Using targeted quality improvement methods, a hospital more than tripled the proportion of short courses of antibiotics prescribed for children discharged from hospitalization for uncomplicated skin and soft tissue infections (SSTIs), according to a recent study.
“Short courses of antibiotics may be beneficial to help prevent development of resistant bacteria, lessen cost, and reduce the chances of unintended effects of antimicrobial therapy,” explained Dr. Christine L. Schuler and her associates at the Cincinnati Children’s Hospital Medical Center (Pediatrics. 2016 Jan 18. doi: 10.1542/peds.2015-1223). They aimed specifically to increase the percentage of patients receiving antibiotic prescriptions for 7 days or fewer from their baseline of 23% to 80% over 6 months.
For nonpurulent cellulitis, 5-day courses of antibiotics are recommended as sufficiently effective by the Infectious Diseases Society of America, which recommends an extension only if the patient hasn’t improved in that time. Awareness of these guidelines and relevant evidence through two 15-minute education sessions comprised one of the four key components for the initiative’s implementation. The three other components involved “changing the culture of physician prescribing to include discussion of duration of therapy at admission, buy in from prescribers, and effective monitoring of prescribing,” Dr. Schuler and her associates wrote.
Following the sessions, a second intervention provided clinicians with reminder lanyard cards containing information about recommended treatment regimes. Next, electronic order defaults for antibiotics for SSTIs were changed from 14-day courses of antibiotics to 7-day courses, which then automatically subtracted the days on antibiotics during hospitalization, a median 1.2 days.
Last, the hospital started reviewing medical records daily to identify all patients admitted with SSTIs. An intern or senior resident then contacted the patient’s medical team and reminded them that the patient may be appropriate for a short course of antibiotics, that the lanyard card provided therapy recommendations, and that the medical team could contact the project team with questions.
Of 641 patients – aged 3 months to 18 years – admitted for SSTIs between January 2012 and November 2013, one-third occurred before the intervention and two-thirds after. Clindamycin was prescribed in 88% of cases, trimethoprim-sulfamethoxazole in 8%, and cephalexin in 4%.
The proportion of short courses of antibiotics prescribed increased from a baseline of 23% to 74% by February 2013, where it remained for the next 6 months. From March to November 2013, the median duration of antibiotic courses prescribed was 7 days. A total of 2% of the patients were readmitted for recurrence, and 2% were admitted for treatment failure, but these numbers were similar before and after the intervention.
“We suspect that our sustained improvement in prescriptions for short courses of antibiotics over multiple months was in large part due to modification of our electronic order set used to generate outpatient prescriptions,” the authors wrote.