The critical role of phlebolymphedema in cellulitis associated with lymphedema: Its incidence and economic impact in a large real-world population.

OBJECTIVE: The aims of this study were: to define the incidence of cellulitis in patients with lymphedema (LED) overall and relate this to the etiology of LED; to determine how this rate might be affected by recurrence of cellulitis; and to quantify the contemporary economic burden of treatment. Understanding these factors is essential in developing targeted cellulitis prevention strategies and reducing health care costs. METHODS: The IBM MarketScan Research Database was examined from April 2013 to March 2019 for patients with a new diagnosis of LED (n = 85,601). Based on International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, the incidence and cost of cellulitis were ascertained during the 3-year follow-up period. Incidence rates (per 100 patient-years [PYs]) and cost (per patient per year) of cellulitis were evaluated among all patients with LED and within subgroups of LED etiologies. RESULTS: Among the three most common morbidities associated with LED (breast cancer-related lymphedema [BCRL], n = 17,954 [20.97%]; gynecological cancer-related LED [GCRL], n = 1256 [1.47%]; and phlebolymphedema [PLED], n = 8406 [9.82%]), rates of cellulitis were markedly lower for BCRL (8.9; 95% confidence interval [CI], 8.7-9.2) and GCRL (14.8; 95% CI, 13.4-16.4) vs PLED (47.7; 95% CI, 46.7-48.8). Patients with a history of cellulitis had markedly higher cellulitis rates during follow-up than those without-overall, 74.0% vs 16.4%; BCRL, 42.9%; 95% CI, 39.7%-46.3% vs 7.6%; 95% CI, 7.3%-7.9%; GCRL, 67.5%; 95% CI, 56.4%-80.8% vs 11.0%; 95% CI, 9.8%-12.4%; and PLED, 81.7%; 95% CI, 79.4%-84.1% vs 30.4%; 95% CI, 29.4%-31.4%, respectively. The mean $/patient/year of cellulitis-related costs for a patient with PLED ($2836; 95% CI, $2395-$3471) was significantly greater than that for BCRL ($503; 95% CI, $212-$1387) and GCRL ($609; 95% CI, $244-$1314). CONCLUSIONS: The incidence of cellulitis associated with LED varies by the etiology of LED. PLED has the highest rates of both an initial cellulitis episode and recurrent cellulitis events. Additionally, PLED has one of the largest cellulitis-related total costs per patient per year. Prevention, as well as early identification and treatment of PLED-associated cellulitis, could significantly decrease health care costs and improve patient quality of life.

Effects of a focused training on first-year osteopathic medical students' ability to incorporate point-of-care ultrasound in assessment of the anterior knee.

CONTEXT: Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery. OBJECTIVES: The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis. METHODS: First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires. RESULTS: Of 101 students completing the written pretest and pretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest and posttest for identification of all three pathologies (all p<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis and cellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee. CONCLUSIONS: Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.

Smaller hospital discharge volume and urban area are associated with higher proportional cellulitis discharges.

Cellulitis is commonly misdiagnosed, resulting in increased healthcare costs and complications. There is little published work regarding the relationship between hospital characteristics and cellulitis discharge rates. Here, we performed a cross-sectional analysis of cellulitis inpatient discharges using publicly available national data to examine hospital characteristics associated with higher proportional cellulitis discharge rates. The results of our study showed a strong association of increased proportion of cellulitis discharges in association with hospitals that discharged fewer total patients and a direct association with urban location. The factors that influence hospital cellulitis discharge diagnoses are numerous, and while its overdiagnosis remains a source of medical overspending and complications, our study may provide direction for more focused efforts to increase dermatology care in lower volume hospitals and urban areas.

Cost of lameness in dairy herds: An integrated bioeconomic modeling approach.

