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.

Estimating the health care costs associated with recurrent cellulitis managed in the outpatient setting.

BACKGROUND: Recurrent cellulitis is diagnosed in 22% to 49% of all cellulitis cases, but little is known about the costs associated with these cases. OBJECTIVE: To characterize patients with recurrent cellulitis in the outpatient setting and estimate the associated costs. METHODS: A retrospective chart review was conducted for adult patients who presented to the outpatient facilities at our institution from January 1, 2007, to December 31, 2011, with recurrent cellulitis. Data provided by the Centers for Medicare and Medicaid Services were used. RESULTS: A total of 157 patients were identified; 56% were male, with a mean age of 62.7 years. The mean number of episodes of cellulitis per patient was 3. Antibiotics were prescribed for all patients with a diagnosis of recurrent cellulitis, with 93% treated with oral antibiotics and 17.6% treated with intravenous antibiotics. A total of 1081 laboratory and 175 radiologic imaging tests were ordered. The minimum average cost per cellulitis episode was $586.91; the average cost per visit was $292.50. LIMITATIONS: Retrospective study; use of a single, large academic institution; and utilization of cost estimates that may not adequately reflect the variation of costs across closed-system sites or geographic regions. There was no accounting for the nonfinancial or opportunity costs associated with hospitalization, such as lost days of employment or child care and any long-term morbidities, among others. CONCLUSIONS: Recurrent cellulitis in the outpatient setting costs about $586.91 per episode. Although there is no criterion standard for diagnosis or treatment of cellulitis, our analysis demonstrates the need for more evidence-based management to achieve better outcomes and reduce the significant health care costs.

The Burden of Facial Cellulitis Leading to Inpatient Hospitalization.

PURPOSE: The purpose of the present study was to present nationally representative estimates of hospitalizations primarily attributed to facial cellulitis and to conduct an exploratory analysis on identifying factors associated with outcomes, such as hospital charges, length of stay (LOS), disposition status, and occurrence of infectious complications. MATERIALS AND METHODS: The present study is a retrospective analysis of the Nationwide Inpatient Sample (NIS) for 2012 and 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of "682.0" in the primary diagnosis field of NIS (reason for hospitalization) was used to identify cases with facial cellulitis. All patients at least 18 years old who were hospitalized for facial cellulitis were included. Outcome variables examined in the present study were hospital charges, LOS, disposition status, and occurrence of infectious complications. Descriptive statistics and a multivariable linear regression model were used to examine association between independent variables and patient disposition and infectious complications. RESULTS: In 2012 and 2013, 74,480 hospitalizations involved facial cellulitis in adults at least 18 years old in the United States. Most were women (mean age, 47.5 yr). Most patients were routinely discharged home. Age was associated with an increase in odds of discharge to another facility. Variables associated with decreased odds of bacterial infections were age and black or Hispanic race. Women with at least 1 comorbidity had higher odds of mycoses. Statistically relevant predictors of longer than average LOS were age, race, insurance, presence of sepsis, and location. CONCLUSIONS: This study presented nationally representative estimates of hospitalizations attributed primarily to facial cellulitis in the adult population in the United States in 2012 and 2013. The presence of a comorbid condition predicted worse outcomes. Public health efforts should focus on targeting high-risk patients and providing monitoring or early treatment of face cellulitis.

An antibiotic formulary for a tertiary care foot clinic: admission avoidance using intramuscular antibiotics for borderline foot infections in people with diabetes.

AIMS: To develop an antibiotic foot formulary for the empirical treatment of diabetes-related foot infections presenting to our service. Subsequently, to asses costs associated with the introduction of our protocol, in particular to assess the effect on admissions avoidance and any cost savings achieved. METHODS: We reviewed several existing antibiotic protocols. We analysed data on costs related to treatment and admission rates prior to and after the introduction of the protocol. RESULTS: We rationalized our antibiotic protocol and adapted the Infectious Disease Society of America guideline by introducing a category of 'moderate infection-borderline admission' to our classification. This enabled the administration of outpatient intramuscular antibiotics. After introducing the rationalized protocol, our average antibiotic prescribing costs for a 3-week course of treatment fell from £17.12 to £16.42. Over 22 months of follow-up, 26 episodes were eligible for treatment with intramuscular antibiotics. Over the same time period, 121 people were admitted directly from the foot clinic. The costs saved as a result of avoided or delayed admission for those 26 episodes was over £76 000. For 12 people who required subsequent admission, their length of hospital stay was significantly shorter than those admitted directly [9.25 days (range 2-25) vs. 16.11 (2-64), P = 0.045]. CONCLUSIONS: By modifying the Infectious Disease Society of America classification and adopting a protocol to administer outpatient oral and intramuscular antibiotics, we have led to substantial cost savings, shorter hospital admissions and also have developed a successful admissions avoidance strategy.

Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial.

BACKGROUND: Cellulitis (erysipelas) of the leg is a common, painful infection of the skin and underlying tissue. Repeat episodes are frequent, cause significant morbidity and result in high health service costs. OBJECTIVES: To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes. METHODS: Double-blind, randomized controlled trial including patients recently treated for an episode of leg cellulitis. Recruitment took place in 20 hospitals. Randomization was by computer-generated code, and treatments allocated by post from a central pharmacy. Participants were enrolled for a maximum of 3 years and received their randomized treatment for the first 6 months of this period. RESULTS: Participants (n=123) were randomized (31% of target due to slow recruitment). The majority (79%) had suffered one episode of cellulitis on entry into the study. The primary outcome of time to recurrence of cellulitis included all randomized participants and was blinded to treatment allocation. The hazard ratio (HR) showed that treatment with penicillin reduced the risk of recurrence by 47% [HR 0·53, 95% confidence interval (CI) 0·26-1·07, P=0·08]. In the penicillin V group 12/60 (20%) had a repeat episode compared with 21/63 (33%) in the placebo group. This equates to a number needed to treat (NNT) of eight participants in order to prevent one repeat episode of cellulitis [95% CI NNT(harm) 48 to ∞ to NNT(benefit) 3]. We found no difference between the two groups in the number of participants with oedema, ulceration or related adverse events. CONCLUSIONS: Although this trial was limited by slow recruitment, and the result failed to achieve statistical significance, it provides the best evidence available to date for the prevention of recurrence of this debilitating condition.

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.

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.

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.

Analysis of Readmissions Following Hospitalization for Cellulitis in the United States.

Importance: Cellulitis commonly results in hospitalization. Limited data on the proportion of cellulitis admissions associated with readmission are available. Objective: To characterize the US national readmission rate associated with hospitalization for treatment of cellulitis. Design, Setting, and Participants: This retrospective cohort analysis of cellulitis admissions from the nationally representative 2014 Nationwide Readmissions Database calculated readmission rates for all cellulitis admissions and subsets of admissions. The multicenter population-based cohort included adult patients admitted for conditions other than obstetrical or newborn care. Data were collected from January 1 through November 30, 2014, and analyzed from February 1 through September 18, 2018. Bivariate logistic regression models were used to assess differences in readmission rates by patient characteristics. Costs were calculated for all readmissions after discharge from hospitalization for cellulitis (hereinafter referred to as cellulitis discharge) and by readmission diagnosis. Exposures: Admission with a primary diagnosis of cellulitis. Main Outcomes and Measures: Proportion of cellulitis admissions associated with nonelective readmission within 30 days, characteristics of patients readmitted after cellulitis discharge, and costs associated with cellulitis readmission. Results: A total of 447 080 (95% CI, 429 927-464 233) index admissions with a primary diagnosis of cellulitis (53.8% male [95% CI, 53.5%-54.2%]; mean [SD] age, 56.1 [18.9] years) were included. Overall 30-day all-cause nonelective readmission rate after cellulitis discharge was 9.8% (95% CI, 9.6%-10.0%). Among patients with cellulitis, age (odds ratio for 45-64 years, 0.78; 95% CI, 0.75-0.81; P = .001) and insurance status (odds ratio for Medicare, 2.45; 95% CI, 2.33-2.58; P < .001) were associated with increased readmission rates. The most common diagnosis of readmissions included skin and subcutaneous tissue infections. The total cost associated with nonelective readmissions attributed to skin and subcutaneous infections within 30 days of a cellulitis discharge during the study period was $114.4 million (95% CI, $106.8-$122.0 million). Conclusions and Relevance: Readmission after hospitalization for cellulitis is common and costly and may be preventable with improved diagnostics, therapeutics, and discharge care coordination.

Cycloidal vibration for the treatment of cellulitis in a community setting.

Cellulitis of the lower limb is a common infection seen in primary care resulting in a significant number of hospital admissions per year. The NHS is proposing and developing services to treat patients more effectively in the community to prevent hospital admission. Cycloidal vibration (CV) therapy is a medical device that when combined with standard antibiotic therapy for cellulitis results in an effective treatment. This retrospective analysis is a review of patients with cellulitis seen in a community medical centre before and after the introduction of CV therapy. This therapy in conjunction with antibiotics resulted in the successful recovery of patients with cellulitis that previously required hospital admission for treatment. As a consequence a significant reduction in the cost of treating these patients has been determined.

