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  • Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis

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Original article
Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis
  1. Laila F Ibrahim1,2,3,
  2. Sandy M Hopper2,4,
  3. Tom G Connell3,5,
  4. Andrew J Daley5,6,
  5. Penelope A Bryant1,2,3,5,
  6. Franz E Babl2,3,4
  1. 1 Department of RCH@Home, The Royal Children’s Hospital, Parkville, Victoria, Australia
  2. 2 Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  3. 3 Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
  4. 4 Department of Emergency, The Royal Children’s Hospital, Parkville, Victoria, Australia
  5. 5 Department of General Medicine, Infectious Diseases Unit, The Royal Children’s Hospital, Parkville, Victoria, Australia
  6. 6 Department of Microbiology, The Royal Children’s Hospital, Parkville, Victoria, Australia
  1. Correspondence to Dr Penelope A Bryant, Department of General Medicine, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia; penelope.bryant{at}rch.org.au

Abstract

Objective Children with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children to be treated with intravenous antibiotics at home and aimed to describe the characteristics of patients treated on this pathway and in hospital and to evaluate the outcomes.

Methods This is a prospective, observational cohort study of children aged 6 months–18 years attending the ED with uncomplicated moderate/severe cellulitis in March 2014–January 2015. Patients received either intravenous ceftriaxone at home or intravenous flucloxacillin in hospital based on physician discretion. Primary outcome was treatment failure defined as antibiotic change within 48 hours due to inadequate clinical improvement or serious adverse events. Secondary outcomes include duration of intravenous antibiotics and complications.

Results 115 children were included: 47 (41%) in the home group and 68 (59%) in the hospital group (59 hospital-only, 9 transferred home during treatment). The groups had similar clinical features. 2/47 (4%) of the children in the home group compared with 8/59 (14%) in the hospital group had treatment failure (P=0.10). Duration of intravenous antibiotics (median 1.9 vs 1.8 days, P=0.31) and complications (6% vs 10%, P=0.49) were no different between groups. Home treatment costs less, averaging $A1166 (£705) per episode compared with $A2594 (£1570) in hospital.

Conclusions Children with uncomplicated cellulitis may be able to avoid hospital admission via a home intravenous pathway. This approach has the potential to provide cost and other benefits of home treatment.

  • paediatric emergency medicine
  • admission avoidance
  • soft tissue infection

https://doi.org/10.1136/emermed-2017-206829

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    Footnotes

    • PAB and FEB contributed equally.

    • Contributors LFI conceptualised, designed and coordinated the study, carried out the initial data analysis, drafted the initial manuscript, and approved the final manuscript as submitted. PAB, FEB and SMH were involved in the design of the study, data analysis, reviewed and revised the manuscript, and approved the final draft. TGC and AJD were involved in the design of the study, reviewed and revised the manuscript, and approved the final draft. PAB had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding This study is funded in part by grants from the RCH Foundation, the Murdoch Childrens Research Institute (MCRI) and the Victorian Department of Health, Melbourne, Australia. LFI was supported in part by a scholarship from Avant Mutual Group. PAB was in part supported by a Clinician Scientist Fellowship from the MCRI. FEB was supported in part by a grant from the RCH Foundation. The emergency research group, MCRI, is in part supported by a Centre for Research Excellence Grant for Paediatric Emergency Medicine from the National Health and Medical Research Council, Canberra, Australia, and the Victorian government infrastructure support programme.

    • Competing interests None declared.

    • Ethics approval The Royal Children’s Hospital Ethics Committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.