1. Aim and Key Driver Diagram
Decreasing the duration of discharge antibiotic treatment following inpatient uncomplicated soft tissue abscess drainage: Findings from a quality improvement project
Kevin Drewes, PharmD1, William Barson, MD2, Don Buckingham, MBOE3, Guliz Erdem, MD2
1: Pharmacy, Nationwide Children's Hospital
2: Pediatrics, Nationwide Children's Hospital and the Ohio State University College of Medicine
3: Quality Improvement, Nationwide Children's Hospital
Results
In 2016, of the 418 identified patients admitted and discharged following abscess drainage, only 72 (17%) were discharged on treatment courses ≤ 5 days.
Average treatment duration was 8.6 days.
Typical 10 day treatment course with oral clindamycin was approximately $300 and the decrease in treatment duration saved ~100$ per patient3.
Since implementation in May 2017, discharge duration of antibiotics has decreased to 5 days.
Physician compliance to a treatment of ≤ 5 days increased from 17% to 72%.
There has been no increase in readmission rates.
Background
Aim and Key Driver Diagram
Short courses of antibiotics are indicated for uncomplicated skin and soft tissue infections (SSTI)
A short course of therapy is defined as 5 days or less
Infectious Disease Society of America recommends antibiotic courses of 5 days for non purulent cellulitis1
Rational for shorter courses of therapy include: Prevention of bacterial resistance, decreased cost burden and reduced adverse effects of antimicrobial therapy
Objective
We wanted to decrease the duration of antibiotics prescribed for patients discharged from our inpatient infectious diseases unit following I&D of soft tissue abscesses.
Discussion
Methods
Standardizing definitions of uncomplicated skin and soft tissue abscesses was critical for the success of our project.
Decreasing the duration of antibiotic treatment led no significant change in readmission rates.
Decreased treatment duration possibly decreased antibiotic associated side effects.
Decreased treatment duration possibly increased the treatment adherence and toleration to poor medication taste.
Using a QI framework and after gaining consensus among ID faculty for eligible patients, a retrospective review was performed2. Pharmacy records and discharge summaries of eligible patients were reviewed between January 1, 2016 and December 31, 2016.
A treatment algorithm following I&D that takes into account the epidemiologic changes in microbial etiologies, presence of systemic findings, and outpatient follow up options was implemented in May 2017.  A run chart was used to assess the impact of these interventions over time.
The readmission rates with SSTI within a month of discharge were used as the balancing measure. 
Figure 1 – Project Key Driver Diagram. Yellow highlighted areas are being implemented.
Future Directions
Inclusions:
3 months to 21 years of age
Admission and discharge from ID service following I&D done during hospitalization with or without minimal residual cellulitis at the time of discharge
Residual cellulitis 5cm or less at time of discharge
Exclusions:
Complicated SSTI with signs or symptoms indicating systemic involvement &/or uncontrolled comorbidities that may complicate treatment
Systemic involvement indicators: fever with tachycardia over 8 hours of hospitalization, diaphoresis, fatigue, anorexia and vomiting that is not due to medication taste
Face and neck infections and lymphadenitis
Cat scratch disease
Hidradenitis suppurativa
Pilonidal cyst
Perianal abscesses (not buttock abscesses)
Burns
Wounds requiring a wound vac dressing
Patients with immunodeficiency
Decubitus ulcers
Animal/human bites, foreign body infections
Surgical site infections
Underlying skin disorders at the site of infection such as
severe eczema
Implement a similar process in other areas of the healthcare system (inpatient units, ED, Urgent care, outpatient clinics)
Utilize outpatient pharmacy information to determine antibiotic cost-effectiveness
References
1. Stevens DL, et al; 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 Jul 15;59(2):e10-52
2.Kilo CM. A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement’s Breakthrough Series. Qual Manag Health Care 1998;6:1-14.
3.Nationwide Children’s Hospital outpatient Pharmacy AWP cost
Acknowledgements
We appreciate ID physicians and nurses, Matt Sapko, PharmD, Lindsay Landgrave, PharmD, pediatric surgeons and Nathaniel Gallup.
Figure 2- Weekly process intervention tracking.