Journal Club August 2017 - Cellulitis

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Cellulitis is commonly treated in the emergency department.  Patients who present with cellulitis incur significant health care costs and may be over-treated with antibiotics.  For our August journal club, we selected articles that would help providers avoid treatment errors that lead to high costs, unwanted side effects, overuse of antibiotics and unnecessary admissions.  

 

 

 

 

ARTICLES REVIEWED

1.  Abetz; et al. Skin and soft tissue infection management failure in the emergency department observation unit: a systematic review. Emerg Med J 2016; O: 1-6.

2.  Aboltins; et al. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. Journal of Antimicrobial Chemotherapy. 2015; 70: 581-586.

3.  Volz; et al. Identifying patients with cellulitis who are likely to require inpatient admission after a stay in an ED observation unit. American Journal of Emergency Medicine. 2013. 31, 360-364.

 

ADDITIONAL READING

4.  McCreary; et al. Top 10 Myths regarding the diagnosis and treatment of cellulitis. The Journal of Emergency Medicine. Clinical Review.ersus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. Journal of Antimicrobial Chemotherapy. 2015; 70: 581-586.

  

ABETZ ET AL 2013

Fever, high total white blood cell count, and known MRSA expsosure were the most common variables associated with treatment failure in ED observation units.

This was a systematic review of several studies, including the Volz, et al. study.  The management failure rate for skin and soft tissue infections in emergency department observation units is high, as evidenced by a large proportion of patients requiring inpatient admission. This systematic review sought to quantify the management failure rate and identify risk factors associated with management failure.  The management failure rate in this study ranged from 15-38%.  Fever, high total white blood cell count, and known MRSA exposure were the most commonly reported variables associated with management failure. 

The presence of fever, high total white blood cell count, and known MRSA exposure should prompt the physician to consider direct admission to the hospital rather than spending time (and money) in the observation unit (where they are likely to fail).   

 

ABOLTINS ET AL 2015

Are outcomes for patients with cellulitis treated with oral antimicrobials as good as for those who are treated with parenteral antimicrobials?  This study compared the outcomes for patients with uncomplicated cellulitis who are treated with oral antimicrobials versus those who are treated with parenteral antimicrobials.   They looked at oral cephalexin versus cefazolin and oral clindamycin versus IV clindamycin.  The findings of Aboltins et al. indicate that the oral treatment was non-inferior to parenteral treatment for simple cellulitis.  This is supported by other studies showing good oral biovailability of many antibiotics used for cellulitis.   

Admitting uncomplicated cellulitis to our observation units for IV antibiotics may be unnecessary as they do equally well at home with appropriately dosed oral antibiotics.  

 

VOLZ ET Al.

This was a nicely run retrospective chart review with good p values.  Emergency department observation units (EDOU) are often used for patients with cellulitis to provide intravenous antibiotics followed by a transition to an oral regimen for discharge.  This study was designed to identify characteristics in patients with cellulitis that are predictive of EDOU failure and need for hospitalization.  Their results suggested that patients with cellulitis placed into ED observation status were more likely to fail an observation trial (and need admission to the hospital) if they had an objective fever, an elevated lactate, or a cellulitis that involved the hand. 

 

Physicians should consider direct admission (over EDOU stay) for cellulitis patients with objective fever, elevated lactate or cellulitis of the involved hand.  

 

Summary:  

Admission to the EDOU for cellulitis is a daily occurrence.   However, the literature on cellulitis and EDOU’s is far from complete.   Voltz et al. discovered that patients with cellulitis placed into ED observation status were more likely to fail an observation trial if they had an objective fever in the ED, an elevated lactate, or a cellulitis that involved the hand.  Other investigators (Abetz, et al.) report that fever, high total WBC count, and known MRSA exposure are the most common variables to be associated with ED observation management failure.   Taking these risk factors in to consideration can help better disposition the patient, whether it be into an EDOU, inpatient or home.  

Aboltins, et al. found that oral antimicrobials may be as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.  Recognition of risk factors, local antibiotic efficacy and resistance patterns, and the increased application of clinical decision tools may help to improve disposition of patients  that are safe to be treated at home and those that are at high risk for management failure.

During this journal club we also discussed the limited utility of giving one or two doses of an IV antibiotic (like vancomycin) and then discharging the patient on an all-together different oral antibiotic.  Vancomycin, for example, takes several doses over several days to reach effective blood concentrations and there is no evidence that 1-2 doses offers any benefit to patients.  Vancomycin should also be reserved for patients that are quite sick (septic), have purulence or strong MRSA risk factors.

 

 

 

download article summaries

 ABETZ et al. 

ABETZ et al. 

 aboltins et al.

aboltins et al.

 volz et al 

volz et al 

 

Written by Sara Nelson, MD and Carl Germann, MD

Edited and Posted by Jeffrey A. Holmes, MD