Infection Control & Hospital Epidemiology (2018), 39, 936–940 doi:10.1017/ice.2018.124


Original Article


Outpatient antimicrobial stewardship targets for treatment of skin and soft-tissue infections


Preeti Jaggi MD1, Ling Wang PhD, MPH2, Sean Gleeson MD, MBA3, Melissa Moore-Clingenpeel MA, MAS4 and Joshua R. Watson MD3 1Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia, 2Nationwide Children’s Hospital, Partners for Kids, Columbus,


Ohio, 3Department of Pediatrics, The Ohio State University, Nationwide Children’s Hospital, Partners for Kids, Columbus, Ohio and 4Biostatistics Core, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio


Abstract


Objective: We sought to identify factors associated with long duration and/or non–first-line choice of treatment for pediatric skin and soft- tissue infections (SSTIs). Design: Retrospective cohort study. Setting: Ambulatory encounter claims of Medicaid-insured children lacking chronic medical conditions treated for SSTI and/or animal bite injury in Ohio in 2014. Methods: For all diagnoses, long treatment duration was defined as treatment >7 days. Non–first-line choice of treatment for SSTI included treatment with 2 antimicrobials dispensed on the same calendar day or any treatment not listed in the Infectious Diseases Society of America guidelines. The adjusted odds of (1) long treatment duration and (2) non–first-line choice of treatment were calculated for patient age, prescriber type, and patient county of residence characteristics (ie, rural vs metropolitan area and poverty rate). Results: Of 10,310 encounters with complete data available, long treatment duration was prescribed in 7,968 (77.3%). The most common duration of treatment prescribed was 10 days. A non–first-line choice was prescribed in 1,030 encounters (10%). Dispensation of 2 antimicrobials on the same calendar day was the most common reason for the non–first-line choice, and of these, trimethoprim- sulfamethoxazole plus a first-generation cephalosporin was the most common regimen. Compared to pediatricians, the adjusted odds ratio of long treatment duration was significantly lower for all other primary care specialties. Conversely, nonpediatricians were more likely to prescribe a non–first-line treatment choice. Patient residence in a high-poverty county increased the odds of both long duration and non–first-line choice of treatment. Conclusions: Healthcare claims may be utilized to measure opportunities for first-line choice and/or shorter duration of treatment for SSTI.


(Received 1 March 2018; accepted 2 May 2018; electronically published July 2, 2018)


In 2015, the National Action Plan for Combating Antibiotic- Resistant Bacteria set the goal of reducing inappropriate antibiotic use in outpatient settings by 50%by 2020.1 Stewardship efforts with feedback on prescribing patterns have focused primarily on respiratory conditions2 and have been shown to successfully decrease inappropriate prescribing. After respiratory infections,3 skin and soft-tissue infections (SSTIs) are the next most common diagnoses associated with antimicrobial prescribing among pedia- tric outpatients, accounting for 11.9% of antibiotic prescriptions.4,5 The burden of inappropriate prescribing and/or excessive days of therapy for these infections is still not completely clear. Recent


Author for correspondence: Preeti Jaggi, MD, Department of Pediatrics, Emory


University School of Medicine and Children’s Healthcare of Atlanta, 2015 Uppergate Drive, NE, Rm. 504A, Atlanta, GA, 30322. E-mail: preeti.jaggi@emory.edu or Joshua R. Watson, MD, Division of Infectious Diseases, Department of Pediatrics, The Ohio State University, Nationwide Children’s Hospital, Partners for Kids, 700 Children’s Drive, Columbus, OH 43205. E-mail: joshua.watson@nationwidechildrens.org


Cite this article: Jaggi P, et al. (2018). Outpatient antimicrobial stewardship targets


for treatment of skin and soft-tissue infections. Infection Control & Hospital Epidemiology 2018, 39, 936–940. doi: 10.1017/ice.2018.124


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


quality improvement strategies have shown that shorter courses of therapy (≤7 days) for inpatients with SSTIs did not result in read- missions or poor outcomes.6 This finding highlights an important stewardship opportunity that may be extrapolated to the outpatient setting. The objective of this study was to utilize healthcare claims data to examine factors associated with long duration and/or non–first-line choice of antibiotic treatment for pediatric outpatient SSTI. We also examined animal bites as another skin and soft- tissue–related indication for antibiotic therapy.


Methods


As previously described,7 we analyzed healthcare claims of chil- dren aged 0–18 years in 2014 from Partners for Kids, an accountable care organization serving ~330,000 Medicaid managed-care children in central and southeastern Ohio. The treatment provided to these children included multiple institu- tions as well as community providers in both academic and nonacademic settings. From medical claims, we identified an outpatient encounter for SSTI or presumed animal bite (Figure 1


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