Abstract
The Infectious Disease Society of America (IDSA) publishes guidelines regularly for the management of skin and soft tissue infections; however, the extent to which practice patterns follow these guidelines and if this can affect treatment failure rates is unknown. We observed the treatment failure rates from a multicentre retrospective ambulatory cohort of adult emergency department patients treated for a non-purulent skin infection. We used multivariable logistic regression to examine the role of IDSA classification and whether adherence to IDSA guidelines reduced treatment failure. A total of 759 ambulatory patients were included in the cohort with 17.4% failing treatment. Among all patients, 56.0% had received treatments matched to the IDSA guidelines with 29.1% over-treated, and 14.9% under-treated based on the guidelines. After adjustment for age, gender, infection location and medical comorbidities, patients with a moderate infection type had three times increased risk of treatment failure (adjusted risk ratio (aRR) 2.98; 95% confidence interval (CI) 1.15-7.74) and two times increased risk with a severe infection type (aRR 2.27; 95% CI 1.25-4.13) compared with mild infection types. Patients who were under-treated based on IDSA guidelines were over two times more likely to fail treatment (aRR 2.65; 95% CI 1.16-6.05) while over-treatment was not associated with treatment failure. Patients ⩾70 years of age had a 56% increased risk of treatment failure (aRR 1.56; 95% CI 1.04-2.33) compared with those <70 years. Following the IDSA guidelines for non-purulent SSTIs may reduce the treatment failure rates; however, older adults still carry an increased risk of treatment failure.
Highlights
There has been a dramatic increase in the prevalence and severity of skin and soft tissue infections (SSTIs) in the USA over the past two decades [1]
The objectives of this study were to: (1) describe the frequency with which treatment failure occurs among adults treated and discharged home from one of four emergency departments (ED) and the frequency with which clinicians practice patterns followed the severity classification treatment recommendation indicated in the 2014 Infectious Disease Society of America (IDSA) guidelines for non-purulent skin infection; (2) evaluate whether not following the IDSA guidelines was an independent risk factor for treatment failure; and (3) evaluate other patient/treatment characteristics associated with treatment failure
Patients that failed treatment after their ED visit were older in age, with infections primarily involving an extremity not including the structures of the hand (Table 1)
Summary
There has been a dramatic increase in the prevalence and severity of skin and soft tissue infections (SSTIs) in the USA over the past two decades [1]. Methicillin-resistant S. aureus (MRSA), a common species causing purulent SSTIs, is an uncommon organism causing cellulitis [6], and β-lactam monotherapy remains the recommended first-line choice for non-purulent skin infections [8]. Antibiotics targeting MRSA are only needed in selective patient populations [8]. This is supported by recent randomised clinical trials of patients with cellulitis demonstrating no additional benefit of adding MRSA coverage to β-lactam treatment [9, 10]. Despite the multiple antibiotic classes available for the treatment of cellulitis, it has a high treatment failure rate with, on average, 20% of cellulitis patients involved in clinical trials failing treatment [12, 13]
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