherence, and adverse Acknowledgments events. Lack of concerns over antibiotic cost may reflect current Financial support. This work was supported by Allergan plc (Jersey ASP restrictions in place at these institutions, which may limit City, NJ). 6 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Potential conifl cts of interest. K.R.K.  is a full-time employee of 13. Pallin DJ, Camargo CA Jr, Schuur JD. Skin infections and antibiotic steward- ship: analysis of emergency department prescribing practices, 2007–2010. West Allergan plc and may hold stock or stock options. J.L.K. serves as an advisor J Emerg Med 2014; 15:282–9. and is a member of the speakers’ bureau for Allergan plc. The other authors 14. Morgan SR, Acquisto NM, Coralic Z, et  al. Clinical pharmacy services in the have nothing to disclose. All authors have submitted the ICMJE Form for emergency department. Am J Emerg Med 2018; 36:1727–32. Disclosure of Potential Conflicts of Interest. Conflicts that the editors con- 15. Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: character- sider relevant to the content of the manuscript have been disclosed. istics of patients with “observation status” at an academic medical center. JAMA Intern Med 2013; 173:1991–8. References 16. Claeys KC, Lagnf AM, Patel TB, et  al. Acute bacterial skin and skin structure 1. Pollack CV Jr, Amin A, Ford WT Jr, et al. 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Rising United States hospital admissions lower extremity cellulitis in a population-based cohort. Arch Intern Med 2007; for acute bacterial skin and skin structure infections: recent trends and economic 167:709–15. impact. PLoS One 2015; 10:e0143276. 19. Suaya JA, Eisenberg DF, Fang C, Miller LG. Skin and soft tissue infections and 4. Stevens DL, Bisno AL, Chambers HF, et  al; Infectious Diseases Society of associated complications among commercially insured patients aged 0-64  years America. Practice guidelines for the diagnosis and management of skin and soft with and without diabetes in the U.S. PLoS One 2013; 8:e60057. tissue infections: 2014 update by the Infectious Diseases Society of America. Clin 20. Dryden M, Baguneid M, Eckmann C, et al. Pathophysiology and burden of infec- Infect Dis 2014; 59:e10–52. tion in patients with diabetes mellitus and peripheral vascular disease: focus on 5. Talan DA, Salhi BA, Moran GJ, et al. Factors associated with decision to hospi- skin and soft-tissue infections. Clin Microbiol Infect 2015; 21(Suppl 2):S27–32. talize emergency department patients with skin and soft tissue infection. West J 21. Nowak M, Rappo U, Gonzalez PL, et al. Efficacy and safety of dalbavancin for the Emerg Med 2015; 16:89–97. treatment of acute bacterial skin and skin structure infection (ABSSSI) in patients 6. Sabbaj A, Jensen B, Browning MA, et  al. Soft tissue infections and emergency with diabetes mellitus (Abstract 210). Paper presented at: IDWeek 2017; October department disposition: predicting the need for inpatient admission. Acad Emerg 4–8, 2017; San Diego, CA. Med 2009; 16:1290–7. 22. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and 7. Lane S, Johnston K, Sulham KA, et  al. Identification of patient characteristics guidelines for the use of innovative therapies in sepsis. 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Transitions of care in the management of Methicillin-resistant S.  aureus infections among patients in the emergency acute bacterial skin and skin structure infections: a paradigm shift. Expert Rev department. N Engl J Med 2006; 355:666–74. Clin Pharmacol 2016; 9:1039–45. 10. Almarzoky Abushussain SS, Krawczynski M, Tart S, et al. Patient preferences in 27. Dunne MW, Puttagunta S, Giordano P, et al. A randomized clinical trial of sin- the emergency department (ED) before treatment for acute bacterial skin and gle-dose versus weekly dalbavancin for treatment of acute bacterial skin and skin skin structure infection (ABSSSI) (Abstract 700). Paper presented at: IDWeek structure infection. Clin Infect Dis 2016; 62:545–51. 2017; October 4–8, 2017; San Diego, CA. 28. Llor C, Bayona C, Hernández S, et al. Comparison of adherence between twice- 11. Jenkins TC, Sabel AL, Sarcone EE, et al. Skin and soft-tissue infections requiring and thrice-daily regimens of oral amoxicillin/clavulanic acid. Respirology 2012; hospitalization at an academic medical center: opportunities for antimicrobial 17:687–92. stewardship. Clin Infect Dis 2010; 51:895–903. 29. Eells SJ, Nguyen M, Jung J, et  al. Relationship between adherence to oral anti- 12. May L, Cosgrove S, L’Archeveque M, et al. Antimicrobial stewardship in the emer- biotics and postdischarge clinical outcomes among patients hospitalized with gency department and guidelines for development. Ann Emerg Med 2013;62:69– Staphylococcus aureus skin infections. Antimicrob Agents Chemother 2016; 77.e2. 60:2941–8. Provider Variability in ABSSSI Care • OFID • 7 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education

