Hrev_master [page 28] [Emergency Care Journal 2017; 13:6343] The management of cellulitis and erysipelas at an academic emergency department: current practice versus the literature Jeffrey W. Martin,1 Ruth Wilson,1 Tim Chaplin2 1Department of Family Medicine, Queen’s University, Kingston, Ontario; 2Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada Abstract Cellulitis and erysipelas are common presentations to emergency departments and family physicians. Evidence-based guidelines for appropriate management of these infections exist in Canada, but incon- sistent practices persist. Our objective was to determine the level of adherence to cur- rent evidence and guidelines by emergency physicians at the two hospitals in Kingston, Ontario, Canada. We identified all of the electronic medical records of patients who were seen at Kingston General Hospital or Hotel Dieu Hospital between January 1, 2015 and June 30, 2015 and given a diagno- sis of cellulitis or erysipelas. We randomly selected 182 charts and conducted a retro- spective chart review, manually collecting data for patient demographics, medical his- tory, and medical management. Oral cephalexin alone was given to 44% of our sample, and it was the most common form of therapy for uncomplicated cellulitis. 36% of patients given any antibiotics at all received at least one dose of parenteral antibiotics, despite only 6.7% of these patients showing systemic signs of illness. 88% of those receiving parenteral antibi- otics received ceftriaxone, a broad-spec- trum, third generation cephalosporin. We found wide variation in antibiotic selection and route of administration for patients pre- senting to the emergency department with cellulitis or erysipelas. Overuse of antibi- otics is common, and we believe the use of parenteral antibiotics may have been unnec- essary for some patients in our sample. Emergency physicians should align their management plans more closely with the current guidelines to improve practice and reduce unnecessary administration of broad-spectrum parenteral antibiotics. Introduction Visits for cellulitis and erysipelas repre- sent a large proportion of cases seen by emergency physicians. Basic emergency department management consists of antibi- otics and appropriate supportive care, deter- mining if an admission to hospital is neces- sary, and arranging appropriate follow-up. Antibiotic therapy targeted against beta- hemolytic streptococci and Staphylococcus aureus, methicillin-sensitive or methicillin- resistant, is the mainstay of treatment for children and adults with these infections.1 However, overall severity of illness and underlying comorbidities ultimately deter- mine variables such as delivery route, dosage, frequency, and class of agent.2 Cephalexin, a first generation cephalosporin, is the preferred oral antibiot- ic for uncomplicated cellulitis without abscess.3 Published indications for parenter- al antibiotics in cellulitis include compro- mised oral administration, immunocompro- mise, and signs of systemic infection.2 These guidelines are incorporated into rec- ommendations for providers across Canada.4-6 Outpatient parenteral antibiotic therapy (OPAT) is chosen for some patients, and has several advantages, namely as a cost-saving measure for the healthcare sys- tem, because patients avoid admission to hospital and repeat visits to the emergency department.7 In this study, we describe the management practices of emergency physi- cians in Kingston, Ontario for patients diag- nosed with cellulitis or erysipelas. Materials and Methods Study design and population We conducted a retrospective chart review at Kingston General Hospital (KGH) and Hotel Dieu Hospital (HDH) in Kingston, Ontario, Canada. KGH is a ter- tiary care centre and HDH is an ambulatory urgent care centre. They are both teaching hospitals and serve about 500,000 residents in southeastern Ontario. A team of emergen- cy physicians staff both the KGH emergen- cy department and the HDH urgent care centre and see approximately 100,000 patients per year. Ethics approval was obtained from the Queen’s University Health Sciences Research Ethics Board. Data collection We identified all of the charts from the electronic medical record (EMR) for the 6- month period between January 1, 2015 and June 30, 2015 for patients with a discharge diagnosis of cellulitis or erysipelas. We ran- domly selected a subset of these charts for data collection, but excluded charts if they were inaccessible or did not contain usable data, patients were not seen by an emergen- cy physician, patients were younger than 1 year old, or there was a suspected diagnosis of preseptal or orbital cellulitis. Patient