Foot disorders are costly health disorders in dairy farms, and their prevalence is related to several factors such as breed, nutrition, and farmer's management strategy. Very few modeling approaches have considered the dynamics of foot disorders and their interaction with farm management strategies within a holistic farm simulation model. The aim of this study was to estimate the cost of foot disorders in dairy herds by simulating strategies for managing lameness. A dynamic and stochastic simulation model (DairyHealthSim) was used to simulate the herd dynamics, reproduction management, and health events. A specific module was built for lameness and related herd-level management strategies. Foot disorder occurrences were simulated with a base risk for each etiology [digital dermatitis (DD), interdigital dermatitis, interdigital phlegmon, sole ulcer (SU), white line disease (WLD)]. Two state machines were implemented in the model: the first was related to the disease-induced lameness score (from 1 to 5), and the second concerned DD-state transitions. A total of 880 simulations were run to represent the combination of the following 5 scenarios: (1) housing (concrete vs. textured), (2) hygiene (2 different scraping frequencies), (3) the existence of preventive trimming, (4) different thresholds of DD prevalence detected and from which a collective footbath is applied to treat DD, and (5) farmer's ability to detect lameness (detection rate). Housing, hygiene, and trimming scenarios were associated with risk factors applied for each foot disorder etiologies. The footbath and lameness detection scenarios both determined the treatment setup and the policy of herd observance. The economic evaluation outcome was the gross margin per year. A linear regression model was run to estimate the cost per lame cow (lameness score ≥3), per case of DD and per week of a cow's medium lameness duration. The bioeconomic model reproduced a lameness prevalence varying from 26 to 98% depending on the management scenario, demonstrating a high capacity of the model to represent the diversity of the field situations. Digital dermatitis represented half of the total lameness cases, followed by interdigital dermatitis (28%), SU (19%), WLD (13%), and interdigital phlegmon (4%). The housing scenarios dramatically influenced the prevalence of SU and WLD, whereas scraping frequency and threshold for footbath application mainly determined the presence of DD. Interestingly, the results showed that preventive trimming allowed a better reduction in lameness prevalence than spending time on early detection. Scraping frequency was highly associated with DD occurrence, especially with a textured floor. The regression showed that costs were homogeneous (i.e., did not change with lameness prevalence; marginal cost equals average cost). A lame cow and a DD-affected cow cost €307.50 ± 8.40 (SD) and €391.80 ± 10.0 per year on average, respectively. The results also showed a cost of €12.10 ± 0.36 per week-cow lameness. The present estimation is the first to account for interactions between etiologies and for the complex DD dynamics with all the M-stage transitions, bringing a high level of accuracy to the results.

Evaluating the cost of managing patients with cellulitis in Wales, UK: A 20-year population-scale study.

This study aimed to estimate costs associated with managing patients with cellulitis from the UK National Health Service (NHS) perspective. The analysis was undertaken through the Secure Anonymised Information Linkage Databank, which brings together population-scale, individual-level anonymised linked data from a wide range of sources, including 80% of primary care general practices within Wales (population coverage ~3.2 million). The data covered a 20-year period from 1999 to 2019. All patients linked to the relevant codes were tracked through primary care settings, recording the number of general practice visits (number of days with an event recorded) and number of in-patient stays. Resources were valued in monetary terms (£ sterling), with costs determined from national published sources of unit costs. These resources were then extrapolated out to reflect UK NHS costs. This is the first attempt to estimate the financial burden of cellulitis using routine data sources on a national scale. The estimated direct annual costs to the Welsh NHS (£28 554 338) are considerable. In-Patient events and length of stay costs are the main cost drivers, with annual Welsh NHS estimates of £19 664 126 with primary care events costing £8 890 212. Initiatives to support patients and healthcare professionals in identifying early signs/risks of cellulitis, improve the accuracy of initial diagnosis, prevent cellulitis recurrence, and improve evidence-based treatment pathways would result in major financial savings, to both the Welsh and UK NHS. In light of these findings, Wales has developed the innovative National Lymphoedema cellulitis Improvement Programme to address these burdens; providing a proactive model of cellulitis care.

Comparison of Inpatient Standard-of-Care to Outpatient Oritavancin Therapy for Patients With Acute Uncomplicated Cellulitis.

BACKGROUND: Shifting inpatient antibiotic treatment to outpatient parenteral antimicrobial therapy may minimize treatment for acute bacterial skin and skin structure infections, including cellulitis. The purpose of this evaluation was to compare 30-day hospital readmission or admission due to cellulitis and economic outcomes of inpatient standard-of-care (SoC) management of acute uncomplicated cellulitis to outpatient oritavancin therapy. METHODS: This retrospective, observational cohort study was conducted at a 941-bed community teaching hospital. Adult patients 18 years and older treated for acute uncomplicated cellulitis between February 2015 to December 2018 were eligible for inclusion. Information was obtained from hospital and billing department records. Patients were assigned to either inpatient SoC or outpatient oritavancin cohorts for comparison. RESULTS: 1,549 patients were included in the study (1,348 in the inpatient SoC cohort and 201 in the outpatient oritavancin cohort). The average length of stay for patients admitted was 3.6 ± 1.5 days. The primary outcome of 30-day hospital readmission or admission due to cellulitis occurred in 49/1348 (3.6%) patients in the inpatient SoC cohort versus 1/201 (0.5%) in the outpatient oritavancin cohort (p = 0.02). The difference between costs and reimbursement was improved in the outpatient oritavancin group (p < 0.001). CONCLUSION: Outpatient oritavancin for acute uncomplicated cellulitis was associated with reduction in 30-day hospital readmissions or admissions compared to inpatient SoC. Beneficial economic outcomes for the outpatient oritavancin cohort were observed. Additional studies are required to confirm these findings.