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Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Open Forum Infectious Diseases MAJOR ARTICLE Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education 1,2 3 4 5 6 7 8 Safa S. Almarzoky Abuhussain, Michelle A. Burak, Danyel K. Adams, Kelsey N. Kohman, Serina B. Tart, Athena L. V. Hobbs, Gabrielle Jacknin, 3,a 9 1 1 Michael D. Nailor, Katelyn R. Keyloun, David P. Nicolau, and Joseph L. Kuti 1 2 3 Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut; Umm Al-Qura University, Makkah, Saudi Arabia; Department of Pharmacy, Hartford Hospital, 4 5 6 Hartford, Connecticut; Department of Pharmacy, Baystate Medical Center, Springfield, Massachusetts; Department of Pharmacy, Baylor University Medical Center, Dallas, Texas; Department 7 8 of Pharmacy, Cape Fear Valley Health, Fayetteville, North Carolina; Department of Pharmacy, Baptist Memorial Hospital-Memphis, Memphis, Tennessee; Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado; Allergan plc, Jersey City, New Jersey Background. Acute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions. Methods. An anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, partic- ipants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision. Results. e s Th urvey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses. Conclusions. Variability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment. Keywords. abscess; antibiotics; cellulitis; education. Acute bacterial skin and skin structure infections (ABSSSIs), total hospitalizations [2, 3]. Guidelines by the Infectious Diseases defined by erythema extending ≥ 75 cm , are frequent and chal- Society of America (IDSA) recommend that many patients with lenging infections associated with high direct and indirect costs ABSSSI can be successfully treated in the outpatient setting with to both the medical system and society [1]. These infections are either oral agents or outpatient parenteral antibiotic therapy responsible for a growing number of emergency department (OPAT) [4]. However, administration of intravenous antibiotics (ED) visits and hospital admissions. Between 2005 and 2010, in 1 study was the sole reason provided for admission in 41.5% more than 3 million patients annually received care for a skin of skin infection patients [5]. Other reported factors associated or skin structure infection in the ED; furthermore, during that with hospital admission include advanced age, fever or clinical time, ABSSSI-related admissions increased from 1.6% to 1.9% of instability on presentation, failure of previous antibiotic therapy, and presence of comorbidities [5–7]. That said, many patients with simple ABSSSI are still admitted to the hospital [8]. Received 8 May 2018; editorial decision 13 August 2018; accepted 16 August 2018. Present affiliation: St. Joseph’s Hospital and Medical Center, Phoenix, Arizona ABSSSIs are most oen c ft aused by Gram-positive cocci, Correspondence: J. L. Kuti, PharmD, FIDP, Center for Anti-Infective Research and Development, including Staphylococcus aureus and Streptococcus spp., and Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 (joseph.kuti@hhchealth.org). ® more rarely by Gram-negatives and anaerobes [1, 4, 9]. Despite Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases this limited list of likely pathogens, antibiotic therapy for Society of America. This is an Open Access article distributed under the terms of the Creative ABSSSIs frequently varies from narrow-spectrum oral agents to Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ empiric administration of a combination of intravenous agents by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work with activity against methicillin-resistant S. aureus (MRSA) and is properly cited. For commercial re-use, please contact journals.permissions@oup.com Pseudomonas aeruginosa (eg, piperacillin/tazobactam) [8, 10]. DOI: 10.1093/ofid/ofy206 Provider Variability in ABSSSI