Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis.

BACKGROUND: Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses. METHODS: Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome. RESULTS: Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I2 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema). DISCUSSION: The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics. TRIAL REGISTRATION: Open Science Framework ( https://osf.io/9zt72 ).

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis.

BACKGROUND: CT performed within 6 hours of headache onset is highly sensitive for the detection of subarachnoid haemorrhage (SAH). Beyond this time frame, if the CT is negative for blood, a lumbar puncture is often performed. Technology improvements in image noise reduction, resolution and motion artefact have enhanced the performance of multislice CT (MSCT) and may have further improved sensitivity. We aimed to describe how the sensitivity to SAH of modern MSCT changes with time from headache onset. METHODS: This was a retrospective analysis of electronic data collected as part of routine care among all patients presenting to Christchurch Hospital diagnosed with a SAH between 1 January 2008 and 31 December 2017. Patients were imaged with MSCT. The primary outcome was the proportion of patients with spontaneous aneurysmal SAH (identified via coding and confirmed by clinical and radiological records) that had a positive MSCT. The secondary outcome was the proportion of patients with any type of spontaneous SAH that had a positive MSCT. RESULTS: There were 347 patients with an SAH of whom 260 were aneurysmal SAH. MSCT identified 253 (97.3%) of all aneurysmal SAH and 332 (95.7%) of all SAH. The sensitivity of MSCT was 99.6% (95% CI 97.6 to 100) for aneurysmal SAH and 99.0% (95% CI 97.1 to 99.8) for all SAH at 48 hours after headache onset. At 24 hours after headache onset, the sensitivity for aneurysmal SAH was 100% (95% CI 98.3 to 100). CONCLUSION: These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH.

Anti-inflammatories as adjunct treatment for cellulitis: a systematic review and meta-analysis.

OBJECTIVES: Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) as adjunct cellulitis treatment improves clinical response and cure. METHODS: Systematic review and meta-analysis including randomized controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) vs. placebo or no intervention. Medline (PubMed), Embase (via Elsevier), and Cochrane CENTRAL were searched from inception to August 1, 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure. RESULTS: Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95%CI 1.42-2.31, I2 = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95%CI 0.62-2.26), although heterogeneity was high (I2 = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (N = 3 trials) were infrequent. CONCLUSIONS: For patients with cellulitis, the best available data suggest that oral nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies. REGISTRATION: Open Science Framework:   https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81 .

RéSUMé: OBJECTIFS: Les recommandations existantes suggèrent d'envisager des corticostéroïdes pour le traitement complémentaire de la cellulite, mais cela est basé sur un seul essai avec une faible certitude des preuves. L'objectif était de déterminer si les anti-inflammatoires (anti-inflammatoires non stéroïdiens [AINS], corticostéroïdes) comme traitement d'appoint de la cellulite améliorent la réponse clinique et la guérison. MéTHODES: Revue systématique et méta-analyse comprenant des essais contrôlés randomisés de patients atteints de cellulite traités avec des antibiotiques, indépendamment de l'âge, du sexe, de la gravité et du contexte, et une intervention d'anti-inflammatoires (AINS ou corticostéroïdes) contre placebo ou sans intervention. Medline (PubMed), Embase (via Elsevier) et Cochrane CENTRAL ont été recherchés de la création au 1er août 2023. L'extraction des données a été effectuée indépendamment par paires. Le risque de biais a été évalué à l'aide de l'outil Cochrane sur le risque de biais 2. Les données ont été regroupées à l'aide d'un modèle à effets aléatoires. Les principaux résultats sont le temps de réponse clinique et de guérison. RéSULTATS: Cinq études (n = 331) ont été incluses, toutes des études adultes. Trois essais ont indiqué le délai de réponse clinique. Il y avait un avantage avec l'utilisation d'un AINS par voie orale comme traitement d'appoint au jour 3 (risque ratio 1,81, 95%CI 1,42 à 2,31, I2 = 0%). Il n'y avait pas de différence entre les groupes au jour 5 (rapport de risque 1,19, IC à 95% 0,62 à 2,26), bien que l'hétérogénéité était élevée (I2 = 96 %). La guérison clinique a été rapportée par trois essais, et il n'y avait aucune différence entre les groupes à tous les points de temps jusqu'à 22 jours. L'hétérogénéité statistique était modérée à faible. Les événements indésirables (N = 3 essais) étaient peu fréquents. CONCLUSIONS: Pour les patients atteints de cellulite, les meilleures données disponibles suggèrent que les anti-inflammatoires non stéroïdiens oraux (AINS) comme traitement d'appoint aux antibiotiques peuvent entraîner une amélioration de la réponse clinique précoce, bien que cela ne soit pas soutenu au-delà de quatre jours. Les données sont insuffisantes pour commenter le rôle des corticostéroïdes dans la réponse clinique. Ces résultats doivent être interprétés avec prudence en raison du petit nombre d'études incluses. ENREGISTREMENT: Cadre de la science ouverte:   https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81 .

