Infection Control & Hospital Epidemiology
SSTI/bite associated encounters in 2014: 27,413
937
Excluded: 11,317
Met inclusion criteria: 16,096
Exclusion criteria (may have > 1 per encounter): 1. Complex chronic medical condition (155) 2. Concomitant infectious diagnosis (2,311) 3. Antibiotic treatment in previous 30 days (4,386) 4. SSTI/bite encounter in previous 30 days (7,560)
Encounters with associated systemic antibiotics: 10,394 (64.6%)
Encounters with associated systemic antibiotics and complete data available: 10,310 (64.0%)
Fig. 1. Online. Encounters for children with skin/soft tissue infection and/or animal bites included in the analysis.
online). Visits included were office visits, emergency department visits, and other outpatient facility claims. No inpatient claims were included. To minimize potential confounding variables, we included encounters only if the patient had not received anti- biotics in the previous 30 days, did not have another SSTI encounter in the previous 30 days, and did not have a complex chronic condition8 or a concomitant presumed infectious diag- nosis listed on the medical claim (Table 1 online). From phar- macy claims, we identified antibiotics (excluding topical and inhaled formulations) dispensed within 3 days following the medical encounter. If antibiotics were dispensed on multiple days within the 3-day period, only those on the earliest dispense date were included in the analysis. The reason for antibiotic treatment was inferred from the primary and secondary International Classification of Disease Ninth Revision (ICD-9) codes listed on the medical claim. The national provider identification number listed on the pharmacy prescription claim indicated the specialty of the prescriber. Specialties were grouped as follows: pediatric medicine (primary care or subspecialty), family medicine, nurse practitioner, physician assistant, emergency medicine, or other. The pharmacy claims also included the duration of treatment as described by the retail pharmacists. Encounter diagnoses were grouped into 1 of 2 subcategories: SSTI (cellulitis/abscess or impetigo/folliculitis) or presumed animal bite (Table 1 online).
Long Duration and Non–First-Line Treatment Definition
We defined a long treatment duration for SSTIs and presumed animal bites as >7 days. In accordance with national guidelines, non–first-line therapy for SSTIs was defined as dispensation of 2 unique antibiotics on the same calendar day or any treatment other than amoxicillin, amoxicillin-clavulanate, clindamycin, a penicillinase resistant penicillin, tetracyclines, trimethoprim-sulfamethoxazole, or a first-generation cephalosporin.9,10 Among encounters for presumed animal bites, any treatment other than amoxicillin-clavulanate or the combination of clindamycin plus trimethoprim-sulfamethoxazole was considered non–first-line treatment.
Statistical Analyses
To identify the factors associated with the outcomes of long treatment duration or non–first-line choice of treatment, we assessed univariate logistic regression models, followed by mul- tivariable logistic regression models, with the multivariable model including relevant demographic, clinical, and/or statistically sig- nificant factors in univariate analyses. The 2 models were per- formed for (1) long treatment duration, and (2) non–first-line antimicrobial choice. Patient age (0–2, 3–5, and ≥6 years), pre- scriber type, category of diagnosis, and patient county of resi- dence characteristics were included as covariates. County characteristics included the metropolitan versus rural area des- ignation of the US Department of Health and Human Services Office of Rural Health Policy (
https://www.hrsa.gov/sites/default/ files/ruralhealth/resources/forhpeligibleareas.pdf) and poverty rate (percent of children aged <18 years living in poverty in 2014) from the US Census Bureau Small Area Income and Poverty Estimates (SAIPE).11 Counties with poverty rates greater than the median in the cohort (>25%) were defined as high poverty. Age categories were chosen a priori in accordance with a prior analysis of overall antimicrobial prescribing in the same cohort in 2014.12 Results were considered statistically significant for 2-sided P<.05 for univariate and multivariable analyses. All analyses were con- ducted using SAS version 9.4 software (SAS Institute, Cary, NC). Model assumptions were verified using Hosmer-Lemeshow tests and residual plots.
Results
In total, 10,394 encounters were associated with 10,450 unique antimicrobial prescriptions dispensed within 3 days that met inclusion criteria for SSTI and/or animal bite in 2014. Analysis was limited to 10,310 encounters due to incomplete data (eg, missing provider type and/or county of residence). Among these included encounters, 7,344 (71.2%) had codes indicating cellulitis/ abscess; 2,445 (23.7%) had codes indicating impetigo/folliculitis
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