Care • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 As a result, ABSSSI treatment selection is an appropriate target nurses (APRNs) and physician assistants (PAs). Any students for an Antimicrobial Stewardship Program (ASP) intervention or other members of the clinical team (eg, pharmacists, nurses, in the hospital setting, including in the ED [11–14]. Given that etc.) were excluded, and providers who previously participated intravenous antibiotic administration in the ED can be a gateway were not permitted to retake the survey. to hospital admission [5], improved antibiotic choices in the ED Survey Tool for ABSSSI may also reduce unnecessary hospital admission. Eight case-based survey questions were designed to assess treat- ASP interventions in the ED could present unique challenges ment decisions based on the same patient presenting to the ED due to the variety of provider types, rapid patient turnover, and with various clinical scenarios escalating in severity (Table  1) the need for quick treatment decisions. In the absence of a clear from simple ABSSSI (Case 1)  to recurrent infection (Case 2), ABSSSI clinical pathway in the ED or hospital, an understand- concurrent controlled diabetes (Case 3), or sepsis (Case 4). ing of patient factors that influence emergency medicine (EM) Each case was then followed by the same questions pertaining providers to prescribe intravenous therapy or admit a patient to decisions on choice of intravenous vs oral antibiotic treat- with ABSSSI would help to streamline educational efforts as ment and hospital admission. Data were also collected on pro- part of ASP interventions. Herein, we surveyed EM providers vider type, years of experience, and ranking of the following from 6 US EDs using a case-based questionnaire to capture patient/antibiotic characteristics considered important in the their treatment decisions for patients with ABSSSI. treatment of ABSSSI: patient comorbidities, patient severity of METHODS presentation, patient adherence to antibiotic therapy, antibiotic microbiological spectrum of activity, antibiotic cost, antibiotic Study Design treatment schedule, antibiotic route of administration, and anti- This was a multicenter study conducted in 6 EDs across the biotic adverse event profile. Finally, providers were asked how United States. Participating centers included Hartford Hospital often they engaged patients directly and involved them in their (Hartford, CT), Cape Fear Valley Medical Center (Fayetteville, preferences for ABSSSI treatment. NC), Baylor University Medical Center at Dallas (Baylor, TX), University of Colorado Hospital (Aurora, CO), Baptist Analyses Memorial Hospital–Memphis (Memphis, TX), and Baystate Survey results were descriptively reported as the proportion Medical Center (Springfield, MA). The study was approved of participants selecting each response for each question. The by the institutional review board at each participating hospi- ranking of specific antibiotic/patient characteristic importance tal. A  short 12-item anonymous survey was administered to was based on the mode score from 1 (most important) to 8 local ED providers. By completing the survey, providers were (least important). Questions with no response were included giving permission to participate in the study. No Protected by adjusting the denominator of each individual question, as Health Information was collected. Questionnaires were distrib- required. Responses to cases were assessed by provider type uted by the clinical ED or ASP pharmacists at each institution (MD vs APP) and years of clinical practice experience (>5 years over a 6-month time period between December 2016 and May vs ≤ 5 years). Odds ratios with 95% confidence intervals (CIs) 2017; this was frequently done at monthly department meet- were generated to compare survey results by provider type and ings. Eligible providers included EM physicians, including MD/ years of clinical practice experience. All analyses were per- DO attendings, residents, or fellows, as well as advanced prac- formed in Sigma Plot, version 13.0 (Systat Software Inc., San tice providers (APPs), including advanced practice registered Jose, CA). Table 1. Case-Based Survey Questions to EM Providers Survey Questions and Answer Case Description Options How would you treat this patient? Case 1: Simple ABSSSI An adult patient presents to the ED with cellulitis on the lower leg, where a. An oral antibiotic the lesion size is ≥75 cm (larger than the average cell phone). The patient b. 1–2 doses of IV antibiotic followed is afebrile, has a normal white blood cell count, and has no comorbidities; by an oral antibiotic this is their first ABSSSI presentation. c. A full IV antibiotic course Case 2: Recurrent ABSSSI After completing treatment as outlined above, the patient returns to the ED Where would you send this patient? approximately 30 days later with a second ABSSSI episode at the same a. Admit to inpatient unit site. b. Admit to observation unit Case 3: Controlled diabetes Assume the patient described in Case 1, presenting with first episode of c. Discharge the patient home with ABSSSI, has insulin-dependent but controlled diabetes. further instructions Case 4: Septic patient Assume the patient described in Case 1 presenting with a first episode of ABSSSI is tachycardic, febrile, and has a white blood cell count of 15 000 cells/microliter. Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; ED, emergency department; EM, emergency medicine; IV, intravenous. 2 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 RESULTS (34.6%) of the remaining respondents. Participants reported less than 1 year (20, 15.4%), 1–5 years (58, 44.6%), >5–10 years Providers (16, 12.3%), and >10 years (36, 27.7%) of experience. Out of a total of 443 EM providers employed in the 6 partici- pating EDs at time of the study, 130 (29.3%) completed the sur- Survey Responses vey. The numbers of providers included by site were as follows: Participant choices for admission and intravenous vs oral anti- n = 30 (Hartford, CT), n = 26 (Baystate, MA), n = 23 (Baylor, biotic therapy for cases are presented in Figure  1. Variability TX), n  =  19 (Cape Fear, NC), n  =  17 (Baptist-Memphis, TN), in responses for recommended treatment and disposition was and n = 15 (Univ. Colorado, CO). All providers answered every observed for the recurrent ABSSSI and controlled diabetes survey question, except for Case 3 (n = 129), Case 4 (n = 128), cases, and less so for the septic patient. The least variability was and the question about engaging patients in antibiotic pref- observed for the simple ABSSSI case, with most providers dis- erence (n  =  125). Physicians accounted for the majority of charging the patient home on oral antibiotic therapy. Notably, respondents (85, 65.4%), with 51 (39.2%) listed as attendings 34 (40%) and 51 (60%) providers chose to give 1–2 intravenous and 34 (26.2%) as residents or fellows. APPs accounted for 45 doses in the ED and discharge the patient on oral therapy for the Recommended Antibiotic Treatment 4.7 29.7 48.5 53.5 93.1 32.2 65.6 38.8 5.4 10 19.2 7.8 1.5 Case 1: Simple ABSSSI Case 2: Recurrent ABSSSI Case 3: Controlled Case 4: Septic Patient Diabetes A full IV antibiotic course 1–2 doses of IV antibiotic followed by an oral antibiotic An oral antibiotic Recommended Patient Disposition 3.9 51.5 62.8 96.2 30.5 39.2 67.2 31.8 3.1 9.2 0.8 5.4 Case 1: Simple ABSSSI Case 2: Recurrent ABSSSI Case 3: Controlled Case 4: Septic Patient Diabetes Discharge the patient home with further instructions Admit to observation unit Admit to inpatient unit Figure 1. Percentage of providers selecting each response for the 4 cases. Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; IV, intravenous. Provider Variability in ABSSSI Care • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 recurrent ABSSSI and controlled diabetes cases, respectively. treatment decision-making process), 7 (5.6%), 36 (28.8%), 61 Comparisons in responses by type of provider and experience (48.8%), and 21 (16.8%) indicated always, frequently, rarely, and level are provided in Table 2. Compared with PHYs, APPs were never, respectively. The rank order of the 8 factors influencing 2.59 (95% CI, 1.23–5.47) times more likely to select 1–2 doses providers’ antibiotic treatment decisions is provided in Table 3. of IV antibiotic followed by oral therapy for the controlled dia- DISCUSSION betes case; APPs were also 56% (95% CI, 0.07–0.79) less likely to choose oral antibiotics for this case. For the septic case, APPs Despite guidelines supporting transitions of care to outpa- were 2.19 (95% CI, 1.01–4.74) times more likely to choose to tient treatment for low-risk patients with ABSSSI, observa- admit the septic patient to an inpatient unit. There was no dif- tional studies indicate that providers couple hospitalization ference in responses by years of experience. with administration of parenteral