Despite detailed Infectious Disease Society of America (IDSA) skin and soft tissue infection guidelines, patients with cellulitis at our institution consistently receive antibiotics with high local resistance or that are inappropriate based on IDSA guidelines. Our baseline data showed that 55 percent of patients receive antibiotics per IDSA guidelines and only 33 percent of patients received appropriate antibiotics per IDSA guidelines and our institutional antibiogram.
We pursued a multidisciplinary quality improvement project with the objective to increase appropriate antibiotic choice based on IDSA guidelines and local resistance patterns, minimize antibiotic changes between emergency department and inpatient teams and reduce length of stay for cellulitis.
A core team of physicians from hospital medicine and emergency medicine collaborated on an initiative to improve accurate prescription of antibiotics in both departments. We performed a chart review including six months of cellulitis admissions at our institution to review baseline statistics on cellulitis management. We also distributed surveys to faculty and residents in emergency and hospital medicine to assess knowledge gaps. We subsequently provided structured teaching on current guidelines for management of cellulitis and also developed and implemented a simplified cellulitis orderset which was in accordance with current IDSA guidelines and our antibiogram. We performed a post-intervention chart review to evaluate the effect of our interventions on antibiotic choice, length of stay and monitored the utilization of the cellulitis orderset.
There was improvement in compliance with IDSA recommended antibiotic use for cellulitis from baseline of 33 percent to above 60 percent. The length of stay decreased for inpatient status patients from 76 to 49 hours. However, the length of stay for observation patients increased from 28 to 37 hours for unclear reasons. We observed a decrease in the use of clindamycin from 47.8 percent to 2.9 percent and an increase in use of a cephalosporin/penicillin from 15 percent to 53 percent. The use of the cellulitis orderset increased by 10 percent. This relatively low increase in orderset use compared with baseline suggests that formal education regarding IDSA guidelines and local resistance patterns to emergency department and internal/hospital medicine staff was the reason for increased use of appropriate antibiotics in our study. Continued educational efforts will need to be pursued in both resident and faculty curriculum to maintain this trend.