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Risueño Blanco, J. A. (2023). Factors related to the inappropriate prescription of antibiotic therapy in adults with skin infections in outpatient clinics. Biosalud, 18(2), 7–18. https://doi.org/10.17151/biosa.2019.18.2.1
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Abstract
Introduction: Skin and soft tissue infections (SSTIs) are a frequent reason for outpatient consultation. The study of the factors related to antibiotic inadequacy in SSTI constitutes the starting point to face bacterial resistance. Objective: Relate the factors of non-purulent STI in adult outpatients with inadequate prescription of antibiotic therapy in an IPS in Palmira in 2019. Methods: Retrospective analytical cross-sectional study. Simple random sampling was used. Information was collected from medical records. Antibiotic treatment was considered adequate if it was in accordance with the guidelines. Descriptive statistics of all the variables were performed, then group comparisons were made according to whether the antibiotic therapy was adequate or not; Finally, multivariate analysis was performed to control for confusion. Results: For a sample of 213 medical records, the most prescribed antibiotic was cephalexin (37.1 %); antibiotic self-medication is found (13.1 %) and 76.1 % of the prescriptions were adequate. In the multivariate analysis, antibiotic self-medication (OR 17.523, 95 % CI 1.127-272.5) and the intramuscular route (OR 44.358, 95 % CI 1.161-1695.461) were related to inappropriate antibiotic prescription. Conclusion: The implementation of local guidelines in outpatient medical services is recommended, strengthening their guidelines and educating the community regarding antibiotic self-medication from primary care to reduce the inappropriateness of antibiotic therapy.
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References
1. Valderrama-Beltrán S, Cortés J, Caro M, Cely-Andrade L, Osorio-Pinzón J, Gualtero S, et al. Clinical Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections in Colombia. Infectio [Internet]. 2019; 23(4):318-46. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0123-93922019000400318
2. Yunquera-Romero L, Márquez-Gómez I, Henares-López A, Morales-Lara M, Gallego Fernández C, Asensi-Díez R. Appropriateness of antimicrobial prescriptions in the emergency department of a tertiary hospital. Rev Española Quimioter [Internet]. 2018; 31(3):209-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29771104
3. Yadav K, Nath A, Suh K, Sikora L, Eagles D. Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review. Infection [Internet]. 2020; 48(1):75-83. Available from: https://doi.org/10.1007/s15010-019-01347-w
4. Fritz S, Shapiro D, Hersh A. National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015. Clin Infect Dis [Internet]. 2019; 0(0):pii: ciz977. Available from: https://academic.oup.com/cid/advance-articleabstract/doi/10.1093/cid/ciz977/5586461?redirectedFrom=fulltext
5. Castrillón-Spitia J, Ocampo-Palacio A, Rivera-Echeverry C, Londoño-Montes J, Martínez-Betancur S, Machado-Alba J. Prescription of antibiotics in infections of the skin and soft tissues. Ces Med [Internet]. 2018; 32(1):3-13. Available from: http://revistas.ces.edu.co/index.php/medicina/article/view/4015
6. Broek A, Hest R, Lettinga K, Jimmink A, Lauw F, Visser C, et al. The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands. Antimicrob Resist Infect Control [Internet]. 2020; 9(1):40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036246/
7. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. Prevalence of inappropriate antibiotic prescriptions among us ambulatory care visits, 2010-2011. JAMA - J Am Med Assoc [Internet]. 2016; 315(17):1864-73. Available from: https://jamanetwork.com/journals/jama/fullarticle/2518263
8. Shively NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of inappropriate antibiotic prescribing in primary care clinics within a veterans affairs health care system. Antimicrob Agents Chemother [Internet]. 2018; 62(8):1-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105840/pdf/e00337-18.pdf
9. Jeong D, Nguyen H, Tyndall M, Schreiber Y. Antibiotic use among twelve Canadian First Nations communities: A retrospective chart review of skin and soft tissue infections. BMC Infect Dis [Internet]. 2020; 20(1):118. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011559/
10. O’Keefe C, Thompson A, McKenzie D, Lee K. Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy. Int J Clin Pract [Internet]. 2019; 00:e13427. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/ijcp.13427
11. Pulia M, Kern M, Schwei R, Shah M, Sampene E, Crnich C. Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: A cross-sectional analysis. Antimicrob Resist Infect Control [Internet]. 2018; 7(74):1-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6000953/
12. Hansen M, Arpi M, Hedin K, Melander E, Hertz F, Thorsted A, et al. Antibiotic-prescribing and antibiotic-resistance patterns among elderly citizens residing in two Nordic regions. Infect Dis (Auckl) [Internet]. 2020; 52(4):257-65. Available from: https://doi.org/10.1080/23744235.2019.1711159
13. Higuita-Gutiérrez L, Molina-Garcia V, Acevedo Guiral J, Gómez Cadena L, Roncancio G, Jiménez J. Knowledge regarding antibiotic use among students of three medical schools in Medellin, Colombia: A cross-sectional study. BMC Med Educ. 2020; 20(1):22.
