title: Failure of outpatient antibiotics among patients hospitalized for acute bacterial skin infections: What is the clinical relevance?
abstract: BACKGROUND
  Infectious Diseases Society of America guidelines recommend that patients hospitalized for acute bacterial skin infections after failure of outpatient antibiotic therapy be managed as "severe" infections; however, the clinical relevance of apparent failure of outpatient therapy is not clear.
  
  
  METHODS
  This was a secondary analysis of a multicenter, retrospective cohort of adults and children hospitalized for cellulitis, abscess, or wound infection. We compared clinical features, laboratory and microbiology findings, antibiotic treatment, and outcomes among patients who received outpatient antibiotics prior to admission and those who did not.
  
  
  RESULTS
  Of 533 patients, 179 (34%) received outpatient antibiotics prior to admission. Compared with those who did not, patients who received antibiotics prior to admission less frequently had fever (18% vs 26%, P=.04) and leukocytosis (33% vs 51%, P<.001). In the 202 cases where a microorganism was identified, Staphylococcus aureus was more common among those who received antibiotics prior to admission (75% vs 58%, P=.02), particularly methicillin-resistant S aureus (41% vs 27%, P=.049), whereas aerobic gram-negative bacilli were less common (3% vs 13%, P=.03). After hospitalization, clinical failure occurred with similar frequency between the 2 groups (12% vs 11%, P=.73).
  
  
  CONCLUSIONS
  Patients hospitalized with skin infections after apparently failing outpatient therapy had clinical features suggestive of less severe infection and similar outcomes compared with patients who did not receive antibiotics prior to admission. Our results suggest that inpatient treatment for patients not responding to outpatient therapy should focus on methicillin-resistant S aureus, not gram-negative pathogens.
authors.affiliation: Department of Medicine, Denver Health, Denver, co; Division of Infectious Diseases, Denver Health, Denver, co; Department of Patient Safety and Quality, Denver Health, Denver, Colorado; Department of Medicine, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, co. Electronic address: timothy.jenkins@dhha.org.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Jenkins
authors.affiliation: Department of Patient Safety and Quality, Denver Health, Denver, Colorado.
authors.forename: Bryan C
authors.initials: BC
authors.lastname: Knepper
authors.affiliation: Department of Medicine, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, co.
authors.forename: Bruce D
authors.initials: BD
authors.lastname: McCollister
authors.affiliation: Department of Trauma and Critical Care Services, Vail Valley Medical Center, Vail, co.
authors.forename: S Jason
authors.initials: SJ
authors.lastname: Moore
authors.affiliation: Colorado Infectious Disease Associates, Denver, co.
authors.forename: Sean W
authors.initials: SW
authors.lastname: Pawlowski
authors.affiliation: Department of Medicine, Porter Adventist Medical Center, Denver, co.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Perlman
authors.affiliation: Department of Medicine, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, co.
authors.forename: Carla C
authors.initials: CC
authors.lastname: Saveli
authors.affiliation: Department of Medicine, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, Children's Hospital Colorado, Aurora, co.
authors.forename: Sean T
authors.initials: ST
authors.lastname: O'Leary
authors.affiliation: Department of Medicine, Denver Health, Denver, co; Division of Infectious Diseases, Denver Health, Denver, co; Department of Medicine, University of Colorado School of Medicine, Aurora, co; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, co; Denver Public Health, Denver Health, Denver, co.
authors.forename: William J
authors.initials: WJ
authors.lastname: Burman
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D017192:Skin Diseases, Bacterial / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology; D017211:Treatment Failure
chemical_list: D000900:Anti-Bacterial Agents