Prevalence of misdiagnosis of cellulitis: A systematic review and meta‐analysis

Abstract

Background: There is no gold standard test to accurately identify patients with cellulitis and therefore misdiagnosis is common. Using the clinical impression of a dermatology or an infectious disease specialist as a reference standard, we sought to determine the prevalence of misdiagnosis of cellulitis among nonspecialist physicians.Methods: A systemic search was performed using MEDLINE, Cochrane Library, and EMBASE databases for studies reporting diagnostic accuracy of cellulitis. Inclusion criteria required dermatology or infectious disease consultation for all patients diagnosed with cellulitis by generalist physicians. We used random effects modeling to estimate the prevalence of misdiagnosis using consultant diagnosis as a reference standard.Results: Eight studies contributed to the analysis. For the seven studies involving inpatients, the results were sufficiently homogeneous to justify pooling data. Of 858 inpatients initially diagnosed with cellulitis, 335 (39%, 95% confidence interval: 31-47) received an alternative diagnosis from the specialist. Heterogeneity was large (I 2 = 74%) and the greatest contributor to between-study variance was the year of publication. Alternative diagnoses were mostly noninfectious (68%, 221/327), with stasis dermatitis (18%, 60/327) being the most common. An abscess was the most common alternative infectious diagnosis (10%, 32/327).Discussion: Cellulitis is commonly misdiagnosed among inpatients, leading to unnecessary hospital admissions and antibiotic overuse. Most alternative diagnoses are noninfectious. Continuing medical education among general practitioners and urgent care providers will likely reduce cellulitis misdiagnoses. BACKGROUNDCellulitis is a frequently diagnosed infection of the skin and subcutaneous tissue. 1 It is estimated that 14.5 million patients are diagnosed with cellulitis in the United States annually, accounting for 650,000 hospital admissions. 1 Although cellulitis comprises 10% of all infectious disease hospitalizations 2 and 11% of all dermatologic admissions, 3 there is no laboratory test, microbiologic result, or imaging study that can reliably confirm the diagnosis of cellulitis. 4 Diseases that mimic cellulitis are myriad, 5 thus offering ample opportunity for misdiagnosis. 6,7 Cellulitis misdiagnoses can lead to inappropriate treatment with antibiotics, unnecessary hospitalization, and delay in definitive diagnosis and treatment. [8][9][10] Dermatologists have special training and experience in differentiating among diseases of the skin and soft tissue and therefore

Attitudes, Beliefs, and Behaviors of Topical Antibiotic Prescribing among Primary Care Providers in Saudi Arabia: A Cross-Sectional Study

“…The risk of increased MRSA resistance to fusidic acid is expected to be high [10] and the reported improper use of this commonly used topical antibiotic is alarming. It is worth noting that misdiagnosis of skin infections is widespread [16,17]. Many primary care doctors over-diagnosed skin infections and under-diagnosed inflammatory conditions [18,19].…”

Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single‐centre audit of cellulitis outcomes

“…Several alternative conditions, including venous insufficiency, may have been misdiagnosed as cellulitis. 18 While we excluded patients subsequently found to have an alternative diagnosis, the potential for misdiagnosis of cellulitis may have reduced our ability to detect differences in outcomes before and after the change to the outpatient cellulitis treatment pathway due to other conditions. Another limitation of the study was that we were unable to account for other differences between the 2 years, such as the influence of pre-ED antimicrobials on outcomes.…”

“…Since this study was a retrospective audit, we were unable to assess the accuracy of the clinical diagnoses of cellulitis. Several alternative conditions, including venous insufficiency, may have been misdiagnosed as cellulitis 18 . While we excluded patients subsequently found to have an alternative diagnosis, the potential for misdiagnosis of cellulitis may have reduced our ability to detect differences in outcomes before and after the change to the outpatient cellulitis treatment pathway due to other conditions.…”

Skin and soft tissue infections in solid organ transplants

“…SSTI in SOT may present with a wide range of clinical pictures, since skin may be infected as a result of a primary infection or reflect the dissemination of an invasive infection [3 ▪▪ ,4]. Moreover, in SOT cutaneous manifestations can be misdiagnosed and secondary to other noninfectious causes, which include mostly neoplastic lesions, drug induced toxicities or stasis dermatitis [5,6,7 ▪ ,8,9]. The net state of immunosuppression, along with the virulence, the prompt diagnosis and early treatment, influence the severity of the infection.…”