Prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department patients with acute bacterial skin and skin structure infections: a pilot, prospective cohort study

Michael Quirke, Niamh Mitchell, Jarlath Varley, Stephen Kelly, Fiona Boland, Adrian Moughty, Joseph McKeever, Tom Fahey, Abel Wakai, Michael Quirke, Niamh Mitchell, Jarlath Varley, Stephen Kelly, Fiona Boland, Adrian Moughty, Joseph McKeever, Tom Fahey, Abel Wakai

Abstract

Objective: To determine the prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department (ED) patients with acute bacterial skin and skin structure infections (ABSSSIs).

Design: Multicentre, pilot cohort study.

Setting: Three urban EDs in Dublin, Ireland.

Participants: Consecutive ED patients aged >16 years old with ABSSSIs between March 2015 and September 2016.

Intervention: Oral flucloxacillin 500 mg-1 g four times a day (alternative in penicillin allergy).

Primary and secondary outcome measures: The primary outcome was to determine the prevalence and predictors of oral to intravenous antibiotic switch. Secondary outcomes were to determine the prevalence and predictors of receiving an extended course of oral antibiotic treatment and measurement of interobserver reliability for clinical predictors at enrolment.

Results: Overall, 159 patients were enrolled of which eight were lost to follow-up and five were excluded. The majority of patients were male (65.1%) and <50 years of age (58.2%). Oral to intravenous antibiotic switch occurred in 13 patients (8.9%; 95% CI 4.8% to 14.7%). Increased lesion size (OR 1.74; 95% CI 1.09 to 2.79), white cell count (OR 1.32; 95% CI 1.05 to 1.67), athlete's foot (OR 8.00; 95% CI 2.31 to 27.71) and fungal nail infections (OR 7.25; 95% CI 1.99 to 26.35) were associated with oral to intravenous antibiotic switch. 24.8% (95% CI 18.1% to 33.0%) of patients received an extended course of oral antibiotic treatment.

Conclusion: The prevalence of oral to intravenous antibiotic switch in this pilot study is 8.9% (95% CI 4.8% to 14.7%). We identify the predictors of oral to intravenous switch worthy of future investigation.

Trial registration number: NCT02230813.

Keywords: abscess; cellulitis; emergency department; treatment failure; wound infection.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow diagram of patient screening and enrolment. BH, Beaumont Hospital; CHB, Connolly Hospital Blanchardstown; MMUH, Mater Misericordiae University Hospital.

References

    1. Eron LJ, Lipsky BA, Low DE, et al. . Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52:3i–17. 10.1093/jac/dkg466
    1. Ansari F, Erntell M, Goossens H, et al. . The European surveillance of antimicrobial consumption (ESAC) point-prevalence survey of antibacterial use in 20 European hospitals in 2006. Clin Infect Dis 2009;49:1496–504. 10.1086/644617
    1. Dong SL, Kelly KD, Oland RC, et al. . Ed management of cellulitis: a review of five urban centers. Am J Emerg Med 2001;19:535–40. 10.1053/ajem.2001.28330
    1. Gunderson CG. Cellulitis: definition, etiology, and clinical features. Am J Med 2011;124:1113–22. 10.1016/j.amjmed.2011.06.028
    1. Pallin DJ, Binder WD, Allen MB, et al. . Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis 2013;56:1754–62. 10.1093/cid/cit122
    1. US Food and Drug Administration, Center for Drug Evaluation and Research Guidance for industry. acute bacterial skin and skin structure infections: developing drugs for treatment, 2013. Available:
    1. Stevens DL, Bisno AL, Chambers HF, et al. . Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases Society of America. Clin Infect Dis 2014;59:e10–52. 10.1093/cid/ciu296
    1. Pallin DJ, Egan DJ, Pelletier AJ, et al. . Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2008;51:291–8. 10.1016/j.annemergmed.2007.12.004
    1. Edelsberg J, Taneja C, Zervos M, et al. . Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis 2009;15:1516–8. 10.3201/eid1509.081228
    1. Bouchiat C, Curtis S, Spiliopoulou I, et al. . Mrsa infections among patients in the emergency department: a European multicentre study. J Antimicrob Chemother 2017;72:372–5. 10.1093/jac/dkw431
    1. Clinical Resource Efficiency Support Team Crest guidelines on the management of cellulitis in adults. Northern Ireland: DHSS, 2005: 1–31.
    1. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: a review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol 2008;19:173–84. 10.1155/2008/846453
    1. Marwick C, Rae N, Irvine N, et al. . Prospective study of severity assessment and management of acute medical admissions with skin and soft tissue infection. J Antimicrob Chemother 2012;67:1016–9. 10.1093/jac/dkr554
    1. Murray H, Stiell I, Wells G. Treatment failure in emergency department patients with cellulitis. CJEM 2005;7:228–34. 10.1017/S1481803500014342
    1. Peterson D, McLeod S, Woolfrey K, et al. . Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis. Acad Emerg Med 2014;21:526–31. 10.1111/acem.12371
    1. Yadav K, Suh KN, Eagles D, et al. . Predictors of oral antibiotic treatment failure for Nonpurulent skin and soft tissue infections in the emergency department. Acad Emerg Med 2019;26:51–9. 10.1111/acem.13492
    1. Quirke M, Boland F, Fahey T, et al. . Prevalence and predictors of initial oral antibiotic treatment failure in adult emergency department patients with cellulitis: a pilot study. BMJ Open 2015;5:e008150. 10.1136/bmjopen-2015-008150
    1. Quirke M, Ayoub F, McCabe A, et al. . Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol 2017;177:382–94. 10.1111/bjd.15186
    1. Mortimer PS, Cefai C, Keeley V. Consensus document on the management of cellulitis in lymphoedema. British Lymphology Society and Lymphoedema Support Network 2005.
    1. Wiley MM. Using HIPE data as a research and planning tool: limitations and opportunities: a response. Ir J Med Sci 2005;174:52–7. 10.1007/BF03169130
    1. Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 2011;164:1326–8. 10.1111/j.1365-2133.2011.10275.x
    1. Obaitan I, Dwyer R, Lipworth AD, et al. . Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis. Am J Emerg Med 2016;34:1645–52. 10.1016/j.ajem.2016.05.064

Source: PubMed

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