Advice on Deciding Between Oral, Intravenous Antibiotics in Skin Infections
When are oral antibiotics appropriate for patients with non-purulent skin and soft-tissue infections? A new study provides some guidance on which cases require intravenous antibiotics vs. those which can safety go the oral route. Here are the details.
OTTAWA, ONTARIO – How often are the oral antibiotic prescriptions that pharmacists fill for non-purulent skin and soft tissue infections (SSTI) actually inappropriate?
That is the question raised by in Academic Emergency Medicine questioning whether intravenous antibiotics should be used in more cases presenting to the hospital emergency department.
University of Ottawa-led researchers conducted a health records review of adults with non-purulent SSTIs treated at two tertiary care EDs. Included were 500 patients, 55.8% male and with a mean age of 64. A fourth of the patients had been diagnosed with diabetes, the report notes.
The goal was to determine how often oral antibiotic treatment failed. Failure was defined as either/or hospitalization, change in class of oral antibiotic or switch to intravenous therapy after a minimum of 48 hours of oral therapy due to worsening infection.
Results indicate that, Of 288 patients who had received a minimum of 48 hours of oral antibiotics, treatment failure occurred in 85, 29.5%. Independently associated with oral antibiotic treatment failure were:
- tachypnea at triage (odds ratio [OR] = 6.31, 95% confidence interval [CI] = 1.80 to 22.08),
- chronic ulcers (OR = 4.90, 95% CI = 1.68–14.27),
- history of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection (OR = 4.83, 95% CI = 1.51 to 15.44), and
- cellulitis in the past 12 months (OR = 2.23, 95% CI = 1.01 to 4.96).
Noting that their study was the first to evaluate predictors of oral antibiotic treatment failure for non-purulent SSTIs treated in the ED, study authors recommended, "Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for outpatient management of non-purulent SSTIs."
In 2014, the Infectious Diseases Society of America (IDSA) updated its guidelines to recommend oral dicloxacillin, cephalexin, amoxicillin/clavulanate or clindamycin for mild infection.
Intravenous nafcillin or oxacillin, ceftriaxone, cefazolin or clindamycin are advised for moderate infection, while the IDSA urges use of vancomycin plus piperacillin/tazobactam for severe infection.