The Management of Outpatient Cellulitis at The Moncton Hospital before and after the Initiation of a Clinical Treatment Pathway

Abstract

Background. Antimicrobial Stewardship is a coordinated effort to improve and measure the appropriate use of antimicrobials. Antibiotic resistance is an emerging world health problem and unnecessary prescribing of broad-spectrum antibiotics is a major contributor to this. Skin and soft-tissue infections are a common reason to receive a prescription for antibiotics. Currently there exists a trend for using broad-spectrum intravenous antibiotics for moderate to severe infections when more narrow-spectrum options would be adequate. This study aimed to characterize the choice of antibiotic being prescribed for the management of outpatient cellulitis requiring intravenous antibiotics and evaluate the success of a clinical order set outlining optimal therapy. Methods. This study was a retrospective chart review looking at antibiotic prescribing through the Emergency Department at The Moncton Hospital, in Moncton, New Brunswick. Charts were reviewed before and after the introduction of a clinical order set outlining optimal antibiotic therapy. The goal was to review charts from the pre- and post-intervention group and compare antibiotic usage, treatment failure rates, and adverse events. Results. Of the 54 patients receiving IV antibiotics in the pre-intervention group, 3 received cefazolin, 50 received ceftriaxone, while 1 received levofloxacin. The median duration of IV therapy was four days. After the introduction of the clinical order set there was an absolute increase of 53.8% (n = 35) in the use of cefazolin and absolute decrease of 53.7% (n = 23) in the use of ceftriaxone in the post-intervention group of 59 patients. Both results were statistically significant (P < 0.001). The median duration of IV therapy in this group was 3.5 days. In eligible patients, the clinical order set was utilized 61.1% of the time. There was no significant difference in rates of treatment failure or adverse events between cefazolin and ceftriaxone. Conclusion. The introduction of a clinical order set outlining the preferential use of once-daily cefazolin plus probenecid for the treatment of outpatient cellulitis lead to a statistically significant increase use of cefazolin, and decrease use of ceftriaxone, thus demonstrating a positive stewardship effect at a local level.