data were manually collected for vital signs at time of triage, and patient fac- tors or comorbidities that may increase the risk of complications of cellulitis and erysipelas or may predispose to communi- ty-acquired MRSA infection. The comor- bidities and patient factors we included were known diabetes, active cancer treat- ment, documented cancer diagnosis within 6 months, history of organ transplant, intra- venous drug use, or residence in an assisted living environment or shelter. We deter- mined whether antibiotics were given; the dose and route of the antibiotics (parenteral, topical, oral); whether they were admitted Emergency Care Journal 2017; volume 13:6343 Correspondence: Jeff Martin, Department of Family Medicine, Queen’s University, Kingston, 76 Stuart St, Kingston, ON K7L 2V7, Canada. Tel: +613-548-3232. E-mail: jeffrey.martin@dfm.queensu.ca Key words: Cellulitis, Antibiotics, Emergency medicine. Acknowledgements: we thank David Barber for assisting with electronic medical record data collection. Contributions: JWM contributed to study con- cept and design, acquisition of the data, analy- sis and interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. CRW and TC contributed to study concept and design, critical revision of the manuscript for important intellectual content, and study supervision. Conflicts of interest: the authors declare no potential conflict of interest. Conference presentation: a poster based on this manuscript was accepted for presentation at the Canadian Association of Emergency Physicians (CAEP) Conference 2017. Received for publication: 11 October 2016. Revision received: 24 May 2017. Accepted for publication: 25 May 2017. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright J.W. Martin et al., 2017 Licensee PAGEPress, Italy Emergency Care Journal 2017; 13:6343 doi:10.4081/ecj.2017.6343 [Emergency Care Journal 2017; 13:6343] [page 29] or discharged home with follow up; dura- tion and length of time until route switch, where applicable; as well as any explicit reasoning behind the choice of treatment. We also tracked who returned to the emer- gency department within two weeks of ini- tial presentation for worsening disease, adverse events related to treatment; and whether there were any complications relat- ed to treatment, such as allergic reactions. Data analysis Data were analysed using descriptive statistics. Data abstraction and analysis were done using Microsoft Excel. Results Patients’ characteristics There were 707 visits to KGH and HDH for cellulitis or erysipelas between January 2015 and June 2015. We randomly selected 182 of these charts for study, 178 of which were for patients diagnosed with cellulitis and four of which were for patients with erysipelas. Patient characteristics for our sample population are presented in Table 1. Four charts selected in the process were for return visits to the emergency department for worsening disease or complications, or for scheduled reassessment. We collected data from these records but also from the patient’s initial presentation for the infection. Management plans In 16 of 182 visits, patients received no antibiotics (Table 1; Figure 1). One of these patients was a 63-year-old man with normal vital signs who had an incision and drainage performed for an abscess at his initial visit, but returned the next day with cellulitis. This man had normal vital signs at his return visit and received two doses of intra- venous ceftriaxone 24 hours apart before starting a course of cephalexin. The remain- ing fifteen patients did not return to the emergency department within the following two weeks. 106 patients received oral antibiotics only or were advised to continue existing courses of oral antibiotics (Table 1; Figure 1). Although cephalexin was the sole agent prescribed in 72 of those cases, seven patients received combinations with trimethoprim/sulfamethoxazole (n=1), ciprofloxacin (n=2), doxycycline (n=1), or metronidazole (n=3). In those not receiving any cephalexin initially, initial agents were clindamycin (n=7), trimethoprim/sul- famethoxazole (n=4), ciprofloxacin (n=3), amoxicillin-clavulanate (n=1; for a cat bite victim), or doxycycline (n=4; for suspected early localized Lyme disease), or combina- tions thereof (n=5). Three patients were noted to be discharged with oral antibiotics, but no specific details were available. Thirteen of those given only oral antibiotics returned to the emergency department for a scheduled recheck or to request reassess- ment. Six of these patients continued their existing course of management, but six oth- ers received parenteral antibiotics, and one patient started ciprofloxacin and metronida- zole but was eventually admitted after fur- ther return visits. Greater than one third of the patients given any antibiotics at their first visit (60 of 166) received empiric parenteral therapy for cellulitis, then were switched to or aug- mented with oral antibiotics if improvement was observed. 