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Trottier ED, Farley St-Amand B, Vincent M, Chevalier I, Autmizguine J, Tremblay S, Gouin S. Outpatient management of moderate cellulitis in children using high-dose oral cephalexin. Paediatr Child Health 2022; 27:213-219. [PMID: 35859686 PMCID: PMC9291389 DOI: 10.1093/pch/pxac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.
Methods
In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.
Results
A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).
Conclusions
With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.
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Affiliation(s)
- Evelyne D Trottier
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Beatrice Farley St-Amand
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Mélanie Vincent
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Isabelle Chevalier
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Julie Autmizguine
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
- Department Pharmacology and Physiology, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Stéphanie Tremblay
- Department of Pharmacy, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Serge Gouin
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
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Cross ELA, Jordan H, Godfrey R, Onakpoya IJ, Shears A, Fidler K, Peto TEA, Walker AS, Llewelyn MJ. Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment. J Infect 2020; 81:521-531. [PMID: 32745638 DOI: 10.1016/j.jinf.2020.07.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children. METHODS We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response. PROSPERO CRD42018100602. RESULTS We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I2=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I2 = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse. CONCLUSIONS The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Harriet Jordan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Rebecca Godfrey
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annalie Shears
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Katy Fidler
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Timothy E A Peto
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
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3
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Ong BS, Ngian VJJ, Yeong C, Keighley C. Out Of Hospital And In Hospital Management Of Cellulitis Requiring Intravenous Therapy. Int J Gen Med 2019; 12:447-453. [PMID: 31819595 PMCID: PMC6890169 DOI: 10.2147/ijgm.s230054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/06/2019] [Indexed: 12/29/2022] Open
Abstract
Background Cellulitis requiring intravenous therapy can be managed via out of hospital programs, but a high number of patients are still admitted to hospital. Objective We aimed to review the clinical features, management and outcomes of patients with cellulitis requiring intravenous therapy in a Hospital in the Home (HITH) program compared to patients who are admitted to hospital. Methods A prospective cohort study of patients with limb cellulitis requiring intravenous antibiotics was conducted at a metropolitan principal referral hospital. Results A total of 100 patients out of 113 eligible patients were recruited. Forty-eight were treated entirely in hospital and 52 were treated entirely or partially via HITH. Patients treated in hospital were older (mean 69.2 vs 56.7 years, p<0.001), less mobile, have more comorbidities (Charlson Comorbidity Index mean 2.2 vs 1.2, P=0.005) and more associated active illness. All patients with Eron Class III were admitted to hospital. Patients treated in hospital had a higher incidence of acute renal failure (27.1% vs 3.8%, p=0.001), nosocomial infection (10.4% vs 0.0%, P=0.023), and a higher 28-day hospital readmission rate (10.4% vs 0.0%, P=0.023). Conclusion Approximately half of the patients who require intravenous therapy can be treated via an out of hospital program. Patients admitted to hospital were more unwell and more likely to suffer complications. The presence of comorbid illness does not necessarily exclude participation in HITH and careful selection is essential to ensure safe outcomes.
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Affiliation(s)
- Bin S Ong
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Department of Ambulatory Care, Bankstown-Lidcombe Hospital, Bankstown, NSW 2200, Australia
| | - Vincent Jiu Jong Ngian
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
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4
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Clarke MC, Cheng AC, Pollard JG, Birch M, Cowan RU, Linke JA, Walton AL, Friedman ND. Lessons Learned From a Randomized Controlled Trial of Short-Course Intravenous Antibiotic Therapy for Erysipelas and Cellulitis of the Lower Limb (Switch Trial). Open Forum Infect Dis 2019; 6:ofz335. [PMID: 31660410 PMCID: PMC6798252 DOI: 10.1093/ofid/ofz335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/16/2019] [Indexed: 01/22/2023] Open
Abstract
Background The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. Methods This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7–10 days’ duration for the treatment of lower limb cellulitis. Results Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17–40) hours, and in the ≥72-hour group it was 78 (41.5–210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. Conclusions The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. Australia Council of Clinical Trials Registry No ACTRN12613001366741.
