Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation
Authors: Sutton Jesse D , Carico Ronald , Burk Muriel , Jones Makoto M , Wei XiangMing , Neuhauser Melinda M , Goetz Matthew Bidwell , Echevarria Kelly L , Spivak Emily S , Cunningham Francesca E ,   Skin and Soft Tissue Infection Medication Use Evaluation Group, Goolsby Tiffany , Witt Lucy , Hong Joseph , Landayan Patrick , Shatz Katelyn , Pontefract Benjamin , Murdock Kaysie , Gallegos-Salazar Jaime , Strymish Judith , Chang Mei , Poon Henry , Vest Kirsten , Tinsley Nicholas , Bockenstedt Gregory , Patel Darshan , Message John , Ang Gordon , Banerjee Archana , Fry Sarah , Rose Michael , Hiett Jason , Tate Victoria , Fisher Ann , Kotansky Brian , Vu Van , Dhar Sorabh , Kuhn Ryan , Willis Sandra , Britt Rachel , Townsend Mary , Little Erica , Williams Lisa , Ficek Elizabeth , Tell Renae , Liu Xuxuan , Pasciak John , Iliuta Ruth , Bennett Jessica , Germinario Victoria , Jacobs Elizabeth , Spivey Justin , Vannoy Marty , Foral Pamela , Feller Christine , Nguyen Hien , Lu Shu , Burns Tim , Khan Paris , Kouma Marcus , Buehrle Deanna , Ruzzi Nicholas , MacKay Kimberly , Tran Lisa , Emberger Jennifer , Sann Khine , Tassone Daniel , Spivak Emily , Sutton Jesse , Chow Sean , Ma Ariel , Gonzalez-Gonzalez Edmarielis , Cintron Hector , Aylward Andrea , Daniel K Taylor , Welu Jenna , Pickard Cameron , Sanchez Chelsea , Shafiq Ashfaq , Skouby Danielle , O’Donnell Jill , Surdy Michael 
Published: January 2020

Abstract

Background
Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics.

Methods
A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5–10 days of antibiotics. Data were analyzed and reported using descriptive statistics.

Results
Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration &gt;10 days.

Conclusions
We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.