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

Overview

Journal BMJ Open

Specialty General Medicine

Date 2020 Sep 2

PMID 32868346

Authors

Michael Quirke

Niamh Mitchell

Jarlath Varley

Stephen Kelly

Fiona Boland

Adrian Moughty

Joseph McKeever

Tom Fahey

Abel Wakai

Affiliations

Soon will be listed here.

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.

References

Bouchiat C, Curtis S, Spiliopoulou I, Bes M, Cocuzza C, Codita I . MRSA infections among patients in the emergency department: a European multicentre study. J Antimicrob Chemother. 2016; 72(2):372-375. DOI: 10.1093/jac/dkw431. View

Marwick C, Rae N, Irvine N, Davey P . Prospective study of severity assessment and management of acute medical admissions with skin and soft tissue infection. J Antimicrob Chemother. 2012; 67(4):1016-9. DOI: 10.1093/jac/dkr554. View

Yadav K, Suh K, Eagles D, MacIsaac J, Ritchie D, Bernick J . Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018; 26(1):51-59. DOI: 10.1111/acem.13492. View

Edelsberg J, Taneja C, Zervos M, Haque N, Moore C, Reyes K . Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009; 15(9):1516-8. PMC: 2819854. DOI: 10.3201/eid1509.081228. View

Quirke M, Boland F, Fahey T, OSullivan R, Hill A, Stiell I . Prevalence and predictors of initial oral antibiotic treatment failure in adult emergency department patients with cellulitis: a pilot study. BMJ Open. 2015; 5(6):e008150. PMC: 4486970. DOI: 10.1136/bmjopen-2015-008150. View

Gunderson C . Cellulitis: definition, etiology, and clinical features. Am J Med. 2011; 124(12):1113-22. DOI: 10.1016/j.amjmed.2011.06.028. View

Levell N, Wingfield C, Garioch J . Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol. 2011; 164(6):1326-8. DOI: 10.1111/j.1365-2133.2011.10275.x. View

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. 2009; 19(2):173-84. PMC: 2605859. DOI: 10.1155/2008/846453. View

Quirke M, Ayoub F, McCabe A, Boland F, Smith B, OSullivan R . Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2016; 177(2):382-394. DOI: 10.1111/bjd.15186. View

10.

Eron L, Lipsky B, Low D, Nathwani D, Tice A, Volturo G . Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother. 2003; 52 Suppl 1:i3-17. DOI: 10.1093/jac/dkg466. View

11.

Pallin D, Binder W, Allen M, Lederman M, Parmar S, Filbin M . 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(12):1754-62. DOI: 10.1093/cid/cit122. View

12.

Murray H, Stiell I, Wells G . Treatment failure in emergency department patients with cellulitis. CJEM. 2007; 7(4):228-34. DOI: 10.1017/s1481803500014342. View

13.

Stevens D, Bisno A, Chambers H, Dellinger E, Goldstein E, Gorbach S . 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(2):e10-52. DOI: 10.1093/cid/ciu444. View

14.

Pallin D, Egan D, Pelletier A, Espinola J, Hooper D, Camargo Jr C . 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(3):291-8. DOI: 10.1016/j.annemergmed.2007.12.004. View

15.

Peterson D, McLeod S, Woolfrey K, McRae A . Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis. Acad Emerg Med. 2014; 21(5):526-31. DOI: 10.1111/acem.12371. View

16.

Ansari F, Erntell M, Goossens H, Davey P . The European surveillance of antimicrobial consumption (ESAC) point-prevalence survey of antibacterial use in 20 European hospitals in 2006. Clin Infect Dis. 2009; 49(10):1496-504. DOI: 10.1086/644617. View

17.

Dong S, Kelly K, Oland R, Holroyd B, Rowe B . ED management of cellulitis: a review of five urban centers. Am J Emerg Med. 2001; 19(7):535-40. DOI: 10.1053/ajem.2001.28330. View

18.

Obaitan I, Dwyer R, Lipworth A, Kupper T, Camargo Jr C, Hooper D . Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis. Am J Emerg Med. 2016; 34(8):1645-52. DOI: 10.1016/j.ajem.2016.05.064. View

19.

OLoughlin R, Allwright S, Barry J, Kelly A, Teljeur C . Using HIPE data as a research and planning tool: limitations and opportunities. Ir J Med Sci. 2005; 174(2):40-5. DOI: 10.1007/BF03169128. View