Hospital cost analysis of children with preseptal cellulitis.

OBJECTIVE: Hospitalization of the children with preseptal cellulitis creates a burden on healthcare costs. This study aimed to analyze the hospital costs for preseptal cellulitis and determine the factors contributing. METHODS: Children, between 1 and 18 years old, who were admitted to hospital for preseptal cellulitis from May 2013 to December 2016 were included in the study. Patients were divided into groups by age (under or equal to five years and older than five years) and by the presence of sinusitis. Demographics, length of stay and total and categorical hospital costs were evaluated retrospectively. RESULTS: The study included 54 patients with a mean age of 5 years. Thirty one of the patients were under five years of age. The most common symptoms were swelling (94.4%) and redness (83.3%) around eye. Among the predisposing factors, sinusitis was the most common one (37%). The average length of stay was 4.5 days. Total hospital cost of all patients was $11,841. Antibiotic costs (37%) and inpatient floor costs (36%) were the greatest expenditures. Between age groups, length of stay was longer, and inpatient floor and antibiotic costs were significantly higher in the group of >5 years (p = 0.007, p = 0.004 and p = 0.001, respectively). In the group with sinusitis, length of stay was longer, and all hospital costs were significantly higher compared to the group without sinusitis (p < 0.001). There was a strong, positive correlation between length of stay and hospital costs (r = 0.854, n = 53, p < 0.001). Sinusitis was a significant factor (p < 0.001) for longer length of stay, but age was not (p = 0.841). CONCLUSION: Sinusitis was found to be an important factor contributing to longer length of stay and higher hospital costs for preseptal cellulitis. Oral or ambulatory intravenous antimicrobial treatment strategies might decrease the hospital expenditure in these patients; however care should be taken in the presence of sinusitis.

Pediatric lateral neck infections - Computed tomography vs ultrasound on initial evaluation.

OBJECTIVE: Review the evaluation of children with a deep lateral neck infection and define the impact of initial imaging modality on outcomes and costs. METHOD: Case series, pediatric patients <18 years of age admitted to a tertiary care hospital with lateral neck infection between 01/01/14-05/31/16 as identified by ICD-9 and ICD-10 codes: 289.3 (lymphadenitis, unspecified), 682.1 (cellulitis and abscess of neck), 683 (acute lymphadenitis), I88.9 (nonspecific lymphadenitis, unspecified), L02.11 (cutaneous abscess of neck), L03.221 (cellulitis of neck), and L03.222 (acute lymphangitis of neck). Patients were divided into two groups based on initial imaging modality: primary ultrasound or primary computed tomography. Differences in length of stay, type and total number of imaging studies obtained, number of procedures, hospital readmission, and hospital cost were compared between cohorts. RESULTS: There were 40 (31%) primary ultrasound and 88 (69%) primary computed tomography patients (128 total). Median length of stay was 46 (IQR: 25,90) hours (1.9 days) for primary ultrasound and 63 (IQR: 39,88) hours (2.6 days) for primary computed tomography patients (p = 0.33). Drainage was performed in 48% of both groups. Additional imaging occurred in 17 (43%) primary ultrasound and 18 (20%) primary computed tomography patients (p = 0.02). Readmission occurred in 8 patients (6.3%). Retropharyngeal infection was encountered in 13 patients (10%); this was only discovered in patients who had a computed tomography performed. Median cost per primary ultrasound patients was $5363 (IQR: 3011, 7920) and $5992 (IQR: 3450, 8060) for primary computed tomography patients. CONCLUSIONS: The primary imaging modality (ultrasound or computed tomography) used to work-up children with a lateral neck infection did not impact length of stay or hospital cost. However, a significant subset had a coexisting retropharyngeal infection that was only identified on computed tomography. Future studies are needed to identify appropriate criteria for imaging in the work-up of lateral neck infections.

Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes.

