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95 Decreased Antibiotic Utilization after Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Timothy C. Jenkins, MD , Denver Health Medical Center, Denver, CO
Bryan C. Knepper, MPH, MSc , Denver Health Medical Center, Denver, CO
Allison L. Sabel, MD, PhD, MPH , Denver Health Medical Center, Denver, CO
Ellen E. Sarcone, MD , Denver Health Medical Center, Denver, CO
Jeremy A. Long, MD, MPH , Denver Health Medical Center, Denver, CO
Jason S. Haukoos, MD, MSc , Denver Health Medical Center, Denver, CO
Steven J. Morgan, MD , Denver Health Medical Center, Denver, CO
Walter L. Biffl, MD , Denver Health Medical Center, Denver, CO
Andrew W. Steele, MD, MPH, MSc , Denver Health Medical Center, Denver, CO
Connie S. Price, MD , Denver Health Medical Center, Denver, CO
Philip S. Mehler, MD , Denver Health Medical Center, Denver, CO
William J. Burman, MD , Denver Health Medical Center, Denver, CO
Background:  Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been well-studied. 

Objective: To determine whether implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess decreases antibiotic and health care resource utilization. 

Methods:  A quasi-experimental study was performed to compare management before and after the intervention (1 Jan 2007 – 31 Dec 2007 and 9 Jul 2009 – 8 Jul 2010).

Results:  169 (66 cellulitis, 103 abscess) and 175 (82 cellulitis, 93 abscess) patients were included in the baseline and intervention cohorts, respectively.  The intervention led to significant decreases in the use of blood cultures (51% vs. 38%, p = .02), plain films in cases of cellulitis (71% vs. 47%, p = .003), and magnetic resonance imaging (5% vs. 1%, p = .02) as well as fewer requests for inpatient consultations (46% vs. 30%, p = .004).  The median duration of antibiotic therapy decreased from 13 (interquartile range [IQR] 10-15) to 10 days (IQR 9-12) (p <.001).  Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs. 36%, p<.001), anti-pseudomonal activity (28% vs. 18%, p = .02), or broad anaerobic activity (76% vs. 49%, p<.001).  Clinical failure occurred in 7.7% and 7.4% of cases (p = .93), respectively. 

Conclusions: Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.