14. Fernández-Urrusuno R, Flores-Dorado M, Vilches-Arenas A, Serrano-Martino C, Corral-Baena S, Montero-Balosa MC. Adecuación de la prescripción de antibióticos en un área de atención primaria: estudio descriptivo transversal. Enferm Infecc Microbiol Clin[Internet]. 2014; 32(5):285-92. Available from: http://dx.doi.org/10.1016/j.eimc.2013.05.004
15. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008; 47(6):735–43.
16. Macía-Rodríguez C, Alende-Castro V, Vazquez-Ledo L, Novo-Veleiro I, González-Quintela A. Skin and soft-tissue infections: Factors associated with mortality and re-admissions. Enferm Infecc Microbiol Clin (English ed) [Internet]. 2017; 35(2):76-81. Available from: http://dx.doi.org/10.1016/j.eimce.2017.01.028
17. Valderrama-Beltrán S, Gualtero S, Álvarez-Moreno C, Gil F, Ruiz AJ, Rodríguez JY, et al. Risk factors associated with methicillin-resistant Staphylococcus aureus skin and soft tissue infections in hospitalized patients in Colombia. Int J Infect Dis [Internet]. 2019; 87:60-6. Available from: https://www.ijidonline.com/article/S1201-9712(19)30292-9/fulltext
18. Barlam TF, Cosgrove SE, Abbo LM, Macdougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62(10):e51-77.
19. Haran J, Wu G, Bucci V, Fischer A, Boyer E, Hibberd P. Treatment of bacterial skin infections in ED observation units: Factors influencing prescribing practice. Am J Emerg Med [Internet]. 2015; 33(12):1780-5. Available from: http://dx.doi.org/10.1016/j.ajem.2015.08.035
20. Rath E, Skrede S, Oppegaard O, Bruun T. Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort. Infect Dis (Auckl) [Internet]. 2020; 0(0):1-11. Available from: https://doi.org/10.1080/23744235.2020.1726447
21. Lipsky B, Napolitano L, Moran G, Vo L, Nicholson S, Kim M. Inappropriate initial antibiotic treatment for complicated skin and soft tissue infections in hospitalized patients: Incidence and associated factors. Diagn Microbiol Infect Dis [Internet]. 2014; 79(2):273-9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0732889314000741?via %3Dihub
22. Haran J, Goulding M, Campion M, Scully G, Chandra A, Goldberg R, et al. Reduction of Inappropriate Antibiotic Use and Improved Outcomes by Implementation of an Algorithm-Based Clinical Guideline for Nonpurulent Skin and Soft Tissue Infections. Ann Emerg Med [Internet]. 2020; 0(0):1-11. Available from: https://doi.org/10.1016/j.annemergmed.2019.12.012
23. Goss F, Bookman K, Barron M, Bickley D, Landgren B, Kroehl M, et al. Improved antibiotic prescribing using indication based clinical decision support in the emergency department. J Am Coll Emerg Physicians Open [Internet]. 2020; 1(3):214-21. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12029
24. Stevens D, Bisno A, Chambers H, Dellinger E, Goldstein E, Gorbach S, et al. Executive summary: Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis [Internet]. 2014; 59(2):147-59. Available from: https://academic.oup.com/cid/article/59/2/e10/2895845
25. Kwak Y, Choi S, Kim T, Park S, Seo S, Kim M, et al. Clinical guidelines for the antibiotic treatment for community-acquired skin and soft tissue infection. Infect Chemother [Internet]. 2017; 49(4):301-25. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5754343/
26. Walsh T, Chan L, Konopka C, Burkitt M, Moffa M, Bremmer D, et al. Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients. BMC Infect Dis [Internet]. 2016; 16(1):1-8. Available from: http://dx.doi.org/10.1186/s12879-016-2067-0
27. Haran J, Wilsterman E, Zeoli T, Goulding M, McLendon E, Clark M. Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients. Epidemiol Infect [Internet]. 2019; 5:-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518578/
28. Sutton J, Carico R, Burk M, Jones M, Wei X, Neuhauser M, et al. Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation. Open Forum Infect Dis [Internet]. 2020; 7(1):ofz554. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984672/
29. Sandoe J, Saeed K, Guleri A, Hand K, Dillon R, Allen M, et al. Opportunities for antimicrobial stewardship in patients with acute bacterial skin and skin structure infections who are unsuitable for beta-lactam antibiotics: a multicenter prospective observational study. Ther Adv Infect Dis [Internet]. 2019; 6:204993611882365. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365991/