88% (53 of 60) received cef- triaxone, some augmented with van- comycin (n=3) or metronidazole (n=2), and the remaining patients received cefazolin (n=5 [one patient received both ceftriaxone and cefazolin]), clindamycin (n=1), cef- tazidime (n=1), or an unknown parenteral antibiotic (n=1) (Figure 1). One patient given parenteral antibiotics during their ini- tial visit was also admitted. Four of the 60 patients (6.7%) exhibited tachycardia or fever at triage. Six patients were sent home with supports set up to administer OPAT, although one was subsequently admitted. Of the 55 patients with one or more comorbidities as listed above, all received antibiotics. 44% (24 of 55) received cephalexin only. Clindamycin, trimetho- prim/sulfamethoxazole, and metronidazole were used alone or in combination with a cephalosporin in 22% (12 of 55) of cases, but explicit reasoning was not recorded in most of the charts (Figure 2). Emergency physicians used a variety of antibiotic classes, combinations, and routes of administration (Table 2). Four patients were noted to have allergies to penicillin or cephalexin, but clinical reasoning for antibi- otic choice and acknowledgment of the presence of allergies was otherwise absent in the documentation. There were 62 return visits to the emergency department within 2 weeks of discharge from emergency. This number included 46 who returned for scheduled rechecks, repeat doses of IV antibiotics; or addition of IV antibiotics to the manage- ment plan, due to worsening infection (n=3). Nine patients were admitted upon returning for rechecks. Of the remaining visits, one patient returned with anaphy- laxis, possibly secondary to the cephalexin or doxycycline prescribed; a second patient returned with a possible drug rash after receiving two intravenous doses of ceftriaxone and oral trimethoprim/sul- famethoxazole; and a third patient needed an indwelling IV line removed and rein- serted. The other return visits by patients to the emergency department (n=13) were for separate reasons unrelated to the initial diagnosis. Article Table 1. Patients’ characteristics. Characteristics N = 182 Median age (range), years 49 (2-94) Sex, male/female, n (%) 103 (57) / 79 (43) Institution visited KGH 66 (36) HDH 116 (64) Vital signs at triage Fever*, n (%) 6 (3) Tachycardia°, n (%) 30 (16) Comorbidities Diabetes, type I or II, n (%) 31 (17) End-stage renal disease, n (%) 3 (2) Organ transplant#, n (%) 1 (0.5) Concurrent malignancy, n (%) 6 (3) HIV/AIDS, n (%) 1 (0.5) Intravenous drug use, n (%) 13 (7) Living in assisted environment or shelter, n (%) 10 (5) History of MRSA infection, n (%) 5 (3) Initial antibiotic therapy administered No antibiotics, n (%) 16 (9) Oral antibiotics only, n (%) 106 (58) Empiric parenteral antibiotics, n (%) 60 (33) *Oral temperature >38.0°C; °heart rate greater than 160 beats per minute (bpm) for infants (<2 years), greater than 140 bpm; for children (2 to 12 years), and greater than 100 bpm for adolescents and adults; #the only patient with an organ transplant had had a renal transplant. Discussion Cellulitis and erysipelas are common reasons for emergency department and urgent care visits in our population. In fact, within our study period of six months, we identified over 700 visits related to the skin infections. Outpatient management with self-administration of oral cephalexin was the most common choice of management for cellulitis and erysipelas. This is the rec- ommended antibiotic for uncomplicated cellulitis considering its spectrum of activi- ty.2,3 We note more than one third of the patients in our study given any antibiotics were initially treated with empiric parenter- al therapy for cellulitis then switched to or continued on oral antibiotics if improve- ment was noted after 48 to 72 hours. However, almost all of these patients were systemically well at the time of their triage assessment. Canadian expert guidelines dic- tate conservative management with oral medication, with the addition of parenteral medication if there are signs of worsening disease despite two or more days of oral therapy.4,5 Skin infections are largely clinical diag- noses, and in the absence of systemic signs of illness, clinical improvement in cellulitis and erysipelas should be monitored during the 48 to 72 hour period after initiation of treatment. Of those patients in our study population