Senin, 28 Februari 2011

Low hanging fruit: making antibiotic treatment of skin infections less awful

I recently posted about withholding antibiotics after drainage of uncomplicated purulent skin infections. The group at Denver Health now points to another opportunity for antimicrobial stewardship when treating skin or soft tissue infections (SSTI). Believe it or not, patients admitted with SSTI do not all require treatment with vancopime (or its close relative vancopiptaz (piptamycin?)). These investigators implemented a clinical practice guideline to standardize and simplify the management of patients hospitalized with cellulitis and/or skin abscess. The guideline encouraged more judicious use of testing and imaging, avoidance of broad spectrum gram negative and anaerobic coverage, and shorter courses of therapy with earlier IV to oral transition. You can read the details here, but the guideline resulted in improvement in all areas, significant reductions in use of broad spectrum antibiotics, and no difference in clinical failure rates. The study was single center and quasi-experimental, but clearly points out an area ripe for drastic improvement in most hospitals.

The accompanying editorial by Brad Spellberg is also well worth reading, and locates the cloud in this silver lining: even after the intervention, over one-third of the patients were receiving broad spectrum gram negative active agents and almost half were still receiving broad spectrum anaerobic coverage. And yes, the investigators did exclude those patients who had complicating features (e.g. diabetes, recurrence, fasciitis, etc.) that may have justified such broad spectrum therapy. So even though the intervention was a partial success, challenges to optimizing therapy for SSTI remain.

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