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Affiliation(s)
- Marcus C Clarke
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Gd Pollard
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Hospital in the Home Service, Barwon Health, Geelong, Victoria, Australia
| | - Mark Birch
- Department of Infectious Diseases, Christchurch Public Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Raquel U Cowan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Jake A Linke
- Deakin University, School of Medicine, Geelong, Victoria, Australia
| | - Aaron L Walton
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
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5
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Yusuf S, Hagan JL, Adekunle-Ojo AO. Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit. Pediatr Emerg Care 2019; 35:204-208. [PMID: 27902667 DOI: 10.1097/pec.0000000000000975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics. OBJECTIVES The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI. METHODS A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted. RESULTS One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study. CONCLUSIONS The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.
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6
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Suzuki J, Johnson J, Montgomery M, Hayden M, Price C. Outpatient Parenteral Antimicrobial Therapy Among People Who Inject Drugs: A Review of the Literature. Open Forum Infect Dis 2018; 5:ofy194. [PMID: 30211247 PMCID: PMC6127783 DOI: 10.1093/ofid/ofy194] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/06/2018] [Indexed: 11/14/2022] Open
Abstract
Hospitalizations for people who inject drugs (PWID) with infectious complications requiring prolonged antibiotic therapy are increasing in the context of the opioid epidemic. Although outpatient parenteral antimicrobial therapy (OPAT) is routinely offered to patients without a history of injection drug use (IDU), PWID are often excluded from consideration of OPAT. To better assess the evidence base for the safety and effectiveness of OPAT for PWID, we conducted a review of the published literature. Results suggest that OPAT may be safe and effective for PWID, with rates of OPAT completion, mortality, and catheter-related complications comparable to rates among patients without a history of IDU. Rates of hospital readmissions may be higher among PWID, but instances of misuse of the venous catheter were rarely reported. More research is needed to study the safety and effectiveness of OPAT among PWID, as well as studying the combination of OPAT and addiction treatment.
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Affiliation(s)
- Joji Suzuki
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jennifer Johnson
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mary Montgomery
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Christin Price
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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7
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Smismans A, Vantrappen A, Verbiest F, Indevuyst C, Van den Poel B, von Winckelmann S, Peeters A, Ombelet S, Lybeert P, Heremans A, Frans E, Ho E, Frans J. OPAT: proof of concept in a peripheral Belgian hospital after review of the literature. Acta Clin Belg 2018; 73:257-267. [PMID: 29385901 DOI: 10.1080/17843286.2018.1424503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Since its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.
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Affiliation(s)
- Annick Smismans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | | | - Bea Van den Poel
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | - Sara Ombelet
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Peter Lybeert
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | | | - Eric Frans
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Erwin Ho
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | - Johan Frans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
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8
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Inaoki M, Inaoki A, Nishijima C. Factors that affect the duration of antimicrobial therapy for cellulitis. J Infect Chemother 2018; 24:256-261. [DOI: 10.1016/j.jiac.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/30/2017] [Accepted: 11/13/2017] [Indexed: 01/22/2023]
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9
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Outpatient parenteral antibiotic therapy in a suburban tertiary referral centre in Australia over 10 years. Infection 2018; 46:349-355. [PMID: 29464675 DOI: 10.1007/s15010-018-1126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/14/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Outpatient parenteral antibiotic therapy (OPAT) is a widely accepted and safe therapeutic option for carefully selected patients. This study reviewed the practice of an OPAT service in a large Australian tertiary teaching hospital in Western Sydney over a 10-year period. METHOD Data were retrieved from a prospectively maintained electronic database which included information on patient demographics, clinical diagnosis, microbiological identity, antimicrobial therapy, complications and readmissions. Data were analysed using descriptive statistics. RESULTS There were 3435 referrals made to the service between January 2004 and June 2014, amounting to 25,289 antibiotic days. The most frequent referral was for Skin and Soft Tissue Infections (SSTIs), 61.28%, followed by Bone and Joint Infections (BJIs), 15.30%. The most common organism identified was methicillin-sensitive Staphylococcus aureus. Readmission was uncommon (5.15%), with the highest rate of readmission noted for Cardiovascular System Infections (16.67%) followed by BJIs (10.31%). Line infection, aseptic thrombophlebitis and drug hypersensitivity or reaction were the cause of 68.55% of all complications. There was a decline in line-related complications throughout the study period. CONCLUSION OPAT service is in increasing demand in Australia, providing a significant relief in in-hospital days. Growth in referrals was seen not only with SSTIs and BJIs, but also a diverse range of other infective entities with limited literature in its treatment in an OPAT setting. This study highlights the need to improve data collection, develop risk stratification strategies and standardisation of OPAT services in Australia.