Impact of the Covid-19 pandemic context on the microbiological epidemiology and management of flexor sheath phlegmons.

INTRODUCTION: The COVID-19 pandemic in France has recently modified the patients' lifestyles, as well as methods of medical and surgical management. This could explain subsequent changes to the microbiological spectrum, the severity, as well as the scalability of phlegmons of the flexor tendon sheath. The objective of this study was to construct an epidemiological and bacteriological inventory of these hand infections, and to compare the clinical and microbiological data, before and after the COVID-19 pandemic. HYPOTHESIS: The hypothesis of this work was that the phlegmons of the flexor tendon sheath presented specific microbiological characteristics in the tropical environment of our University Hospital Center, and that these characteristics could have changed with the recent introduction of hydro-alcoholic solution (HAS) associated to the COVID-19 pandemic. MATERIAL AND METHODS: The preoperative epidemiological data of our patients were collected between January 2016 and December 2020. The stage of severity, according to the classification of Michon, the use of hydro-alcoholic solution, as well as the early clinical evolution were collected. The cohort was then divided into two groups in order to compare the microbiological profiles, the management and the clinical evolution of patients in the pre-COVID period with those in the post-COVID period. RESULTS: A total of 199 patients were included, 154 patients in the pre-COVID period and 26 in the post-COVID period. We found a majority of MSSA (58.3%, N=105) and negative samples comprised 18.9% (N=34). No statistically significant difference was found between the two groups regarding the bacteriological results. The clinical course was judged to be favorable in 93.5% of cases in the pre-COVID group compared to 80.8% in the post-COVID group (p=0.046). The use of HAS (p<0.0001), as well as the initial stage of severity according to Michon, were significantly higher in group 2 (p=0.04). DISCUSSION: The COVID-19 pandemic has not shown any change in the microbiological spectrum, despite the now daily use of HAS in everyday life. The postoperative clinical evolution was significantly less favorable after the onset of COVID and could be explained by an increase in cases with a more advanced initial stage of severity. LEVEL OF EVIDENCE: IV, Observational epidemiological study.

Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema.

Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.

Outpatient parenteral antibiotic therapy (OPAT) and inpatient treatment strategies for emergency department patients with cellulitis: a cost analysis.

OBJECTIVES: Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be treated via outpatient parenteral antibiotic therapy (OPAT) as opposed to hospitalization. The primary objective was to compare healthcare costs for the following strategies: community intravenous antibiotics with referral to an OPAT clinic operated by infectious disease specialists ('OPAT clinic' strategy); community intravenous antibiotics with return to ED if necessary ('return to ED' strategy); and hospital admission. METHODS: Using a hospital administrative database, we conducted a cost analysis using patient-level data of adult cellulitis patients presenting to two tertiary care EDs and were treated with intravenous antibiotics in one of three ways: OPAT clinic strategy; return to ED strategy; and hospital admission. Costs were estimated from Canada's publicly funded health system perspective. The primary outcome was the mean total cost (2015 CAD) per patient for each treatment strategy. A generalized linear model was performed to adjust for baseline characteristics, including age, sex and comorbidities. RESULTS: A total of 808 patients met inclusion criteria: OPAT clinic strategy (N = 341); return to ED strategy (N = 228) and hospital admission (N = 239). The mean total cost of care for the treatment strategies were: OPAT clinic: $2170 (95% CI $1905-$2436); return to ED: $1493 (95 %CI $1264-$1722); and hospital admission: $10,145 (95% CI $8668-$11,622). Results from the regression analysis suggested that the OPAT clinic strategy was associated with a cost-saving of $7394 (95% CI $6154-$8633, p < 0.001) compared to hospital admission and an increased cost of $651 (95% CI $367-$935, p < 0.001) when compared to the return to ED approach. CONCLUSIONS: This is the first Canadian study that compares the cost of different OPAT strategies for cellulitis patients. While both OPAT strategies are safe and far less costly than hospital admission, our findings suggest that a dedicated OPAT clinic for patients with cellulitis is more expensive than the return to ED strategy.

