SSTIs and improved antibiotic stewardship

Background

Broad- and extended-spectrum antibiotics are routinely used instead of standard-spectrum antibiotics for hospitalized patients with skin and soft tissue infections (SSTIs) despite the low likelihood of infection with multidrug-resistant organisms (MDROs) in this population.

Methods

The INSPIRE 3 Skin and Soft Tissue trial was a cluster-randomized clinical trial of antibiotic stewardship. It specifically evaluated if management involving computerized order entry prompts that provided patient- and pathogen-specific MDRO infection risk estimates could limit the use of broad-spectrum antibiotics in noncritically ill patients with an SSTI. The comparison management was usual care associated with routine antibiotic stewardship.

The main study outcome was empiric broad-spectrum antibiotic days of therapy (total number of different agents targeting Pseudomonas organisms and/or MDR gram-negative bacteria received per patient each day). Additional outcomes were secondary antipseudomonal days of therapy, hospital length of stay, and days to intensive care unit (ICU) transfer.

Results

In total, 118,562 patients were hospitalized with an SSTI (56.7% male; mean age, 58.0 years).

Empiric broad-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens during the intervention period was 359.1 days in the computer order entry–directed stewardship group and 488.7 days in the routine stewardship group (rate ratio, 0.72; 95% CI, 0.67-0.79).

There were no significant differences in the computer order entry group and the usual care group for the outcomes of mean hospital length of stay (6.4 vs 6.5 days, respectively) and days to ICU transfer (6.3 vs 6.3 days).

Conclusions

The authors concluded that computerized order entry prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI significantly reduced the use of extended-spectrum antibiotics without increasing the hospital length of stay or ICU admissions.

McMaster editors’ commentary

Antibiotic misuse is widespread, leading to the emergence of antimicrobial resistance, selection of pathogenic organisms such as Clostridioides difficile, and direct antibiotic drug toxicity. Efforts described in this trial are a small but important step forward towards a more judicious use of antibiotics. However, it must be noted these attempts can only succeed with changes in physician practices and behaviors under the premise that “less is more.”