Original Contributions
ED management of cellulitis: A review of five urban centers*,**,

Presented in part at the Canadian Association of Emergency Physicians Annual Meeting, Quebec City, Quebec, Canada, October 1999 and the American College of Emergency Physicians Annual Meeting, Las Vegas, NV, October 1999.
https://doi.org/10.1053/ajem.2001.28330Get rights and content

Abstract

Cellulitis is a common problem presenting to the emergency department (ED). This study examines the epidemiology of cellulitis in 5 Canadian urban EDs and determines the practice variation in this management among sites. From computerized provincial ED diagnosis information, 10% of cellulitis charts from April 1, 1997 to March 31, 1998 were randomly selected for review. All 5 EDs in one urban region were sampled; physicians were unaware of the study when seeing patients. A standardized audit form was used to collect information pertaining to visits for the incident infection case. Cases were excluded if simple cellulitis was not the primary diagnosis or if procedures such as incision and drainage were initially required. A total of 416 adult charts were retrospectively identified. The mean age was 46 years and 61% were men; 38% had seen another physician before the ED presentation. Cellulitis was most commonly located in the upper (41%) and lower (48%) extremities. Most cases were treated with intravenous cefazolin (58%; range among sites: 49%-66%); however, over 25 different antibiotics and doses were initially prescribed. Each case required a median of 4 (interquartile range [IQR]: 1, 9) ED visits. Some patients (14%) received an increase in dose (3%) or a change in antibiotic regimen (11%) during their treatment. Few patients (3%) required a second change in regimen. Specialist consultations were obtained in only 6% of patients and hospitalization was rare (7%). The most common discharge prescription was oral cephalexin (62%); however; many different regimens were prescribed. Cellulitis is a common ED problem which consumes considerable resources to treat. Considerable practice variation exists with respect to in-ED and post-ED management. These results suggest the need for the development of practice guidelines for the treatment of this common ED problem. (Am J Emerg Med 2001;19:535-540. Copyright © by W.B. Saunders Company)

Section snippets

Study setting

The Capital Health Region is located in Edmonton and St. Albert, Alberta, Canada, and serves a population of 870,000 (1996 Census data). At the time of the study, the region had 5 acute care hospitals, all of which accepted emergency patients and were linked by the Capital Health Authority. All 5 sites are urban teaching hospitals staffed by full time emergency physicians who teach both emergency medicine and off-service residents. Two of the centers are tertiary care centers with predominantly

Sample

A total of 416 charts were identified and included in the study; all charts were recovered and reviewed. Of the charts reviewed, excellent agreement between the research assistant and the reviewers was obtained for demographic and event details. Other more important outcomes such as duration of infection (ICC = 0.82), precipitating symptoms (ICC = 0.67), location of infection (k = 1.0), first medication (k = 1.0), and admission (k = 0.74) indicate excellent agreement.

Health service use

A large portion (158

Discussion

This study is the largest study published to date that describes the epidemiology and practice patterns of this common infectious disease problem in a multicenter ED setting. Using accepted methodology, this study described an older population of patients from 5 urban Canadian EDs who had a discharge diagnosis of cellulitis. In this setting, the treatment practice variation is striking, with more than 25 different antibiotic regimens identified as initial treatment options. Although over half

Conclusion

Cellulitis is a common presenting problem in EDs in this region. This study described some of the risk factors and predisposing conditions of cellulitis in a large urban setting and compared its findings to past studies from the ED setting. Although most patients are successfully treated with systemic antibiotics, practice patterns vary widely, indicating that there may be a role for the development of clinical practice guidelines. In addition, the frequency of visits suggest that programs such

Acknowledgements

The authors thank the medical records department for their assistance with chart location. They thank Samantha Barker for data abstraction and also Diane Milette for her invaluable assistance in preparing this manuscript for publication.

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*

Supported by a salary award (to B.H.R.) from the Canada Research Council as the Chair of Emergency Airway Diseases, Ottawa, ON; the Division of Emergency Medicine, University of Alberta (S.D., B.H.P., B.R.H.) in Edmonton, Alberta, Canada. Dr Kelly has received funding from the Research Excellence Envelope in the Faculty of Medicine and Dentistry at the University of Alberta. Mr Oland was funded by the College of Physicians and Surgeons of Alberta.

**

Address reprint requests to Brian H Rowe, MD, MSc, Division of Emergency Medicine, University of Alberta, Walter Mackenzie Centre, Room 1G1.63, 8440-112 Street Edmonton, Alberta, Canada T6G 2B7. E-mail: [email protected]

0735-6757/01/1907-0001$35.00/0

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