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Resurrecting Lowly Cephalexin for Non-purulent SSTI

March 5, 2020

Written by Clay Smith

Spoon Feed
Treating non-purulent cellulitis with narrow spectrum antibiotics improves meaningful patient outcomes. We don’t need to add vancomycin or TMP/SMX to cephalexin if there is no pus. See this algorithm.

Why does this matter?
Trying to get clinicians to practice a certain way can be like herding cats. The IDSA guidelines recommend narrow spectrum beta-lactam antibiotics for non-purulent SSTIs (you need to read this publication, by the way…). Most SSTIs with no purulent drainage or abscess are caused by Streptococcus pyogenes (a.k.a. group A strep or group A beta hemolytic strep – the same one that causes strep throat). Even if it is Staphylococcus aureus, with no pus, it is most often methicillin sensitive S. aureus (MSSA), not MRSA. Yet, we often treat non-purulent cellulitis with vancomycin or add TMP/SMX to cephalexin. Could a treatment algorithm reduce overly broad antibiotic prescribing for non-purulent SSTI?

Don’t call it a comeback…cephalexin or dicloxacillin still kills strep
This was a before and after study of prescribing in 1,360 patients from 2 EDs in 2017. On June 1 they introduced a new treatment intervention targeting adherence to SSTI prescribing guidelines. Clinician prescribing showed improved concordance with guidelines, 43% to 55%, after intervention. Admissions for SSTI also dropped from 36.5% to 12%, an adjusted 26% decline; aRR 0.74 (95%CI 0.64 to 0.87). Secondary outcomes included fewer treatment failures (adjusted 46% decline) and readmissions (adjusted 45% decline). It’s a win if we can both reduce overly broad antibiotic use and improve meaningful clinical outcomes. What was the intervention? Clinicians got this pocket card plus personal vancomycin prescribing metrics initially and a month later. Prescribing data was also presented for 4 months afterward in faculty meeting.

From cited article, inspired and adapted from the 2014 IDSA guidelines

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 Feb 13. pii: S0196-0644(19)31453-2. doi: 10.1016/j.annemergmed.2019.12.012. [Epub ahead of print]

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What are your thoughts?