antibiotics, regardless of the When queried about how oen p ft roviders asked patients absence of need for other services that can only be provided in about their antibiotic preference (ie, involving patients in the the hospital and availability of outpatient intravenous antibiotic Table 2. Case Scenario Answers by EM Provider Type and Experience EM Provider Type Experience in Years PHY APP ≤5 >5 Cases and Answer Options n = 85 n = 45 OR (95% CI) n = 78 n = 52 OR (95% CI) Case 1: Simple ABSSSI Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 4 (4.7) 3 (6.7) 1.45 (0.31–6.76) 3 (3.8) 4 (7.7) 2.08 (0.45–9.72) A full IV antibiotic course 1 (1.2) 1 (2.2) 1.91 (0.12–31.26) 0 2 (3.9) N/A An oral antibiotic 80 (94.1) 41 (91.1) 0.64 (0.16–2.52) 75 (96.2) 46 (88.5) 0.31 (0.07–1.29) Patient disposition Admit to observation unit 3 (3.5) 1 (2.2) 0.62 (0.06–6.15) 3 (3.8) 1 (1.9) 0.49 (0.05–4.86) Admit to inpatient unit 0 1 (2.2) N/A 0 1 (1.9) N/A Discharge home 82 (96.5) 43 (95.6) 0.79 (0.13–4.89) 75 (96.2) 50 (96.2) 1.00 (0.16–6.20) Case 2: Recurrent ABSSSI Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 25 (29.4) 17 (37.8) 1.46 (0.68–3.12) 29 (37.2) 13 (25.0) 0.56 (0.26–1.23) A full IV antibiotic course 17 (20.0) 8 (17.8) 0.86 (0.34–2.19) 12 (15.4) 13 (25.0) 1.83 (0.76–4.41) An oral antibiotic 43 (50.6) 20 (44.4) 0.78 (0.38–1.61) 37 (47.4) 26 (50.0) 1.11 (0.55–2.24) Patient disposition Admit to observation unit 32 (37.7) 19 (42.2) 1.21 (0.58–2.53) 29 (37.2) 22 (42.3) 1.24 (0.61–2.54) Admit to inpatient unit 10 (11.8) 2 (4.4) 0.35 (0.07–1.67) 8 (10.3) 4 (7.7) 0.73 (0.21–2.56) Discharge home 43 (50.6) 24 (53.3) 1.12 (0.54–2.30) 41 (52.6) 26 (50.0) 0.90 (0.45–1.82) Case 3: Controlled diabetes Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 26 (30.6) 24 (54.6) 2.59 (1.23–5.47) 34 (43.6) 16 (31.4) 0.58 (0.27–1.21) A full IV antibiotic course 8 (9.4) 2 (4.6) 0.45 (0.09–2.20) 7 (9.0) 3 (5.9) 0.62 (0.15–2.52) An oral antibiotic 51 (60.0) 18 (40.9) 0.44 (0.21–0.93) 37 (47.4) 32 (62.8) 1.77 (0.87–3.62) Patient disposition Admit to observation unit 26 (30.6) 15 (34.1) 1.13 (0.52–2.46) 26 (33.8) 15 (28.9) 0.81 (0.38–1.74) Admit to inpatient unit 6 (7.1) 1 (2.3) 0.30 (0.03–2.57) 5 (6.5) 2 (3.9) 0.58 (0.11–3.13) Discharge home 53 (62.4) 28 (63.6) 0.99 (0.47–2.10) 46 (59.7) 35 (67.3) 1.43 (0.69–2.99) Case 4: Septic patient Recommended treatment 1–2 doses of IV antibiotic followed by oral antibiotic 28 (33.3) 10 (22.7) 0.58 (0.25–1.34) 20 (26.3) 18 (34.6) 1.54 (0.71–3.30) A full IV antibiotic course 50 (59.5) 34 (77.3) 2.16 (0.97–4.84) 54 (71.1) 30 (57.7) 0.61 (0.29–1.26) An oral antibiotic 6 (7.1) 0 N/A 2 (2.6) 4 (7.7) 3.17 (0.56–17.96) Patient disposition Admit to observation unit 27 (31.8) 12 (26.7) 0.78 (0.35–1.74) 20 (25.6) 19 (36.5) 1.67 (0.78–3.57) Admit to inpatient unit 54 (63.5) 32 (71.1) 2.19 (1.01–4.74) 56 (71.8) 30 (57.7) 0.54 (0.26–1.12) Discharge home 4 (4.7) 1 (2.2) 0.94 (0.17–5.35) 2 (2.6) 3 (5.8) 2.33 (0.38–14.43) All data are number (%) and odds ratio with 95% confidence interval of the difference between APP vs PHY and >5 years’ vs ≤5 years’ experience.  Abbreviations: ABSSSI, acute bacterial skin and skin structure infection; APP, advanced practice provider; CI, confidence interval; EM, emergency medicine; IV, intravenous; OR, odds ratio; PHY, physician. 4 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Table  3. Rank Order of Factors Influencing Provider Decisions When intravenous followed by oral therapy, and full intravenous Selecting Antibiotics for Treatment of ABSSSI courses were selected by 48.5%, 32.2%, and 19.9% of providers, respectively. Discharge home was selected in 51.5%, followed by Factor Mode admission to an observation unit in 39.2%. The frequent selec- Severity of infection presentation 1 tion of the observation unit is supported by a growing trend Presence of patient comorbidities 2 in this strategy among Medicare beneficiaries [15]. However, Microbiological spectrum of activity 3 in practice, ABSSSI is not a common diagnosis in medical or Route of administration 4 Patient adherence 5 surgical observation units. In a single-center study of ABSSSI Adverse event profile 5 patients receiving intravenous antibiotics for less than 24 Antibiotic treatment schedule 6 hours, 28.7% were sent to the observational unit. Notably, these Antibiotic cost 8 patients more frequently had comorbid conditions and met cri- Ranked by mode (1 = most important; 8 = least important). teria for SIRS, which were not characteristics described in Case Abbreviation: ABSSSI, acute bacterial skin and skin structure infection. 