Early dermatology consultation linked to improved diagnostic accuracy and care in cellulitis

1. Among patients admitted to the hospital for a provisional diagnosis of cellulitis, early dermatologic consultation was associated with improved recognition of pseudo-cellulitis, decreased antibiotic use, and earlier discharge.

2. For patients in whom pseudo-cellulitis was recognized, antibiotics and in-patient management were less common, while topical steroids and conservative measures were more common.

Evidence Rating Level: 2 (Good)          

Study Rundown: Infection of the dermis and subcutaneous tissue (cellulitis) represents a common infection and reason for admission to hospital. Prior studies have demonstrated high rates of misdiagnosis, with many patients having a form of pseudocellulitis (conditions such as stasis or contact dermatitis). Improved recognition may lead to decreased use of inappropriate antibiotics, and overall healthcare utilization. The current study sought to evaluate the effectiveness of early dermatologic evaluation for in-patients with a diagnosis of cellulitis. Early dermatologic consultation was linked to improved recognition of pseudo-cellulitis, decreased antibiotic use, and earlier discharge from in-hospital stays. In those patients in whom pseudo-cellulitis was diagnosed and management changed, there were no patients reported to have worsening condition during the planned 30-day follow-up.

The study’s main strength was in the design allowing for efficient evaluation by dermatologists, where management was changed in a high proportion of patients. The main limitations of the study included its small size and single institution design which limits its generalizability, and low rate of follow-up for the patients diagnosed with pseudocellulitis. The lack of gold-standard for cellulitis diagnosis beyond dermatologist opinion may also influence the results of the study.

Click to read the study in JAMA Dermatology

Relevant Reading: The Impact of Dermatology Consultation on Diagnostic Accuracy and Antibiotic Use Among Patients With Suspected Cellulitis Seen at Outpatient Internal Medicine Offices

In-Depth [prospective cohort]: This was a prospective cohort study of patients evaluated at an emergency department at a single institution in 2017, with a presumptive diagnosis of cellulitis. Patients were excluded if they were to be discharged from the emergency department without admission, or required antibiotics for other indications. Patients were evaluated by a dermatologist, and for patients diagnosed with a pseudocellulitis condition recommendations were made to the primary team. Patients were arranged to have follow-up evaluations for 30-days post-discharge.

For the 116 patients included in the study, 39 (33.6%) were diagnosed with a pseudocellulitis condition by the dermatologist with 87.2% having already begun antibiotics by the primary care team. Antibiotics were recommended to be discontinued in 28/34 (82.4%) of patients, and were discontinued in 26 cases. Discharge from hospital was recommended in 20 cases (51.3%) of pseudocellulitis, of which 17 patients were discharged. Of the 30 patients (76.9%) with pseudocellulitis who were available for follow-up, none experienced worsening clinical condition following change of management.

Image: PD

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