Guidelines vs actual management of skin and soft tissue infections in the emergency department

Rahul S. Kamath, Deepthi Sudhakar, Julianna G. Gardner, Vagish S. Hemmige, Hossam Safar, Daniel M. Musher

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. Methods We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. Results The decision to hospitalize did not comply with guidelines in 19.6% of cases. Nonrecommended antibiotics were begun in the ED in 71% of patients with nonpurulent infections and 68.4% of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29% of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1% of cases. Conclusions Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.

Original languageEnglish (US)
JournalOpen Forum Infectious Diseases
Volume5
Issue number1
DOIs
StatePublished - Jan 1 2018
Externally publishedYes

Fingerprint

Soft Tissue Infections
Hospital Emergency Service
Guidelines
Abscess
Skin
Cellulitis
Anti-Bacterial Agents
Drainage
Guideline Adherence
Hospital Departments
Sulfamethoxazole Drug Combination Trimethoprim
Tertiary Healthcare
Infection
Tertiary Care Centers
Communicable Diseases
Education

Keywords

  • abscess
  • antibiotic stewardship
  • cellulitis
  • skin and soft tissue infection

ASJC Scopus subject areas

  • Oncology
  • Clinical Neurology

Cite this

Guidelines vs actual management of skin and soft tissue infections in the emergency department. / Kamath, Rahul S.; Sudhakar, Deepthi; Gardner, Julianna G.; Hemmige, Vagish S.; Safar, Hossam; Musher, Daniel M.

In: Open Forum Infectious Diseases, Vol. 5, No. 1, 01.01.2018.

Research output: Contribution to journalArticle

Kamath, Rahul S. ; Sudhakar, Deepthi ; Gardner, Julianna G. ; Hemmige, Vagish S. ; Safar, Hossam ; Musher, Daniel M. / Guidelines vs actual management of skin and soft tissue infections in the emergency department. In: Open Forum Infectious Diseases. 2018 ; Vol. 5, No. 1.
@article{fba70c14bc6348648076345fd0f897bb,
title = "Guidelines vs actual management of skin and soft tissue infections in the emergency department",
abstract = "Background Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. Methods We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. Results The decision to hospitalize did not comply with guidelines in 19.6{\%} of cases. Nonrecommended antibiotics were begun in the ED in 71{\%} of patients with nonpurulent infections and 68.4{\%} of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29{\%} of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1{\%} of cases. Conclusions Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.",
keywords = "abscess, antibiotic stewardship, cellulitis, skin and soft tissue infection",
author = "Kamath, {Rahul S.} and Deepthi Sudhakar and Gardner, {Julianna G.} and Hemmige, {Vagish S.} and Hossam Safar and Musher, {Daniel M.}",
year = "2018",
month = "1",
day = "1",
doi = "10.1093/ofid/ofx188",
language = "English (US)",
volume = "5",
journal = "Open Forum Infectious Diseases",
issn = "2328-8957",
publisher = "Oxford University Press",
number = "1",

}

TY - JOUR

T1 - Guidelines vs actual management of skin and soft tissue infections in the emergency department

AU - Kamath, Rahul S.

AU - Sudhakar, Deepthi

AU - Gardner, Julianna G.

AU - Hemmige, Vagish S.

AU - Safar, Hossam

AU - Musher, Daniel M.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. Methods We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. Results The decision to hospitalize did not comply with guidelines in 19.6% of cases. Nonrecommended antibiotics were begun in the ED in 71% of patients with nonpurulent infections and 68.4% of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29% of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1% of cases. Conclusions Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.

AB - Background Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. Methods We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. Results The decision to hospitalize did not comply with guidelines in 19.6% of cases. Nonrecommended antibiotics were begun in the ED in 71% of patients with nonpurulent infections and 68.4% of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29% of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1% of cases. Conclusions Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.

KW - abscess

KW - antibiotic stewardship

KW - cellulitis

KW - skin and soft tissue infection

UR - http://www.scopus.com/inward/record.url?scp=85054397972&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85054397972&partnerID=8YFLogxK

U2 - 10.1093/ofid/ofx188

DO - 10.1093/ofid/ofx188

M3 - Article

VL - 5

JO - Open Forum Infectious Diseases

JF - Open Forum Infectious Diseases

SN - 2328-8957

IS - 1

ER -