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Clinical and Economic Consequences of Failure of Initial Antibiotic Therapy for Hospitalized Patients With Complicated Skin and Skin-Structure Infections

Published online by Cambridge University Press:  02 January 2015

John Edelsberg ,
Ariel Berger ,
David J. Weber ,
Rajiv Mallick ,
Andreas Kuznik  and
Gerry Oster
John Edelsberg
Affiliation:
Policy Analysis, Brookline, Massachusetts
Ariel Berger
Affiliation:
Policy Analysis, Brookline, Massachusetts
David J. Weber
Affiliation:
School of Medicine, University of North Carolina, Chapel Hill School of Public Health, University of North Carolina, Chapel Hill
Rajiv Mallick
Affiliation:
Wyeth Pharmaceuticals, Collegeville, Pennsylvania
Andreas Kuznik
Affiliation:
Pfizer, New York, New York
Gerry Oster*
Affiliation:
Policy Analysis, Brookline, Massachusetts
*
Policy Analysis, Four Davis Court, Brookline, MA 02445 ([email protected])
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Abstract

Objective.

To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections.

Design.

Retrospective cohort study.

Setting.

Large US multihospital database.

Patients.

We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges.

Results.

For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patient's Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of $5,285 (in 2003 dollars) in additional inpatient charges (all P <.01).

Conclusion.

Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 29 , Issue 2 , February 2008 , pp. 160 - 169
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2008

