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Table 1. Factors Associated with Long Treatment Duration and Non–First-Line Choice of Treatment for Skin and Soft-Tissue Infections and Presumed Animal Bites
Long Duration Non–First-Line Choice aOR (95% CI)a P Value aOR (95% CI)a P Value
County of residence Rural
0.71 (0.586–0.848) .0002 1.73 (1.352–2.219) <.0001
High Poverty 1.45 (1.207–1.747) <.0001 1.23 (0.962–1.571) .0987 Prescriber type
Pediatric medicine
Referent Referent
Emergency medicine 0.37 (.317–0.423) <.0001 3.14 (2.549–3.868) <.0001
Family medicine 0.43 (0.368–0.507) <.0001 2.77 (2.212–3.469) <.0001 Nurse practitioner 0.64 (0.546–0.752) <.0001 1.82 (1.452–2.291) <.0001
Physician assistant
Other
Facility charge onlyb
Age, y 0–2 3–5 ≥6
Type of infection
Presumed animal bite 0.41 (0.255–0.682) .0005 2.05 (1.145–3.66) .0157
Impetigo/ folliculitis
Cellulitis/ abscess
1.25 (0.798–1.973) .3256 1.54 (0.931–2.547) .0925 1.05 (0.663–1.673) .8253 2.22 (1.314–3.747) .0029
Note. aOR, adjusted odds ratio; CI, confidence interval. aAdjusted odds ratios presented account for all factors listed in the model (all are listed in
the table). bA facility, rather than a specific prescriber, was listed on the pharmacy claim. Most facility charges only are in an emergency department setting.
(some encounters had codes for both); and 660 (6.4%) had codes indicating presumed animal bites. For 90% of the encounters, the prescriber type was pediatric medicine, family medicine, nurse practitioner, physician assistant, or emergency medicine. Median patient age was 7 years (IQR, 3–13 years); 4,175 (40.5%) resided in a high-poverty county; and 4,269 (41.4%) resided in a rural county. The most commonly prescribed antimicrobials were trimethoprim-sulfamethoxazole (n=3,318, 32.2%), cephalexin (n=3009, 29.2%), amoxicillin-clavulanate (n=1,312, 12.7%), and clindamycin (n=1,282, 12.4%).
Duration of Treatment
A long duration treatment was prescribed in association with 7,968 encounters (77.3%). The most common duration of therapy
0.37 (0.313–0.448) <.0001 2.81 (2.182–3.627) <.0001 0.33 (0.275–0.404) <.0001 2.34 (1.766–3.098) <.0001
0.36 (0.277–0.456) <.0001 1.42 (0.887–2.282) .1431 Referent Referent
0.91 (0.776–1.074) .2717 1.21 (0.95–1.534) .1231 0.67 (0.592–0.762) <.0001 1.66 (1.378–1.994) <.0001
Preeti Jaggi et al
was 10 days (7,240 encounters, 70.2% of the cohort), and ≤7 days of treatment was prescribed in 2,356 encounters (22.7%). The results from our multivariable analysis are presented in Table 1. Factors that decreased the odds of long treatment duration included (1) residence in a rural county (aOR, 0.71 [95% CI, 0.59– 0.85] compared to metropolitan county), (2) nonpediatrician prescribers (aORs all significantly lower than for pediatric med- icine), (3) age ≥6 years (aOR, 0.67 [95% CI, 0.59–0.76] compared to age 0–2 years), and (4) diagnosis of presumed animal bite (aOR, 0.41; 95% CI, 0.26–0.68).
Choice of Treatment
Non–first-line treatment choices were prescribed in 1,030 encounters (10.0%). Among these, dispensation of 2 antibiotics on the same calendar day was the most common reason (n=612, 59.4%), and the most common combination therapy dispensed was trimethoprim-sulfamethoxazole and a first-generation cepha- losporin (n=480). Patients aged 6 years and older and patients seen by nonpediatricians were more likely to receive a non–first-line antibiotic choice. According to Table 1, cellulitis/abscess was asso- ciated with greater odds of non-first-line antibiotic, not impetigo/ folliculitis.
Discussion
We utilized healthcare claims to define possible outpatient anti- microbial stewardship targets for children with SSTI or animal bites. These data indicate that monitoring for duration of treat- ment for such infections and for antibiotic choice, specifically the combination of trimethoprim-sulfamethoxazole and a first- generation cephalosporin, could be considered. We chose to define >7 days as a long duration of treatment for
SSTI based on national guidelines, prospective studies, and studies that have utilized quality improvement methodology. The Infec- tious Diseases Society of America guidelines9,10 recommend 7 days of treatment for impetigo, 5 days of treatment for uncomplicated cellulitis based on a prospective study,13 and 7–10 days for purulent cellulitis. Treatment for SSTI in 2 large prospective trials showed higher rates of clinical cure when adding an antimicrobial agent after drainage for those with purulent cellulitis,14,15 and in one of these trials, 7 days of treatment with trimethoprim- sulfamethoxazole after skin drainage resulted in a high rate of clinical cure.15 Some pediatric data suggest that even shorter courses of 3 days of treatment may be sufficient for drained purulent cellulitis in children with documented methicillin- susceptible Staphylococcus aureus.16 In addition, Schuler et al6 used quality improvement methodology in hospitalized pediatric patients with SSTIs and demonstrated that increasing the per- centage of children treated with shorter total durations of anti- microbials (≤7 days) for uncomplicated SSTIs was not associated with readmissions or documented recurrences. Although the American Academy of Pediatrics Red Book recommends only 3–5 days of antibiotics treatment to prevent infection after certain animal bite wounds,17,18 we defined long treatment duration as >7 days, even for presumed animal bites, because it is difficult to distinguish prophylaxis from treatment of bite-related infection using claims data. Several findings in this study highlight challenges for targeted stewardship efforts. Children residing in rural counties were more likely to receive a shorter duration of treatment than children residing in metropolitan counties, but they were also more likely
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