Patient Safety and Quality

Guideline management of inpatient cellulitis and cutaneous abscess reduces antibiotic use

Since 1999, there has been a dramatic rise in the number of cellulitis and cutaneous abscess infections in the United States. These infections account for nearly 600,000 hospital admissions each year. A recent study has detailed how a health care system in Denver, CO, developed and implemented a clinical practice guideline to standardize and streamline the management of these infections. Use of the guideline resulted in several improvements, including reduced antibiotic use and less frequent use of unnecessary microbiological studies.

The guideline recommended selective rather than routine use of several diagnostic tests. In terms of antibiotics, intravenous vancomycin was suggested, while use of agents with a broad spectrum of gram-negative or anaerobic activity were discouraged. A 7-day course of therapy was recommended for patients responding to treatment. Once developed, the guideline was sent to all clinicians via electronic mail and available on the intranet. Hard copies were also posted in work areas and nursing stations. A standardized computerized provider order entry admission order set was created. An educational campaign reinforced use of the guideline by way of assigning physician peer champions to deliver key messages. Finally, during the 12-month intervention period, quarterly audits were undertaken to determine how well the guideline was being used with feedback to peer champions.

After one year, the use of microbiological cultures declined from 80 percent before the intervention to 66 percent after implementation. In addition, requests for inpatient consultation declined from 46 percent to 30 percent. The guideline was successful in discouraging the use of agents with broad-spectrum gram-negative activity, which declined from 66 percent to 36 percent, and anaerobic activity, which declined from 76 percent to 49 percent. The median duration of therapy decreased from 13 days to 10 days with the intervention. The incidence of adverse clinical outcomes was similar before and after implementation of the guideline. The study was supported in part by the Agency for Healthcare Research and Quality (HS17526).

See "Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess," by Timothy C. Jenkins, M.D., Bryan C. Knepper, M.P.H., M.Sc., Allison L. Sabel, M.D., Ph.D., M.P.H., and others in the Archives of Internal Medicine 171(12), pp. 1072-1079, 2011.

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