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References

1.Nichols, RL. Optimal treatment of complicated skin and skin structure infections. J Antimicrob Chemother 1999;44:19–23.CrossRefGoogle ScholarPubMed
2.Center for Drug Evaluation and Research, Food and Drug Administration. Guidance for Industry: Uncomplicated and Complicated Skin and Skin Structure Infections—Developing Antimicrobial Drugs for Treatment. Washington, DC: Food and Drug Administration, US Department of Health and Human Services; 1998.Google Scholar
3.Graham, DR, Lucasti, C, Malafaia, O, et al.Ertapenem once daily versus piperacillin-tazobactam 4 times per day for treatment of complicated skin and skin-structure infections in adults: results of a prospective, randomized, double-blind multicenter study. Clin Infect Dis 2002;34: 1460–1468.CrossRefGoogle ScholarPubMed
4.Graham, DR, Talan, DA, Nichols, RL, et al.Once-daily, high-dose levo-floxacin versus ticarcillin-clavulanate alone or followed by amoxicillin-clavulanate for complicated skin and skin-structure infections: a randomized, open-label trial. Clin Infect Dis 2002;35:381–389.CrossRefGoogle ScholarPubMed
5.Li, JZ, Willke, RJ, Rittenhouse, BE, Rybak, MJ. Effect of linezolid versus vancomycin on length of hospital stay in patients with complicated skin and soft tissue infections caused by known or suspected methicillin-resistant staphylococci: results from a randomized clinical trial. Surg Infect (Larchmt) 2003;4:57–70.CrossRefGoogle ScholarPubMed
6.Deery, HG II. Outpatient parenteral anti-infective therapy for skin and soft-tissue infections. Infect Dis Clin North Am 1998;12:935–949.CrossRefGoogle ScholarPubMed
7.Nichols, RL, Florman, S. Clinical presentations of soft-tissue infections and surgical site infections. Clin Infect Dis 2001;33:S84–S93.CrossRefGoogle ScholarPubMed
8.Fung, HB, Chang, JY, Kuczynski, S. A practical guide to the treatment of complicated skin and soft tissue infections. Drugs 2003;63:1459–1480.CrossRefGoogle Scholar
9.Doern, GV, Jones, RN, Pfeiler, MA, Kugler, KC, Beach, ML, SENTRY Study Group (North America). Bacterial pathogens isolated from patients with skin and soft tissue infections: frequency of occurrence and antimicrobial susceptibility patterns from the SENTRY antimicrobial surveillance program (United States and Canada, 1997). Diagn Microbiol Infect Dis 1999;34:65–72.CrossRefGoogle Scholar
10.Summanen, PH, Talan, DA, Strong, C, et al.Bacteriology of skin and soft-tissue infections: comparison of infections in intravenous drug users and individuals with no history of intravenous drug use. Clin Infect Dis 1995;20:S279–S282.CrossRefGoogle ScholarPubMed
11.Nathwani, D. Impact of methicillin-resistant Staphylococcus aureus infections on key health economic outcomes: does reducing the length of hospital stay matter? J Antimicrob Chemother 2003;51:ii37–ii44.CrossRefGoogle ScholarPubMed
12.Boyce, JM. Methicillin-resistant Staphylococcus aureus in hospitals and long-term care facilities: microbiology, epidemiology, and preventive measures. Infect Control Hosp Epidemiol 1992;13:725–737.CrossRefGoogle ScholarPubMed
13.Stevens, DL, Bisno, AL, Chambers, HF, et al.Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41:1373–1830.CrossRefGoogle ScholarPubMed
14.Cattan, P, Yin, DD, Sarfati, E, Lyu, R, De Zelicourt, M, Fagnani, F. Cost of care for inpatients with community-acquired intra-abdominal infections. Eur J Clin Microbiol Infect Dis 2002;21:787–793.CrossRefGoogle ScholarPubMed
15.Deyo, RA, Cherkin, DC, Ciol, MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619.CrossRefGoogle ScholarPubMed
16.Wilson, SE, Solomkin, JS, Le, V, Cammarata, SK, Bruss, JB. A severity score for complicated skin and soft tissue infections derived from phase III studies of linezolid. Am J Surg 2003;185:369–375.CrossRefGoogle ScholarPubMed
17.Duan, N. Smearing estimate: a nonparametric retransformation model. J Am Stat Assoc 1983;78:605–610.CrossRefGoogle Scholar
18.Efron, B, Tibshirani, R. Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy. Stat Sci 1986;1:54–77.Google Scholar
19.Raghavan, M, Linden, PK. Newer treatment options for skin and soft tissue infections. Drugs 2004;64:1621–1642.CrossRefGoogle ScholarPubMed
20.Moet, GJ, Jones, RN, Biedenbach, DJ, Stilwell, MG, Fritsche, TR. Contemporary causes of skin and soft tissue infections in North America, Latin America, and Europe: report from the SENTRY Antimicrobial Surveillance Program (1998-2004). Diagn Microbiol Infect Dis 2007;57:7–13.CrossRefGoogle ScholarPubMed
21.Stevens, DL, Bisno, AL, Chambers, HF, et al.Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41:1373–1406.CrossRefGoogle ScholarPubMed
22.Naimi, TS, LeDell, KH, Como-Sabetti, K, et al.Comparison of community-and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 2003;290:2976–2984.CrossRefGoogle ScholarPubMed
23.US Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) net. Available at: http://hcupnet.ahrq.gov/. Accessed February 22, 2007.Google Scholar
24.Rennie, RP, Jones, RN, Mutnick, AH, the SENTRY Program Study Group (North America). Occurrence and antimicrobial susceptibility patterns of pathogens isolated from skin and soft tissue infections: report from the SENTRY Antimicobial Surveillance Program (United States and Canada, 2000). Diagn Microbiol Infect Dis 2003;45:287–293.CrossRefGoogle Scholar
25.Lee, SY, Kuti, JL, Nicolau, DP. Antimicrobial management of complicated skin and skin structure infections in the era of emerging resistance. Surg Infect (Larchmt) 2005;6:283–295.CrossRefGoogle ScholarPubMed
26.van der Eerden, MM, Vlaspolder, F, de Graaff, CS, et al.Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomized study. Thorax 2005;60:672–678.CrossRefGoogle Scholar
27.Krobot, K, Yin, D, Zhang, Q, et al.Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis 2004;23:682–687.CrossRefGoogle Scholar
28.Falagas, ME, Barefoot, L, Griffith, J, Ruthazar, R, Snydman, DR. Risk factors leading to clinical failure in the treatment of intra-abdominal or skin/soft tissue infections. Eur J Clin Microbiol Infect Dis 1996;15:913–921.CrossRefGoogle ScholarPubMed
29.Dupont, H, Mentec, H, Sollet, JP, Bleichner, G. Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia. Intensive Care Med 2001;27:355–362.CrossRefGoogle Scholar
30.Ruiz, M, Torres, A, Ewig, S, et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med 2000;162:119–125.CrossRefGoogle ScholarPubMed
31.Kollef, MH, Sherman, G, Ward, S, Fraser, VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999;115:462–474.CrossRefGoogle ScholarPubMed
32.Kollef, MH, Ward, S. The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia. Chest 1998;113:412–420.Google ScholarPubMed
33.Sanchez-Nieto, JM, Torres, A, Garcia-Cordoba, F, et al.Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: a pilot study. Am J Respir Crit Care Med 1998;157:371–376.CrossRefGoogle ScholarPubMed
34.Rello, J, Rue, M, Jubert, P, et al.Survival in patients with nosocomial pneumonia: impact of the severity of illness and the etiologic agent. Crit Care Med 1997;25:1862–1867.CrossRefGoogle ScholarPubMed
35.Luna, CM, Vujacich, P, Niederman, MS, et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest 1997;111:676–685.CrossRefGoogle ScholarPubMed
36.Alvarez-Lerma, F. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit: ICU-Acquired Pneumonia Study Group. Intensive Care Med 1996;22:387–394.CrossRefGoogle ScholarPubMed
37.Mosdell, DM, Morris, DM, Voltura, A, et al.Antibiotic treatment for surgical peritonitis. Ann Surg 1991;214:543–549.CrossRefGoogle ScholarPubMed