Management of skin and soft tissue infections in community practice before and after implementing a 'best practice' approach: an Iowa Research Network (IRENE) intervention study.

摘要

CONTEXT: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a major pathogen among skin and soft tissue infections (SSTIs). Most CA-MRSA infections are managed initially on an outpatient basis. It is critical that primary care clinicians recognize and appropriately treat patients suspected of having such infections. OBJECTIVE: To identify and evaluate best methods and procedures for primary care clinicians to manage skin and soft tissue infections. DESIGN, SETTING, AND PATIENTS: Preintervention/postintervention study in eight Iowa Research Network offices conducted between October 2007 and August 2010. We reviewed medical records of 216 patients with SSTI before a set of interventions (preintervention) and 118 patients after the intervention (postintervention). INTERVENTIONS: Included a focus group meeting at each office, distribution of a modified Centers for Disease Control and Prevention (CDC) algorithm, "Outpatient Management of MRSA Skin and Soft Tissue Infections," education handouts, and an office policy for patients with skin infections. MAIN OUTCOME MEASURES: Proportion of subjects who were prescribed an antibiotic that would cover MRSA at the initial visit and proportion who were prescribed an antibiotic that would cover MRSA at any time. RESULTS: Three hundred sixty-eight forms (244 preintervention and 124 postintervention) were returned; 216 (89%) preintervention forms and 118 (95%) postintervention forms were usable. Multivariable logistic regression models found statistically significant and independent factors associated with MRSA coverage at the initial visit included being in the postintervention rather than the preintervention group, having an abscess component compared with cellulitis alone, having a culture sent, being prescribed two or fewer antibiotics, and not being hospitalized. CONCLUSIONS: The CDC algorithm was feasible for offices to use. Following a discussion of SSTI management in the outpatient setting, use of MRSA coverage increased both initially and overall. Thus, involving clinicians in a discussion about guidelines rather than simply providing guidelines or a didactic session may be a useful way to change physician practices.