Study Finds Poor Adherence To Guidelines For Skin and Soft Tissue Infections

John P. Haran MD Assistant Professor of Emergency Medicine University of Massachusetts Medical School, Worcester, MA

MedicalResearch.com Interview with:

John P. Haran MD
Assistant Professor of Emergency Medicine
University of Massachusetts Medical School, Worcester, MA

Medical Research: What is the background for this study? What are the main findings?
Dr. Haran: The Infectious Disease Society of America (IDSA) publishes evidence based guidelines for the treatment of skin and soft tissue infections, however, how closely clinicians follow these guidelines is unknown. Observation units have been increasingly used over the past decade in emergency medicine for short-term care of patients for many medical conditions including skin infections. These units offer a great alternative to hospitalization especially for older adults. We set out to describe the treatment patterns used in the observation unit of an academic institute and compare them to the IDSA guidelines. We found that physicians had poor adherence to these guidelines. Additionally, we discovered that older adults were at increased risk of being over-treated while women were at increased risk for being under-treated. These age and gender biases are not new to medicine and emergency departments should standardize antibiotic treatments to reduce treatment bias.

Medical Research: What should clinicians and patients take away from your report?

Dr. Haran: Clinicians should recognize that easy to follow guidelines are available to help make treatment decisions for patients with a skin infection. Not using these guidelines introduces biases and places the patient at increased risks of being either over or under-treated for the infection. The decision to give antibiotics to a patient with an abscess hinges on the presence of SIRS or a systemic inflammatory response syndrome. Antibiotic abscess treatment should be given to patients with impaired host defenses or if they are already failing antibiotic treatment. The decision to give intravenous antibiotics for a cellulitis should depend on systemic signs of infection, such as fever, or once again in patients with impaired host defenses or those already failing antibiotic treatment. More aggressive antibiotic therapy does lead to increased risks of Clostridium difficile infection and increased antibiotic resistance while it may not be necessary for clinical treatment.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Haran: I would recommend two main concepts to be covered in any future research as a result of this study.

  • First, these findings of poor compliance with national guidelines and biases in treatment need to be demonstrated in the general ED population that is discharged home on antibiotics for a skin or soft tissue infection from multiple centers. One of the main limitations of this study was that it was done at a single center.
  • Second, treatment decisions need to be linked to outcomes. A patient outcome study should try to demonstrate if those under-treated had higher rates of treatment failure and/or if those over-treated had the same rates as those that were treated in accordance with IDSA guideline recommendations. If patients in the over-treatment category had the same failure rates then more aggressive antibiotic treatment regimens would only lead to higher rates of antibiotic resistance and increased risk of Clostridium difficile infection without any benefit to the individual patient.

Citation:

Treatment of Bacterial Skin Infections in Emergency Department Observation Units: Factors Influencing Prescribing Practice

Haran, John P. et al.

The American Journal of Emergency Medicine
Received: August 7, 2015; Received in revised form: August 16, 2015; Accepted: August 17, 2015; Published Online: August 21, 2015

DOI: http://dx.doi.org/10.1016/j.ajem.2015.08.035

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John P. Haran MD (2015). Study Finds Poor Adherence To Guidelines For Skin and Soft Tissue Infections 

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