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10
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Chiu SLH, Lam FM, Cheung C. Admission Gatekeeping and Safe Discharge for the Elderly: Referral by the Emergency Department to the Community Nursing Service for Home Visits. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790701400203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED). Methods Descriptive review analysis of the referrals in 2002–2004. Results Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged ≥65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15–28 days. The ≤14 days and 15–28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed-days saved. Living alone was strongly associated with unscheduled return and admission ≤14 and ≤28 days, while age was not. The six categories of community nursing care were fall-related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty-nine patients had phone follow-ups. Conclusion The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission.
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11
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Quirke M, Curran EM, O'Kelly P, Moran R, Daly E, Aylward S, McElvaney G, Wakai A. Risk factors for amendment in type, duration and setting of prescribed outpatient parenteral antimicrobial therapy (OPAT) for adult patients with cellulitis: a retrospective cohort study and CART analysis. Postgrad Med J 2017; 94:25-31. [PMID: 28874503 DOI: 10.1136/postgradmedj-2017-134968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/11/2017] [Accepted: 07/16/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE OF THE STUDY To measure the percentage rate and risk factors for amendment in the type, duration and setting of outpatient parenteral antimicrobial therapy (OPAT) for the treatment of cellulitis. STUDY DESIGN A retrospective cohort study of adult patients receiving OPAT for cellulitis was performed. Treatment amendment (TA) was defined as hospital admission or change in antibiotic therapy in order to achieve clinical response. Multivariable logistic regression (MVLR) and classification and regression tree (CART) analysis were performed. RESULTS There were 307 patients enrolled. TA occurred in 36 patients (11.7%). Significant risk factors for TA on MVLR were increased age, increased Numerical Pain Scale Score (NPSS) and immunocompromise. The median OPAT duration was 7 days. Increased age, heart rate and C reactive protein were associated with treatment prolongation. CART analysis selected age <64.5 years, female gender and NPSS <2.5 in the final model, generating a low-sensitivity (27.8%), high-specificity (97.1%) decision tree. CONCLUSIONS Increased age, NPSS and immunocompromise were associated with OPAT amendment. These identified risk factors can be used to support an evidence-based approach to patient selection for OPAT in cellulitis. The CART algorithm has good specificity but lacks sensitivity and is shown to be inferior in this study to logistic regression modelling.
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Affiliation(s)
- Michael Quirke
- Emergency Care Research Unit (ECRU),Royal College of Surgeons Ireland (RCSI), Dublin, Ireland
| | - Emma May Curran
- Department of Medicine, RCSI, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Statistics, Renal Medicine Unit,Beaumont Hospital, Dublin, Ireland
| | - Ruth Moran
- VHI Homecare, Waverly Business Park, Dublin, Ireland
| | - Eimear Daly
- VHI Homecare, Waverly Business Park, Dublin, Ireland
| | | | - Gerry McElvaney
- Department of Medicine, RCSI, Beaumont Hospital, Dublin, Ireland
| | - Abel Wakai
- Emergency Care Research Unit (ECRU),Royal College of Surgeons Ireland (RCSI), Dublin, Ireland.,Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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12
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Chan M, Ooi CK, Wong J, Zhong L, Lye D. Role of outpatient parenteral antibiotic therapy in the treatment of community acquired skin and soft tissue infections in Singapore. BMC Infect Dis 2017; 17:474. [PMID: 28683717 PMCID: PMC5501073 DOI: 10.1186/s12879-017-2569-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 06/26/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- Monica Chan
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Outpatient Parenteral Antibiotic Therapy Clinic, Tan Tock Seng Hospital, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Chee Kheong Ooi
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Joshua Wong
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lihua Zhong
- Outpatient Parenteral Antibiotic Therapy Clinic, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Lye
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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13
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Mitchell ED, Czoski Murray C, Meads D, Minton J, Wright J, Twiddy M. Clinical and cost-effectiveness, safety and acceptability of community intra venous antibiotic service models: CIVAS systematic review. BMJ Open 2017; 7:e013560. [PMID: 28428184 PMCID: PMC5775457 DOI: 10.1136/bmjopen-2016-013560] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models. DESIGN A systematic review. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015. STUDY SELECTION All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion. RESULTS 128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT. CONCLUSIONS There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.
