DOI: 10.5281/zenodo.10015997
title: Antibiotic Prescribing Adherence in Treatment of Uncomplicated Cellulitis

description: Authors:
* Talha Rizwan, Adnan Khan
Our Lady's Hospital Navan, Republic of Ireland
*Corresponding Author:* Talha Rizwan, Our Lady's Hospital Navan, Republic of Ireland
description: INTRODUCTION:
Cellulitis is very common infective disease especially in the older age group. It is estimated that the incidence of cellulitis is about 200 cases per 100,000 patients per year and, in non-tropical regions, has a seasonal predilection for warmer months. The outlook for most cellulitis is excellent. The infections are usually mild and in general, usually resolve within five to seven days. Antibiotics help to speed up the recovery time and to avoid complications. The community antimicrobial stewardship subcommittee of the SARI (Strategies for control of anti-microbial resistance in Ireland) national committee developed the standard guidelines. Since 2011, the guidelines have been overseen by the RCPI/ HSE clinical advisory group on healthcare-associated infection and antimicrobial resistance (HCAI/AMR). Flucloxacillin has been introduced as a first line choice for treatment of uncomplicated cellulitis. This guideline does not apply to pregnant patients, critically ill patients, where renal function is changing rapidly or those with acute kidney injury. Caution should be used when prescribing in dehydrated or oedematous patients. Local Louth/Meath antimicrobial guidelines also adhere to the above mentioned guidelines.
 
AIMS AND OBJECTIVES:
1)         To encourage adherence to antibiotic prescribing in view of the current guidelines.
2)         To promote safe and effective use of antibiotics.
 
Criteria: 
All patients [unless pregnant, with renal impairment, critically ill or any other comorbidity] should be offered flucloxacillin as first line antibiotic for Cellulitis. 
 
Standard: 
70% of our patients   presenting with Cellulitis should receive flucloxacillin as first line antibiotic unless contraindicated. 
 
METHODS AND SAMPLE:
Hospital software IPMS was used to identify the suitable candidates that met the inclusion criterion. Patients irrespective of gender, race and ethnicity were included. We wanted to exclude pregnant patients, critically ill patients and those with renal impairment but there were no such patients in our sample. Patients who were penicillin or Flucloxacillin allergic were excluded from the study. Most patients included in the study were of uncomplicated Cellulitis i.e., no abscess, gangrene, necrotizing fasciitis or fever. 
Audit was conducted in two cycles. Retrospective data for the month of November 2022 was collected for first cycle whereas retrospective data for the month of February 2023 was collected for second cycle post intervention. The search was carried out by using words like cellulitis and antibiotics like flucloxacillin, Co-amoxiclav, doxycycline, cefazolin, ceftriaxone, vancomycin, cefaclor, clindamycin. Then each file was reviewed for prescription notes. 
 
RESULTS:
In the first cycle, around 69% of the doctors were adherent to the guidelines and prescribed flucloxacillin as first choice for cellulitis. In our opinion, Doctors were fully motivated, however they needed regular encouragement to change their prescribing practice. We tried to give frequent reminders through group discussions, by arranging frequent meetings with all NCHDs and by distribution of leaflets of current guidelines. Weekly hospital meetings were arranged and doctors/nurses were informed of above guidelines and were asked to incorporate them in their routine day-to-day practice. Each doctor in the hospital was shown website with specific subsection twice during audit i.e., at end of first cycle & again midway during second cycle.
We conducted the 2nd cycle in February 2023 post interventions to see the change. The change was quite satisfactory as the percentage of doctors adhering to the standard guidelines of antibiotic prescription increased from 69% to 86% which was a significant improvement in just a few months. Even though the result was not 100% but there was still a significant improvement and we are hopeful that this percentage will further improve.