30. Hurley H, Knepper B, Price C, Mehler P, Burman W, Jenkins T. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med [Internet]. 2013; 126(12):1099-106. Available from: http://dx.doi.org/10.1016/j.amjmed.2013.08.016
31. Nickerson E, West T, Day N, Peacock S. Staphylococcus aureus disease and drug resistance in resource-limited countries in south and east Asia. Lancet Infect Dis [Internet]. 2009; 9(2):130-5. Available from: http://dx.doi.org/10.1016/S1473-3099(09)70022-2
2. Yunquera-Romero L, Márquez-Gómez I, Henares-López A, Morales-Lara M, Gallego Fernández C, Asensi-Díez R. Appropriateness of antimicrobial prescriptions in the emergency department of a tertiary hospital. Rev Española Quimioter [Internet]. 2018; 31(3):209-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29771104
3. Yadav K, Nath A, Suh K, Sikora L, Eagles D. Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review. Infection [Internet]. 2020; 48(1):75-83. Available from: https://doi.org/10.1007/s15010-019-01347-w
4. Fritz S, Shapiro D, Hersh A. National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015. Clin Infect Dis [Internet]. 2019; 0(0):pii: ciz977. Available from: https://academic.oup.com/cid/advance-articleabstract/doi/10.1093/cid/ciz977/5586461?redirectedFrom=fulltext
5. Castrillón-Spitia J, Ocampo-Palacio A, Rivera-Echeverry C, Londoño-Montes J, Martínez-Betancur S, Machado-Alba J. Prescription of antibiotics in infections of the skin and soft tissues. Ces Med [Internet]. 2018; 32(1):3-13. Available from: http://revistas.ces.edu.co/index.php/medicina/article/view/4015
6. Broek A, Hest R, Lettinga K, Jimmink A, Lauw F, Visser C, et al. The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands. Antimicrob Resist Infect Control [Internet]. 2020; 9(1):40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036246/
7. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. Prevalence of inappropriate antibiotic prescriptions among us ambulatory care visits, 2010-2011. JAMA - J Am Med Assoc [Internet]. 2016; 315(17):1864-73. Available from: https://jamanetwork.com/journals/jama/fullarticle/2518263
8. Shively NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of inappropriate antibiotic prescribing in primary care clinics within a veterans affairs health care system. Antimicrob Agents Chemother [Internet]. 2018; 62(8):1-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105840/pdf/e00337-18.pdf
9. Jeong D, Nguyen H, Tyndall M, Schreiber Y. Antibiotic use among twelve Canadian First Nations communities: A retrospective chart review of skin and soft tissue infections. BMC Infect Dis [Internet]. 2020; 20(1):118. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011559/
10. O’Keefe C, Thompson A, McKenzie D, Lee K. Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy. Int J Clin Pract [Internet]. 2019; 00:e13427. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/ijcp.13427
11. Pulia M, Kern M, Schwei R, Shah M, Sampene E, Crnich C. Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: A cross-sectional analysis. Antimicrob Resist Infect Control [Internet]. 2018; 7(74):1-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6000953/
12. Hansen M, Arpi M, Hedin K, Melander E, Hertz F, Thorsted A, et al. Antibiotic-prescribing and antibiotic-resistance patterns among elderly citizens residing in two Nordic regions. Infect Dis (Auckl) [Internet]. 2020; 52(4):257-65. Available from: https://doi.org/10.1080/23744235.2019.1711159
13. Higuita-Gutiérrez L, Molina-Garcia V, Acevedo Guiral J, Gómez Cadena L, Roncancio G, Jiménez J. Knowledge regarding antibiotic use among students of three medical schools in Medellin, Colombia: A cross-sectional study. BMC Med Educ. 2020; 20(1):22.
14. Fernández-Urrusuno R, Flores-Dorado M, Vilches-Arenas A, Serrano-Martino C, Corral-Baena S, Montero-Balosa MC. Adecuación de la prescripción de antibióticos en un área de atención primaria: estudio descriptivo transversal. Enferm Infecc Microbiol Clin[Internet]. 2014; 32(5):285-92. Available from: http://dx.doi.org/10.1016/j.eimc.2013.05.004
15. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008; 47(6):735–43.
