Variability in Emergency Medicine (EM) Provider Decisions on Hospital Admission and Antibiotic (ABX) Treatment for Acute Bacterial Skin and Skin Structure Infections (ABSSSI)

BACKGROUND: ABSSSI are a frequent cause of emergency room visits. Physicians (PHY) and Advanced Practice Providers (APP) have many decisions to make during the initial treatment of ABSSSI, including intravenous (IV) vs. oral (PO) ABX, and hospital admission vs. discharge home. There are limited data, however, on factors that influence the provider’s decision for the treatment of ABSSSI. METHODS: An anonymous survey was offered to EM providers at 5 hospitals across the US. The survey presented patient cases with ABSSSI ≥ 75cm(2) and escalating clinical scenarios including relapse, controlled diabetes (DM), and SIRS. For each case, participants were queried on their decision for admission vs. discharge, ABX therapy (IV, PO, or both), and to rank factors that influenced their ABX decision. Descriptive and inferential statistics were used for analyses. RESULTS: Across the 5 hospitals, 104 providers completed the survey; 59 (56.7%) were PHY and 45 (43.3%) were APP. Experience was evenly represented with 50 (48.1%) providers practicing for ≥5 years and 54 (51.9%) less than 5 years. For the first case with no relapse, DM, or SIRS, most providers selected PO ABX [95 (91.4%)] and discharge [100 (96.2%)]. In case 2, the presence of relapse resulted in PO ABX for 50 (48.1%) and discharge in 54 (51.9%) of responses. In case 3, the presence of controlled DM resulted in PO ABX for 55 (53.4%) and discharge home in 65 (63.1%) of responses. Four (3.8%) and 13 (12.5%) providers chose to give 1–2 IV doses followed by PO and discharge the relapsed and DM cases, respectively. Compared with APP, PHY more frequently prescribed PO ABX for the DM case (62.7% vs. 40.9%, P = 0.046) and incorporated PO ABX into the treatment of the SIRS case (48.3% vs. 22.7%, P = 0.015). The addition of SIRS criteria in case 4 resulted in initiation with IV ABX [97 (95.1%)] and admission [100 (96.2%)]. The highest ranked factors influencing ABX selection were infection severity and co-morbidities; the lowest were patient convenience, adverse events, and cost. CONCLUSION: These data highlight factors influencing EM provider decisions in the treatment of ABSSSI. Variability in responses to patient cases suggests opportunities for education and the development of an ABSSSI clinical pathway to guide treatment. DISCLOSURES: K. R. Keyloun, Allergan: Employee, Salary. D. P. Nicolau, Allergan: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. J. L. Kuti, Allergan: Grant Investigator, Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium