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Akhavan H, Habibzadeh SR, Maleki F, Foroughian M, Ahmadi SR, Akhavan R, Abbasi B, Shahi B, Kalani N, Hatami N, Mangouri A, Jamalnia S. Accuracy of CREST Guideline in Management of Cellulitis in Emergency Department; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e69. [PMID: 34870235 PMCID: PMC8628644 DOI: 10.22037/aaem.v9i1.1422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hospitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team (CREST) guideline in management of cellulitis in emergency department. Method: Studies that had evaluated cellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database, from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate Guideline Network (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AUROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriateness of antimicrobial treatment in management of cellulitis in emergency department was evaluated. Results: Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation of the rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95% confidence interval (CI): 0.06 – 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicrobial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department, OR=0.21 (95% CI: 0.009 – 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 – 0.89) showed accuracy of the CREST classification in prediction of being hospitalized more or less than 24 hours. Conclusion: CREST classification shows good accuracy in determining the duration of hospitalization or observation in ED but it could lead to inevitable over/under treatment with empirical antimicrobial agents.
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Affiliation(s)
- Hossein Akhavan
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Reza Habibzadeh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Maleki
- Department of Emergency Medicine, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Mahdi Foroughian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sayyed Reza Ahmadi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Akhavan
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Behzad Shahi
- Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Navid Kalani
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Naser Hatami
- Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Mangouri
- Division of Vascular Surgery and Endovascular Therapy, Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sheida Jamalnia
- Medical Journalism Department, Shiraz University of Medical Sciences, Shiraz, Iran
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Venugopalan V, Crawford R, Ho K, Garg M, Park H, Premraj S, Klinker K, Cherabuddi K, DeSear K. Resource Over-Utilization in Hospitalized Patients With Uncomplicated Skin and Soft Tissue Infections. J Pharm Pract 2021; 35:675-679. [PMID: 33752488 DOI: 10.1177/08971900211000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inpatient management of SSTIs utilizes considerable healthcare resources. The CREST+SEWS score categorizes patients with SSTIs into 4 severity classes. Hospitalizations can be avoided in Class I as they are treated as outpatients with oral antibiotics, whereas Class IV require hospitalization for intravenous antibiotics. OBJECTIVE The purpose of this study was to perform a budget impact analysis on CREST+SEWS Class 1 patients, to compare the medical costs of current treatment, in the inpatient setting with intravenous antibiotics, with a proposed alternative of using oral antibiotics in the outpatient setting. Further, resource utilization in Class I was evaluated. METHODS This was a retrospective study of adult patients hospitalized in 2015 for SSTIs who received >24 hours of antimicrobials. The CREST+SEWS scoring system was used to stratify patients into Class I to IV. Pharmacy and medical costs and resources associated with inpatient management of Class I SSTIs were derived from the itemized discharge records. RESULTS Of the 252 patients who met the inclusion criteria, 61 (24%) were classified as Class I. The total cost of treating Class I SSTI patients in the inpatient setting was $281,816 (cost per patient: $4,619) in 2015 USD. In the hypothetical situation of treatment with oral antibiotics in the outpatient setting, the cost savings were estimated to be $4,398 per patient. Fifty-three percent of patients had blood cultures, and on average, each patient received 2 radiographic tests. CONCLUSIONS Identifying outpatient candidates, and avoiding tests with low diagnostic can reduce the economic burden of SSTIs.
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Affiliation(s)
- Veena Venugopalan
- University of Florida Health Shands Hospital, Fl, USA.,15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Robert Crawford
- 8674Novant Health, Forsyth Medical Center Winston-Salem, NC, USA
| | - Kennedy Ho
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Mahek Garg
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Haesuk Park
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Sasha Premraj
- 138492Ascension Sacred Heart Hospital Pensacola, FL, USA
| | | | - Kartikeya Cherabuddi
- University of Florida Health Shands Hospital, Fl, USA.,University of Florida, College of Medicine, FL, USA
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Ritchie SR, Cutfield T, Lee A, Walter H, Gow R, Gammie T, Punnoose C, Nagarkar S, Thomas MG. The impact of the Auckland cellulitis pathway on length of hospital stay, mortality readmission rate, and antibiotic stewardship. Clin Infect Dis 2021; 73:859-865. [PMID: 33639623 DOI: 10.1093/cid/ciab181] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Dundee classification of cellulitis severity, previously shown to predict disease outcomes, provides an opportunity to improve the management of patients with cellulitis. METHODS We developed and implemented a pathway to guide the management of adults with cellulitis based on their Dundee severity class, and measured its effect on patient outcomes. We compared the outcomes in patients admitted to Auckland City Hospital (ACH) between July 2014 and July 2015 (the baseline cohort) with those in patients admitted between June 2017 and June 2018 (the intervention cohort). RESULTS The median length of stay was shorter in the intervention cohort (0.7 days, IQR 0.1 to 3.0 days) than in the baseline cohort (1.8 days, IQR 0.1 to 4.4 days; P<0.001). The 30 day mortality rate declined from 1.8% (19/1092) in the baseline cohort to 0.7% (10/1362; P=0.02) in the intervention cohort. The 30 day cellulitis readmission rate increased from 6% in the baseline cohort to 11% (P<0.001) in the intervention cohort. Adherence to the ACH cellulitis antibiotic guideline improved from 38% to 48% (P<0.01) and was independently associated with reduced length of stay. CONCLUSIONS The implementation of the Auckland cellulitis pathway, readily generalizable to other settings, improved the outcomes in patients with cellulitis, and resulted in an annual saving of approximately 1,000 bed days.