STUDY OBJECTIVE: To assess the effect of daptomycin compared with vancomycin on the clinical and economic outcomes in patients with complicated skin and skin structure infections. DESIGN: Prospective, open-label study. SETTING: Level 1 trauma center in Detroit, Michigan. PATIENTS: Fifty-three adult patients with complicated skin and skin structure infections at risk for methicillin-resistant Staphylococcus aureus (MRSA) infection who were treated with daptomycin and a matched cohort of 212 patients treated with vancomycin. INTERVENTION: Patients in the prospective arm received intravenous daptomycin 4 mg/kg every 24 hours for at least 3 days but not more than 14 days. Historical controls received at least 3 days of vancomycin dosed to achieve trough concentrations of 5-20 microg/ml. MEASUREMENTS AND MAIN RESULTS: Outcomes evaluated included blinded assessments of clinical resolution, duration of therapy, and costs. The most common diagnoses were cellulitis (31%), abscess (22%), and both cellulitis with abscess (37%). Microbiology differed significantly between groups, with S. aureus found in 27 patients (51%) in the daptomycin group and 167 patients (79%) in the vancomycin group and MRSA in 22 (42%) and 159 (75%), respectively (p<0.001). The proportions of patients with clinical improvement or resolution of their infections on days 3 and 5 were 90% versus 70% and 98% versus 81% in the daptomycin versus vancomycin groups, respectively (p<0.01 for both comparisons), and 100% at the end of therapy in both groups. Among patients with complete resolution of their infections (41 patients [77%] with daptomycin vs 89 patients [42%] with vancomycin, p<0.05), median duration of intravenous therapy was 4 and 7 days, respectively, (p<0.001), and hospital costs were $5027 and $7552 (p<0.001). CONCLUSIONS: Patients receiving daptomycin achieved more rapid resolution of symptoms and clinical cure and had a decreased duration of inpatient therapy compared with those receiving vancomycin. This study suggests that daptomycin is a cost-effective alternative to vancomycin for complicated skin and skin structure infections.

Analysis of empiric antimicrobial strategies for cellulitis in the era of methicillin-resistant Staphylococcus aureus.

BACKGROUND: The rise in community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections potentially complicates the empiric management of cellulitis. The threshold at which drugs active against MRSA, such as clindamycin and trimethoprim/sulfamethoxazole (TMP/SMX), should be incorporated into empiric therapy is unknown. OBJECTIVE: To evaluate the cost-effectiveness of using cephalexin, TMP/SMX, or clindamycin for outpatient empiric therapy of cellulitis, given various likelihoods of infection due to MRSA. METHODS: A decision analysis of the empiric treatment of cellulitis was performed from the perspective of a third-party payer. The model included initial therapy with cephalexin, clindamycin, or TMP/SMX, followed by treatment with linezolid in cases of clinical failure. Probability and cost estimates were obtained from clinical trials, epidemiologic data, and publicly available cost data and were subjected to sensitivity analysis. RESULTS: Under the base-case scenario (37% probability of infection by S. aureus and a 27% MRSA prevalence), cephalexin was the most cost-effective option. Clindamycin became a more cost-effective therapy at MRSA probabilities from 41-80% when the probability of staphylococcal infection was greater than 40%. TMP/SMX was cost-effective only at very high likelihoods of MRSA infection. Variables with the most influence in the model were probability of S. aureus being methicillin-resistant, cost of linezolid, probability of a cure with cephalexin for a non-MRSA infection, and probability of infection due to S. aureus. CONCLUSIONS: Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels. Cephalexin was the most cost-effective choice over most of the modeled range of probabilities, with clindamycin becoming more cost-effective at high likelihoods of MRSA infection. TMP/SMX is unlikely to be cost-effective for treatment of simple cellulitis. Further studies of the microbiology of cellulitis, the epidemiology of MRSA, and the clinical effectiveness of clindamycin and TMP/SMX in skin and soft tissue infections are needed.

Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times?

OBJECTIVE: This single-centre non-blind randomised controlled trial aimed to compare clinical outcomes in terms of recovery time of standard treatment of lower limb cellulitis versus standard treatment combined with cycloidal vibration (Vibro-Pulse) therapy. METHOD: Thirty-six patients (18 per group) with lower limb cellulitis were randomised to receive either standard treatment (intravenous or oral antibiotic therapy) and bed rest or standard treatment combined with cycloidal vibration treatment three times per day, 30 minutes per treatment. The outcome measure was the daily amount of reduction in erythema/cellulitis and oedema reduction against time for up to seven days of treatment and the resources required. RESULTS: There was a clinically significant difference between the two groups, with 66% of the study group fully recovering within the seven days compared with 11% of the control group. CONCLUSION: Cycloidal vibration combined with standard therapy can significantly reduce cellulitis treatment time. This can reduce both hospital bed days and the resources required.

Hospital costs for patients with lower extremity cellulitis: a retrospective population-based study.

