Evidence-Based Medicine Commentary

1. Before/After Study Design: One drawback to this type of study design is the possible contamination of treatment effect by confounders such as other system or local factors. For example, it’s not clear how much the protocol to ensure close outpatient follow-up or education contributed to the lower hospitalization rates.
2. Hawthorne Effect: It is possible that some portion of the treatment effect was the result of the clinicians being aware that their management of SSTI was being evaluated and that discharge was encouraged. This could have introduced a Hawthorne effect, which is when people change their normal behavior in response to knowing they are being observed.
3. Magnitude of Impact: There was a large absolute decrease in hospitalizations after the pathway was introduced (21 percent). However, only 5 percent of patients screened for eligibility were enrolled. That means the data do not directly apply to most patients who present with SSTI, which limits impact of this intervention.
4. Cost and Creep: This medication costs approximately $5,000 for 1,500 mg. It is unclear if this would be a cost-effective strategy compared to admitting patients. It would depend on in which country the pathway was implemented. There could also be a concern with indication creep, which could lead to overuse and potentially increased antibiotic resistance.
5. Conflict of Interest: This was an industry-funded study with multiple authors declaring conflicts of interest. While this does not make the data or interpretation wrong, it should make us more skeptical.

Bottom Line

A clinical pathway that provides a long-acting IV and the ability to establish expedited telephone and in-person follow-up is associated with a decrease in hospitalizations for patients with moderately severe cellulitis.

Case Resolution

You engage in shared decision making with the woman and offer her admission to the hospital for IV antibiotic inpatient management or a single-dose long-acting IV antibiotic and outpatient management. She chooses not to be admitted and is discharged home with follow-up instructions.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Thank you to Dr. Lauren Westafer, an assistant professor in the department of emergency medicine at the University of Massachusetts Medical School–Baystate, for her help with this review. 

References:

1. Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298.
2. Edelsberg J, Taneja C, Zervos M, et al. Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516-1518.
3. Suaya JA, Mera RM, Cassidy A, et al. Incidence and cost of hospitalizations associated with Staphylococcus aureus skin and soft tissue infections in the United States from 2001 through 2009. BMC Infect Dis. 2014;14:296.
4. Sabbatini AK, Nallamothu BK, Kocher KE. Reducing variation in hospital admissions from the emergency department for low-mortality conditions may produce savings. Health Aff (Millwood). 2014;33(9):1655-1663.
5. LaPensee KT, Fan W, Economic burden of hospitalization with antibiotic treatment for bacteremia, sepsis in the US. Paper presented at: ID Week Annual Meeting; October 17–21, 2012; San Diego, CA.
6. Talan DA, Salhi BA, Moran GJ, et al. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. West J Emerg Med. 2015;16(1):89-97.