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Affiliation(s)
- Stephen R Ritchie
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tim Cutfield
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Arier Lee
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Hannah Walter
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Robert Gow
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Todd Gammie
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Christy Punnoose
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Suyog Nagarkar
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mark G Thomas
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Rath E, Skrede S, Oppegaard O, Bruun T. Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort. Infect Dis (Lond) 2020; 52:361-371. [DOI: 10.1080/23744235.2020.1726447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Cutfield T, Walter H, Hobbs M, Chuang A, Thomas MG, Ritchie SR. Association of the Dundee severity classification with mortality, length of stay and readmission in adult inpatients with cellulitis. J Antimicrob Chemother 2020; 74:200-206. [PMID: 30295790 DOI: 10.1093/jac/dky400] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022] Open
Abstract
Background The Dundee classification is a simple severity assessment tool that could optimize treatment decisions and clinical outcomes in adult patients with cellulitis; however, it has not been validated in a large cohort. Objectives To determine whether the Dundee classification reliably identified those patients with cellulitis who had a higher mortality, a longer length of hospital stay or an increased risk of readmission. Methods We performed a retrospective study of all adults with a primary discharge diagnosis of cellulitis admitted to Auckland City Hospital from August 2013 to June 2015. We classified patients by severity using the Dundee scoring system. Results The 30 day all-cause mortality in adult patients with a discharge diagnosis of cellulitis was 2% (29/1462) overall, and was 1% (10/806), 2% (6/271), 3% (10/353) and 9% (3/32) in Classes 1, 2, 3 and 4 of the Dundee classification, respectively (P = 0.01). Mortality was strongly associated with age >65 years (OR 9.37, 95% CI 3.00-41.23) and with heart failure (OR 6.16, 95% CI 2.73-14.23). There were significant associations between the Dundee classification and the incidence of bacteraemia, the length of hospital stay and the rate of readmission to hospital. Conclusions The Dundee classification is a simple, reliable tool that can be easily applied in clinical settings to predict risk of mortality in order to determine which patients can be managed in the community with oral or intravenous therapy, and which require inpatient care.
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Affiliation(s)
- Tim Cutfield
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Hannah Walter
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mark Hobbs
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Ariel Chuang
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mark G Thomas
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Stephen R Ritchie
- Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
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The what, when and how in performing and interpreting microbiological diagnostic tests in skin and soft tissue infections. Curr Opin Infect Dis 2019; 31:104-112. [PMID: 29337704 DOI: 10.1097/qco.0000000000000433] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To summarize and classify the most recent and relevant microbiological studies for each type of skin and soft tissue infection (SSTI). RECENT FINDINGS Following Infectious Diseases Society of America and Food and Drug Administration classifications of SSTIs, we differentiate between two large groups, the superficial or uncomplicated infections and the complicated infections with deep involvement. It is not usually necessary to obtain microbiological samples in uncomplicated infections, except in cases of recurrences or for epidemiological control purposes. In the case of complicated infections, the samples are of two different types: those obtained from the affected area (surgical samples, punctures of abscesses or swabs) and systemic samples (i.e. blood cultures). The clinical condition also determines the type of samples to be obtained. In cases of systemic involvement, blood cultures are mandatory. For immunocompromised patients, who may present atypical infections, detection of antigens, serologies or molecular biology techniques may be helpful. The rapid diagnosis is currently the goal to be pursued by implementing techniques such as matrix assisted laser desorption ionization-time of flight, commercial real-time PCR or the promising metagenomics. SUMMARY Microbiological diagnosis is one of the cornerstones of the management of SSTIs. Prompt obtaining and processing of the necessary samples, depending on the clinical situation of the patient, is of relevance in the decision-making process. Rapid and fluid reporting of the results (identification, mechanisms of resistance and antibiogram) will improve the management of these patients.
