Hospitalizations for cellulitis in Canada: a database study

Development and external validation of machine learning-based models to predict patients with cellulitis developing sepsis during hospitalisation

OBJECTIVE

Cellulitis is the most common cause of skin-related hospitalisations, and the mortality of patients with sepsis remains high. Some stratification models have been developed, but their performance in external validation has been unsatisfactory. This study was designed to develop and compare different models for predicting patients with cellulitis developing sepsis during hospitalisation.

DESIGN

This is a retrospective cohort study.

SETTING

This study included both the development and the external-validation phases from two independent large cohorts internationally.

PARTICIPANTS AND METHODS

A total of 6695 patients with cellulitis in the Medical Information Mart for Intensive care (MIMIC)-IV database were used to develop models with different machine-learning algorithms. The best models were selected and then externally validated in 2506 patients with cellulitis from the YiduCloud database of our university. The performances and robustness of selected models were further compared in the external-validation group by area under the curve (AUC), diagnostic accuracy, sensitivity, specificity and diagnostic OR.

PRIMARY OUTCOME MEASURES

The primary outcome of interest in this study was the development based on the Sepsis-3.0 criteria during hospitalisation.

RESULTS

Patient characteristics were significantly different between the two groups. In internal validation, XGBoost was the best model, with an AUC of 0.780, and AdaBoost was the worst model, with an AUC of 0.585. In external validation, the AUC of the artificial neural network (ANN) model was the highest, 0.830, while the AUC of the logistic regression (LR) model was the lowest, 0.792. The AUC values changed less in the boosting and ANN models than in the LR model when variables were deleted.

CONCLUSIONS

Boosting and neural network models performed slightly better than the LR model and were more robust in complex clinical situations. The results could provide a tool for clinicians to detect hospitalised patients with cellulitis developing sepsis early.

The utility of augmented teledermatology to improve dermatologist diagnosis of cellulitis: a cross-sectional study

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1 month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84 ± 4% with the history and physical to 89 ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76 ± 6% to 88 ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

The Quality of Life and Psychosocial Implications of Cancer-Related Lower-Extremity Lymphedema: A Systematic Review of the Literature

Lower-extremity lymphedema (LEL) is a progressive, lifelong complication of cancer that places a substantial burden upon cancer survivors' quality of life (QOL) and psychosocial well-being. Despite its prevalence, cancer-related LEL is inconsistently diagnosed, treated, and poorly recognized by health care professionals. The purpose of this systematic review was to summarize and appraise the quantitative literature evaluating the impact of cancer-related LEL on patients' psychosocial well-being and QOL. Three databases (PubMed, PROQuest, and Scopus) were searched for observational research articles published before May 1st, 2020. Twenty-one articles were eligible (cross-sectional (n = 16), prospective cohort designs (n = 3), and retrospective cohort designs (n = 2)). The majority of studies reported a negative relationship between cancer-related LEL and global QOL and/or one or more psychosocial domains including (1) physical and functional; (2) psycho-emotional; (3) social, relational and financial. A greater number of LEL symptoms and higher LEL severity were associated with poorer QOL. Although the evidence to date suggests a negative relationship between cancer-related LEL and patients' QOL and psychosocial well-being, there is a substantial need for longitudinal analyses to examine the directionality and temporality of this effect in order to inform cancer survivorship care modelling and improve patient outcomes after cancer.

The Canadian Dermatology Association's Top Five Choosing Wisely Canada Recommendations

INTRODUCTION

In this article, we present the Canadian Dermatology Association's (CDA) Choosing Wisely Canada (CWC) list of top "Five Things Physicians and Patients Should Question in Dermatology" and the evidence in support of each recommendation.

METHODS

Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019.

RESULTS

The top five recommendations are as follows: (1) Don't routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don't routinely prescribe topical combination corticosteroid/antifungal products; (3) Don't routinely use topical antibiotics on a surgical wound; (4) Don't prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don't use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy.

DISCUSSION

This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology.

CONCLUSIONS

This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

Clinical predictors and impact of bacteremia in cirrhotic patients with acute skin and skin structure infection

OBJECTIVE

Acute bacterial skin and skin structure infection (ABSSSI) is a common cause of acute admissions in patients with cirrhosis worldwide, but the disease is not well-understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. The aim of this study was to understand the utility of blood cultures and the association between bacteremia and mortality in cirrhotic patients with ABSSSI. We conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in cirrhotic patients with ABSSSI.

METHODS

A retrospective cohort study of hospitalized adult cirrhotic patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016.