RéSUMé: OBJECTIFS: Les patients des services d'urgence atteints de cellulite nécessitant des antibiotiques intraveineux peuvent être traités par une antibiothérapie parentérale ambulatoire (OPAT) plutôt que par une hospitalisation. L'objectif principal était de comparer les coûts des soins de santé pour les stratégies suivantes : antibiotiques intraveineux communautaires avec orientation vers une clinique OPAT gérée par des spécialistes des maladies infectieuses (stratégie "clinique OPAT") ; antibiotiques intraveineux communautaires avec retour aux urgences si nécessaire (stratégie de "retour aux urgences") ; et admission à l'hôpital. MéTHODES: À l'aide d'une base de données administratives hospitalières, nous avons effectué une analyse des coûts en utilisant les données relatives aux patients adultes atteints de cellulite se présentant à deux urgences de soins tertiaires et traités par antibiotiques intraveineux de l'une des trois manières suivantes : Stratégie de la clinique OPAT ; stratégie de retour aux urgences; et admission à l'hôpital. Les coûts ont été estimés du point de vue du système de santé public du Canada. Le principal résultat était le coût total moyen (2015 CAD) par patient pour chaque stratégie de traitement. Un modèle linéaire généralisé a été réalisé pour ajuster les caractéristiques de base, y compris l'âge, le sexe et les comorbidités. RéSULTATS : Au total, 808 patients répondaient aux critères d'inclusion : stratégie clinique OPAT (N = 341) ; stratégie de retour aux urgences (N = 228) et admission à l'hôpital (N = 239). Le coût total moyen des soins pour les stratégies de traitement était le suivant : Clinique OPAT: 2 170 $ (IC 95 %: 1 905 $­2 436 $) ; retour aux urgences : 1 493 $ (IC à 95 %: 1 264 $­1 722 $) ; et hospitalisation : 10 145 $ (IC à 95 %: 8 668 $­11 622 $). Les résultats de l'analyse de régression suggèrent que la stratégie de la clinique OPAT est associée à une économie de 7 394 $ (IC à 95 %: 6 154 $­8 633 $, p < 0,001) par rapport à l'admission à l'hôpital et à une augmentation des coûts de 651 $ (IC à 95 %: 367 $­935 $, p < 0,001) par rapport à l'approche du retour aux urgences. CONCLUSIONS : Il s'agit de la première étude canadienne qui compare le coût de différentes stratégies d'OPAT pour les patients atteints de cellulite. Si les deux stratégies OPAT sont sûres et bien moins coûteuses que l'admission à l'hôpital, nos résultats suggèrent qu'une clinique OPAT dédiée aux patients atteints de cellulite est plus coûteuse que la stratégie de retour aux urgences.

Disease and economic burden of infections in hospitalised children in New South Wales, Australia.

Objectives To describe the burden of disease and hospitalisation costs in children with common infections using statewide administrative data. Methods We analysed hospitalisation prevalence and costs for 10 infections: appendicitis, cellulitis, cervical lymphadenitis, meningitis, osteomyelitis, pneumonia, pyelonephritis, sepsis, septic arthritis, and urinary tract infections in children aged <18 years admitted to hospital within New South Wales, Australia, using an activity-based management administrative dataset over three financial years (1 July 2016-30 June 2019). Results Among 339 077 admissions, 28 748 (8.48%) were coded with one of the 10 infections, associated with a total hospitalisation cost of AUD230 905 190 and a per episode median length-of-stay of 3 bed-days. Pneumonia was the most prevalent coded infection (3.1% [n = 10 524] of all admissions), followed by appendicitis (1.61%; n = 5460), cellulitis (1.22%; n = 4126) and urinary tract infections (0.94%; n = 3193). Eighty per cent of children (n = 22 529) were admitted to a non-paediatric hospital. Mean costs were increased 1.18-fold per additional bed-day, 2.14-fold with paediatric hospital admissions, and 5.49-fold with intensive care unit admissions, which were both also associated with greater total bed-day occupancy. Indigenous children comprised 9.7% of children admitted with these infections, and mean per episode costs, and median bed-days were reduced compared with non-Indigenous children (0.84 [95% CI 0.78, 0.89] and 3 (IQR: 2,5) vs 2 (IQR: 2,4), respectively. Conclusions Infections in children requiring hospitalisation contributea substantial burden of disease and cost to the community. This varies by infection, facility type, and patient demographics, and this information should be used to inform and prioritise programs to improve care for children.