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Development of a Risk-Scoring Tool to Determine Appropriate Level of Care in Acute Bacterial Skin and Skin Structure Infections in an Acute Healthcare Setting. Infect Dis Ther 2018; 7:495-507. [PMID: 30244362 PMCID: PMC6249187 DOI: 10.1007/s40121-018-0212-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Acute bacterial skin and skin structure infections (ABSSSIs) represent a large burden to the US healthcare system. There is little evidence-based guidance regarding the appropriate level of care for ABSSSIs. This study aimed to develop a prediction model and risk-scoring tool to determine appropriate levels of care. Methods This was a single-center observational cohort study of adult patients treated for ABSSSIs from 2012 to 2015 at the Detroit Medical Center. The predictive model used to create a novel risk-scoring tool was derived using multinomial regression analysis. The overall accuracy of this tool was compared to the Clinical Resource Efficacy Support Team (CREST) Classification and Standardized Early Warning Score (SEWS) using area-under-the- receiver-operator-curve (AUROC) analysis and Z-statistic. Results Final patient disposition was 230 (45.5%) home from the emergency department (ED), 65 (12.8%) observation unit (OU), and 211 (41.7%) initial inpatient. IV antibiotic therapy was used in 358 (70.8%) patients. CREST and SEWS were not accurate in the determination of ED versus OU disposition [AUROC CREST 0.0.682 (95% CI 0.640–0.724), AUROC SEWS 0.686 (95% CI 0.641–0.731)], but performed better in determining ED/OU versus inpatient [AUROC CREST = 0.678 (95% CI 0.630–0.725), AUROC SEWS 0.693 (95% CI 0.645–0.740)]. These scores were also not accurate in determining IV versus PO antibiotic therapy [AUROC CREST = 0.586 (95% CI 0.530–0.624), AUROC SEWS = 0.630 (95% CI 0.576–0.684)]. A risk-scoring tool ranging from 0 to 10 points was derived incorporating WBC, temperature, site of infection, and past medical history of diabetes, liver disease, PVD, AKI, and/or CKD. The AUROC of the new model was 0.675 (95% CI 0.611–0.739) ED versus OU, 0.789 (95% CI 0.748–0.829) ED/OU versus inpatient, and 0.742 (95% CI 0.694–0.789) IV versus oral antibiotics. The new score had a significantly higher AUROC compared to both the CREST and SEWS for determining ED/OU versus inpatient (p < 0.001). Conclusion Prediction models based on patient risk may be useful for determining appropriate level of care during for ABSSSIs. While the prediction model demonstrated moderate to high levels of correlation with patient level of care, further validation of a prospective cohort of patients is warranted. Electronic supplementary material The online version of this article (10.1007/s40121-018-0212-3) contains supplementary material, which is available to authorized users.
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Abstract
PURPOSE OF REVIEW Skin and soft tissue infections (SSTIs) are the most frequent infectious cause of referrals to emergency departments and hospital admissions in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology and management of SSTIs. RECENT FINDINGS Incidence trends of SSTIs were increasing worldwide with Staphylococcus aureus and streptococci predominating and methicillin-resistant S. aureus (MRSA) posing additional challenges, because of high rates of treatment failure and relapse. Development of new antimicrobials was associated with an appraisal of regulatory definitions and endpoints. Prediction of clinical response can be very tricky, because of variable risk factors for recurrence or treatment failure, depending mostly on the host. Precise indications for new antimicrobials should be established; their integration into clinical practice algorithms may serve reduction of unnecessary admissions, overtreatment and total costs. SUMMARY New antimicrobials with activity against MRSA have been recently launched. Long-acting agents, mainly oritavancin and dalbavancin, provide the opportunity of single-dose treatment and early discharge. Further outpatient treatment options include new per os antibiotics such as oxazolidinones. Validated assessment tools are urgently needed to support decision-making toward rational resource utilization and delivery of optimal treatment.
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Lipsky BA, Silverman MH, Joseph WS. A Proposed New Classification of Skin and Soft Tissue Infections Modeled on the Subset of Diabetic Foot Infection. Open Forum Infect Dis 2016; 4:ofw255. [PMID: 28480249 PMCID: PMC5413991 DOI: 10.1093/ofid/ofw255] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/21/2016] [Indexed: 01/22/2023] Open
Abstract
Schemes for classifying skin and soft tissue infections (SSTIs) pose limitations for clinicians and regulatory agencies. Diabetic foot infections (DFIs) are a subset of SSTIs. We developed and are proposing a classification to harmonize current schemes for SSTIs and DFIs. Existing schemes for classifying SSTIs are limited in both their usefulness to clinicians and to regulatory agencies. The guidelines on SSTI from the Infectious Diseases Society of America (IDSA) and the guidance from the US Food and Drug Administration do not adequately address many types of wound infections. However, guidelines developed by the IDSA for DFIs provide a classification scheme that has been validated and widely used. Diabetic foot infections are similar to SSTIs in pathophysiology, microbiology, and treatment and can be seen as a subset of SSTI. Thus, based on the documents noted above, and our review of the literature, we have developed a proposed classification scheme for SSTI that harmonizes well with the DFI classification. We believe this new scheme will assist clinicians in classifying most wound infections and potentially aid regulatory agencies in testing and approving new antimicrobials for these infections.
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