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Affiliation(s)
- E D Mitchell
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - C Czoski Murray
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Minton
- Department of Infection and Travel Medicine, Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Twiddy
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Minton J, Murray CC, Meads D, Hess S, Vargas-Palacios A, Mitchell E, Wright J, Hulme C, Raynor DK, Gregson A, Stanley P, McLintock K, Vincent R, Twiddy M. The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BackgroundOutpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.ObjectivesThe aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.MethodsThis mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.ResultsThe systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.LimitationsRecruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.ConclusionsThe quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.Future workFurther research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.FundingThe National Institute for Health Research Health Service and Delivery Research programme.
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Affiliation(s)
- Jane Minton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephane Hess
- Institute of Transport Studies, University of Leeds, Leeds, UK
| | | | | | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Philip Stanley
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kate McLintock
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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15
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Garg A, Lavian J, Lin G, Sison C, Oppenheim M, Koo B. Clinical characteristics associated with days to discharge among patients admitted with a primary diagnosis of lower limb cellulitis. J Am Acad Dermatol 2017; 76:626-631. [PMID: 28089727 DOI: 10.1016/j.jaad.2016.11.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Clinicians have limited ability to classify risk of prolonged hospitalization among patients with lower limb cellulitis. OBJECTIVE We sought to identify characteristics associated with days to discharge and prolonged stay. METHODS We conducted retrospective cohort analysis including patients admitted with a primary diagnosis of lower limb cellulitis at community and tertiary hospitals. RESULTS There were 4224 admissions for lower limb cellulitis among 3692 patients. Mean age of the cohort was 64.4 years. Frequencies of tobacco smoking, obesity, and diabetes mellitus were 25.1%, 44.9%, and 19.3%, respectively. Patients having decreased likelihood of discharge included those with the following: 10-year age increments 0.90 (95% confidence interval [CI] 0.88-0.92), obesity 0.90 (95% CI 0.83-0.97), diabetes mellitus 0.90 (95% CI 0.82-0.98), tachycardia 0.76 (95% CI 0.67-0.85), hypotension 0.77 (95% CI 0.65-0.90), leukocytosis 0.86 (95% CI 0.79-0.93), neutrophilia 0.80 (95% CI 0.73-0.87), elevated serum creatinine 0.74 (95% CI 0.68-0.81), and low serum bicarbonate 0.84 (95% CI 0.75-0.95). LIMITATIONS This analysis is retrospective and based on coded data. Unknown confounding variables may also influence prolonged stay. CONCLUSIONS Patients with lower limb cellulitis and prolonged stay have a number of clinical characteristics which may be used to classify risk for prolonged stay.