who returned to the emergency department reassessment after starting an oral agent, just less than half received par- enteral antibiotics despite normal vital signs. It is difficult for us to comment on whether parenteral antibiotics were given for worsening clinical appearance because of limited detail in charting. However, in the absence of abnormal vital signs and given the erythema and edema of cellulitis may worsen in the first 24 to 48 hours of treatment,4,7 we question whether a switch to or augmentation with parenteral antibi- otics was necessary in all cases. Overuse of parenteral antibiotics is very common,8 but a recent Cochrane review suggests oral antibiotics (macrolides/strep- togramins) may be more effective for cel- lulitis and erysipelas than penicillin given parenterally and recommends further study on this subject.9 We must assume physicians seeing patients included in our study chose parenteral administration based on gross appearance of the cellulitis possibly in com- bination with other patient factors, such as poor reliability. Such extenuating patient factors, if present, were not described in the chart records, so we cannot accurately anal- yse decision-making. Management of these infections should vary depending on the presence of chronic illnesses and signs of systemic involvement to minimize treat- ment failure.10 However, there should not be overreliance on parenteral therapy when there is no evidence of improved efficacy. Overuse of antibiotics in general, though not a focus of this study, has other risks. Two patients returned after suspected allergic response to antibiotics, including one with anaphylaxis. Allergic reaction to antibiotics is not uncommon11 and it rein- forces the importance of justification for antibiotics whenever they are prescribed. There is no widely used infection sever- ity scale in Canada but evidence-based sources do exist to help inform treatment plans.12 We found substantial variation among emergency physicians in manage- ment of cellulitis and erysipelas. This mir- rors a previous review of emergency depart- ment management of cellulitis in the province of Alberta, Canada.13 However, they describe a significantly higher use of intravenous cefazolin (47% of initial treat- ment regimens) versus oral cephalexin (8% of initial treatment regimens). In our data set, oral cephalexin was given in 44% of the initial treatment plans versus intravenous cefazolin in only 2.7% of the initial treat- ment plans. Ceftriaxone, a broad-spectrum third generation cephalosporin with good coverage of Gram-negative bacteria but less activity against Gram-positive bacteria than earlier generation cephalosporins, was the most frequently used parenteral antibiotic in our study. Current guidelines reserve ceftri- axone for severe, deep infections involving Article Table 2. Type/route of antibiotics received for cellulitis/erysipelas at the initial visit to the emergency department. Type Number (% of 182 total) Cephalexin PO 80 (44.0) Ceftriaxone IV, cephalexin PO 30 (16.5) Clindamycin PO 6 (3.3) Ceftriaxone IV/IM 4 (2.2) Ceftriaxone IV, Septra PO 4 (2.2) Ciprofloxacin PO 4 (2.2) Septra PO 3 (1.6) Cefazolin IV 3 (1.6) Ceftriaxone IV, clavulin PO 3 (1.6) Cephalexin PO and septra PO 2 (1.1) Cephalexin PO, doxycycline PO 2 (1.1) Amoxicillin PO 2 (1.1) Clarithromycin PO 2 (1.1) Ceftriaxone IV, vancomycin IV, septra PO 2 (1.1) Cefazolin IV, Cephalexin PO 2 (1.1) Clindamycin IV, Clindamycin PO 1 (0.5) Ciprofloxacin PO, Clindamycin PO 1 (0.5) Amoxicillin-clavulinate PO 1 (0.5) Doxycycline PO and metronidazole PO 1 (0.5) Cephalexin PO and metronidazole PO 1 (0.5) Ceftriaxone IV, Cloxacillin PO 1 (0.5) Ceftriaxone IV, Cefazolin IV, Cephalexin PO 1 (0.5) Ceftriaxone IV, Metronidazole IV, Cephalexin PO 1 (0.5) Ceftriaxone IV, cephalexin PO, valacyclovir PO 1 (0.5) Ceftriaxone IV, vancomycin IV 1 (0.5) Ceftriaxone IV, Penicillin V PO 1 (0.5) Doxycycline PO 1 (0.5) Ceftazidime IV, Cefprozil PO 1 (0.5) Vancomycin IV 1 (0.5) Ceftriaxone IM, Cephalexin PO, Ciprofloxacin PO 1 (0.5) Ceftriaxone IV, Cephalexin PO, fluconazole PO 1 (0.5) Unknown antibiotic IV, Cephalexin PO 1 (0.5) No antibiotics 16 (8.8) [page 30] [Emergency Care Journal 2017; 13:6343] [Emergency Care Journal 2017; 13:6343] [page 31] other tissues and organs; and promote cefa- zolin intravenously for mild, moderate, or severe cellulitis.2,4-6 However, some advo- cate for ceftriaxone given its smaller side effect profile and ease of administration.7 In the United Kingdom, the narrow-spectrum penicillin flucloxacillin, which is available orally or intravenously, is suggested ahead of broader-spectrum agents.14 Regarding OPAT and return visits