Treatment failure in emergency department patients with cellulitis

ABSTRACTObjective:To identify the rate of treatment failure in emergency department patients with cellulitis.Methods:This prospective observational convenience study enrolled adult patients with uncomplicated cellulitis. Physicians performed a standardized assessment prior to treatment. To calculate the interrater reliability of the assessment, duplicate data collection forms were completed on a small subsample of patients. Treatment failure was defined as the occurrence of any one of the following events after the initial emergency department visit: incision and drainage of abscess; change in antibiotics (not due to allergy/intolerance); specialist consultation; or, hospital admission. Comparison of means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate.Results:Seventy-five patients were enrolled; 57% were male, the mean age was 48 (standard deviation 19), 71 (95%) patients had extremity cellulitis and 10 (13%) had abscess with cellulitis. Fourteen episodes (18.7%, 95% confidence interval [CI] 11%–28%) were classified as treatment failures, with an oral antibiotic failure rate of 6.8% (95% CI 2%–22%) and an emergency department-based intravenous antibiotic failure rate of 26.1% (95% CI 16%–40%). Patients with treatment failure were older (mean age 59 yr v. 46 yr,p= 0.02) and more likely to have been taking oral antibiotics at enrolment (50% v. 16.4%,p= 0.01). Patients with a larger surface area of infection were also more likely to fail treatment (465.1 cm2v. 101.5 cm2,p< 0.01). Interrater agreement was high for the presence of fever (kappa 1.0) and the size of surface area of infection (intraclass correlation coefficient 0.98), but low for assessments of both severity (kappa 0.35) and need for admission (kappa 0.46).Conclusions:The treatment of cellulitis with daily emergency department–based intravenous antibiotics has a failure rate of more than 25% in our centre. Cellulitis patients with a larger surface area of infection and previous (failed) oral therapy are more likely to fail treatment. Further research should focus on defining eligibility for treatment with emergency department-based intravenous antibiotics.

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Prevalence and predictors of initial oral antibiotic treatment failure in adult emergency department patients with cellulitis: a pilot study

BMJ Open ◽

10.1136/bmjopen-2015-008150 ◽

2015 ◽

Vol 5 (6) ◽

pp. e008150 ◽

Cited By ~ 2

Author(s):

Michael Quirke ◽

Fiona Boland ◽

Tom Fahey ◽

Ronan O'Sullivan ◽

Arnold Hill ◽

...

Keyword(s):

Emergency Department ◽

Pilot Study ◽

Treatment Failure ◽

Antibiotic Treatment ◽

Oral Antibiotic ◽

Emergency Department Patients

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1342. Clinical failure rates of amoxicillin for the treatment of acute otitis media in young children

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1524 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S682-S683

Author(s):

Holly M Frost ◽

Samuel Dominguez ◽

Sarah Parker ◽

Andrew Byars ◽

Sara Michelson ◽

...

Keyword(s):

Treatment Failure ◽

Otitis Media ◽

Failure Rate ◽

Acute Otitis Media ◽

Relative Reduction ◽

Failure Rates ◽

Beta Lactamase ◽

Clinical Failure ◽

Recurrence Rates ◽

Antibiotic Failure

Abstract Background Acute otitis media(AOM) is the most common indication for antibiotics in children. The primary pathogens that cause AOM have changed since the introduction of the pneumococcal conjugate vaccine(PCV). The clinical failure rate of amoxicillin for treatment of AOM post-PCV is unknown.We aimed to determine the clinical failure rate of amoxicillin for the treatment of uncomplicated AOM in children. Organisms identified on culture and amoxicillin treatment failure from nasopharyngeal specimens of children age 6-35 months with uncomplicated acute otitis media at Denver Health, Denver, CO from April 2019-March 2020. Methods Children age 6-35 months seen at Denver Health, Denver, CO with uncomplicated AOM and prescribed amoxicillin were prospectively enrolled. An interim analysis of patients enrolled from April 2019-March 2020 was completed. Patients completed surveys that included the AOM-SOS©(UPMC, Pittsburgh, PA) at enrollment, days 5, 14, and 30 and had chart abstraction completed. Treatment failure was defined as: (1) requiring a new antibiotic within 14 days; (2) AOM-SOS© score on day 5 or 14 not improved by a relative reduction of ≥ 55% from baseline. Recurrence was defined as requiring a new antibiotic within 15-30 days. Nasopharyngeal swabs were obtained and bacterial culture was completed. Results In total,110 patients were enrolled. Rates of treatment failure defined by AOM-SOS© were 28.4%(37; 95%CI:25.5-33.6%) at 5 days and 15.5%(27; 95%CI:17.5-24.5%) at 14 days. However, only 4.5%(5; 95%CI:2.0-4.5%) required a new antibiotic. Recurrence occurred in 5.5% (6, 95%CI:2.5-5.5%) of patients. Of patients who had not received antibiotics before enrollment(82), culture yielded no organism in 17.0%, one organism in 42.7%, and multiple organisms in 40.0% (Table). M.catarrhalis was the most frequently identified organism (53.7% of children). Of H.influenzae isolates 52.9% (9/17) produced beta-lactamase, resulting in no treatment failures or recurrences requiring a new antibiotic. Failure rates were similar between organisms. Conclusion Despite the change in otopathogen prevalence post-PCV, preliminary data suggest that while early subjective treatment failure was common, the 14 day treatment failure and 30 day recurrence rates was low when measured by need for a new antibiotic. Failure was low even among patients with organisms that would not be expected to be treated successfully with amoxicillin, such as those with beta-lactamase producing H.influenzae and M.catarrhalis. Disclosures Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

