Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis

• Published in: JAMA dermatology (Chicago, Ill.) Vol. 154; no. 5; p. 537
• Main Authors: Li, David G, Xia, Fan Di, Khosravi, Hasan, Dewan, Anna K, Pallin, Daniel J, Baugh, Christopher W, Laskowski, Karl, Joyce, Cara, Mostaghimi, Arash
• Format: Journal Article
• Language: English
• Published: United States 01-05-2018
• Subjects: Adult; Aged; Cellulitis - diagnosis; Cellulitis - therapy; Dermatology; Diagnostic Errors; Female; Hospitalization; Humans; Male; Middle Aged; Prospective Studies; Referral and Consultation; Treatment Outcome
• DOI: 10.1001/jamadermatol.2017.6197
• EISSN: 2168-6084

Many inflammatory skin dermatoses mimic cellulitis (pseudocellulitis) and are treated with antibiotics and/or hospitalization, leading to unnecessary patient morbidity and substantial health care spending.
To evaluate the impact of early dermatology consultation on clinical and economic outcomes associated with misdiagnosed cellulitis.
This prospective cohort study enrolled patients with presumed diagnosis of cellulitis in the emergency department, in the emergency department observation unit, or within 24 hours of admission to an inpatient unit of a large urban teaching hospital between February and September 2017. Patients were provided with telephone and clinic follow-up during the 30-day postdischarge period. We screened 165 patients with the primary concern of cellulitis. Of these, we excluded 44 who required antibiotics for cutaneous, soft-tissue, and deeper-tissue and/or bone infections irrespective of cellulitis status, and 5 who were scheduled to be discharged by the emergency department.
Early dermatology consultation for presumed cellulitis.
Primary outcomes were patient disposition and rates of antibiotic use.
Of 116 patients (63 [54.3%] women; 91 [78.4%] non-Hispanic white; mean [SD] age, 58.4 [19.1] years), 39 (33.6%) were diagnosed with pseudocellulitis by dermatologists. Of these, 34 (87.2%) had started using antibiotics for presumed cellulitis as prescribed by the primary team at the time of enrollment. The dermatology team recommended antibiotic discontinuation in 28 of 34 patients (82.4%), and antibiotics were stopped in 26 of 28 cases (92.9%). The dermatologists also recommended discharge from planned observation or inpatient admission in 20 of 39 patients with pseudocellulitis (51.3%), and the primary team acted on this recommendation in 17 of 20 cases (85.0%). No patients diagnosed with pseudocellulitis experienced worsening condition after discharge based on phone and clinic follow-up (30 of 39 [76.9%] follow-up rate). Extrapolating the impact of dermatology consultation for presumed cellulitis nationally, we estimate 97 000 to 256 000 avoided hospitalization days, 34 000 to 91 000 patients avoiding unnecessary antibiotic exposure, and $80 million to $210 million in net cost savings annually.
Early consultation by dermatologists for patients with presumed cellulitis represents a cost-effective intervention to improve health-related outcomes through the reduction of inappropriate antibiotic use and hospitalization.