1
|
Nightingale RS, Etheridge N, Sweeny AL, Smyth G, Dace W, Pellatt RAF, Snelling PJ, Yadav K, Keijzers G. Cellulitis in the Emergency Department: A prospective cohort study with patient-centred follow-up. Emerg Med Australas 2024; 36:579-588. [PMID: 38481041 DOI: 10.1111/1742-6723.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to describe the demographics, clinical features (erythema, warmth, swelling and pain), patient-reported disease trajectory and medium-term follow-up for ED patients with cellulitis. METHODS Prospective observational cohort study of adults diagnosed with cellulitis in two EDs in Southeast Queensland, Australia. Patients with (peri)orbital cellulitis and abscess were excluded. Data were obtained from a baseline questionnaire, electronic medical records and follow-up questionnaires at 3, 7 and 14 days. Clinician adjudication of day 14 cellulitis cure was compared to patient assessment. Descriptive analyses were conducted. RESULTS Three-hundred patients (mean age 50 years, SD 19.9) with cellulitis were enrolled, predominantly affecting the lower limb (75%). Cellulitis features showed greatest improvement between enrolment and day 3. Clinical improvement continued gradually at days 7 and 14 with persistent skin erythema (41%) and swelling (37%) at day 14. Skin warmth was the feature most likely to be resolved at each time point. There was a discrepancy in clinician and patient assessment of cellulitis cure at day 14 (85.8% vs. 52.8% cured). CONCLUSIONS A clinical response of cellulitis features can be expected at day 3 with ongoing slower improvement over time. Over one third of patients had erythema or swelling at day 14. Patients are less likely than clinicians to deem their cellulitis cured at day 14. Future research should include parallel patient and clinician evaluation of cellulitis to help develop clearer definitions of treatment failure and cure.
Collapse
Affiliation(s)
- Rachael S Nightingale
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Nimai Etheridge
- Department of Emergency Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Amy L Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - Graham Smyth
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - William Dace
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Richard A F Pellatt
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
| | - Peter J Snelling
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Ontario, Canada
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
2
|
Obucina M, Hamill L, Huynh R, Alcorn K, Cross J, Sweeny A, Keijzers G. How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography. QUALITATIVE HEALTH RESEARCH 2023; 33:1333-1348. [PMID: 37870924 PMCID: PMC10666467 DOI: 10.1177/10497323231198144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.
Collapse
Affiliation(s)
- Mila Obucina
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Laura Hamill
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
- Canterbury Health DHB, Christchurch, New Zealand
| | - Ronald Huynh
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
| | - Kylie Alcorn
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
| | - Jack Cross
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
- Bond University, Gold Coast, QLD, Australia
| |
Collapse
|
3
|
Yadav K, Krzyzaniak N, Alexander C, Scott AM, Clark J, Glasziou P, Keijzers G. The impact of antibiotics on clinical response over time in uncomplicated cellulitis: a systematic review and meta-analysis. Infection 2022; 50:859-871. [PMID: 35593975 DOI: 10.1007/s15010-022-01842-7] [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: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Antibiotic treatment of uncomplicated cellulitis is highly variable with respect to agent, dose, and route of administration. As there is uncertainty about optimal/appropriate time to reassess, we aimed to assess time to clinical response. METHODS We conducted a systematic review of randomized controlled trials reporting clinical response of uncomplicated cellulitis to antibiotic treatment over multiple timepoints. PubMed, Embase, CENTRAL, WHO ICTRP, and clinicaltrials.gov were searched from inception to June 2021 without language restrictions. The primary outcome was time to clinical response. Other outcomes were components of clinical response (pain, severity score, redness, edema measured at ≥ 2 timepoints) and the proportion of patients with treatment failure. We performed a pooled estimate of the average time to clinical response together with 95% confidence intervals using a random effects model. RESULTS We included 32 randomized controlled trials (n = 13,576 participants). The mean time to clinical response was 1.68 days (95%CI 1.48-1.88; I2 = 76%). The response to treatment for specific components was as follows: ~ 50% reduction of pain and severity score by day 5, a ~ 33% reduction in area of redness by day 2-3, and a 30-50% reduction of proportion of patients with edema by day 2-4. Treatment failure was variably defined with an overall failure rate of 12% (95%CI 9-16%). CONCLUSION The best available data suggest the optimal time to clinical reassessment is between 2 and 4 days, but this must be interpreted with caution due to considerable heterogeneity and small number of included studies.