2 in our study [16]. In the study by Talan and colleagues, failure of prior anti- strategies [5, 8, 10]. The purpose of this study was to identify biotic therapy was significantly associated with admission EM provider treatment hypothetical choices for hospital admis- to the hospital (present in 16% of admissions vs 6.0% of dis- sion and route of antibiotic administration based on escalating charges) but was not directly listed by physicians as a reason clinical scenarios commonly observed in patients with ABSSSI. for admission [7]. An important distinction here may be the In brief, we observed good agreement in treatment strategies difference between treatment “failure” and “recurrence/relapse.” for ABSSSI patients first presenting with simple cellulitis but Recurrence/relapse is generally accepted as cellulitis that has variability in provider selections when ABSSSI patients pre- improved aer ft completing a course of antibiotics but that sub- sented with infection recurrence, controlled diabetes, or sepsis. sequently reappeared, whereas treatment failure is clinically With few exceptions, the type of provider and experience level accepted as lack of improvement during the course of antibiot- did not significantly influence the choices. These observations ics. Treatment failure, from a clinical perspective, is unlikely to could prove useful in targeting ASP education efforts to EM occur 30 days out from presentation as antibiotic therapy would providers or when developing a clinical pathway in the ED for have been completed well before then. Patients with previous treatment of patients with ABSSSI. cellulitis may have annual recurrence rates as high as 20% [17, As noted previously, common reasons for hospital admission 18]. A number of factors including edema, venous insufficiency, of patients with ABSSSI include advanced age, clinical instability, tinea pedis, unresolved or past trauma, obesity, tobacco use, the presence of certain comorbidities, recurrence or reinfection, cancer, and homelessness can all contribute to infection recur- and provider perception that these infections require intrave- rence; therefore, IDSA guidelines recommend evaluation of nous therapy [5–7]. We are not aware of any other studies in the risks and resolution of these factors in addition to oral penicillin literature that have directly measured EM provider hypothet- or monthly injections with intramuscular penicillin [4]. These ical decisions in the treatment of ABSSSI. Beginning with the treatments can be accomplished in the outpatient setting for a simple cellulitis case scenario (Case 1: Simple ABSSSI), 93.1% patient with no signs of systemic infection. Consistent with the and 96.2% of providers selected an oral antibiotic and discharge guidelines, physicians surveyed in our study most commonly home with further instructions, respectively. This case was writ- selected oral therapy in the outpatient setting overall, yet >50% ten to explicitly state that the patient presented with their first of providers chose a regimen that included IV antibiotics for ABSSSI, no systemic inflammatory response syndrome (SIRS), Case 2. Further ASP education, along with implementation of a and no comorbidities. Age was not noted, nor was the pre- clinical pathway, may be helpful to identify appropriate candi- cise size of the lesion, only that it was ≥75 cm . Although both dates for either oral therapy or OPAT (including the use of sin- ≥65  years of age and larger lesion size (ie, 313–367  cm ) were gle-dose, long-acting lipoglycopeptides) and avoid unnecessary significantly associated with hospital admission in 1 study, nei- observation use or hospital admission in these scenarios. ther of these patient factors was listed as a reason for admission Diabetes is among the most common underlying comor- [5]. IDSA guidelines recommend oral therapy in the outpatient bidities present in patients with ABSSSI, existing in 10% of setting for the treatment of a simple skin infection in patients patients presenting with an episode [19]. Patients with diabetes such as Case 1, and it appears that most EM providers surveyed are 3-fold more likely to acquire infection and oen ft have lower would have followed these recommendations [4]. clinical success rates [20]. However, a recent comparison of Case 2 portrayed the same ABSSSI patient described