Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis

Abstract

IMPORTANCE Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost. OBJECTIVE To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups. INTERVENTIONS Dermatology consultation within 24 hours of hospitalization. MAIN OUTCOMES AND MEASURES Length of hospital stay and duration of intravenous antibiotic treatment. RESULTS Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, −2.4%; 95% CI, −9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines. CONCLUSIONS AND RELEVANCE Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01706913

Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis: a multicentre randomized, double-blind, placebo-controlled, non-inferiority trial

“…Our data cannot be extrapolated to outpatients with mild infections, nor can it be generalized to all severe cellulitis patients. Furthermore, up to 30% of cellulitis diagnoses have been reported to be mimics [25]. Additionally, one has to be cautious about generalizing the results to antibiotics other than flucloxacillin.…”

“…Participants were managed with the guidelinerecommended drug. Randomization at day 5 reduces bias towards non-inferiority by filtering out patients with possible cellulitis mimics [25] and patients with pathogens intrinsically resistant to flucloxacillin. Bias towards non-inferiority is further reduced by high compliance and near-complete clinical follow-up of patients.…”

Dermatology hospitalists: a multicenter survey study characterizing the infrastructure of consultative dermatology in select American hospitals

“…Furthermore, previous studies have shown that rapid clinical and pathologic correlation from dermatology expertise may decrease length of hospitalization . A more recent study looking at outcomes of cellulitis patients found a significantly higher rate of 2‐week improvement in those seen by dermatologists compared to those treated with standard of care …”

“…18 A more recent study looking at outcomes of cellulitis patients found a significantly higher rate of 2week improvement in those seen by dermatologists compared to those treated with standard of care. 19 Beyond their benefit to patient care and healthcare cost, inpatient dermatologists can play an important role in teaching and learning. As evidenced by this study, they have both interest and expertise in complex medical dermatology as well as the ways systemic conditions affect the skin and vice versa.…”

Impact of dermatology and teledermatology consultations for patients admitted with cellulitis: A pilot study

“…To the Editor: Pseudocellulitis is a significant cause of resource overuse. 1,2 Although dermatology consults are associated with reduced readmission rates and adjusted length of stay in hospitalized patients, 3,4 specialists often are unavailable, and cellulitis remains one of the most frequent and costly reasons for dermatologic readmission. 5 Therefore, we piloted a randomized controlled trial to evaluate the effect of dermatology and teledermatology recommendations on patients admitted for cellulitis.…”