A Retrospective Evaluation of the Management of Skin and Soft Tissue Infections in the Emergency Department

Context

Skin and soft tissue infections (SSTI) are commonly managed in an Emergency Department (ED) setting.  Prior to the study, the outpatient intravenous (IV) antibiotic program at this major teaching hospital operated without any set protocol with respect to inclusion/exclusion criteria, treatment guidelines, and clinical pathways.  The objective of this study was to evaluate the management of SSTI in the ED, in order to determine the therapeutic implications of implementing a new treatment program.

Design

Retrospective health record assessment for selected patients evaluating two 6-month treatment periods pre- and post-implementation of the new program.

Setting

Emergency Department of a major Canadian tertiary care teaching hospital.

Subjects

Adult patients with SSTI (as diagnosed by emergency physicians and entered into the outpatient IV antibiotic program)

Intervention

The pre-protocol management of SSTI was left at the discretion of the attending emergency physician.  The outpatient IV antibiotic program for SSTI utilized standardized protocols for both intravenous and oral therapy. Cefazolin 2 g IV every 24 hours with probenecid 1 g PO daily is the mainstay of therapy for simple cellulitis. Ceftriaxone 2 g IV every 24 hours was the therapy of choice for those with SSTI resulting from a cat, dog or human bite wound.  Oral (PO) regimens for step-down therapy were also included in the new program protocol for all SSTI.  The optimal treatment duration in the outpatient program was defined as less than or equal to 5 days.

Main Outcome Measures

The primary outcome was clinical treatment success defined as successful treatment in the outpatient program utilizing either

(i) PO therapy alone;

(ii) IV therapy alone; or

(iii) IV to PO stepdown

following resolution of infection. Secondary outcomes included compliance with the new protocol, overall treatment duration as well as appropriate use of recommended IV to PO step-down therapy.

Results

428 patients (211 pre and 217 post) met our pre-defined inclusion criteria for the 12-month study period.  Simple cellulitis was the most common diagnosis between phases at 91% and 89%, respectively; and IV cefazolin and PO probenecid combination was the primary treatment regimen in both phases at 86% and 83%, respectively.  Overall treatment success was similar in both periods at 86% and 81% respectively.  Overall, compliance with the new outpatient program protocol was 96% with a significant improvement in the use of appropriate IV to PO therapy from 21% pre-protocol to 60% post-protocol.  Overall, 89% of patients were successfully treated in the ideal program duration of less than or equal to 5 days in following implementation of the new program.

Conclusions

The use of a standardized protocol for the outpatient management of SSTI from the ED has proven effective resulting in the prevention of many hospitalizations.

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