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Affiliation(s)
- Amit Garg
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York.
| | - Jonathan Lavian
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Gloria Lin
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Cristina Sison
- Biostatistics Unit, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York
| | - Michael Oppenheim
- Division of Infectious Diseases, Department of Medicine, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Bonnie Koo
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
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16
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Mirón-Rubio M, González-Ramallo V, Estrada-Cuxart O, Sanroma-Mendizábal P, Segado-Soriano A, Mujal-Martínez A, Del Río-Vizoso M, García-Lezcano M, Martín-Blanco N, Florit-Serra L, Gil-Bermejo M. Intravenous antimicrobial therapy in the hospital-at-home setting: data from the Spanish Outpatient Parenteral Antimicrobial Therapy Registry. Future Microbiol 2016; 11:375-90. [DOI: 10.2217/fmb.15.141] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aim: To evaluate outpatient parenteral antimicrobial therapy (OPAT) in the hospital-at-home (HaH) model, using data from a Spanish registry. Patients & methods: We describe episodes/characteristics of patients receiving OPAT. Results: Four thousand and five patients were included (mean age 66.2 years), generating 4416 HaH episodes, 4474 infections and 5088 antibiotic treatments. Most patients were from the hospital admission ward and emergency department. Respiratory, urinary and intra-abdominal infections predominated (72%). Forty-six different antimicrobials were used, including combinations of ≥2 drugs (20.7%). Most HaH episodes had a successful outcome (91%). Conclusion: Our findings are similar to those obtained previously although our study case profiles differ, suggesting that disease processes of greater severity and complexity can be treated using this healthcare model, without compromising patient safety.
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Affiliation(s)
| | | | | | | | | | - Abel Mujal-Martínez
- Hospital de Sabadell. Corporació Universitària Parc Taulí, Sabadell, Barcelona, Spain
| | | | | | | | | | - Mercè Gil-Bermejo
- Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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17
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Efficacy of hospital in the home services providing care for patients admitted from emergency departments. INT J EVID-BASED HEA 2014; 12:128-41. [DOI: 10.1097/xeb.0000000000000011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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MacKenzie M, Rae N, Nathwani D. Outcomes from global adult outpatient parenteral antimicrobial therapy programmes: A review of the last decade. Int J Antimicrob Agents 2014; 43:7-16. [DOI: 10.1016/j.ijantimicag.2013.09.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/16/2022]
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19
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Lower limb cellulitis and its mimics. J Am Acad Dermatol 2012; 67:163.e1-12; quiz 175-6. [DOI: 10.1016/j.jaad.2012.03.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 12/17/2022]
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20
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Garrett T, Harbort Y, Trebble M, Docherty T. Once or twice-daily, algorithm-based intravenous cephazolin for home-based cellulitis treatment. Emerg Med Australas 2012; 24:383-92. [DOI: 10.1111/j.1742-6723.2012.01553.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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21
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Seaton R, Sharp E, Bezlyak V, Weir C. Factors associated with outcome and duration of therapy in outpatient parenteral antibiotic therapy (OPAT) patients with skin and soft-tissue infections. Int J Antimicrob Agents 2011; 38:243-8. [DOI: 10.1016/j.ijantimicag.2011.05.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/10/2011] [Indexed: 10/18/2022]
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22
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Larivière D, Blavot-Delépine A, Fantin B, Lefort A. [Survey of general practitioners management of erysipelas]. Rev Med Interne 2011; 32:730-5. [PMID: 21862184 DOI: 10.1016/j.revmed.2011.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 05/30/2011] [Accepted: 07/15/2011] [Indexed: 01/22/2023]
Abstract
PURPOSE A few studies only have focused on ambulatory management of erysipelas. METHODS To assess the diagnostic and therapeutic management of erysipelas by general practitioners, and their adherence to the French Society of Infectious Diseases and Dermatology joint 2000 recommendations, we surveyed 114 general practitioners during a 1 year period (from May 1st, 2005 to April 30th, 2006). RESULTS Seventy-three general practitioners accepted to participate to the study and 54 cases of erysipelas were reported. Median age of patients was 63 years (range, 18-94) and sex ratio was 0.77. Lower limbs were affected in 83% out of the cases. A skin lesion was reported in 65% of the cases. None of the 15 doppler ultrasonography that were performed identified deep vein thrombosis. Five patients (9%) were initially hospitalized. Only 18% out of the patients were treated by amoxicillin. Most prescribed antimicrobial agents were pristinamycin (31%) and amoxicillin-clavulanate (27%). Median duration of treatment was 10 days. Six patients received an anti-inflammatory drug. Among the 44 patients who had a follow-up visit, 37 patients (84%) recovered and two patients were hospitalized after this follow-up assessment. Two patients experienced a recurrence of erysipelas during the study. CONCLUSION As previously reported in the literature, outcome of erysipelas after ambulatory management remains excellent, although recommendations are poorly followed.
