Antibiotic route and duration of therapy for cellulitis: data extracted from a multi-center clinical trial

Optimal Pediatric Outpatient Antibiotic Prescribing

Importance

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing.

Objective

To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration.

Design, Setting, and Participants

This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration.

Main Outcomes and Measures

Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model.

Results

A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86).

Conclusions and Relevance

This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

Improving Short Course Treatment of Pediatric Infections: A Randomized Quality Improvement Trial

BACKGROUND AND OBJECTIVES

Short courses of antibiotic treatment are effective for pediatric community-acquired pneumonia (CAP) and skin and soft tissue infections (SSTI). We compared the effectiveness of education with performance feedback, clinical decision support (CDS), and the combination in encouraging appropriately short treatment courses by primary care clinicians.

METHODS

We designed a site-randomized, quality improvement trial within a large pediatric primary care network. Each practice was randomly assigned to 1 of 4 groups: education and feedback; CDS; both interventions ("combined group"); and control. We performed difference-in-differences analysis to compare the proportion of cases with short course treatment before and after intervention among the 4 groups.

RESULTS

For all cases of CAP and SSTI, the proportion in the control group treated with the recommended duration did not change from the baseline period (26.1% [679 of 2603]) to the intervention period (25.8% [196 of 761]; P = .9). For the education and feedback group, the proportion rose from 22.3% (428 of 1925) to 45.0% (239 of 532; P < .001); for the CDS group, from 26.6% (485 of 1824) to 52.3% (228 of 436; P < .001); and for the combined group, from 26.2% (491 of 1875) to 67.8% (314 of 463; P < .001). A difference-in-differences analysis showed that all 3 intervention groups improved performance compared with the control group (P < .001); the combined group had greater improvement than the education and feedback group or the CDS group (P < .001).

CONCLUSIONS

In this quality improvement project to encourage shorter duration treatment of CAP and SSTI, both education with performance feedback and CDS were effective in modifying clinician behavior; however, the combination of the two was substantially more effective than either strategy alone.

The Natural History of Antibiotic-Treated Lower Limb Cellulitis: Analysis of Data Extracted From a Multicenter Clinical Trial

Background

Although cellulitis is a relatively common skin infection, there remains uncertainty about management, particularly the length and route of antimicrobials required. Further information on the symptomatology and biomarker changes associated with cellulitis over time would guide clinicians and patients as to the expected natural history.

Methods

We extracted data from a randomized clinical trial (NCT01876628) of clindamycin as adjunctive therapy in cellulitis to illustrate the evolution of local parameters (pain, swelling, local erythema, and warmth) and the resolution of biomarkers over time.

Results

Data from 247 individuals with mild to moderate unilateral lower limb cellulitis, who attended at least 1 face-to-face interview following recruitment, were used to examine response dynamics. Although there was a local improvement in swelling, warmth, erythema, and pain by day 5 compared with baseline, some individuals still had evidence of local inflammation at 10 days. Most biomarkers demonstrated a return to normal by day 3, although the initial fall in albumin only returned to baseline by day 10.

Conclusions

Although there was initial resolution, a significant number of individuals still had local symptoms persisting to day 10 and beyond. Clinicians can use these data to reassure themselves and their patients that ongoing local symptoms and signs after completion of antibiotic treatment do not indicate treatment failure or warrant extension of the initial antibiotic treatment or a change in antibiotic class or mode of administration.

Cellulitis: A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis

Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.