Skin and Soft Tissue Infections Clinical Pathway Concordance in Pediatric Emergency and Urgent Care Sites

Introduction Skin and soft tissue infections (SSTIs) are major drivers of antibiotic prescribing in pediatric emergency departments (EDs) and urgent care clinics (UCCs). Although guidelines recommend limited diagnostics and antibiotics, practice variation persists, and the influence of sociodemographic factors remains underexplored. We evaluated concordance with a pediatric SSTI clinical pathway (CP) and examined variation across sociodemographic factors.Methods This retrospective cohort study included children aged 6 months to 18 years evaluated for SSTIs at 2 EDs and 3 UCCs in a Midwestern academic health system from July 2022 through June 2024. We defined concordance per national guidelines and institutional CP, including appropriate diagnostic, antibiotic selection, and antibiotic treatment duration. Generalized linear mixed model examined associations between concordance and patient/visit characteristics.Results Among 4190 encounters, overall CP concordance was 59.0%. Diagnostic concordance was high (86.0%), as was treatment duration concordance (87.8% when antibiotics were indicated). Antibiotic selection showed the lowest concordance (72.6%), largely driven by unnecessary prescribing for diagnoses not requiring antibiotics, such as paronychia. Overall concordance was highest in the younger age group (6 months-2 years) and UCC visits. Black non-Hispanic children had higher odds of concordant care compared with White Non-Hispanic children (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.28-1.88). Return visits were uncommon (2.1% concordant vs 3.3% non-concordant).Conclusion Standardized SSTI pathways support consistent diagnostics and appropriate treatment duration, but reducing unnecessary antibiotic prescribing remains a key stewardship opportunity.