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Evaluation of Skin and Soft Tissue Infection Outcomes and Admission Decisions in Emergency Department Patients

Emergency Medicine International ◽

10.1155/2018/7142825 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Nicholas Black ◽

Jon W. Schrock

Keyword(s):

Emergency Department ◽

Soft Tissue ◽

Treatment Failure ◽

Soft Tissue Infection ◽

Clinical Information ◽

Positive Association ◽

Antibiotic Use ◽

Tissue Infection ◽

Secondary Outcome ◽

Emergency Department Patients

Background. Skin and soft tissue infections are common presenting complaints for Emergency Department (ED) patients. Although they are common, there remain no definitive guidelines on decisions of admission for these patients. Objectives. To determine the influence of demographic and clinical information of those presenting with skin and soft tissue infection(s) (SSTI) on both disposition and treatment failure. Methods. We prospectively enrolled adults with SSTI seen at a large urban ED. Secondary outcome was treatment failure. Statistics utilized t-tests and multivariate logistic regression. Results. We enrolled 125 subjects and 32 were admitted. 15.2% of patients failed treatment with both increasing age and infection area correlating with admission. IV drug use (IVDU) (OR: 10.2; 95% confidence interval [CI]: 1.9 to 50.0) and recent antibiotic use (OR: 2.9; 95% CI 1.003 to 8.333) independently predicted admission. Age and recent surgery in the area of infection (OR: 6.4; 95% CI 1.3 to 30.8) showed positive association with treatment failure. IV antibiotics (OR: 22.3; 95% CI 2.8 to 179.4) and admission (OR: 12.1; 95% CI 2.9 to 50.4) strongly predicted treatment failure. Conclusions. Age, infection size, IVDU, and recent antibiotics predicted admission. Age, recent surgery at infection site, IV antibiotics, and admission correlated with treatment failure.

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Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections

Western Journal of Emergency Medicine ◽

10.5811/westjem.2015.7.26213 ◽

2015 ◽

Vol 16 (5) ◽

pp. 642-652 ◽

Cited By ~ 7

Author(s):

Larissa May ◽

Mark Zocchi ◽

Catherine Zatorski ◽

Jeanne Jordan ◽

Richard Rothman ◽

...

Keyword(s):

Emergency Department ◽

Soft Tissue ◽

Treatment Failure ◽

Soft Tissue Infections ◽

Emergency Department Patients

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Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients

Epidemiology and Infection ◽

10.1017/s0950268818003291 ◽

2018 ◽

Vol 147 ◽

Author(s):

J. P. Haran ◽

E. Wilsterman ◽

T. Zeoli ◽

M. Goulding ◽

E. McLendon ◽

...

Keyword(s):

Emergency Department ◽

Treatment Failure ◽

Treatment Guidelines ◽

Infection Type ◽

Severe Infection ◽

Failure Rates ◽

Adjusted Risk ◽

Increased Risk ◽

Emergency Department Patients ◽

Risk Of Treatment

AbstractThe Infectious Disease Society of America (IDSA) publishes guidelines regularly for the management of skin and soft tissue infections; however, the extent to which practice patterns follow these guidelines and if this can affect treatment failure rates is unknown. We observed the treatment failure rates from a multicentre retrospective ambulatory cohort of adult emergency department patients treated for a non-purulent skin infection. We used multivariable logistic regression to examine the role of IDSA classification and whether adherence to IDSA guidelines reduced treatment failure. A total of 759 ambulatory patients were included in the cohort with 17.4% failing treatment. Among all patients, 56.0% had received treatments matched to the IDSA guidelines with 29.1% over-treated, and 14.9% under-treated based on the guidelines. After adjustment for age, gender, infection location and medical comorbidities, patients with a moderate infection type had three times increased risk of treatment failure (adjusted risk ratio (aRR) 2.98; 95% confidence interval (CI) 1.15–7.74) and two times increased risk with a severe infection type (aRR 2.27; 95% CI 1.25–4.13) compared with mild infection types. Patients who were under-treated based on IDSA guidelines were over two times more likely to fail treatment (aRR 2.65; 95% CI 1.16–6.05) while over-treatment was not associated with treatment failure. Patients ⩾70 years of age had a 56% increased risk of treatment failure (aRR 1.56; 95% CI 1.04–2.33) compared with those <70 years. Following the IDSA guidelines for non-purulent SSTIs may reduce the treatment failure rates; however, older adults still carry an increased risk of treatment failure.

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