RESULTS

A total of 122 hospitalized cirrhotic patients with ABSSSI were included. The overall mortality rate was 9% (11/122), and 23 patients had positive blood culture results. Comorbidities that were significant risk factors for a positive blood culture included diabetes mellitus, acute kidney injury (AKI), and acute-on-chronic liver failure (ACLF). Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease (MELD) score, higher serum lactate, and lower serum albumin level. Bacteremia was also a significant factor associated with mortality.

CONCLUSION

A blood culture should be considered for cirrhotic patients with ABSSSI with diabetes mellitus, AKI, ACLF or those exhibiting abnormal albumin, lactate levels, or high MELD score because of the positive correlation between bacteremia and mortality.

Canadian Burden of Skin Disease From 1990 to 2017: Results From the Global Burden of Disease 2017 Study [Formula: see text]

Background

Skin diseases can have high morbidity that can be costly to society and individuals. To date, there has been no comprehensive assessment of the burden of skin disease in Canada.

Objectives

To evaluate the burden of 18 skin and subcutaneous diseases from 1990 to 2017 in Canada using the Global Burden of Disease (GBD) data.

Methods

The 2017 GBD study measures health loss from 359 diseases and injuries in 195 countries; we evaluated trends in population health in Canada from 1990 to 2017 using incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Data are presented as rates (per 100 000), counts, or percent change with the uncertainty interval in brackets.

Results

From 1990 to 2017 for all skin diseases, DALY rates increased by 8% to 971 per 100 000 (674-1319), YLD rates increased by 8% to 897 per 100 000 (616-1235), YLL rates increased by 4% to 74 per 100 000 (53-89), and death rates increased by 18% to 5 per 100 000 (3-6). DALY rates for melanoma increased by 2% to 54 per 100 000 (39-68), for keratinocyte carcinoma by 14% to 17 per 100 000 (16-19), and for skin and subcutaneous disease by 8% to 900 per 100 000 (619-1233). The observed over expected ratios were higher for skin and subcutaneous disease (1.37) and keratinocyte carcinoma (1.17) and were lower for melanoma (0.73).

Conclusions

The burden of skin disease has increased in Canada since 1990. These results can be used to guide health policy regarding skin disease in Canada.

Hot Stuff: Thermal Imaging Aids in Cellulitis Diagnosis

Cellulitis is commonly misdiagnosed, with resultant health care expenditures and complications from antibiotic overprescription. Ko et al. evaluate the use of thermal imaging to aid in the diagnosis of cellulitis, with promising results. Limitations include a small sample size and questionable applicability to bilateral leg findings, where cellulitis is unlikely regardless of temperature differential. Nevertheless, this technology has potential to improve patient care.

Risk factors associated with bacteremia correlated with mortality in patients with acute bacterial skin and skin structure infection

Acute bacterial skin and skin structure infections (ABSSSI) is a common cause of acute admissions worldwide, but the disease is not well understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. To understand the utility of blood cultures and the association between bacteremia and mortality in patients with ABSSSI, we conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in patients with ABSSSI. A retrospective cohort study of hospitalized adult patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016. A total of 1322 hospitalized patients with ABSSSI are included. The overall mortality rate is 2.1% (28/1322), and 122 patients had positive blood culture results. Comorbidities that are significant risk factors for a positive blood culture include diabetes mellitus and chronic kidney disease. Significant risk factors evident in laboratory evaluations include high C-reactive protein (CRP) level (> 20 mg/dL), hyperglycemia, and hypoalbuminemia. Bacteremia is also a significant factor associated with mortality. A blood culture should be considered for patients with ABSSSI with diabetes mellitus or chronic kidney disease or those exhibiting abnormal CRP, glucose, or albumin levels because of the positive correlation between bacteremia and mortality.

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

BACKGROUND

Cellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code "other cellulitis and abscess" accounts for 1.4% of all admissions and $5.5 billion in annual costs. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis and to ascertain if the rate is comparable to the rate for low risk patients with community acquired pneumonia that are currently recommended for outpatient management.

METHODS

A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random effects model. Heterogeneity was estimated using the I² statistic.

RESULTS

Eighteen studies met inclusion criteria. The overall worldwide mortality rate was 1.1% (95% confidence interval (CI), 0.7-1.8). For studies from the USA, the rate was 0.5% (95% CI 0.3-0.9). The actual cause of death was generally poorly described, and only one third of deaths appeared to be due to infection.

DISCUSSION

The estimated mortality rate for patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that are recommended for outpatient management by the Pneumonia Severity Index and CURB65 prediction models and strongly endorsed by major infectious disease societies. Outpatient management of these patients could result in large cost savings and may be much preferred by patients.

