The Management of Cellulitis and Erysipelas at an Academic
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Emergency Care Journal 2017; volume 13:6343 The management of cellulitis and erysipelas at an academic Introduction Correspondence: Jeff Martin, Department of Visits for cellulitis and erysipelas repre- Family Medicine, Queen’s University, emergency department: current Kingston, 76 Stuart St, Kingston, ON K7L sent a large proportion of cases seen by practice versus the literature 2V7, Canada. emergency physicians. Basic emergency Tel: +613-548-3232. department management consists of antibi- E-mail: [email protected] Jeffrey W. Martin,1 Ruth Wilson,1 otics and appropriate supportive care, deter- Tim Chaplin2 mining if an admission to hospital is neces- Key words: Cellulitis, Antibiotics, Emergency medicine. 1Department of Family Medicine, Queen’s sary, and arranging appropriate follow-up. Antibiotic therapy targeted against beta- University, Kingston, Ontario; Acknowledgements: we thank David Barber hemolytic streptococci and Staphylococcus 2Department of Emergency Medicine, for assisting with electronic medical record aureus, methicillin-sensitive or methicillin- data collection. Queen’s University, Kingston, Ontario, resistant, is the mainstay of treatment for 1 Canada children and adults with these infections. Contributions: JWM contributed to study con- However, overall severity of illness and cept and design, acquisition of the data, analy- underlying comorbidities ultimately deter- sis and interpretation of the data, drafting of mine variables such as delivery route, the manuscript, and critical revision of the dosage, frequency, and class of agent.2 manuscript for important intellectual content. Abstract CRW and TC contributed to study concept and Cephalexin, a first generation design, critical revision of the manuscript for Cellulitis and erysipelas are common cephalosporin, is the preferred oral antibiot- important intellectual content, and study presentations to emergency departments ic for uncomplicated cellulitis without supervision. and family physicians. Evidence-based abscess.3 Published indications for parenter- guidelines for appropriate management of al antibiotics in cellulitis include compro- Conflicts of interest: the authors declare no these infections exist in Canada, but incon- mised oral administration, immunocompro- potential conflict of interest. sistent practices persist. Our objective was mise, and signs of systemic infection.2 Conference presentation: a poster based on These guidelines are incorporated into rec- to determine the level of adherence to cur- this manuscript was accepted for presentation rent evidence and guidelines by emergency ommendations for providers across 4-6 at the Canadian Association of Emergency physicians at the two hospitals in Kingston, Canada. Outpatient parenteral antibiotic Physicians (CAEP) Conference 2017. Ontario, Canada. We identified all of the therapy (OPAT) is chosen for some patients, electronic medical records of patients who and has several advantages, namely as a Received for publication: 11 October 2016. cost-saving measure for the healthcare sys- Revision received: 24 May 2017. were seen at Kingston General Hospital or Accepted for publication: 25 May 2017. Hotel Dieu Hospital between January 1, tem, because patients avoid admission to hospital and repeat visits to the emergency 2015 and June 30, 2015 and given a diagno- This work is licensed under a Creative department.7 In this study, we describe the sis of cellulitis or erysipelas. We randomly Commons Attribution 4.0 License (by-nc 4.0). management practices of emergency physi- selected 182 charts and conducted a retro- cians in Kingston, Ontario for patients diag- ©Copyright J.W. Martin et al., 2017 spective chart review, manually collecting nosed with cellulitis or erysipelas. Licensee PAGEPress, Italy data for patient demographics, medical his- Emergency Care Journal 2017; 13:6343 tory, and medical management. Oral doi:10.4081/ecj.2017.6343 cephalexin alone was given to 44% of our sample, and it was the most common form Materials and Methods of therapy for uncomplicated cellulitis. 