Antimicrobial Prescribing in the Emergency Department; Who Is Calling the Shots?

Objective: Inappropriate antimicrobial prescribing in the emergency department (ED) can lead to poor outcomes. It is unknown how often the prescribing clinician is guided by others, and whether prescriber factors affect appropriateness of prescribing. This study aims to describe decision making, confidence in, and appropriateness of antimicrobial prescribing in the ED. Methods: Descriptive study in two Australian EDs using both questionnaire and medical record review. Participants were clinicians who prescribed antimicrobials to patients in the ED. Outcomes of interest were level of decision-making (self or directed), confidence in indication for prescribing and appropriateness (5-point Likert scale, 5 most confident). Appropriateness assessment of the prescribing event was by blinded review using the National Antibiotic Prescribing Survey appropriateness assessment tool. All analyses were descriptive. Results: Data on 88 prescribers were included, with 61% making prescribing decisions themselves. The 39% directed by other clinicians were primarily guided by more senior ED and surgical subspecialty clinicians. Confidence that antibiotics were indicated (Likert score: 4.20, 4.35 and 4.35) and appropriate (Likert score: 4.07, 4.23 and 4.29) was similar for juniors, mid-level and senior prescribers, respectively. Eighty-five percent of prescriptions were assessed as appropriate, with no differences in appropriateness by seniority, decision-making or confidence. Conclusions: Over one-third of prescribing was guided by senior ED clinicians or based on specialty advice, primarily surgical specialties. Prescriber confidence was high regardless of seniority or decision-maker. Overall appropriateness of prescribing was good, but with room for improvement. Future qualitative research may provide further insight into the intricacies of prescribing decision-making.

Picking the low-hanging fruit: Why not choose oral antibiotics for skin and soft-tissue infections in the emergency department.

Skin and soft-tissue infections are a common presentation to EDs in Australasia. In the absence of sepsis or decreased oral absorption, substantial supportive data exists that shows oral antibiotics are non-inferior to intravenous antibiotics for uncomplicated skin and soft-tissue infections. However, despite a fair evidence base, clinicians are not consistently putting this into practice. This perspective reviews the relevant literature, discusses barriers to the implementation of this more parsimonious approach and also proposes several potential solutions. It is important that ED clinicians are encouraged to use oral antibiotics for uncomplicated infections, as this would lead to similar clinical outcomes but with fewer resources for staff and patient, as well as increased patient satisfaction.

Exhaled breath temperature measurement and asthma control in children prescribed inhaled corticosteroids: A cross sectional study.

BACKGROUND: Exhaled breath temperature (EBT) reflects airways (both eosinophilic and neutrophilic) inflammation in asthma and thus may aid the management of children with asthma that are treated with anti-inflammatory drugs. A new EBT monitor has become available that is cheap and easy to use and may be a suitable monitoring device for airways inflammation. Little is known about how EBT relates to asthma treatment decisions, disease control, lung function, or other non-invasive measures of airways inflammation, such as exhaled nitric oxide (ENO). OBJECTIVE: To determine the relationships between EBT and asthma treatment decision, current control, pulmonary function, and ENO. METHODS: Cross-sectional prospective study on 159 children aged 5-16 years attending a pediatric respiratory clinic. EBT was compared with the clinician's decision regarding treatment (decrease, no change, increase), asthma control assessment (controlled, partial, uncontrolled), level of current treatment (according to British Thoracic Society guideline, BTS step), ENO, and spirometry. RESULTS: EBT measurement was feasible in the majority of children (25 of 159 could not perform the test) and correlated weakly with age (R = 0.33, P = <0.01). EBT did not differ significantly between the three clinician decision groups (P = 0.42), the three asthma control assessment groups (P = 0.9), or the current asthma treatment BTS step (P = 0.57). CONCLUSIONS & CLINICAL IMPLICATIONS: EBT measurement was not related to measures of asthma control determined at the clinic. The routine intermittent monitoring of EBT in children prescribed inhaled corticosteroids who attend asthma clinics cannot be recommended for adjusting anti-inflammatory asthma therapy.