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Cellulitis & Associated SSTI

– Avenues of Treatment
SPH GRAND ROUNDS
MARCH 11, 2015
MICHAEL LI, MD, CCFP-EM
ANDREW KESTLER, MBA, MD, FACEP, DTMH, FRCP

Outline

Background

When should patients go home (PO), come back (IV) or go
upstairs (admit)?

And when do we get it wrong?

OPAT – rationale

OPAT at St Paul’s – now and future

Take home lessons

Epidemiology

Cellulitis and associated SSTI (erysipelas, abscess-associated
cellulitis) are a common presenting complaint to physician
offices, outpatient hospital clinics and EDs

Increasing prevalence, correlated with increases in community
MRSA especially in the early 21st century

CID 2008) Rates of MRSA SSTI in 12 US EDs in 2004 vs 2008 • 59% prevalence of MRSA unchanged with increasing appropriate MRSA coverage (57% in 2004 vs 97% in .98% • Associated increase in MRSA coverage with antibiotics • (Talan. AEM 2008) analysis of US NHAMCS (1993-2005) • % of all ED visits with SSTI increased from 1.35% to 2.Increasing ED visits for cellulitis in early 21st century • (Palin.

JPH 2006) prospective cohort study of 883 IVUs in Vancouver  60% accessed SPH ER services in the last 12-24 months  Most common reason was SSTI (18%) 40% 32% 30% 20% 14% 10% 5% 0% Abscess Cellulitis Both Cumulative .Special local concerns Abscess  (Binswanger. CID 2000) survey of 169 IVUs in San Francisco 50% had active untreated abscess or cellulitis 60% 51% 50%  Over  (Kerr.

34-2.13-3.90)  HIV+ AHR 1.76-7.85 (1.55)  Hospital referral AHR 2.2 per 100 person-years  Require assistance injecting AHR 1.38 (1.8 per 100 person-years   DTES residence AHR 2.97 (1.48 (2.01-1.Special local concerns  (Lloyd-Smith.30) Male incidence 19. tracking incidence of St Paul’s ED use for cutaneous injection-related infections (“CIRI” – cellulitis & abscess)  Predictors of ED use based on IVU patterns/demographics (not clinical)  Female incidence 23.78)  Hospital referral AHR 4.93-4. OIDJ 2013) – 4-year study of 1083 Insite users.06 (1.57) .

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“Mild vs moderate” cellulitis  IDSA 2014  Mild – no systemic signs of infection   Outpatient oral antibiotics for “patients who do not have SIRS. chronic venous insufficiency. or hemodynamic instability”  Moderate – systemic signs of infection (? but not meeting SIRS)  Severe – failed oral antibiotic treatment. immunocompromised CREST 2005  Class I – systemically well. SIRS criteria. no uncontrolled comorbidities  Class II – systemically ill OR systemically well + higher-risk comorbidity (PVD. altered mental status. obesity)  (Class III & IV) – SIRS -> severe sepsis/life threatening .

Potential regimens  Spectrum of regimens – choice of regimen based on clinical judgement of severity and resource availability  Topical antibiotics  PO antibiotics  ED IV dose + home PO  ED IV dose + return to ED for IV dosing  ED IV dose + outpatient IV antibiotics (OPAT clinic)  ED IV with observation x 24-48 hours .SSU / DTU / CDU  Admit to ward  Admit to ICU / OR .

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p = 0.39 (“fair agreement”) for assessment of severity .01) Subset interobserver agreement .kappa 0. 26% failure rate  “Treatment failure” = admission to hospital (7%). speciality consult (1%). CJEM 2005) prospective convenience sample of 75 patients (2 ED sites Ontario) with uncomplicated cellulitis treated with PO Keflex or IV ancef/probenecid or IV ceftriaxone (based on clinical judgement)  39% treated with oral antibiotics.Outpatient treatment  (Heather. p = 0. I&D (4%)  overall rate of 20%  Significant differences in treatment failure group:   Older (46 vs 59. change in antibiotics (8%).02)  More previous antibiotic treatment (16% vs 50%. 7% failure rate  61% treated with IV antibiotics.

ON) treated with outpatient PO or IV antibiotics (RT ED).Outpatient treatment  (Peterson. hospitalization  overall rate 21%  majority  4% (17%) due to change in antibiotics due to admission to hospital . AEM 2014) Prospective cohort study of 497 patients diagnosed with cellulitis (2 EDs in London. variable regimens based on ERP discretion  “Treatment failure” = change in antibiotics (not including step-down from IV to PO).