Looking Beyond the Cell in Cellulitis

BACKGROUND

Patients with erythematous skin are likely to receive a diagnosis of cellulitis; however, the accuracy of this diagnosis is approximately only 33%. The diagnosis of cellulitis should be made only after a thorough evaluation of all possible differential diagnoses. Cellulitis may be a primary process (superficial spreading infective process involving only the epidermis and dermis) versus a secondary (reactive) process incited by a subcutaneous process, such as an abscess, tenosynovitis, necrotizing fasciitis, and osteomyelitis.

CASE PRESENTATION

A 50-year-old man was admitted to a general hospital with the diagnosis of cellulitis. He was initially treated with systemic antibiotics without improvement. Following consultation with a wound management physician, the patient received a diagnosis of a pretibial abscess and was treated with surgical evacuation and postoperative systemic antibiotic therapy guided by tissue cultures. A postoperative wound was successfully treated with inelastic compression therapy.

CONCLUSIONS

This case demonstrates the potential for misdiagnosis when evaluating erythematous skin. Furthermore, concluding that the erythema is due to a primary cellulitis may result in monotherapy with systemic antimicrobial agents. In such cases, making a correct diagnosis through a skillful and complete physical examination of the patient, coupled with appropriate investigations, will lead to the best possible outcome. A comprehensive treatment approach may include systemic antimicrobials, as well as surgical options and compression therapy.

Clinical characteristics associated with days to discharge among patients admitted with a primary diagnosis of lower limb cellulitis

BACKGROUND

Clinicians have limited ability to classify risk of prolonged hospitalization among patients with lower limb cellulitis.

OBJECTIVE

We sought to identify characteristics associated with days to discharge and prolonged stay.

METHODS

We conducted retrospective cohort analysis including patients admitted with a primary diagnosis of lower limb cellulitis at community and tertiary hospitals.

RESULTS

There were 4224 admissions for lower limb cellulitis among 3692 patients. Mean age of the cohort was 64.4 years. Frequencies of tobacco smoking, obesity, and diabetes mellitus were 25.1%, 44.9%, and 19.3%, respectively. Patients having decreased likelihood of discharge included those with the following: 10-year age increments 0.90 (95% confidence interval [CI] 0.88-0.92), obesity 0.90 (95% CI 0.83-0.97), diabetes mellitus 0.90 (95% CI 0.82-0.98), tachycardia 0.76 (95% CI 0.67-0.85), hypotension 0.77 (95% CI 0.65-0.90), leukocytosis 0.86 (95% CI 0.79-0.93), neutrophilia 0.80 (95% CI 0.73-0.87), elevated serum creatinine 0.74 (95% CI 0.68-0.81), and low serum bicarbonate 0.84 (95% CI 0.75-0.95).

LIMITATIONS

This analysis is retrospective and based on coded data. Unknown confounding variables may also influence prolonged stay.

CONCLUSIONS

Patients with lower limb cellulitis and prolonged stay have a number of clinical characteristics which may be used to classify risk for prolonged stay.

Examination of hospital length of stay in Canada among patients with acute bacterial skin and skin structure infection caused by methicillin-resistant Staphylococcus aureus

PURPOSE

Skin infections, particularly those caused by resistant pathogens, represent a clinical burden. Hospitalization associated with acute bacterial skin and skin structure infections (ABSSSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is a major contributor to the economic burden of the disease. This study was conducted to provide current, real-world data on hospitalization patterns for patients with ABSSSI caused by MRSA across multiple geographic regions in Canada.

PATIENTS AND METHODS

This retrospective cohort study evaluated length of stay (LOS) for hospitalized patients with ABSSSI due to MRSA diagnosis across four Canadian geographic regions using the Discharge Abstract Database. Patients with ICD-10-CA diagnosis consistent with ABSSSI caused by MRSA between January 2008 and December 2014 were selected and assigned a primary or secondary diagnosis based on a prespecified ICD-10-CA code algorithm.

RESULTS

Among 6,719 patients, 3,273 (48.7%) and 3,446 (51.3%) had a primary and secondary diagnosis, respectively. Among patients with a primary or secondary diagnosis, the cellulitis/erysipelas subtype was most common. The majority of patients presented with 0 or 1 comorbid condition; the most common comorbidity was diabetes. The mean LOS over the study period varied by geographic region and year; in 2014 (the most recent year analyzed), LOS ranged from 7.7 days in Ontario to 13.4 days in the Canadian Prairie for a primary diagnosis and from 18.2 days in Ontario to 25.2 days in Atlantic Canada for a secondary diagnosis. A secondary diagnosis was associated with higher rates of continuing care compared with a primary diagnosis (10.6%-24.2% vs 4.6%-12.1%).

CONCLUSION

This study demonstrated that the mean LOS associated with ABSSSI due to MRSA in Canada was minimally 7 days. Clinical management strategies, including medication management, which might facilitate hospital discharge, have the potential to reduce hospital LOS and related economic burden associated with ABSSSI caused by MRSA.