Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections

Abstract

Objectives: Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single-dose, long-acting IV antibiotic.

Methods: We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm² without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24-hour follow-up telephone call and had a 48- to 72-hour in-person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate.

Results: Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm² and 289.0 (IQR = 161.3 to 555.0) cm² , respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP).

Conclusions: Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764.

Keywords: abscess; antibacterial agents; cellulitis; critical pathways; dalbavancin; emergency department; health resources; hospital; hospitalization; infectious; skin diseases; wound infection.

FIGURE 1

During the usual care and clinical pathway periods, patients were selected if they fulfilled eligibility requirements, i.e., adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm² and a known or suspected Gram‐positive infection without other indications for hospitalization (e.g., unstable coorbidities, requiring the operating room or intensive care). In the usual care period, participants were treated for SSTI based on usual care. Once the usual care period was completed, over 2 to 4 weeks prior to the initiation of the clinical pathway period, each site's principal investigator and study coordinators trained physicians and other ED staff on the clinical pathway. During the clinical pathway period, all participants were administered a single IV dose of dalbavancin in the ED. For participants who did not have follow‐up contact through 44 days, it was assumed that there were no additional hospitalizations beyond the last follow‐up contact if review of their electronic medical records at the site hospital did not identify subsequent hospital admission. SSTI, skin and soft tissue infection