Proportion of treatment failures Overall IV + PO Abx IV Abx PO Abx 0% 5% 10% 15% 20% 25% 30% .

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06 (1.34 (1. IJEM 2008) – retrospective cohort review of 183 patients admitted to ED observation unit for 24 hours for abscess/cellulitis  38% from EDOU required admission  Risk factor 5.53-10.16) WBC > 15 4.)  5% (!!) mortality Gender (female) 2.6% returned within 7 days of discharge for admissionOR (95% C.74) .ED observation unit  May be a sicker patient population – unclear initial disposition as to home vs admission  Often RTED for daily IV ABx or OPAT not available  Associated with cost savings – managed by ED doctors during shift  (Schrock.06-5.I.

2% . 2012 AJEM) single-site retrospective cohort study of 377 patients with cellulitis admitted to an ED observation unit for IV antibiotics and to assess response to treatment  Decision within 24 hours of admission to hospital vs discharge with PO antibiotics  Overall “treatment failure” / admission rate 29.ED observation unit  (Volz.

50% hospitalized  8% referred for hospital admission  78% of those hospitalized  11% .Which patients need admission?  (Sabaj. AJEM 2009) single-site retrospective cohort study of 674 ED patients presenting with soft tissue infection  primary outcome hospital stay > 24 hours discharged with PO antibiotics  1% returned requiring admission  81% admitted to EDOU  all remained > 24 hours.

8% was 30.8% specific for outcome .9% sensitivity and 94. initial ED temp > 37.Which patients need admission?  In this study.

 (Talan. WJEM 2015) – prospective multi-site study (12 US EDs) of 619 adults presenting with a SSTI  ED physicians surveyed on clinical reasons for admission  Patient risk factors analyzed to look for independent predictors of admission  15.2% hospitalization rate (13% to ward. 1. 0.8% to EDOU)   0% overall mortality “Needs IV Abx” sole reason in 42% of admitted patients (no availability of outpatient therapy) .5% to ICU.

7% 27.6% 10.6% 11.4% 1.2% 5.3% Age > 65 years • At least one risk factor present in 89 of 94 patients (“95% sensitivity”) • All risk factors absent in 291 of 525 patients (“45% specificity”) .1% 6% Any co-morbidity 61.3% History of failed treatment 16.Which patients need admission? Independent risk factor for admission % in admitted patients % in discharged patients History of fever 43.5% Maximal length of erythema > 10cm 43.

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a consistent response to a well-defined antimicrobial therapy and a low likelihood of acute deterioration”  tends to be run by ID. well established clinical literature  “infections managed via OPAT should have a predictable course. office. sometimes by internists  when we bring patients back to the ED for repeat IV antibiotics . EJIM 2013) “the administration of a parenteral antimicrobial in a non inpatient or ambulatory setting (clinic. home) with the explicit aim of facilitating admission avoidance or early discharge”  around for decades.OPAT – Outpatient Parental Antibiotic Therapy  (Seaton.

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JAC 2009) 2-year cohort study of 334 OPAT clinic patients  59%  87% for SSTI cure or improvement. 9.OPAT – review of the evidence  (Barr. 39-59% estimated cost savings (versus inpatient treatment) . IJAA 2012) 10-year cohort study of 2233 OPAT clinic patients  53% for SSTI  92. 6.1% admission rate  (Chapman.4% cure or improvement.3% admission rate.

$6326  Estimated 55-87% cost savings per patient compared to hospital stay .1% (Wai.OPAT – review of the evidence   (Esposito. Pharmacoeconomics 2000) Cost-analysis of OPAT program at VGH (?UBC) hospital based on 117 patients over a 3-year period  Estimated cost per patient from hospital . 981 UK patients. 620 Italian patients  USA – cure or improvement in 92.$1910  Estimated cost per patient from MOH .5%  UK – cure or improvement in 96. IJAA 2004) analysis of International OPAT Registry of 9826 US patients.8%  Italy – cure or improvement in 95.

IJAA 2004) .(Esposito.

OPAT – rationale for specialist care in cellulitis  Presentation by Dr. Richard Bachand (PharmD) – Director of Antimicrobial Stewardship at VIHA  OPAT data from RJH in 2006 .

145 patients referred from ERPs for admission for cellulitis. BJD 2011) UK single site. 28% had other diagnoses as reviewed by ID or dermatology  (Previous pilot study showed 100% concordance between ID & dermatology)  Most common misdiagnosis stasis dermatitis . DOJ 2011) two US sites . 635 patients referred from GPs to dermatologists for lower limb cellulitis – 33% had other diagnoses  (David.OPAT – rationale for specialist care in cellulitis  (Levell.

