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

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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Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department

Academic Emergency Medicine ◽

10.1111/acem.13492 ◽

2018 ◽

Cited By ~ 2

Author(s):

Krishan Yadav ◽

Kathryn N. Suh ◽

Debra Eagles ◽

John MacIsaac ◽

Darmyn Ritchie ◽

...

Keyword(s):

Emergency Department ◽

Soft Tissue ◽

Treatment Failure ◽

Antibiotic Treatment ◽

Oral Antibiotic ◽

Soft Tissue Infections

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Characteristics of the prehospital phase of adult emergency department patients with an infection: A prospective pilot study

PLoS ONE ◽

10.1371/journal.pone.0212181 ◽

2019 ◽

Vol 14 (2) ◽

pp. e0212181 ◽

Cited By ~ 3

Author(s):

Gideon H. P. Latten ◽

Lieke Claassen ◽

Marnix Jonk ◽

Jochen W. L. Cals ◽

Jean W. M. Muris ◽

...

Keyword(s):

Emergency Department ◽

Pilot Study ◽

Prospective Pilot Study ◽

Prehospital Phase ◽

Emergency Department Patients

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LO52: Predictors of oral antibiotic treatment failure for non-purulent skin and soft tissue infections in the emergency department

CJEM ◽

10.1017/cem.2018.114 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S24-S25 ◽

Cited By ~ 1

Author(s):

K. Yadav ◽

K. Suh ◽

D. Eagles ◽

J. MacIsaac ◽

D. Ritchie ◽

...

Keyword(s):

Treatment Failure ◽

Antibiotic Treatment ◽

Oral Antibiotic ◽

Soft Tissue Infections ◽

Emergency Physicians ◽

Intravenous Antibiotic ◽

The Past ◽

History Of ◽

Chronic Ulcers ◽

Mrsa Colonization

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.

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