Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age >=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p < 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were <2% and adverse events were <5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.

Cellulitis is a common infection of the skin and soft tissue. Susceptibility to cellulitis is related to microorganism virulence, the host immunity status and environmental factors. This retrospective study from 2001 to 2013 investigated relationships between the monthly incidence rate of cellulitis and meteorological factors using data from the Taiwanese Health Insurance Dataset and the Taiwanese Central Weather Bureau. Meteorological data included temperature, hours of sunshine, relative humidity, total rainfall and total number of rainy days. In otal, 195 841 patients were diagnosed with cellulitis and the incidence rate was strongly correlated with temperature (γS = 0.84, P < 0.001), total sunshine hours (γS = 0.65, P < 0.001) and total rainfall (γS = 0.53, P < 0.001). The incidence rate of cellulitis increased by 3.47/100 000 cases for every 1° elevation in environmental temperature. Our results may assist clinicians in educating the public of the increased risk of cellulitis during warm seasons and possible predisposing environmental factors for infection.

A 47-year-old homeless male presents to the emergency department (ED) with right lower extremity swelling, erythema and pain. He has diabetes mellitus, and had one prior episode of cellulitis three months ago affecting the same leg. He has a history of medication noncompliance. At triage, his temperature is 38.3°C but the remaining vital signs are unremarkable. On examination of the affected leg, there is an approximately 10 × 10 cm area of erythema, induration and increased warmth. There is mild tenderness to palpation and you wonder if there is a small degree of fluctuance. There is no lymphangitis, crepitus, necrosis or pain out of proportion to clinical findings.

Introduction: Current guideline recommendations for optimal management of non-purulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is currently a lack of evidence to guide emergency physicians on when to select oral versus intravenous antibiotic therapy. The primary objective was to identify risk factors associated with oral antibiotic treatment failure. A secondary objective was to describe the epidemiology of adult emergency department (ED) patients with non-purulent SSTIs. Methods: We performed a health records review of adults (age 18 years) with non-purulent SSTIs treated at two tertiary care EDs. Patients were excluded if they had a purulent infection or infected ulcers without surrounding cellulitis. Treatment failure was defined any of the following after a minimum of 48 hours of oral therapy: (i) hospitalization for SSTI; (ii) change in class of oral antibiotic owing to infection progression; or (iii) change to intravenous therapy owing to infection progression. Multivariable logistic regression was used to identify predictors independently associated with the primary outcome of oral antibiotic treatment failure after a minimum of 48 hours of oral therapy. Results: We enrolled 500 patients (mean age 64 years, 279 male (55.8%) and 126 (25.2%) with diabetes) and the hospital admission rate was 29.6%. The majority of patients (70.8%) received at least one intravenous antibiotic dose in the ED. Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR]=6.31, 95% CI=1.80 to 22.08), chronic ulcers (OR=4.90, 95% CI=1.68 to 14.27), history of MRSA colonization or infection (OR=4.83, 95% CI=1.51 to 15.44), and cellulitis in the past 12 months (OR=2.23, 95% CI=1.01 to 4.96) were independently associated with oral antibiotic treatment failure. Conclusion: This is the first study to evaluate potential predictors of oral antibiotic treatment failure for non-purulent SSTIs in the ED. We observed a high rate of treatment failure and hospitalization. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for non-purulent SSTIs being managed as outpatients.

Introduction: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). To date, there are no prospective studies describing the performance of an ED-to-OPAT clinic program. Furthermore, there are no studies that have examined physician rationale for intravenous therapy, despite this being a critical first step in the decision to refer to an OPAT program. Methods: We conducted a prospective observational cohort study of adults (age 18 years) with non-purulent SSTIs receiving parenteral therapy at two tertiary care EDs. Patients were excluded if they had purulent infections or could not provide consent. The emergency physician completed a form documenting rationale for intravenous therapy, infection size, and choice of antimicrobial agent, dose and duration. OPAT treatment failure was defined as hospitalization after a minimum of 48 hours of OPAT for: (i) worsening infection; (ii) peripheral intravenous line complications; or (iii) adverse antibiotic events. Patient satisfaction was assessed at a 14-day telephone follow up. Results: We enrolled a consecutive sample of 153 patients (mean age 60 years, 82 male (53.6%) and 38 (24.8%) with diabetes). A total of 137 patients (89.5%) attended their clinic appointment. Of the 101 patients prescribed cefazolin, 50.5% received 1000 mg and 48.5% received 2000 mg per day. There were low rates of OPAT treatment failure (3.9%). None of the adverse peripheral intravenous line events (9.8%) or adverse antibiotic events (7.2%) required hospitalization. Patients reported a high degree of satisfaction with timeliness of clinic referral (median score 9 out of 10) and overall care received (median score of 10 out of 10). The top 5 reasons given by physicians for selecting intravenous therapy were: clinical impression of severity (52.9%); failed oral antibiotic therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). Conclusion: This is the first study to identify physician rationale for the use of intravenous antibiotics for SSTIs. There was significant variability in antibiotic prescribing practices by ED physicians. This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction.

