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. 2020 Jul;76(1):56-66. doi: 10.1016/j.annemergmed.2019.12.012. Epub 2020 Feb 13.


Study objective: Clinicians currently do not reliably adhere to antibiotic treatment guidelines, resulting in unnecessary patient exposure to broad-spectrum antimicrobials. Our objective is to determine whether a treatment intervention for the management of nonpurulent skin and soft tissue infections increases clinician adherence and improves patient outcomes.

Methods: Between January 1 and December 31, 2017, patients presenting to 2 emergency departments (EDs) and who had received a diagnosis of a nonpurulent skin and soft tissue infection were enrolled and assigned to a pre- or postintervention cohort with a treatment intervention implemented on June 1. Primary outcomes were percentage of ED providers following the guidelines and percentage of patients admitted to the hospital. Secondary outcomes were patient self-reported treatment failure and hospital readmission.

Results: There were 1,360 patients, 665 in the preintervention and 695 in the postintervention cohorts. After algorithm implementation, guideline adherence increased (43.0% versus 55.1%; P<.001) and number of patients admitted to the hospital declined (36.5% versus 12.0%; P<.001). In addition, patients reported fewer treatment failures (26.8% versus 16.5%; P=.02) and fewer readmissions (22.3% versus 12.7%; P=.013). After multivariate adjustment, guideline adherence increased by 22% (adjusted relative risk [RR] 1.22; 95% confidence interval [CI] 1.10 to 1.37), whereas hospital admissions were reduced by 26% (adjusted RR 0.74; 95% CI 0.64 to 0.87). In addition, the risks of treatment failure and readmission were reduced by 46% (adjusted RR 0.64; 95% CI 0.43 to 0.97) and 45% (adjusted RR 0.55; 95% CI 0.34 to 0.87), respectively.

Conclusion: Among patients with a nonpurulent skin and soft tissue infection, implementing an easy-to-follow treatment algorithm can reduce unnecessary antibiotic exposure by increasing clinician guideline adherence while reducing patient treatment failure rates.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Algorithms
  • Anti-Bacterial Agents / therapeutic use*
  • Drug Resistance, Bacterial / drug effects*
  • Emergency Service, Hospital*
  • Female
  • Guideline Adherence*
  • Humans
  • Inappropriate Prescribing / prevention & control*
  • Inappropriate Prescribing / statistics & numerical data
  • Male
  • Middle Aged
  • Practice Guidelines as Topic
  • Prospective Studies
  • Soft Tissue Infections / drug therapy*
  • Soft Tissue Infections / microbiology
  • Treatment Failure


  • Anti-Bacterial Agents