An Antimicrobial Stewardship Initiative for the Management of Skin and Soft Tissue Infections in a Pediatric Emergency Department

Purpose/Objectives: Skin and soft tissue infections (SSTIs) are commonly treated in pediatric emergency departments (ED). Purulent SSTIs are more likely to be caused by Staphylococcus aureus, while nonpurulent SSTIs are more likely to be caused by Streptococcus species. Community rates of Methicillin resistant Staphylococcus aureus (MRSA) infections in our ED have been consistent over the past 5 years at around 30% of Staphylococcus aureus isolates. Unnecessarily broad spectrum and prolonged duration of antibiotics lead to increased risk of adverse reactions, higher health care costs and increased bacterial resistance. The primary aim was to decrease the proportion of patients with cellulitis discharged on MRSA directed therapy from 50% to 25%. The secondary aim was to decrease the proportion of patients prescribed longer than recommended antibiotic duration, 5 days for cellulitis and 7 days for abscess, from 71% to 35%. The third aim was to decrease the proportion of patients with drained abscess who were prescribed antibiotics from 93% to 60%.

Design/Methods: A multidisciplinary team created a clinical pathway for the management of SSTIs using institutional antibiograms. Patients over 56 days old who presented to the ED with SSTIs were included. Medically-complex patients and patients with complicated SSTIs/musculoskeletal infections were excluded. Interventions included provider education, clinical decision support in the electronic medical record to promote appropriate antibiotic prescribing, surveying resident physicians to determine reasons for pathway deviation, and monthly chart review with provider-directed feedback. In addition, we gave Maintenance of Certification (MOC) credits to providers interested in helping the improvement team. Plan-do-study-act cycles were performed regularly and performance results were shared. The main outcome measures were the proportion of patients receiving MRSA-directed antibiotics for cellulitis and the proportion of patients treated longer than recommended. The balancing measure was 72 hour ED return rates. Outcomes were measured using statistical process control charts.

Results: 339 pre-implementation and 172 post-implementation encounters were included from August 2019 to April 2021. The proportion of patients prescribed MRSA-directed antibiotics decreased from 50% to 21%. The proportion of patients prescribed longer than recommended antibiotic duration decreased from 71% to 28%. By decreasing the duration of MRSA-directed antibiotics we effectively saved $65 per patient. Overall improvements led to a total savings of $17,253. There were no significant change in the proportion of drained abscesses prescribed systemic antibiotics or ED return rates.

Conclusion/Discussion: Utilization of quality improvement principles with multifaceted interventions successfully achieved the antimicrobial stewardship aims. Namely, these interventions safely and effectively narrowed antibiotic selection and decreased average duration of therapy. These quality improvements had the additional benefit of decreasing healthcare cost.