Outpatient antimicrobial stewardship targets for treatment of skin and soft-tissue infections

Abstract

We sought to identify factors associated with long duration and/or non-first-line choice of treatment for pediatric skin and soft-tissue infections (SSTIs). Retrospective cohort study. Ambulatory encounter claims of Medicaid-insured children lacking chronic medical conditions treated for SSTI and/or animal bite injury in Ohio in 2014. For all diagnoses, long treatment duration was defined as treatment >7 days. Non-first-line choice of treatment for SSTI included treatment with 2 antimicrobials dispensed on the same calendar day or any treatment not listed in the Infectious Diseases Society of America guidelines. The adjusted odds of (1) long treatment duration and (2) non-first-line choice of treatment were calculated for patient age, prescriber type, and patient county of residence characteristics (ie, rural vs metropolitan area and poverty rate). Of 10,310 encounters with complete data available, long treatment duration was prescribed in 7,968 (77.3%). The most common duration of treatment prescribed was 10 days. A non-first-line choice was prescribed in 1,030 encounters (10%). Dispensation of 2 antimicrobials on the same calendar day was the most common reason for the non-first-line choice, and of these, trimethoprim-sulfamethoxazole plus a first-generation cephalosporin was the most common regimen. Compared to pediatricians, the adjusted odds ratio of long treatment duration was significantly lower for all other primary care specialties. Conversely, nonpediatricians were more likely to prescribe a non-first-line treatment choice. Patient residence in a high-poverty county increased the odds of both long duration and non-first-line choice of treatment. Healthcare claims may be utilized to measure opportunities for first-line choice and/or shorter duration of treatment for SSTI.