Collapse
Affiliation(s)
- Krishan Yadav
- Clinical Epidemiology Unit, Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, F660b, Ottawa, ON, K1Y4E9, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Charlotte Alexander
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
| |
Collapse
|
4
|
Evison H, Sweeny A, Ranse J, Carrington M, Marsh N, Byrnes J, Rickard CM, Carr PJ, Keijzers G. Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices. Scand J Trauma Resusc Emerg Med 2021; 29:126. [PMID: 34454555 PMCID: PMC8403444 DOI: 10.1186/s13049-021-00941-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 08/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment. METHODS This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression. RESULTS A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3). CONCLUSION One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.
Collapse
Affiliation(s)
- Hugo Evison
- Queensland Ambulance Service, GPO Box 1425, Brisbane, QLD, 4000, Australia.
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,School of Medicine, Griffith University, Teaching Griffith Health Centre - G40 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4226, Australia
| | - Jamie Ranse
- Department of Emergency Medicine, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia
| | - Mercedes Carrington
- Department of Emergency Medicine, Robina Hospital, 2 Bayberry Lane, Robina, QLD, 4226, Australia
| | - Nicole Marsh
- Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,School of Nursing and Midwifery, Griffith University, N48 Health Sciences Building, Level 2.06, 170 Kessels Road, Southport, QLD, 4111, Australia.,Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Level 2 Building 34 Royal Brisbane and Women's Hospital, Herston, QLD, 4209, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine, Griffith University, N78 Sir Samuel Griffith Building, Level 2.11, 170 Kessels Road, Southport, QLD, 4111, Australia
| | - Claire M Rickard
- Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,School of Nursing and Midwifery, Griffith University, N48 Health Sciences Building, Level 2.06, 170 Kessels Road, Southport, QLD, 4111, Australia.,Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Level 2 Building 34 Royal Brisbane and Women's Hospital, Herston, QLD, 4209, Australia.,Herston Infectious Diseases Institute, Metro North Hospitals and Health Service, Herston, QLD, 4006, Australia.,School of Nursing Midwifery and Social Work, The University of Queensland Centre for Clinical Research, Herston, QLD, 4006, Australia
| | - Peter J Carr
- Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,School of Nursing and Midwifery, National University of Ireland Galway, 26 Upper Newcastle, Galway, H91 E3YV, Ireland
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia.,Department of Emergency Medicine, Robina Hospital, 2 Bayberry Lane, Robina, QLD, 4226, Australia.,School of Medicine, Griffith University, Teaching Griffith Health Centre - G40 Gold Coast Campus Griffith University, Southport, QLD, 4222, Australia.,Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4226, Australia
| |
Collapse
|
5
|
Etheridge N, Keijzers G. Cellulitis: Treatment failure or failure to define treatment failure? Emerg Med Australas 2020; 33:180-181. [PMID: 33200526 DOI: 10.1111/1742-6723.13688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Nimai Etheridge
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
6
|
Brindle RJ, O’Neill LA, Williams OM. Risk, Prevention, Diagnosis, and Management of Cellulitis and Erysipelas. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00287-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
7
|
Baxter M, Denny KJ, Keijzers G. Antibiotic prescribing in patients who presented to the emergency department with dog bites: A descriptive review of current practice. Emerg Med Australas 2020; 32:578-585. [PMID: 31958878 DOI: 10.1111/1742-6723.13467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the current practice of prophylactic antibiotic prescribing for patients presenting to the ED with a dog bite, and compare management against existing guidelines. METHODS We performed a descriptive retrospective study on all consecutive patients who presented to one tertiary teaching hospital and one regional district hospital in Southeast Queensland between 1 July 2017 and 30 June 2018 with a presentation of a dog bite. Data on demographics and management were collected from the electronic medical record using a standardised data collection tool. Risk factors supporting prophylaxis were taken from the electronic Therapeutic Guidelines. RESULTS Of the 336 patients included for analysis, 299 received antibiotics, of which 23 were for established infection. A total of 276 (82% of overall cohort) received a prescription for prophylactic antibiotics, either in hospital (ED or admitting ward) and/or on discharge. Of the 178 patients who received prophylactic antibiotics in hospital, 91 (51.1%) received intravenous antibiotics. Of the patients who presented to ED without a previously established infection 271 (86.6%) received prophylactic antibiotics on discharge. Over one quarter (27.5%) of patients who were given prophylactic antibiotics did not meet any high-risk factors as outlined in guidelines. CONCLUSION Prophylactic antibiotics are extensively used for patients with dog bites. There is scope to rationalise antibiotic use and route of antibiotic administration in patients with dog bites.
Collapse
Affiliation(s)
- Megan Baxter
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Kerina J Denny
- Burns Trauma and Critical Care Research Centre, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| |
Collapse
|