16. Macía-Rodríguez C, Alende-Castro V, Vazquez-Ledo L, Novo-Veleiro I, González-Quintela A. Skin and soft-tissue infections: Factors associated with mortality and re-admissions. Enferm Infecc Microbiol Clin (English ed) [Internet]. 2017; 35(2):76-81. Available from: http://dx.doi.org/10.1016/j.eimce.2017.01.028
17. Valderrama-Beltrán S, Gualtero S, Álvarez-Moreno C, Gil F, Ruiz AJ, Rodríguez JY, et al. Risk factors associated with methicillin-resistant Staphylococcus aureus skin and soft tissue infections in hospitalized patients in Colombia. Int J Infect Dis [Internet]. 2019; 87:60-6. Available from: https://www.ijidonline.com/article/S1201-9712(19)30292-9/fulltext
18. Barlam TF, Cosgrove SE, Abbo LM, Macdougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62(10):e51-77.
19. Haran J, Wu G, Bucci V, Fischer A, Boyer E, Hibberd P. Treatment of bacterial skin infections in ED observation units: Factors influencing prescribing practice. Am J Emerg Med [Internet]. 2015; 33(12):1780-5. Available from: http://dx.doi.org/10.1016/j.ajem.2015.08.035
20. Rath E, Skrede S, Oppegaard O, Bruun T. Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort. Infect Dis (Auckl) [Internet]. 2020; 0(0):1-11. Available from: https://doi.org/10.1080/23744235.2020.1726447
21. Lipsky B, Napolitano L, Moran G, Vo L, Nicholson S, Kim M. Inappropriate initial antibiotic treatment for complicated skin and soft tissue infections in hospitalized patients: Incidence and associated factors. Diagn Microbiol Infect Dis [Internet]. 2014; 79(2):273-9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0732889314000741?via %3Dihub
22. Haran J, Goulding M, Campion M, Scully G, Chandra A, Goldberg R, et al. Reduction of Inappropriate Antibiotic Use and Improved Outcomes by Implementation of an Algorithm-Based Clinical Guideline for Nonpurulent Skin and Soft Tissue Infections. Ann Emerg Med [Internet]. 2020; 0(0):1-11. Available from: https://doi.org/10.1016/j.annemergmed.2019.12.012
23. Goss F, Bookman K, Barron M, Bickley D, Landgren B, Kroehl M, et al. Improved antibiotic prescribing using indication based clinical decision support in the emergency department. J Am Coll Emerg Physicians Open [Internet]. 2020; 1(3):214-21. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12029
24. Stevens D, Bisno A, Chambers H, Dellinger E, Goldstein E, Gorbach S, et al. Executive summary: Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis [Internet]. 2014; 59(2):147-59. Available from: https://academic.oup.com/cid/article/59/2/e10/2895845
25. Kwak Y, Choi S, Kim T, Park S, Seo S, Kim M, et al. Clinical guidelines for the antibiotic treatment for community-acquired skin and soft tissue infection. Infect Chemother [Internet]. 2017; 49(4):301-25. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5754343/
26. Walsh T, Chan L, Konopka C, Burkitt M, Moffa M, Bremmer D, et al. Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients. BMC Infect Dis [Internet]. 2016; 16(1):1-8. Available from: http://dx.doi.org/10.1186/s12879-016-2067-0
27. Haran J, Wilsterman E, Zeoli T, Goulding M, McLendon E, Clark M. Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients. Epidemiol Infect [Internet]. 2019; 5:-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518578/
28. Sutton J, Carico R, Burk M, Jones M, Wei X, Neuhauser M, et al. Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation. Open Forum Infect Dis [Internet]. 2020; 7(1):ofz554. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984672/
29. Sandoe J, Saeed K, Guleri A, Hand K, Dillon R, Allen M, et al. Opportunities for antimicrobial stewardship in patients with acute bacterial skin and skin structure infections who are unsuitable for beta-lactam antibiotics: a multicenter prospective observational study. Ther Adv Infect Dis [Internet]. 2019; 6:204993611882365. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365991/
30. Hurley H, Knepper B, Price C, Mehler P, Burman W, Jenkins T. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med [Internet]. 2013; 126(12):1099-106. Available from: http://dx.doi.org/10.1016/j.amjmed.2013.08.016
31. Nickerson E, West T, Day N, Peacock S. Staphylococcus aureus disease and drug resistance in resource-limited countries in south and east Asia. Lancet Infect Dis [Internet]. 2009; 9(2):130-5. Available from: http://dx.doi.org/10.1016/S1473-3099(09)70022-2
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