36% domly selected a subset of these charts for of patients given any antibiotics at all Study design and population data collection, but excluded charts if they received at least one dose of parenteral We conducted a retrospective chart were inaccessible or did not contain usable antibiotics, despite only 6.7% of these review at Kingston General Hospital data, patients were not seen by an emergen- patients showing systemic signs of illness. (KGH) and Hotel Dieu Hospital (HDH) in cy physician, patients were younger than 1 88% of those receiving parenteral antibi- Kingston, Ontario, Canada. KGH is a ter- year old, or there was a suspected diagnosis tiary care centre and HDH is an ambulatory otics received ceftriaxone, a broad-spec- of preseptal or orbital cellulitis. urgent care centre. They are both teaching trum, third generation cephalosporin. We Patient data were manually collected for hospitals and serve about 500,000 residents found wide variation in antibiotic selection vital signs at time of triage, and patient fac- in southeastern Ontario. A team of emergen- and route of administration for patients pre- tors or comorbidities that may increase the cy physicians staff both the KGH emergen- senting to the emergency department with risk of complications of cellulitis and cy department and the HDH urgent care cellulitis or erysipelas. Overuse of antibi- erysipelas or may predispose to communi- centre and see approximately 100,000 otics is common, and we believe the use of ty-acquired MRSA infection. The comor- patients per year. Ethics approval was parenteral antibiotics may have been unnec- bidities and patient factors we included obtained from the Queen’s University essary for some patients in our sample. Health Sciences Research Ethics Board. were known diabetes, active cancer treat- Emergency physicians should align their ment, documented cancer diagnosis within management plans more closely with the Data collection 6 months, history of organ transplant, intra- current guidelines to improve practice and We identified all of the charts from the venous drug use, or residence in an assisted reduce unnecessary administration of electronic medical record (EMR) for the 6- living environment or shelter. We deter- broad-spectrum parenteral antibiotics. month period between January 1, 2015 and mined whether antibiotics were given; the June 30, 2015 for patients with a discharge dose and route of the antibiotics (parenteral, diagnosis of cellulitis or erysipelas. We ran- topical, oral); whether they were admitted [page 28] [Emergency Care Journal 2017; 13:6343] Article or discharged home with follow up; dura- tions thereof (n=5). Three patients were prim/sulfamethoxazole, and metronidazole tion and length of time until route switch, noted to be discharged with oral antibiotics, were used alone or in combination with a where applicable; as well as any explicit but no specific details were available. cephalosporin in 22% (12 of 55) of cases, reasoning behind the choice of treatment. Thirteen of those given only oral antibiotics but explicit reasoning was not recorded in We also tracked who returned to the emer- returned to the emergency department for a most of the charts (Figure 2). gency department within two weeks of ini- scheduled recheck or to request reassess- Emergency physicians used a variety of tial presentation for worsening disease, ment. Six of these patients continued their antibiotic classes, combinations, and routes adverse events related to treatment; and existing course of management, but six oth- of administration (Table 2). Four patients whether there were any complications relat- ers received parenteral antibiotics, and one were noted to have allergies to penicillin or ed to treatment, such as allergic reactions. patient started ciprofloxacin and metronida- cephalexin, but clinical reasoning for antibi- zole but was eventually admitted after fur- otic choice and acknowledgment of the Data analysis ther return visits. presence of allergies was otherwise absent Data were analysed using descriptive Greater than one third of the patients in the documentation. statistics. Data abstraction and analysis given any antibiotics at their first visit (60 There were 62 return visits to the were done using Microsoft Excel. of 166) received empiric parenteral therapy emergency department within 2 weeks of for cellulitis, then were switched to or aug- discharge from emergency. This number mented with oral antibiotics if improvement included 46 who returned for scheduled was observed. 88% (53 of 60) received cef- rechecks, repeat doses of IV antibiotics; or Results triaxone, some augmented with van- addition of IV antibiotics to the manage- comycin (n=3) or metronidazole (n=2), and ment plan, due to worsening infection Patients’ characteristics the remaining patients received cefazolin There were 707 visits to KGH and HDH (n=5 [one patient received both ceftriaxone (n=3). Nine patients were admitted upon for cellulitis or erysipelas between January and cefazolin]), clindamycin (n=1), cef- returning for rechecks. Of the remaining 2015 and June 2015. We randomly selected tazidime (n=1), or an unknown parenteral visits, one patient returned with anaphy- 182 of these charts for study, 178 of which antibiotic (n=1) (Figure 1). One patient laxis, possibly secondary to the cephalexin were for patients diagnosed with cellulitis given parenteral antibiotics during their ini- or doxycycline prescribed; a second