to the emergency department for repeat parenteral dosing, ceftriaxone may be more sensible given its once daily administration. However, once- daily cefazolin in combination with oral probenecid is equivalent to ceftriaxone in treating moderate/severe cellulitis.15 A significant limitation to managing cellulitis effectively is the lack of standard- ized scales of disease severity. No consis- tent explicit reasoning for choice of man- agement plan was demonstrated in the charting by emergency physicians analysed in this study, and it was not apparent whether physicians were using any grading system or algorithm. The majority of patients were systemically well according to vital signs taken by the triage nurse, and physicians’ notes demonstrated a lack of subjective constitutional symptoms in the majority of cases when details were docu- mented. Some Canadian centres have devel- oped their own guidelines, including the Nova Scotia Adult Cellulitis Guidelines, developed in 2000 and validated in subse- quent studies;6 Toronto’s University Health Network;4 and Providence Health Care in British Columbia.5 The guidelines are large- ly consistent with each other, as well as with other international guidelines,2,12,14 and accurately reflect published evidence in the infectious disease literature. In the present study, we were unable to determine if emer- gency physicians adhered to any of these rules, and documentation in the EMR would suggest they were not. Limitations to this study include the small sample size. We used random sampling to collect 182 charts for this chart review, because our aim was to capture a snapshot of antibiotic use in our sample population. Future studies could make use of systematic sampling to allow for a larger, more representative sample over the course of years rather than several months. Additionally, we were limited by the amount of information documented. Charting by emergency physicians was brief, as is customary; and pertinent fea- tures, such as appearance of the region of cellulitis or details about risk factors com- mon in this part of the province such as intravenous drug use, were often not record- ed. We do note that physicians sometimes used templates for information gathering, but even in those cases, recording of risk factors such as intravenous drug use was frequently incomplete. Conclusions Our study has found a wide variety in the antibiotic selection and route of admin- istration for the treatment of cellulitis and erysipelas in patients presenting to two ter- tiary care emergency departments in the province of Ontario. Outpatient administra- tion of oral cephalexin is the predominant form of therapy for cellulitis and erysipelas and this is consistent with management guidelines. However, a significant number of patients received parenteral broad-spec- trum antibiotics and continued on this as outpatients, returning to the emergency department for repeat dosing. This would contribute considerable cost in terms of money, time, and resources to an already busy emergency medicine system. It may be easier and more economically feasible to administer a once daily broad-spectrum antibiotic, like ceftriaxone. However, we question whether it should be at the expense of existing evidence when we know the most likely culprit organism, and when newer antimicrobials have near-equivalent intravenous and oral bioavailability. The prevalence of antibiotic resistance is increasing and evidence-based prescribing and more appropriate antibiotic usage should become increasingly important. Article Figure 1. Proportions of patients by route of antibiotic administration. The majority of patients receiving parenteral antibiotic were given ceftriaxone. The other antibi- otics given were given vancomycin, metronidazole, or ceftazidime. Of those given any intravenous antibiotic, 6.7% had tachycardia and fever. Figure 2. Numbers of patients by antibiotic regimen received and comorbidities. A wide variety of antibiotics were chosen for initial management of patients with cellulitis. Little consistency was seen with respect to comorbidities. FQ, fluoroquinolones; PEN, peni- cillins; TET, tetracyclines; MAC, macrolides; MTZ, metronidazole; CLI, clindamycin; SXT, trimethoprim/sulfamethoxazole. [page 32] [Emergency Care Journal 2017; 13:6343] References 1. Lopez FA, Lartchenko S. Skin and soft tissue infections. Infect Dis Clin North Am 2006;20:759-72. 2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagno- sis and management of skin and soft tis- sue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59:e10-52. 3. Pallin DJ, Binder WD, Allen MB, et al. 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