Improving the Management of Skin and Soft Tissue Infections in Primary Care: A Report From State Networks of Colorado Ambulatory Practices and Partners (SNOCAP-USA) and the Distributed Ambulatory Research in Therapeutics Network (DARTNet)

Bennett Parnes; Douglas Fernald; Letoynia Coombs; Lauren DeAlleaume; Elias Brandt; Brian Webster; L. Miriam Dickinson; Wilson Pace; David West

doi:10.3122/jabfm.2011.05.110018

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Figure 1.
Summary of Centers for Disease Control and Prevention (CDC) community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).

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Table 1.

Characteristics of All Skin and Soft Tissue Infection Cases (680.x - 682.x) in Both Health Systems for the Preintervention and Intervention Periods

	Texas Clinics			North Carolina Clinics			Combined
	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*
Total number of cases	1870	643	—	1242	763	—	3112	1406	—
Children/adolescents	351 (18.77)	81 (12.60)	.0003	415 (33.41)	258 (33.81)	.8539	766 (24.61)	339 (24.11)	.7155
Mean age	42.83	46.84	.0002	39.65	40.57	.4858	41.56	43.44	.0267
Female	1025 (54.81)	346 (53.81)	.6596	674 (54.27)	419 (54.91)	.7774	1699 (54.6)	765 (54.41)	.9077
Clinician specialty^†
FM	764 (40.86)	264 (41.06)	.9284	396 (31.88)	213 (27.92)	.0607	1160 (37.28)	477 (33.93)	.0301
IM	597 (31.93)	185 (28.77)	.1362	408 (32.85)	293 (38.4)	.0114	1005 (32.29)	478 (34)	.2591
Peds	153 (8.18)	37 (5.75)	.0446	314 (25.28)	203 (26.61)	.5106	467 (15.01)	240 (17.07)	.0772
IM and Peds	81 (4.33)	27 (4.2)	.8864	0 (0)	0 (0)	-	81 (2.6)	27 (1.92)	.1644
Midlevel	236 (12.62)	108 (16.8)	.0079	124 (9.98)	54 (7.08)	.0263	360 (11.57)	162 (11.52)	.9642
Clinical features
Diabetes	270 (14.44)	123 (19.13)	.0047	229 (18.44)	145 (19)	.7521	499 (16.03)	268 (19.06)	.0121
Fever	2 (0.11)	2 (0.31)	.2628	7 (0.56)	3 (0.39)	.5989	9 (0.29)	5 (0.36)	.7100
Previous case SSTI	321 (17.17)	114 (17.73)	.7445	123 (9.9)	150 (19.66)	<.0001	444 (14.27)	264 (18.78)	.0001

↵* P values only calculated for proportions or mean values using Pearson χ² tests, Fisher exact test for small cells, and t tests for continuous variables.
↵† FM, family medicine; IM, internal medicine; Peds, pediatrics; IM and peds (double-boarded in internal medicine and pediatrics); Pre, preintervention period; Interv, intervention period; Midlevel, nurse practitioner or physician assistant; SSTI, skin and soft tissue infection.

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Table 2.

Preintervention and Intervention Rates for Procedures, Cultures, Prescribed Antibiotics, and Methicillin-resistant Staphylococcus aureus (MRSA) Covering Antibiotics of Purulent Skin and Soft Tissue Infections (680.x)

	Texas Clinics			North Carolina Clinics			Combined
	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*
Total 680.x cases	118	46		175	102		293	148
Procedures^†	2 (1.69)	2 (4.35)	.3225	28 (16.00)	5 (4.90)	.0060	30 (10.24)	7 (4.73)	.0488
Culture	21 (17.8)	3 (6.52)	.0665	29 (16.57)	18 (17.65)	.8181	50 (17.06)	21 (14.19)	.4378
Antibiotics prescribed	63 (53.39)	32 (69.57)	.0594	44 (25.14)	37 (36.27)	.0495	107 (36.52)	69 (46.62)	.0408
MRSA-covering antibiotics^‡	34 (53.97)	18 (56.25)	.8328	9 (20.45)	14 (37.84)	.0839	43 (40.19)	32 (46.38)	.4175

↵* P values from Pearson χ² tests, Fisher exact test for small cells, and t tests for continuous variables.
↵† Procedures, incision and drainage only.
↵‡ Trimethoprim-sulfamethoxazole, doxycycline or minocycline, clindamycin, Linezolid.

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Table 3.

Prescribed Antibiotics and Methicillin-resistant Staphylococcus aureus (MRSA) Covering Antibiotics for Cellulitis and Abscess Skin and Soft Tissue Infections (681.x - 682.x)

	Texas Clinics			North Carolina Clinics			Combined
	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*	Pre n (%)	Interv n (%)	p value^*
Total number of 681.x - 682.x cases	1752	597		1067	661		2819	1258
Antibiotics prescribed	738 (42.12)	368 (61.64)	<.0001	265 (24.84)	202 (30.56)	.0092	1003 (35.58)	570 (45.31)	<.0001
MRSA-covering antibiotics^†	289 (39.16)	166 (45.11)	.0582	49 (18.49)	56 (27.72)	.0179	338 (33.7)	222 (38.95)	.0366

↵* P values from Pearson χ² tests, Fisher exact test for small cells, and t tests for continuous variables.
↵† Trimethoprim-sulfamethoxazole, doxycycline or minocycline, clindamycin, Linezolid.

