Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the first of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.
The first step is a retrospective chart review in regards to the duration of treatment for cellulitis. Current IDSA guidelines recommend that the “Duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period.” The primary outcome would be clinician adherence to IDSA guidelines. Previous studies suggest that only about 25% of cellulitis will require treatment beyond 5 days, and only 6% require treatment beyond 7 days. Secondary analysis could include: difference in total days of treatment based on provider (PA, NP, MD), age of the patient, size of area involved, location involved, plus others that may yet to be determined. Exclusion criteria would be if the patient met SIRS criteria, antibiotic use within the last 30 days, admission to the hospital, age <18 years old or >75 years old, use of oral corticosteroids within the last month, insulin controlled diabetes, HIV/AIDS, plus others that may yet to be determined. Subgroup analysis could include bounceback rate within 30 days and if related to short duration of therapy or to bacterial infection resistant to first prescribed antibiotics.
Now, here is where it gets interesting. The second step would be a prospective randomized control trial evaluating a single dose of oral dexamethasone in addition to standard of care antibiotic therapy for cellulitis to placebo plus standard of care antibiotics. In a small study, oral steroids as an adjunct to antibiotic therapy for orbital cellulitis had a statistically significant improvement in ptosis, proptosis, less restriction of movement, and decrease in duration of intravenous antibiotics as well as decreased length of stay. The IDSA gives a weak recommendation to consider steroids in cellulitis, citing this same study. In another study, NSAIDs (400mg ibuprofen every 6 hours for 5 days) hastened resolution of cellulitis such that no patient required treatment beyond 5 days vs 25% in the control arm requiring additional antibiotic therapy. Likewise, 83% of NSAID treated patients showed improvement in 1-2 days vs only 9% treated without NSAIDs. Primary outcome would be resolution at 5 days. Secondary outcomes being improvement within 24-48 hours, pain scale at 24-48 hours or recurrence.
The underlying reason to do this study is to, eventually & hopefully, make all patients with cellulitis that do not meet SIRS criteria observation status (or discharge / outpatient therapy) after an initial steroid dose – provided that the results seen in orbital cellulitis are reproducible to all formats of cellulitis. Cellulitis, in and of itself, has low morbidity and mortality, hence, if we could find a way to hasten patient improvement without significant adverse effects, there is significant cost savings to both the patient and to the healthcare facility.
So, #FOAM-ites, whats on your Wish List? Drop it in the comments on the left or @EMinFocus on Twitter. Happy Holidays!