Introduction: Children with moderate cellulitis are often treated with IV antibiotics in the hospital setting, as per recommendations. Previously in our hospital, a protocol using daily IV ceftriaxone with follow-up at the day treatment center (DTC) was used to avoid admission. In 2013, a new protocol was implanted and suggested the use of high dose (HD) oral cephalexin with follow-up at the DTC for those patients. The aim of this study was to evaluate the safety and efficacy of the HD cephalexin protocol to treat moderate cellulitis in children as outpatient. Methods: A retrospective chart review was conducted. Children were included if they presented to the ED between January 2014 and 2016 and were diagnosed with a moderate cellulitis sufficiently severe to request a follow up at DTC and who were treated according to the standard of care with the HD oral cephalexin (100 mg/kg/day) protocol. Descriptive statistics for clinical characteristics of patients upon presentation, as well as for treatment characteristics in the ED and DTC were analyzed. Treatment failure was defined as: need for admission at the time of DTC evaluation, change for IV treatment in DTC or return visit to the ED. Outcomes were compared to historic controls treated with IV ceftriaxone at the DTC, where admission was avoided in 80% of cases. Results: During the study period, 682 children with cellulitis were diagnosed in our ED. Of these, 117 patients were treated using the oral HD cephalexin outpatient protocol. Success rate was 89.5% (102/114); 3 patients had an alternative diagnosis at DTC. Treatment failure was reported in 12 cases; 10 patients (8.8%) required admission, one (0.9%) received IV antibiotics at DTC, and one (0.9%) had a return visit to the ED without admission or change to the treatment. This compares favorably with the previous study using IV ceftriaxone (success rate of 80%). No severe deep infections were reported or missed; 4 patients required drainage. The mean number of visits per patient required at the DTC was 1.6. Conclusion: Treatment of moderate cellulitis requiring a follow-up in a DTC, using an oral outpatient protocol with HD cephalexin is a secure and effective option. By reducing hospitalization rate and avoiding the need for painful IV insertion, HD cephalexin is a favourable option in the management of moderate cellulitis for pediatric patients, when no criteria of toxicity are present.

Introduction: Cellulitis and erysipelas are common presentations for the general practitioner. Antibiotic therapy targeting beta-hemolytic streptococci and Staphylococcus aureus is the mainstay of treatment for children and adults with these infections. Although evidence-based Canadian guidelines for appropriate management exist, inconsistent practices persist. Our objective was to determine the level of adherence to current evidence by emergency physicians at two academic hospitals in Kingston, Ontario. Methods: We conducted a retrospective chart review of 200 randomly selected electronic medical records. Records belonged to patients with a discharge diagnosis of cellulitis or erysipelas who were seen in the emergency departments of Kingston General Hospital or Hotel Dieu Hospital between January 1 and June 30, 2015. We manually collected data describing patient demographics, medical history, and medical management. Results: There were 707 total visits to the emergency departments in the study period for cellulitis or erysipelas. In our random sample, for those diagnosed with cellulitis, 44% received oral cephalexin alone, which was the most common form of therapy for uncomplicated infection. Of all the patients who received any antibiotics, 36% received at least one dose of parenteral antibiotics, despite only 6.7% showing systemic signs of illness. Emergency physicians chose ceftriaxone for 88% of the patients who received parenteral antibiotics. Conclusion: There was wide variation in antibiotic selection and route of administration for patients with cellulitis or erysipelas. Ceftriaxone was chosen for most patients receiving parenteral antibiotics, but it may not have been the most effective antibiotic in some cases. Overuse of antibiotics is common, and we believe medication choice should be justified based on disease severity, spectrum of activity, and regional antibiotic resistance patterns, among other factors. In conclusion, we found that emergency physicians could more closely align management plans with current guidelines to improve management of uncomplicated infection and reduce unnecessary administration of parenteral antibiotics.

Wound closure with 2-octyl cyanoacrylate (Dermabond; Ethicon, Somerville, New Jersey USA) has recently increased in popularity across a wide spectrum of physicians ranging from surgeons to emergency medicine practitioners. Generally, very few complications are associated with Dermabond and are usually related to application techniques. Uncommonly, patients present with allergic reactions to the adhesive compounds; these allergies are often misdiagnosed as cellulitis or another infectious process, and are incorrectly treated. This report describes a rare case of a diffuse cutaneous allergic reaction to Dermabond following its use to close a surgical incision, its prompt identification, and treatment after presentation to an emergency department.

RicciJA, ParekhNN, DesaiNS. Diffuse Cutaneous Allergic Reaction to Dermabond. Prehosp Disaster Med. 2014;29(5):1-3.

Background: Orbital cellulitis has important complications. Despite this, there are few studies in the literature of large groups of cases of this condition.

Methods: We performed a retrospective case analysis of all patients admitted with periorbital and orbital cellulitis between 2002 and 2004.

Results: A total of 27 cases were included in the study. Of these, 25 had undergone a computed tomography scan, 19 of which had revealed significant sinus disease; 10 had had a microbiology result, with the most common organism being Streptococcus milleri; 20 had had a white cell count taken, with raised results in only 10; 12 had undergone surgery; and 25 had made a good recovery. One case had been found to be squamous cell carcinoma of the nasal cavity.

Conclusions: In this study, sinus disease was the commonest cause of orbital cellulitis, with the commonest organism being Streptococcus milleri. Only 50 per cent of cases with proven disease had had a raised white cell count; this is therefore not a very sensitive test.

Peritonsillar infections include cellulitis and abscess (quinsy). Clinical diagnosis is often supplemented by diagnostic drainage (aspiration or incision) in an effort to distinguish abscess from cellulitis. In a prospective study of 14 patients we have shown that clinical impression alone is unreliable (sensitivity 78 per cent, specificity 50 per cent). Computerized tomography (CT) (sensitivity 100 per cent, specificity 75 per cent) and intraoral ultrasound (sensitivity 89 per cent, specificity 100 per cent) are much more reliable. We propose that intraoral ultrasound could play a useful role in the clinical assessment of peritonsillar infections helping to improve accuracy in distinguishing abscesses from cellulitis.