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in flux)  Currently main source of patients is SSTI referred by SPH ED doctors   Uncomplicated cellulitis or abscess-associated cellulitis (I&D’d) Also take any uncomplicated infection requiring IV Abx  UTI/pyelonephritis. Paul’s OPAT program  Started Jan 19. dental infections. .St. 2015  Patients requiring more than 1 day of IV antibiotics  Managed by Infectious Diseases specialists  Open 7 days a week (11am-7pm. osteomyelitis.

blood cultures when clinically appropriate (not most SSTI. Philip Peters and Dr. Tom Havey  Things ED doctors do well   Generally appropriate referrals  Generally appropriate choice of antibiotics Useful items for the OPAT clinic   Baseline bloodwork on patients. Paul’s OPAT program – feedback for us  Discussions with Dr. consider in pyelonephritis)  + wound cultures if I&D or needle aspiration of associated abscess  + HIV status Some challenges related to patient population . including a CRP  +/.St.

Clinic-based OPAT is effective (comparable to or better than returning to ED for IV therapy). Specialist care available in OPAT may reduce duration or intensity of antibiotic regimen and in identification of alternative diagnoses .Take home lessons 1. and cost-effective when compared to inpatient admission 4. We are generally better at predicting who has mild cellulitis needing PO antibiotics than the disposition for those who have moderate cellulitis  No clear guidelines 2. Beware the history or presence of fever – consistent risk factor for admission and failed outpatient therapy in larger studies 3.

2013 Feb.39(5):407-13. Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with           Schrock JW. Wingfield CG.References          Wai AO. et al. Seaton RA. West J Emerg Med. et al. Cydulka RK. 2011. 2005. Comparison of Staphylococcus aureus from skin and soft-tissue infections in US emergency department patients. Identifying patients with cellulitis who are likely to require inpatient admission after a stay in an ED observation unit. Clinical Resource Efficiency Support Team (CREST) Guidelines on the Management of Cellulitis in Adults. Semple L. Am J Emerg Med. Clin Infect Dis. Pharmacoeconomics 2000. Dermatol Online J. Stiell I. Int J Antimicrob Agents. et al. Kerr T. Wells G. J Antimicrob Chemother. 2008 Jun. 2005 Jul. Garioch JJ. Ann Emerg Med 2008. 2005. et al. Talan DA. 2004 and 2008. Increased US Emergency Department Visits for Skin and Soft Tissue Infections. 18(5):451-7 Palin DJ.30(3):579-81. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Br J Dermatol. Eur J Intern Med. Levell NJ. Cost Analysis of an Adult Outpatient Parenteral Antibiotic Therapy (OPAT) Programme. Acad Emerg Med. and Changes in Antibiotic Choices. J Public Health (Oxf).1(2):85-90.59(2):e10-52. During the Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureus. Laskey S. 2014 Jul 15. Seaton RA. 2013 Oct. 2004 Nov. Murray H. 2000. Lloyd-Smith E.64(6):1316-24. Int J Emerg Med. et al. 2012. Ireland. Clin Infect Dis. Open Infect Dis J. et al. et al. 51(3): 291-8. Stevens DL. et al. et al. Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital-based practice: a retrospective cohort study describing experience and evolution over 10 years.24(5):473-8. Talan DA.16(1):89-97. David CV. et al.31(2):360-4. Sabbaj A. et al.6. et al. Chapman AL.24(7):617-23. Belfast. Soft tissue infections and emergency department disposition: predicting the need for inpatient admission. 2009 Dec. et al. 2015 Jan. Esposito S. Clin Infect Dis. Treatment failure in emergency department patients with cellulitis. Int J Antimicrob Agents. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Peterson D.17(3):1. 2009 Dec. Barr DA. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective.16(12):1290-7. Outpatient parenteral antibiotic therapy (OPAT) in different countries: a comparison. 53(2):144-9 Binswanger IA. 2012 May. Outpatient parenteral antibiotic therapy: principles and practice. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Barr DA. DETERMINANTS OF CUTANEOUS INJECTIONRELATED INFECTIONS AMONG INJECTION DRUG USERS AT AN EMERGENCY DEPARTMENT. 2011 . et al. CJEM. 2011 Mar 15.7(4):228-34. High rates of primary care and emergency department use among injection drug users in Vancouver.27(1):62-6. Volz KA. Predicting observation unit treatment failures in patients with skin and soft tissue infections.

Thank you! .