Discussion

Treatment of SSTIs requires careful assessment of risk factors, exposures, and time course with a need for close monitoring of improvement while on antibiotics. Pseudomonas aeruginosa involvement in SSTIs is rare, and current guidelines recommend against empiric coverage unless evidence of a necrotizing infection or in the setting of fever and neutropenia. ^{Reference Stevens, Bisno and Chambers4} Even in chronic SSTIs (eg, diabetic foot infections), empiric antipseudomonal coverage is not always warranted. ^{Reference Albalawi and van Asten6}

In this investigation, we demonstrate a statistically significant decrease in empiric anti-pseudomonal prescriptions for all SSTIs at a small community hospital with a TASP. We also share an example where targeting a single infection type in a fully remote TASP proved beneficial. An ID provider and ID pharmacist met virtually with ED providers to share preimplementation findings. Based on ED provider feedback, we worked on aligning our sepsis bundle to our internal SSTI guideline. The same virtual in-service presentation and discussion was done with inpatient hospitalist providers. The SSTI guideline was formally approved at the health system’s antimicrobial stewardship committee. We leveraged on-site pharmacists to further ensure guideline adherence. Notably, we experienced more diabetic foot infections in the postimplementation group with a greater tendency to use antipseudomonal agents given prior antibiotic exposure and microbiological history. We hypothesize a greater decrease in antipseudomonal agent prescribing if the proportion of diabetic foot infections were similar between the two cohorts.

The study has several limitations. The small sample size and single-center experience may not be applicable to other antimicrobial stewardship programs, especially at large academic medical centers. We did not investigate other common antimicrobial stewardship metrics, such as days of therapy per 1,000 patient days and standardized antimicrobial administration ratio given the focus of only SSTIs. With two reviewers, one focused on the preimplementation data collection phase and the other on the postphase, reviewer bias may have been introduced. The impact of daily TASP workflows is difficult to quantify. Patients in the preimplementation group represent a period within the first two years of our TASP whereas those in the postgroup were greater than two years out from implementation, a period in which general improvement to our TASP is anticipated. We did not capture the proportion of antibiotic orders once under the care of the hospitalist, which may have better described the impact of our internal guideline. Finally, the impact of the COVID-19 pandemic on antimicrobial prescribing practices remains uncertain.

In summary, we share a targeted tele-antimicrobial stewardship initiative for SSTIs that was shown to decrease empiric anti-pseudomonal prescribing in patients admitted from the ED at a small community hospital. This example may help guide other TASPs looking to improve prescribing practices for a single infection indication. By targeting single infection indications, this may lend to a greater measurable impact on all antimicrobial prescribing as prospective audit and feedback allows for continual monitoring of provider response to antimicrobial stewardship interventions.