earlier, patients with and without diabetes in the ABSSSI clinical tri- only with a recurrent infection or relapse approximately 30 days als for dalbavancin, a long-acting lipoglycopeptide antibiotic, later. In contrast to Case 1, there was significant variance in observed similarly high success rates aer 14 a ft nd 30 days [21]. treatment strategies for this patient. Oral antibiotic therapy, Case 3 portrayed a patient with stable, controlled diabetes, as Provider Variability in ABSSSI Care • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 opposed to diabetic ketoacidosis or hyperglycemic hyperosmo- use of the most expensive agents to infectious diseases consult lar syndrome, the latter 2 requiring immediate medical inter- service or ASP approval. Treatment schedule and patient adher- vention. Thirty-nine percent of providers chose to administer ence go hand in hand; less frequent dosing increases adherence 1–2 doses of an intravenous antibiotic followed by an oral agent and has been linked to improved outcomes in skin infections to complete therapy; furthermore, roughly half of the provid- [28, 29]. Following patient characteristics (severity of infection, ers selected an oral-only antibiotic regimen. Sixty-three percent comorbidities) and microbiological spectrum of activity (ie, were comfortable discharging the patient home, followed by getting the right antibiotic), the next most important consid- 31.8% admitting the patient to an observation unit. Very few eration was route of administration. Historical practices have providers selected hospital admission with a full intravenous primarily reserved intravenous therapy for patients who were course. We found APPs to be less likely than EM physicians to admitted while utilizing oral therapy in the outpatient setting. prescribe a full oral course for patients with diabetes. Like Case However, the availability of oral antibiotics with excellent bio- 2, further ASP educational efforts could focus on identifying availability, as well as the long-acting, single-dose lipoglyco- appropriate candidates for oral therapy vs OPAT. Furthermore, peptides, clearly defines a paradigm shift in how ABSSSI can be improvements in appropriate antibiotic therapy could have a managed in the ED [26]. beneficial downstream effect on reducing observation status er Th e are several limitations to our study. First, the study use in patients with stable comorbidities who could complete was conducted at 6 EDs throughout the United States; how- therapy as an outpatient. ever, some regional differences in antibiotic use or admission e fin Th al case introduced a patient presenting with 3 of 4 SIRS practices may not be accounted for. Our study was also not criteria, thereby meeting the 2012 Surviving Sepsis Campaign large enough to analyze any site effects for the participating (SSC) definition of sepsis [22]. It should be noted that the providers. Second, our survey questions were not validated in updated 2017 SSC guidelines no longer include SIRS but rather advance, and we did not ask any open-ended questions to iden- add other clinical/laboratory requirements; however, the opti- tify reasons for selections. Although the latter may have helped mal definition of sepsis is under debate, with many practitioners us understand selections, it also may have reduced the number still using SIRS criteria to guide treatment decisions [23–25]. of participants as EM provider time is scarce. As a result, we Based on SIRS alone, the majority of EM providers chose to attempted to encourage participation by balancing collection administer a full intravenous course of antibiotics and admit to of data that broadly reflects influences on treatment decisions an inpatient unit. These responses are largely in agreement with with survey burden. That said, a strength of the abbreviated the providers’ documented highest priority of infection severity case design was that it focused providers’ decisions on what was for influencing factors (Table  3); they are also concordant with different between cases (ie, infection recurrence, diabetes, sep- the IDSA guidelines, which recommend admission for patients sis). Finally, our questions on antibiotic therapy selection did who present with clinical instability [4]. However, 30.5% did not query specific generic drug names or treatment with 1 vs select an observation unit. This may reflect differences in sep- 2 agents (eg, vancomycin plus piperacillin/tazobactam or