Infection Control & Hospital Epidemiology
to receive a non–first-line choice of antibiotic. Pediatricians were more likely than all other prescriber types to treat with a long duration (>7 days), but they were less likely to choose a non–first- line antimicrobial agent. Differences in rates of prescribing for upper respiratory infection have been described between physi- cians and other providers,19 but we are unaware of such differ- ences between providers with regard to SSTI. Our findings emphasize the need for comprehensive education and feedback to providers of all types and in all practice settings, including rural areas. We focused this study on what we assume to be relatively uncomplicated clinical scenarios in that patients had not been seen for the same condition in the last month and had not had recent antimicrobial exposure. We also included any possible agents that are listed in national guidelines as first-line antibiotic choices for non–bite-associated SSTIs. However, without addi- tional clinical data, we could not assess whether the antibiotic prescribed was appropriate for a given patient encounter. For example, amoxicillin is considered a first-line option for erysi- pelas, and though this would not be appropriate for staphylo- coccal infections, diagnostic codes provided on medical claims may not reliably distinguish erysipelas from cellulitis or abscess. This permissive definition may have led to an underestimate of the opportunity for improved stewardship. In contrast, our ana- lysis of claims data reliably identified combination antibiotic treatment as a common non–first-line choice for SSTI. The most common combination treatment dispensed on the same calendar day was trimethoprim-sulfamethoxazole plus a first-generation cephalosporin. In 2 prospective trials of adults and children with uncomplicated cellulitis, the addition of trimethoprim- sulfamethoxazole to a first-generation cephalosporin did not confer any additional clinical benefit.20,21 There are inherent limitations of claims data (eg, lack of
precise granular clinical data and reliance on codes to gather data). Specific to this study, claims data do not distinguish between abscess and cellulitis, though we chose 7 days or less as short duration, which should apply to both conditions. Treat- ment for non–bite-associated cellulitis or abscess likely does not require 2 classes of antimicrobials, so the non–first-line choice definition we used should apply to both conditions. The duration of 7 days may have been long for some conditions, such as mammalian bite prophylaxis, though the code for bites was only applied in 6.4% of the total cohort. We did not have clinical follow-up data for these patients, and we did not have data for those who may have failed treatment. Also, Franklin County has the most members in Partners for Kids, and Nationwide Chil- dren’s Hospital is an academic medical center in this county with a large urgent care and ambulatory network in the area. Findings among pediatricians in this study may have disproportionately reflected the prescribing habits of pediatricians with an academic affiliation. Furthermore, we lacked allergy data, which may have affected choice of treatment. However, first-line treatment options for both SSTIs and presumed animal bites included a variety of antibiotic classes. Therefore, allergy likely did not affect the results significantly. In addition, we were unable to confirm the accuracy of coding by practitioners and coding for drainage procedures, which may have affected our results. The duration of antibiotic therapy was provided on the healthcare claim by retail pharmacists without standardized methodology, and we were unable to determine how long patients were instructed to take the medication. Finally, we recognize that several studies sup- porting shorter course therapy were published after 2014, so
939
dissemination of this understanding was not available to clin- icians in 2014.6,15,16 This represents an opportunity to examine changing prescribing patterns over time. In conclusion, while most outpatient stewardship efforts to
date have appropriately focused on acute respiratory infections, the management of SSTIs is another essential opportunity to monitor trends in antibiotic use. Even with its inherent limita- tions, healthcare claims data has the potential to identify oppor- tunities for improved antimicrobial stewardship for relatively uncomplicated SSTIs. The duration of >7 days for SSTI was identified in 77.3% of such encounters in this cohort in 2014. Future interventions could utilize claims data to provide audit and feedback to providers regarding treatment of SSTI.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.124
Financial support. No financial support was provided relevant to this article.
Potential conflicts of interest. Dr Gleeson is President of Partners for Kids and a paid employee. Dr Wang is a paid employee of Partners for Kids. Dr Watson is an unpaid member of the Partners for Kids Board of Directors. No other authors have any financial interest or benefit from this work.
References
1. Zheng G, Horton DB, Deaciuc AG, Dwoskin LP, Crooks PA. Des-keto lobeline analogs with increased potency and selectivity at dopamine and serotonin transporters. Bioorg Med Chem Lett 2006;16:5018–5021.
2. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013;309:2345–2352.
3. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011;128: 1053–1061.
4. Gerber JS, Kronman MP, Ross RK, et al. Identifying targets for antimicrobial stewardship in children’s hospitals. Infect Control Hosp Epidemiol 2013;34:1252–1258.
5. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.
6. Schuler CL, Courter JD, Conneely SE, et al. Decreasing duration of antibiotic prescribing for uncomplicated skin and soft tissue infections. Pediatrics 2016;137:e20151223.
7. Watson JR, Wang L, Klima J, et al. Healthcare claims data: an underutilized tool for pediatric outpatient antimicrobial stewardship. Clin Infect Dis 2017;64:1479–1485.
8. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997. Pediatrics 2000;106:205–209.
9. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin- resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 2011;52:285–292.
10. Stevens DL, Bisno AL, Chambers HF, 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.
11. Small area income and poverty estimates program. US Census Bureau website.
https://www.census.gov/programs-surveys/saipe.html. Published 2016. Accessed May 15, 2018.
12. Saha D, Patel J, Buckingham D, Thornton D, Barber T, Watson JR. Urine culture follow-up and antimicrobial stewardship in a pediatric urgent care network. Pediatrics 2017;139.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140