Orbital cellulitis secondary to sinusitis in upstate New York: current incidence, seasonality, severity, management and outcomes.

PURPOSE: While sinusitis carries a seasonal variation, the temporal features of sinusitis-related orbital cellulitis (SRC) are unclear. This study analyzes the incidence, seasonality, management, and outcomes of SRC in northeastern New York. METHODS: A retrospective review of 79 patients was performed from January 2008 - December 2018. Cases of orbital cellulitis without comitant sinusitis were excluded. Demographic, radiographic, clinical features, month at presentation, interventions (surgical and nonsurgical), microbiology, and hospitalization duration were recorded. Fisher-exact test, Mann-Whitney test, and Kruskal Wallis test statistical analyses were performed in consultation with our institution's statistician via a dedicated software package (vassarstats.net). RESULTS: 79 patients were admitted for SRC. 25 patients were treated with antibiotics only, 31 underwent orbitotomy exclusively and 23 received combined orbitotomy and functional endoscopic sinus surgery (FESS). Of the 31 patients who underwent orbitotomy only, 8 (26%) returned to the operating room. In contrast, of those who underwent concomitant orbitotomy and FESS, only one patient (4.3%) required re-operation (fisher exact test, p = .021). The median length of stay for the antibiotic-only group (4 days), orbitotomy-only group (6 days), and combined surgery group (5 days) were statistically different (Kruskal Wallis, p = .004, Figure 3). Interestingly, there was no significant relationship of incidence or severity of SRC related to seasonality (fisher-exact test, p = .76). CONCLUSION: Our findings suggest that cases requiring surgical management for SRC should undergo coinitial orbitotomy with FESS to reduce re-operation rates. Additionally, SRC incidence and severity did not correlate with season.

Bacterial dacryoadenitis: clinical features, microbiology, and management of 45 cases, with a recent uptick in incidence.

PURPOSE: To review the clinical features, microbiology, management, and incidence of bacterial dacryoadenitis at our institution. METHODS: This was a case series examining patients with bacterial dacryoadenitis from 2004 to 2020. Charts were reviewed for demographics, comorbidities, presenting symptoms and signs, radiology, microbiology, and management. Main outcomes included need for surgical intervention or inpatient admission. RESULTS: Forty-five patients with bacterial dacryoadenitis had a mean age of 46.1 years. Presenting symptoms included eyelid edema (100%), extraocular motility restriction (53.3%), and purulent discharge (75.5%). Based on computed tomography or magnetic resonance imaging, 9 (20.5%) patients presented with definite abscess and 15 (34%) presented with a phlegmon or early abscess. Eleven patients (24.4%) required surgical drainage. Twenty patients (44.4%) required admission, for an average stay of 4 days (range 2-8 days). Common organisms included Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Presence of an early abscess or phlegmon correlated with need for drainage (p < 0.01). Extraocular motility restriction correlated with need for drainage (p = 0.02) and admission (p = 0.05). The incidence of bacterial dacryoadenitis at our institution increased as a percentage of confirmed dacryoadenitis cases; from 2004 to 2010 the incidence was 0 to 9.1% per year, while from 2010 to 2019 the incidence ranged from 7.7 to 36.2%. In 2019, our institution had 17 cases (incidence 36.2%) of bacterial dacryoadenitis. CONCLUSIONS: Bacterial dacryoadenitis is a major cause of dacryoadenitis, and its incidence may be increasing. It can resolve with minimal complications if managed appropriately, although some patients may require surgical drainage or admission for intravenous antibiotics.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management.

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.

Improved economic and clinical outcomes with oritavancin versus a comparator group for treatment of acute bacterial skin and skin structure infections in a community hospital.

