Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines
Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy.
A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)).
Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy.
There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.
KeywordsAdmissions Antimicrobial stewardship Benzylpenicillin Cellulitis Flucloxacillin Guidelines
The authors would like to thank Mr. Grant Nolan for his great assistance with formatting and editing. Some statistical information was attained from the HIPE office at the Wexford General Hospital, Newtown Rd., Wexford. The authors would also like to thank Ms. Maisy Doyle, Surgical Administration, Wexford General Hospital, Newtown Rd., Wexford, for providing surgical audit information across five years.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 2.Quirke M, Saunders J, O’Sullivan R, Wakai A (2016) The management of cellulitis in emergency departments: antibiotic-prescribing practices and adherence to practice guidelines in Ireland. Eur J Emerg Med 23(3):173–178Google Scholar
- 4.Kilburn SA et al (2010) Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev (6):CD004299Google Scholar
- 6.CREST (2005) Guidelines on the management of cellulitis in adults. Clinical Resource Efficiency Support Team.. www.gain-ni.org [Free Full-text]. Accessed 21/06/2019
- 7.(NICE) (2019) N.I.f.H.a.C.E., Cellulitis and Erysipelas: antimicrobial prescribing, M.o.M.C.I.S.A. Committee, edGoogle Scholar
- 8.Turnidge, J. Isoxazolyl Penicillins: Oxacillin, Cloxacillin, Dicloxacillin and Flucloxacillin. in: Kucers' The use of antibiotics. Vol. 1. 6th ed. Hodder Arnold, London; 2010:100–114Google Scholar
- 10.Enquiry (2017) H.I.-p. In: HIPE dataGoogle Scholar
- 11.Formulary BN (2019) Benzylpenicillin Sodium; Available from: https://bnf.nice.org.uk/medicinal-forms/benzylpenicillin-sodium.html. Accessed 23 July 2019
- 13.Intranet (2019) Beaumount Hospital Antimicrobial Guidelines, MMUH, The Mater Misericordiae University Hospital Antimicrobial Guidelines. 2019Google Scholar
- 14.Intranet (2019) St James’s university hospital prescribers capsule, SJH. St James's University Hospital Prescriber's Capsule: Skin and soft tissue infections (cellulitis). 2019Google Scholar
- 15.Weng QY, et al (2016) Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA DermatolGoogle Scholar
- 17.Murchan, M., Burns, Point Prevalence Survey of Hopsital-Acquired Infections & Antimicrobial Use in European Acute Care Hospitals: May 2017Google Scholar