Antibiotic Choices for Inpatients With SSTIs Vary by Race

Christine Kilgore

January 20, 2022

Black patients hospitalized with skin and soft-tissue infections were more likely to receive clindamycin and less likely to receive cefazolin — the latter of which is considered a first-line SSTI treatment — in a national cross-sectional study involving over 1,000 patients in 91 hospitals.

The potential racial disparity in management of SSTI was detected after data were adjusted for penicillin allergy history and for MRSA colonization/infection. The data were also adjusted for hospital day (since admission) in order to control for the administration of more empiric therapy early on.

Dr Kimberly Blumenthal

Clindamycin, a beta-lactam alternative, is not recommended as an SSTI treatment given its frequent dosing requirements and high potential for adverse events including Clostridioides difficile infection (DCI). "Clindamycin is an option but it's considered inferior...It covers MRSA but it shouldn't be a go-to for skin and soft-tissue infections," said senior author Kimberly Blumenthal, MD, MSc, assistant professor of medicine at Harvard University, and an allergist, immunologist, and drug allergy and epidemiology researcher at Massachusetts General Hospital, both in Boston.

Cefazolin, on the other hand, does not cover MRSA but is "a guideline-recommended first-line antibiotic for cellulitis SSTI in the hospital," she said in an interview.

The findings, recently published in JAMA Network Open, offer a valuable portrait of the antibiotics being prescribed in the inpatient setting for SSTIs. Vancomycin, which typically is reserved for MRSA, was the most commonly prescribed antibiotic, regardless of race. Piperacillin-tazobactam, a beta-lactam, was the second most commonly prescribed antibiotic, again regardless of race.

Intravenously administered cefazolin was used in 13% of White inpatients versus 5% of Black inpatients. After controlling for kidney disease, diabetes, and ICU location (in addition to hospital day, penicillin allergy history, and MRSA), White inpatients had an increased likelihood of being prescribed cefazolin (adjusted odds ratio, 2.82; 95% confidence interval, 1.41-5.63) and a decreased likelihood of clindamycin use (aOR, 0.54; 95% CI, 0.30-0.96), compared with Black inpatients.

The investigators utilized the Acute Care Hospital Groups network within Vizient, a member-driven health care performance improvement company, to collect data for the study. Most of the hospitals (91%) that submitted data on adult inpatients with cellulitis or SSTIs (without other infections) were in urban settings and 9% were in rural settings; 60% were community hospitals and 40% were academic medical centers. The researchers accounted for "clustering by hospital" — such as the use of internal guidelines — in their methodology.

Dr Utibe Essien

Differential management and prescribing practices associated with race and ethnicity have been demonstrated for cardiovascular disease and other chronic problems, but "to see such racial differences play out in acute care is striking," Utibe R. Essien, MD, MPH, assistant professor of medicine at the University of Pittsburgh and a core investigator with the Center for Health Equity Research and Promotion at the Veterans Affairs Pittsburgh Healthcare System, said in an interview.

"In acute care, we tend to practice pretty similarly across the board ... so the findings give me pause," said Essien, an internist and a coauthor of the study, who also works with the University of Pittsburgh's Center for Pharmaceutical Policy and Prescribing.

Also notable was the prevalence of historical penicillin allergy documented in the dataset: 23% in Black inpatients and 18% in White inpatients with SSTI. It's a surprisingly high prevalence overall, Blumenthal said, and the racial difference was surprising because penicillin allergy has been commonly described in the literature as being more common in the White population.

Even though penicillin allergy was controlled for in the study, "given that historical penicillin allergies are associated with increased clindamycin use and risk of CDI, but are often disproved with formal testing, racial disparities in penicillin allergy documentation and assessment require additional study," she and her coauthors wrote.

Ideally, Blumenthal said, all inpatients would have access to allergy consultations or testing or some sort of infrastructure for assessing a history of penicillin allergy. At Mass General, allergy consults and challenge doses of beta-lactams (also called graded challenges) are frequently employed.

The study did not collect data on income, educational level, and other structural vulnerability factors. More research is needed to better understand "what's going on in acute care settings and what the potential drivers of disparities may be," said Essien, who co-authored a recent JAMA editorial on "achieving pharmacoequity" to reduce health disparities.

"If guidelines suggest that medication A is the ideal and optimal treatment, we really have to do our best to ensure that every patient, regardless of race or ethnicity, can get that treatment," he said.

In the study, race was extracted from the medical record and may not have been correctly assigned, the authors noted. "Other race" was not specified in the dataset, and Hispanic ethnicity was not captured. The number of individuals identified as Asian and other races was small, prompting the researchers to focus on antibiotic use in Black and White patients (224 and 854 patients, respectively).

Blumenthal and Essien both reported that they had no relevant disclosures. The study was supported with National Institutes of Health grants and the Massachusetts General Hospital department of medicine transformative scholar program.

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