Preview Mode Links will not work in preview mode

ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

Have a listen, subscribe using itunes, and use the Contact page to reach out. 

Jan 29, 2018

Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?

 

The great cellulitis mimic: Stasis Dermatitis

  • Similar in appearance to cellulitis
  • Often bilateral (where cellulitis is usually unilateral)
  • Risk factors include venous stasis, lymphedema
  • Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation

Treatment

  • Many recommendations out there, many of them consensus, opinion or based on weak data
  • Elevation
  • Compression if the patient can tolerate it
  • Wet dressings if there is crusting and exudative eczema
  • Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
  • If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)

 

Admit or go home?

  • Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
  • No validated decision instruments regarding admission or discharge
  • 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis  found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
  • Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
  • Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
  • A nice review of the admit or discharge cellulitis question can be found here

 

Single or double antibiotic coverage

Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235

  • 500 patients with cellulitis
  • Treated cephalexin alone or cephalexin plus TMP/Sulfa
  • No significant difference in outcome

Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080

  • 150 patients with cellulitis
  • Treated cephalexin alone or cephalexin plus TMP/Sulfa
  • No significant difference in outcome

Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin

 

Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation.

 

References

  • Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
  • Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
  • Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
  • Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
  • Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
  • Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
  • Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
  • Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
  • Original Kings of County Analysis of Admit or Discharge Cellulitis