Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA; Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA.
Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA.
Ann Emerg Med. 2020 Jul;76(1):56-66. doi: 10.1016/j.annemergmed.2019.12.012. Epub 2020 Feb 13.
Clinicians currently do not reliably adhere to antibiotic treatment guidelines, resulting in unnecessary patient exposure to broad-spectrum antimicrobials. Our objective is to determine whether a treatment intervention for the management of nonpurulent skin and soft tissue infections increases clinician adherence and improves patient outcomes.
Between January 1 and December 31, 2017, patients presenting to 2 emergency departments (EDs) and who had received a diagnosis of a nonpurulent skin and soft tissue infection were enrolled and assigned to a pre- or postintervention cohort with a treatment intervention implemented on June 1. Primary outcomes were percentage of ED providers following the guidelines and percentage of patients admitted to the hospital. Secondary outcomes were patient self-reported treatment failure and hospital readmission.
There were 1,360 patients, 665 in the preintervention and 695 in the postintervention cohorts. After algorithm implementation, guideline adherence increased (43.0% versus 55.1%; P<.001) and number of patients admitted to the hospital declined (36.5% versus 12.0%; P<.001). In addition, patients reported fewer treatment failures (26.8% versus 16.5%; P=.02) and fewer readmissions (22.3% versus 12.7%; P=.013). After multivariate adjustment, guideline adherence increased by 22% (adjusted relative risk [RR] 1.22; 95% confidence interval [CI] 1.10 to 1.37), whereas hospital admissions were reduced by 26% (adjusted RR 0.74; 95% CI 0.64 to 0.87). In addition, the risks of treatment failure and readmission were reduced by 46% (adjusted RR 0.64; 95% CI 0.43 to 0.97) and 45% (adjusted RR 0.55; 95% CI 0.34 to 0.87), respectively.
Among patients with a nonpurulent skin and soft tissue infection, implementing an easy-to-follow treatment algorithm can reduce unnecessary antibiotic exposure by increasing clinician guideline adherence while reducing patient treatment failure rates.
临床医生目前无法可靠地遵循抗生素治疗指南，导致不必要的广谱抗生素暴露于患者。我们的目的是确定管理非脓性皮肤和软组织感染的治疗干预措施是否会增加临床医生的依从性并改善患者的预后。
2017 年 1 月 1 日至 12 月 31 日，我们招募了在两个急诊科就诊并被诊断为非脓性皮肤和软组织感染的患者，并将他们分为干预前和干预后队列，干预措施于 6 月 1 日实施。主要结局为遵循指南的急诊科医生比例和住院患者比例。次要结局为患者自我报告的治疗失败和医院再入院率。
共有 1360 名患者，干预前组 665 名，干预后组 695 名。在算法实施后，指南的遵循率增加（43.0%对 55.1%；P<.001），住院患者比例下降（36.5%对 12.0%；P<.001）。此外，患者报告的治疗失败率（26.8%对 16.5%；P=.02）和再入院率（22.3%对 12.7%；P=.013）较低。经过多变量调整，指南的遵循率增加了 22%（调整后的相对风险 [RR] 1.22；95%置信区间 [CI] 1.10 至 1.37），而住院率降低了 26%（调整后的 RR 0.74；95% CI 0.64 至 0.87）。此外，治疗失败和再入院的风险分别降低了 46%（调整后的 RR 0.64；95% CI 0.43 至 0.97）和 45%（调整后的 RR 0.55；95% CI 0.34 至 0.87）。
在患有非脓性皮肤和软组织感染的患者中，实施易于遵循的治疗算法可以通过提高临床医生遵循指南的比例，同时降低患者的治疗失败率，从而减少不必要的抗生素暴露。