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Table 4.

Among 680.x Cases, Odds Ratios for Procedure, Culture, Prescribed Antibiotics, and Prescribed Methicillin-resistant Staphylococcus aureus (MRSA) Covering Antibiotics (n = 441)

Variable	Procedures				Cultures				All Antibiotics				MRSA-Covering Antibiotics^*
Variable	Odds Ratio	95% Confidence Limits		p value	Odds Ratio	95% Confidence Limits		p value	Odds Ratio	95% Confidence Limits		p value	Odds Ratio	95% Confidence Limits		p value
Intervention	0.3642	0.1124	1.1796	.0921	0.9354	0.5255	1.665	.8204	2.183	1.4429	3.3026	.0002	2.6241	1.4955	4.6044	.0008
Child or adolescent (age < 18)	3.1741	1.0071	10.0035	.0486	1.9468	0.7196	5.2672	.1896	0.3628	0.1488	0.8846	.0258	1.1417	0.5803	2.2462	.701
Male	2.2339	1.2897	3.8692	.0041	1.8485	1.1097	3.0793	.0183	1.0333	0.6821	1.5651	.8773	1.2734	0.7252	2.236	.4002
Previous case of MRSA	0.7231	0.3465	1.509	.3877	0.5692	0.3235	1.0015	.0506	0.8014	0.4327	1.484	.4812	1.165	0.4693	2.8921	.742
Texas clinics patient	0.3878	0.095	1.5836	.187	0.5563	0.2373	1.304	.1772	2.7345	1.5667	4.7726	.0004	4.2918	2.2836	8.0662	<.0001
Diabetes	2.3839	0.7737	7.3455	.1303	1.2438	0.5756	2.688	.5789	0.5532	0.323	0.9477	.0311	0.9262	0.4455	1.9255	.8373
Specialty: IM vs. FM	0.7122	0.1703	2.9785	.642	2.206	0.5535	8.7918	.2621	0.6585	0.3786	1.1451	.1389	2.762	0.9884	7.7178	.0527
Specialty: Midlevel vs. FM	0.2323	0.0451	1.1957	.0808	8.9855	2.1632	37.3245	.0025	1.6038	0.696	3.6957	.2674	6.6824	2.0818	21.450	.0014
Specialty: Peds vs. FM	0.615	0.1531	2.4702	.4932	2.4239	0.575	10.2187	.2278	2.5667	0.9051	7.2788	.0763	2.4039	0.832	6.7726	.0970

↵* Trimethoprim-sulfamethoxazole, doxycycline or minocycline, clindamycin, Linezolid.
IM, internal medicine; FM, family medicine; Peds, pediatrics.

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Table 5.

Among 681.x-682.x Cases, Odds Ratios for Prescribed Antibiotics and Prescribed Methicillin-resistant Staphylococcus aureus (MRSA) Covering Antibiotics (n = 4077)

Variable	All Antibiotics				MRSA-Covering Antibiotics^†
Variable	Odds Ratio	95% Wald Confidence Limits		P Value	Odds Ratio	95% Wald Confidence Limits		P Value
Intervention period monthly change	1.1221	1.0714	1.1752	<.0001	1.1268	1.0565	1.2019	.0003
Historical period monthly change	1.0501	1.0241	1.0767	.0001	1.0438	1.0089	1.0799	.0136
Child or adolescent (age < 18)	1.1338	0.9047	1.4210	.2755	0.7845	0.5511	1.1167	.1779
Male	1.0992	0.9767	1.2371	.1167	1.1435	0.9737	1.3429	.1021
Previous case of MRSA	0.8764	0.6987	1.0993	.2539	0.8355	0.6147	1.1354	.2508
Texas clinics patient	2.9726	2.2745	3.8848	<.0001	4.0343	2.7350	5.9507	<.0001
Diabetes	0.8955	0.7360	1.0896	.2704	0.8865	0.6913	1.1368	.3425
Specialty: IM vs. FM	0.8660	0.6098	1.2300	.4217	0.6932	0.4415	1.0883	.1113
Specialty: Midlevel vs. FM	1.0596	0.6324	1.7753	.8260	0.9362	0.5464	1.6040	.8103
Specialty: Peds vs. FM	1.1712	0.8283	1.6559	.3713	1.7698	1.0955	2.8589	.0197

↵† Trimethoprim-sulfamethoxazole, doxycycline or minocycline, clindamycin, linezolid.
* IM, internal medicine; FM, family medicine; Peds, pediatrics; Midlevel, nurse practitioner or physician assistant; SSTI, skin and soft tissue infection.