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Affiliation(s)
- D Larivière
- Service de médecine interne, hôpital Beaujon, Clichy, France
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23
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Levell N, Wingfield C, Garioch J. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 2011; 164:1326-8. [DOI: 10.1111/j.1365-2133.2011.10275.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hitchcock J, Jepson AP, Main J, Wickens HJ. Establishment of an outpatient and home parenteral antimicrobial therapy service at a London teaching hospital: a case series. J Antimicrob Chemother 2009; 64:630-4. [DOI: 10.1093/jac/dkp212] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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González Ramallo VJ, Bouza Santiago E. Tratamiento antimicrobiano intravenoso en el domicilio. Med Clin (Barc) 2008. [DOI: 10.1016/s0025-7753(08)72262-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Abrahamian FM, Talan DA, Moran GJ. Management of Skin and Soft-Tissue Infections in the Emergency Department. Infect Dis Clin North Am 2008; 22:89-116, vi. [DOI: 10.1016/j.idc.2007.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
PURPOSE OF REVIEW Acute bacterial skin infections are very common, with various presentations and severity. This review focuses on deep skin infections. We separate acute nonnecrotizing infections of the hypodermis (erysipelas), forms with abscesses or exudates and necrotizing fasciitis. These three types actually differ in risk factors, bacteriology, treatment and prognosis. RECENT FINDINGS Leg erysipelas/cellulitis occurs in more than one person/1000/year. It remains mainly due to streptococci. Foot intertrigo is an important risk factor. Necrotizing fasciitis is much rarer and usually occurs in patients with chronic diseases. Staphylococci, especially community-acquired methicillin-resistant strains in some areas, play a growing role in the intermediate form of cellulitis with abscesses and exudates. For erysipelas or noncomplicated cellulitis, antibiotic treatment at home, when feasible, is much less expensive and as effective as hospital treatment. Intermediate cases with collections and exudates often require surgical drainage. For necrotizing fasciitis early surgery remains essential in order to decrease the mortality rate. SUMMARY Antibiotic treatment of deep skin infections must be active on streptococci; the choice of a larger spectrum of activity depends on clinical presentation, risk factors and the burden of methicillin-resistant staphylococci in the environment.
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Carter K, Kilburn S, Featherstone P. Cellulitis and treatment: a qualitative study of experiences. ACTA ACUST UNITED AC 2007; 16:S22-4, S26-8. [PMID: 17505397 DOI: 10.12968/bjon.2007.16.sup1.27089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although cellulitis is usually a relatively mild condition, it is potentially life threatening, often necessitating emergency treatment in either the acute or community care settings. The treatment of cellulitis with antibiotics is well established, with effectiveness generally measured against purely biochemical and clinical outcomes (Cox, 2002). Although important, these outcomes are centred purely on the disease process from the medical perspective and little is known about patients' experiences of cellulitis. This qualitative study explores patients' view on the management of community-acquired cellulitis in the secondary healthcare setting. Data were collected through semi-structured groups and individual telephone interviews. Participants were selected through purposive sampling and the Framework Analysis Technique was used to analyse the data. Three superordinate themes emerged: initial presentation/motivation for seeking help; confidence and satisfaction; anxiety and dissatisfaction. Severe pain was almost universally a cause of distress and flu-like symptoms delayed recognition. Health information and communication was generally poor. Participants largely welcomed a move from inpatient to day-patient or outpatient care provided there was adequate information and support. To meet the diverse needs of cellulitis patients, services must be more flexible and tailored to the needs of the individual. Patients are often not told what they can do to prevent recurrence.
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Affiliation(s)
- Kim Carter
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth
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