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Libson K, Barba J, Henning A, Fisher K, Kirven RM, Korman AM, Plaza JA, Kaffenberger BH, Chung C. Acute Interstitial Inflammation on Skin Biopsies and Positive Tissue Cultures in Cellulitis Patients Are Associated a Worse Prognosis. Am J Dermatopathol 2024:00000372-990000000-00348. [PMID: 38842316 DOI: 10.1097/dad.0000000000002753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Cellulitis is a significant public health burden and lacks a gold standard for diagnosis. Up to 1/3 of patients are incorrectly diagnosed. The skin biopsy has been proposed as the gold standard. OBJECTIVE In this study, we evaluate the histopathologic characteristics and tissue culture positivity of biopsies in patients diagnosed with cellulitis seen by our inpatient dermatology consultation service. METHODS This retrospective cohort study examined patients who were hospitalized with a skin and soft tissue infection at our institution between 2011 and 2020 and underwent a skin biopsy. RESULTS Those with a positive tissue culture were more likely to die within 30 days compared with those with negative tissue cultures (26% vs. 6%, P = 0.048). Patients who died within 30 days were more likely to have acute interstitial inflammation as a feature on histopathology (38%, P = 0.03). LIMITATIONS Single institutional design, unintentional exclusion of patients with organism-specific diagnosis, and selection for a medically complex patient population because of the nonroutine collection of biopsies. CONCLUSION Positive tissue cultures and histopathology showing acute interstitial space inflammation on skin and soft tissue infection (SSTI) biopsies are associated with increased mortality and thus may serve as indicators of poor prognosis.
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Affiliation(s)
- Karissa Libson
- The Ohio State University College of Medicine, Columbus, OH
| | - Johnny Barba
- The Ohio State University College of Medicine, Columbus, OH
| | - Ania Henning
- Department of Pathology, Summa Health, Akron, OH
| | - Kristopher Fisher
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Rachel M Kirven
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Abraham M Korman
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Jose A Plaza
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Benjamin H Kaffenberger
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Catherine Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
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Pulia MS, Schwei RJ, Alexandridis R, Lasarev MR, Harwick E, Glinert R, Haleem A, Hess J, Keenan TD, McBride JA, Redwood R. Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis. JAMA Dermatol 2024; 160:511-517. [PMID: 38536160 PMCID: PMC10974680 DOI: 10.1001/jamadermatol.2024.0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/16/2023] [Indexed: 05/16/2024]
Abstract
Importance Cellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis. Objectives To validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis. Design, Setting, and Participants This prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023. Main Outcomes and Measures Temperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed. Results The final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P < .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]). Conclusions and Relevance In this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis.
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Affiliation(s)
- Michael S. Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Industrial and Systems Engineering, University of Wisconsin–Madison School of Engineering, Madison
| | - Rebecca J. Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Roxana Alexandridis
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Michael R. Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Edward Harwick
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Robert Glinert
- Department of Dermatology, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Ambar Haleem
- Division of Infectious Disease, Department of Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Jamie Hess
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Thomas D. Keenan
- Department of Dermatology, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Joseph A. McBride
- Division of Infectious Disease, Department of Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Division of Infectious Disease, Department of Pediatrics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Robert Redwood
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
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Jover-Sáenz A, Ramírez-Hidalgo M, Bellés Bellés A, Ribes Murillo E, Batlle Bosch M, Ribé Miró A, Mari López A, Cayado Cabanillas J, Piqué Palacín N, Garrido-Calvo S, Ortiz Valls M, Gracia Vilas MI, Gros Navés L, Javierre Caudevilla MJ, Montull Navarro L, Bañeres Argiles C, Vaqué Castilla P, Ichart Tomás JJ, Saura Codina M, Andreu Mayor E, Martorell Solé R, Vena Martínez A, Albalad Samper JM, Cano Marrón S, Soler Elcacho C, Rodríguez Garrocho A, Terrer Manrique G, Solé Curcó A, Escuin DDLR, Estadella Servalls MJ, Figueres Farreny AM, Montaña Esteban LM, Sanz Borrell L, Morales Valle A, Pallerola Planes M, Hamadi A, Pujol Aymerich F, Toribio Redondo F, Urgelés Castillón MC, Valgañon Palacios J, Olivart Parejo M, Torres-Puig-gros J. Effects of a Primary Care Antimicrobial Stewardship Program on Meticillin-Resistant Staphylococcus aureus Strains across a Region of Catalunya (Spain) over 5 Years. Antibiotics (Basel) 2024; 13:92. [PMID: 38247651 PMCID: PMC10812605 DOI: 10.3390/antibiotics13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Primary care antimicrobial stewardship program (ASP) interventions can reduce the over-prescription of unnecessary antibiotics, but the impact on the reduction in bacterial resistance is less known, and there is a lack of available data. We implemented a prolonged educational counseling ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, which was compared to a pre-intervention period, a significant reduction in antibiotic prescriptions occurred, particularly those associated with greater harmful effects and resistance selection. There was also a decrease in methicillin-resistant Staphylococcus aureus (MRSA) strains and in their co-resistance to other antibiotics, particularly those with an ecological impact.
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Affiliation(s)
- Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - María Ramírez-Hidalgo
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Alba Bellés Bellés
- Sección de Microbiología, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Esther Ribes Murillo
- Unidad de Farmacia de Atención Primaria, Institut Català de la Salut (ICS), 25007 Lleida, Spain;
| | - Meritxell Batlle Bosch
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Anna Ribé Miró
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Alba Mari López
- EAP Pla d’Urgell, 25001 Lleida, Spain; (A.M.L.); (J.C.C.); (N.P.P.)
| | | | | | | | | | | | | | | | | | | | | | - José Javier Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | - Mireia Saura Codina
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | | | | | - Ana Vena Martínez
- Servei de Geriatria, Hospital Universitari Santa Maria, 25198 Lleida, Spain;
| | | | - Susana Cano Marrón
- EAP Onze de Setembre, 25005 Lleida, Spain; (S.C.M.); (C.S.E.); (A.R.G.); (G.T.M.)
| | | | | | | | | | | | | | | | | | | | | | | | - Aly Hamadi
- EAP Balaguer, 25600 Lleida, Spain; (M.P.P.); (A.H.)
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