BACKGROUND: Oritavancin is a lipoglycopeptide antibiotic with in vitro bactericidal activity against gram-positive pathogens indicated for use in adults with acute bacterial skin and skin structure infections (ABSSSI). Its concentration-dependent activity and prolonged half-life provide a convenient single-dose alternative to multi-dose daily therapies for ABSSSI. This retrospective cohort study was conducted to quantify the clinical and economic advantages of using oritavancin compared to other antibiotic agents that have been historically effective for ABSSSI. METHODS: Seventy-nine patients received oritavancin who had failed previous outpatient antibiotic therapy (OPAT) for cellulitis or abscess and were subsequently readmitted to the hospital as an inpatient between 2016 and 2018. These patients were compared to a cohort of 28 patients receiving other antibiotics following OPAT failure and subsequent hospitalization for these two infection types. The primary clinical end point was average length of stay (aLOS) and secondary endpoints included readmission rates for the same indication at 30 and 90 days after discharge and the average hospital cost (aHC). RESULTS: A total of 107 patients were hospitalized for treatment of cellulitis or abscess. Demographic characteristics of both the oritavancin and comparator groups were similar except for the presence of diabetes. The primary clinical endpoint showed a non-significant decrease in aLOS between the oritavancin group versus comparator (2.12 days versus 2.59 days; p = 0.097). The secondary endpoints revealed lower readmission rates associated with oritavancin treatment at 30 and 90 days; the average hospital cost was 5.9% lower for patients that received oritavancin. CONCLUSION: The results of this study demonstrate that oritavancin provides not only a single-dose alternative to multi-day therapies for skin and skin structure infections, but also a clinical and economic advantage compared to other antibiotic agents.

Burden, risk factors, and infectious complications of cellulitis and erysipelas in US adults and children in the emergency department setting.

BACKGROUND: Little is known about the use and burden of emergency department (ED) visits for cellulitis/erysipelas in the United States. OBJECTIVE: To determine the prevalence, risk factors, complications, and cost of emergency care for cellulitis/erysipelas in the United States. METHODS: Cross-sectional study of the 2006 to 2016 National Emergency Department Sample, including a 20% sample of US ED visits (N = 320,080,467). RESULTS: The mean annual incidence of ED visits with a primary diagnosis of cellulitis/erysipelas was 2.42 to 3.55 per million adult and 1.14 to 2.09 per million pediatric ED visits. ED visits for cellulitis/erysipelas decreased significantly from 2006 to 2015 (Rao-Scott chi-square, P < .0001). ED visits with versus without a primary diagnosis of cellulitis/erysipelas were associated with public or no insurance and lower household income quartiles, and were more likely to occur during weekends and summer months. The mean cost of ED visits for cellulitis/erysipelas more than doubled in adults (from $720 to $1680) and tripled in children (from $939 to $2,823) from 2006 to 2016. ED visits for cellulitis/erysipelas were associated with multiple risk factors and increased infectious complications. LIMITATIONS: No data on cellulitis and erysipelas treatment or recurrence. CONCLUSION: There is a substantial and increasing burden of ED visits for cellulitis/erysipelas in the United States. Many ED visits occurred for uncomplicated cellulitis/erysipelas, in part because of health care disparities.

The economic and health burdens of diseases caused by group A Streptococcus in New Zealand.

OBJECTIVES: In preparation for the future arrival of a group A Streptococcus (GAS) vaccine, this study estimated the economic and health burdens of GAS diseases in New Zealand (NZ). METHODS: The annual incidence of GAS diseases was based on extrapolation of the average number of primary healthcare episodes managed each year in general practices (2014-2016) and on the average number of hospitalizations occurring each year (2005-2014). Disease incidence was multiplied by the average cost of diagnosing and managing an episode of disease at each level of care to estimate the annual economic burden. RESULTS: GAS affected 1.5% of the population each year, resulting in an economic burden of 29.2 million NZ dollars (2015 prices) and inflicting a health burden of 2373 disability-adjusted life years (DALYs). Children <5 years of age were the most likely age group to present for GAS-related healthcare. Presentations for superficial throat and skin infections (predominantly pharyngitis and impetigo) were more common than other GAS diseases. Cellulitis contributed the most to the total economic and health burdens. Invasive and immune-mediated diseases disproportionately contributed to the total economic and health burdens relative to their frequency of occurrence. CONCLUSION: Preventing GAS diseases would have substantial economic and health benefits in NZ and globally.

Distinguishing Cellulitis from Its Noninfectious Mimics: Approach to the Red Leg.

Cellulitis is a common clinical diagnosis in the outpatient and inpatient setting; studies have demonstrated a surprisingly high misdiagnosis rate: nearly one-third of cases are other conditions (ie, pseudocellulitis). This high rate of misdiagnosis is thought to contribute to nearly $515 million in avoidable health care spending in the United States each year; leading to the delayed or missed diagnosis of pseudocellulitis and to delays in appropriate treatment. There is a broad differential diagnosis for pseudocellulitis, which includes inflammatory and noninflammatory conditions of the skin. Accurate diagnosis of the specific condition causing pseudocellulitis is crucial to management, which varies greatly.