Cellulitis. Admit, send home?

[danzman]

---

Members do not see this ad.

So Im a 3rd yr EM res and I have seen a lot of practice variation over the years with cellulitis. Trying to find my comfort level with sending em home. What do you guys do?

Saw a17yr old pt recently with very uncomplicated finger cellulitis for 24hr with maybe 1 small area of streak up hand. No systemic stuff, nml vitals, nml labs, no outpt abx. She complained of a "strange feeling in her armpit." Attending was adamant that she be admitted for IV abx for "possible lymphangitis" Peds team was livid but took her for essentially 12 hrs and sent her home on clinda.

I have also seen our surgical service admit very benign looking stuff on the lower ext for nothing more than a days worth of vanc and an Id consult.

On the inpt side, ID tends to get consulted and rec PO abx very very soon, thus they always go home in no time flat.

To this point I guess I think that anything that looks really nasty in an at risk pt (old, DM etc) stays. Any VS abn' should probably stay, and any super young kid should stay.

Pretty much everything else I feel should get a shot at outpt PO abx (keflex/bacrim, doxy, or clinda) and FU/return instructions. But this seems to be a grey area.

What do you guys do?

 

[EM4life]

You'll get a lot of practice variation because there's a huge variation of badness in cellulitis just like you state - your attending is right for being concerned about lymphangitis given how quickly those patients get sicker and potential for complications. My general approach for cellulitis is: if they are systemically ill, have comorbidities, hx of multiple resistance/recurrent infections/IV drug user/recent hospitalizations or procedure related, the very old and very young, should get IV meds and obs admit or full admit. If none of those things, but the cellulitis is rapidly spreading - IV abx, consider dc with oral abx if the patient is reliable to return for worsening sx, if not reliable, obs/admit. Having said that, even if someone has comorbidities, I am OKAY with sending them home if they have reliable close follow up and they know to come back for worsening sx.

 

[danzman]

Hey thanks for the reply. I guess Im fine with all the various co-morbidities staying for IVs as they are pretty easy.

Still, I cant help but think that most every healthy person with no systemic stuff, obv complicated stuff, etc deserves a shot at PO meds. when I moonlight I generally document the discussion as a shared decision about attempting outpt therapy with intent to return if things get bad. And, of course, all of this is predicated on them being reliable/having a PCP etc. I generally call these people a few days later and have yet to have one fail outpt tx.

But even the "rapidly progressing" and lymphangitis cases I feel should still get a shot at outpt PO meds. without a fever or other systemic stuff. Hell, medscape and UTD both say outpt treatment is ok for almost everyone and the oral bioavailability of clinda has got to be around 90%, I just cant see what is so special about IV clinda Vs PO in a healthy, nontoxic pt.

 

[Arcan57]

If you listen to the ACEP ID lectures, they'll say essentially everything can go home with PO. Unless you're worried about compliance or severe immunocompromised states, I think CELLULITIS gets to go home with PO. I think that there are people that we admit or CDU because we think it's probably cellulitis but may be something more severe and it's just early on. I think this partly accounts for the ID recs because by the time they're seeing the patient as a consult it's painfully obvious whether this is severe sepsis/nec fasc or just cellulitis.

 

[EM4life]

If you listen to the ACEP ID lectures, they'll say essentially everything can go home with PO. Unless you're worried about compliance or severe immunocompromised states, I think CELLULITIS gets to go home with PO. I think that there are people that we admit or CDU because we think it's probably cellulitis but may be something more severe and it's just early on. I think this partly accounts for the ID recs because by the time they're seeing the patient as a consult it's painfully obvious whether this is severe sepsis/nec fasc or just cellulitis.

Oh yeah I just listened to this episode very recently, that will change my practice likely as far as giving IV and dc home to PO, thanks for the reminder!

 

[Birdstrike]

whether this is severe sepsis/nec fasc or just cellulitis.

This is the crux of it right here. Decision tree =

1- Is this, or could it become severe sepsis, nec fasc or is there any neurovascular compromise?

If yes, treat aggressively, consult, admit. (Of course, it's takes some experience and clinical judgement to answer this question.)

If not? Then it doesn't really matter what you do as long as you get appropriate antibiotics going, by some route, with a reasonably reliable patient/caregiver.

 

[shookwell]

The IDSA released new guidelines mostly based on expert opinions in 2014

http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296

The guidelines are very reasonable and the main distinction they make (for PO vs. IV) is between people with or without systemic sings of infection. One thing that struck me is that they recommend Vanc/Zosyn and surgical consultation for any failed outpatient therapy, which does seem a bit extreme to me.

 

[Bostonredsox]

I generally admit two types of cellulitis from my Ed docs.

1. septic pts, whom idsa guidelines recommend IV antibiotics

2. Pts with significant pain associated with the infected limb/cellulitic area where the neither the Ed doc nor I am overly concerned with the infection but the pt has had 2 doses of opiate and is still very uncomfortable. These usually only end up staying overnight and go home with PO in the morning.