tri- sis definitions, as well as the aforementioned trend in increased methoprim-sulfamethoxazole plus cephalexin). Nonetheless, admissions to these units. It should be noted that there are mul- we acknowledge that these would be important topics to be tiple noninfectious etiologies of fever, tachycardia, tachypnea, covered in ASP education while expanding on appropriateness and leukocytosis, and a patient may still be a suitable candi- of oral vs intravenous therapies. date for outpatient therapy if he or she has cellulitis, along with known noninfectious causes for positive SIRS criteria with no CONCLUSIONS other signs of organ dysfunction [26]. In the recent, multicenter, This survey study revealed variability in EM provider hypo- double-blind randomized controlled trial comparing single dose thetical decisions for admission and selected route of antibiotic with weekly dalbavancin for ABSSSI, 42.4%–44.4% of partici- therapy in patients presenting with different ABSSSI scenarios. pants had SIRS on presentation, and approximately half of the ASP education efforts should specifically address antibiotic patients were successfully treated completely in the outpatient selection for patients presenting with comorbidities, infec- setting [27]. The identification of OPAT candidates for this sce- tion recurrence/relapse, or sepsis, as there are many treatment nario has the most potential to reduce unnecessary observation strategies that can be considered for an individual patient. The or admission. development of an ABSSSI clinical pathway may also be justi- An interesting observation among the antibiotic characteris- fied to align patient treatment plans and provide decision sup- tics influencing treatment decision was the lower priority given port for ED disposition. to antibiotic cost, treatment schedule (how many times per day the drug is administered), patient adherence, and adverse Acknowledgments events. Lack of concerns over antibiotic cost may reflect current Financial support. This work was supported by Allergan plc (Jersey ASP restrictions in place at these institutions, which may limit City, NJ). 6 • OFID • Almarzoky Abuhussain et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/10/ofy206/5123346 by Ed 'DeepDyve' Gillespie user on 16 October 2018 Potential conifl cts of interest. K.R.K.  is a full-time employee of 13. Pallin DJ, Camargo CA Jr, Schuur JD. Skin infections and antibiotic steward- ship: analysis of emergency department prescribing practices, 2007–2010. West Allergan plc and may hold stock or stock options. J.L.K. serves as an advisor J Emerg Med 2014; 15:282–9. and is a member of the speakers’ bureau for Allergan plc. The other authors 14. Morgan SR, Acquisto NM, Coralic Z, et  al. Clinical pharmacy services in the have nothing to disclose. All authors have submitted the ICMJE Form for emergency department. Am J Emerg Med 2018; 36:1727–32. Disclosure of Potential Conflicts of Interest. Conflicts that the editors con- 15. Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: character- sider relevant to the content of the manuscript have been disclosed. istics of patients with “observation status” at an academic medical center. JAMA Intern Med 2013; 173:1991–8. References 16. Claeys KC, Lagnf AM, Patel TB, et  al. Acute bacterial skin and skin structure 1. Pollack CV Jr, Amin A, Ford WT Jr, et al. 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Factors associated with decision to hospi- skin and soft-tissue infections. Clin Microbiol Infect 2015; 21(Suppl 2):S27–32. talize emergency department patients with skin and soft tissue infection. West J 21. Nowak M, Rappo U, Gonzalez PL, et al. Efficacy and safety of dalbavancin for the Emerg Med 2015; 16:89–97. treatment of acute bacterial skin and skin structure infection (ABSSSI) in patients 6. Sabbaj A, Jensen B, Browning MA, et  al. Soft tissue infections and emergency with diabetes mellitus (Abstract 210). Paper presented at: IDWeek 2017; October department disposition: predicting the need for inpatient admission. Acad Emerg 4–8, 2017; San Diego, CA. Med 2009; 16:1290–7. 22. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and 7. Lane S, Johnston K, Sulham KA, et  al. Identification of patient characteristics guidelines for the use of innovative therapies in sepsis. 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Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Oct 1, 2018

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