Guideline for Inpatient Cellulitis and Abscess Reduces Use of Healthcare Resources

Results of a retrospective study that evaluated treatment of patients hospitalized for cellulites and abscess before and after implementation of a guideline to standardize care [Arch Intern Med. doi:10.1001/archinternmed.2011.29] found that implementation of the guideline led to shorter durations of more targeted antibiotic therapy and decreased use of healthcare resources. Evidence on the optimal management of cellulites and cutaneous abscess that lead to hospitalization is lacking despite the substantial burden of these infections, which cause nearly 600,000 hospital admissions each year. To test their hypothesis that implementation of an institutional guideline to standardize care of inpatient cellulitis and abscess would lead to decreased antibiotic use and use of healthcare resources without adversely affecting clinical outcomes, investigators retrospectively compared diagnostic testing, microbiologic etiology of infection, antimicrobial therapy, and clinical outcomes in 169 patients (baseline group; 66 with cellulites and 103 with abscess) prior to implementation of a guideline between January 1, 2007, and December 31, 2007 and 175 patients (intervention group, 82 with cellulites and 93 with abscess) after guideline implementation between July 9, 2009, and July 8, 2010. The guideline, developed by a multidisciplinary group at a single institution, recommended (1) selective, rather than routine, use of serum C-reactive protein levels, plain film radiographs, and blood cultures for diagnosis; (2) use of parenteral vancomycin for empiric therapy in addition to a nonsteroidal anti-inflammatory agent; and (3) a total course of 7-day therapy, with longer courses reserved for severe or poorly responsive disease. The guideline discouraged (1) use of serum erythrocyte sedimentation rate, superficial wound cultures, computed tomography (CT), and magnetic resonance imaging (MRI) for diagnosis, and (2) antimicrobial agents with broad aerobic gram-negative or anaerobic activity. Compared with the baseline group, patients in the intervention group had a significant decrease in the use of healthcare resources as demonstrated by the significant decrease in microbiologic cultures (80% vs 66%; P=.003) (a difference driven by the decreased use of blood cultures [51% vs 38%, P=.02]), use of MRI (5% vs 1%; P=.02) or MRI or CT in cases not involving the head and neck (15% vs 7%; P=.03), as well as requests for consultations (46% vs 30%; P=.004). The study also found a significant decrease in the median duration of antibiotic use in the intervention group compared with the baseline group from 13 days to 10 days (interquartile range, 10-15 days and 9-12 days, respectively; P<.001). Fewer patients in the intervention group also received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P<.001), antipseudomonal activity (28% vs 18%; P=.02), or broad anaerobic activity (76% vs 49%; P<.001). No differences were seen between the 2 groups in adverse clinical outcomes. There were also no significant differences in clinical failure rates (7.4% and 7.7% for the intervention and baseline groups, respectively; P=.93). Limitations of the study include the retrospective design of the study that could have allowed reviewer bias, the fact that the guidelines proposed in this study reflect only a single potential management strategy, and the inability to generalize the findings of this study because the findings are based on a single institute’s experience and the guideline only addresses management of a subset of patients hospitalized for skin and soft-tissue infection. A primary strength of the study, according to the investigators, is that the guidelines proposed do not require substantial financial resources and are broadly applicable across hospitals. However, they emphasize the need to overcome challenges that interfered with adhering to the guideline. One main challenge is to ensure that all relevant healthcare providers have knowledge of and adhered to the guideline. In conclusion, the investigators believe that the study represents a paradigm of a way to manage common infections in the hospital setting by developing an intervention based on a review of the relevant literature, rigorous evaluation of clinical practices, and assembly of key personnel, and facilitating implementation of the intervention by medical informatics technology when possible, as well as audit and feedback.