When Will Oral Antibiotics for Cellulitis Fail?

February 14, 2019

Happy Valentines Day! Nothing says love like rosy red cellulitis…

Written by Clay Smith

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”Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year,” were the risk factors associated with failure of oral antibiotic therapy for non-purulent erysipelas or cellulitis. I propose we call it the DERM rule.

Why does this matter?
There is a push to reduce admission for cellulitis at our hospital. Many may be safely treated at home with oral antibiotics. But what variables increase the risk of oral antibiotic failure?

Antibiotic fail-o-meter: The DERM Rule
This was a retrospective study of patients with failure of oral antibiotics for non-purulent skin and soft tissue infection, i.e. erysipelas or cellulitis. Failure was defined as hospitalization, change in class of oral antibiotic, or switch to intravenous therapy. They found 500 patients, 288 of which had 48 hours of antibiotic therapy. Of the 288 patients, 85 had failure per the study definition. Using multivariable logistic regression, they found, “tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year were independently associated with oral antibiotic treatment failure.” Surprisingly, diabetes (25% of the 500 patient cohort) and chronic kidney disease were not independently associated with oral antibiotic failure. As we decide which patients go home and which need to stay for IV antibiotics, these risk factors can inform our decision making. I can already see them deriving the next clinical prediction rule. I’ve got a great name for it – DERM: Dx of cellulitis past year; Erosion/ulcer; Respiratory rate too fast; MRSA colonization/infection history.

Source
Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2019 Jan;26(1):51-59. doi: 10.1111/acem.13492. Epub 2018 Jul 4.

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Reviewed by Thomas Davis