Compliance with Institutional Skin and Soft Tissue Infection Guidelines and Associated Outcomes

Background: IDSA guidelines recommend multiple treatment options for skin and soft tissue infections (SSTIs). Institutional guidelines were developed to stratify therapy with the goal of minimizing use of unnecessary broad-spectrum antibiotics and antibiotics that increase risk for C.difficile infection (CDI). There is minimal published data evaluating compliance with institutional guidelines and the impact on outcomes.

Methods: This retrospective, single-center, cohort study evaluated treatment regimens for inpatients with SSTIs and associated outcomes. Patients included were hospitalized between July 2012-July 2013 with an ICD9 associated with SSTIs. Patients were stratified into 2 groups: compliant and non-compliant based institutional SSTI guidelines and the initial antibiotic therapy in the Emergency Department. Outcomes evaluated include 30-day readmission rate, length of stay (LOS), failure of initial therapy, mortality and incidence of CDI.

Results: 259 patients were included in the study: 128 (49%) with non-purulent cellulitis, 11 (4%) with purulent cellulitis without abscess, 35 (14%) with purulent cellulitis with simple abscess, and 72 (28%) with complicated SSTI. Treatment was compliant with guidelines for 62 (26.4%) patients and the most common reason for non-compliance was clindamycin use for uncomplicated SSTIs. Compliance with guidelines did not demonstrate significant differences in LOS (3.3 vs. 3.4 days, p=0.853), mortality (3.2 vs. 0%, p=0.069), readmission (14.5 vs. 9.8%, p=0.347), or failure of initial therapy requiring antibiotic escalation (11.3 vs. 13.9%, p=0.669). Non-compliance with institutional guidelines demonstrated a 2.875 increased relative risk for CDI, but the incidence was not statistically significant (1.6 vs. 4.6%, p=0.351).

Conclusion: Compliance with institutional guidelines was low, and the most common reason for non-compliance was clindamycin use as first-line therapy for uncomplicated SSTIs. However, clinical outcomes were not different between groups. Larger studies are needed to determine if compliance is associated with lower incidence of CDI.