OBJECTIVES: Hospital admissions for non-purulent lower extremity cellulitis (NLEC) are common and can be prolonged and costly. Newer treatment options and preventive strategies are expected to result in cost savings before implementation, but few studies have quantified the cost of conventional treatment. METHODS: Using the Rochester Epidemiology Project, the incidence of NLEC in Olmsted County, MN in 2013 was 176.6 per 100,000 persons. The subset of patients who required hospitalization for NLEC in 2013 was determined. Hospital admissions were analyzed retrospectively using standardized cost analysis within several relevant categories. RESULTS: Thirty-four patients had an average hospital length of stay of 4.7 days. The median total inpatient cost was $7,341. The median cost per day was $2,087, with 49% due to room and board. Antibiotics administered for treatment of NLEC contributed a median cost of $75 per day of hospitalization, and laboratory and imaging test costs were $73 and $44, respectively, per day of hospitalization. CONCLUSION: Hospitalizations for NLEC can be costly and prolonged with room and board accounting for much of the cost. Therefore, newer management strategies should seek to reduce hospital length of stay and/or avoid inpatient admission to reduce cost.

The Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial: update to the study protocol and detailed statistical analysis plan (SAP).

BACKGROUND: Cellulitis is a painful, potentially serious, infectious process of the dermal and subdermal tissues and represents a significant disease burden. The statistical analysis plan (SAP) for the Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial is described here. The PEDOCELL trial is a multicentre, randomised, parallel-arm, double-blinded, non-inferiority clinical trial comparing the efficacy of flucloxacillin (monotherapy) with combination flucloxacillin/phenoxymethylpenicillin (dual therapy) for the outpatient treatment of cellulitis in the emergency department (ED) setting. To prevent outcome reporting bias, selective reporting and data-driven results, the a priori-defined, detailed SAP is presented here. METHODS/DESIGN: Patients will be randomised to either orally administered flucloxacillin 500 mg four times daily and placebo or orally administered 500 mg of flucloxacillin four times daily and phenoxymethylpenicillin 500 mg four times daily. The trial consists of a 7-day intervention period and a 2-week follow-up period. Study measurements will be taken at four specific time points: at patient enrolment, day 2-3 after enrolment and commencing treatment (early clinical response (ECR) visit), day 8-10 after enrolment (end-of-treatment (EOT) visit) and day 14-21 after enrolment (test-of-cure (TOC) visit). The primary outcome measure is investigator-determined clinical response measured at the TOC visit. The secondary outcomes are as follows: lesion size at ECR, clinical treatment failure at each follow-up visit, adherence and persistence of trial patients with orally administered antibiotic therapy at EOT, health-related quality of life (HRQoL) and pharmacoeconomic assessments. The plan for the presentation and comparison of baseline characteristics and outcomes is described in this paper. DISCUSSION: This trial aims to establish the non-inferiority of orally administered flucloxacillin monotherapy with orally administered flucloxacillin/phenoxymethylpenicillin dual therapy for the ED-directed outpatient treatment of cellulitis. In doing so, this trial will bridge a knowledge gap in this understudied and common condition and will be relevant to clinicians across several different disciplines. The SAP for the PEDOCELL trial was developed a priori in order to minimise analysis bias. TRIAL REGISTRATION: EU Clinical Trials Register (EudraCT number: 2016-001528-69). Registered on 5 April 2016. ClinicalTrials.gov, ID: NCT02922686 . Registered on 9 August 2016.

Economic impact of the community-acquired methicillin-resistant Staphylococcus aureus epidemic on the Driscoll Children's Health Plan.

Cellulitis and abscess accounted for increasing percentages of inpatient (4.6-11.1%), outpatient (0.6-1.2%) and total (1.7-3.3%) expenses from 2001 through 2004. The per member per month expenses attributed to cellulitis and abscess increased from $0.74 in 2001 to $1.19 in 2004. The epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections in children has had a significant economic impact on the Driscoll Children's Health Plan.

A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: comparative patient care audits.

In 2000 and 2002, the Royal Perth Hospital (RPH) Burn Unit, Western Australia, conducted two 'before and after' patient care audits comparing the effectiveness and cost of Silvazine (silver sulphadiazine and chlorhexidine digluconate cream) and Acticoat, a new dressing product for in-patient treatment of early burn wounds. The main outcome variables were: burn wound cellulitis, antibiotic use and cost of treatment. Two patient care audits and a comparative sample were used. The two regimes audited were, 'standard treatment' of twice daily showers or washes with 4% chlorhexidine soap and Silvazine cream as a topical dressing (2000, n=51), compared with the 'new treatment' of daily showers of the burn wound with 4% chlorhexidine soap and the application of an Acticoat dressing (2002, n=19). In 2002, costs were also examined using a sample of matched pairs (n=8) of current and previous patients. The main findings were: when using Acticoat the incidence of infection and antibiotic use fell from 55% (28/51) and 57% (29/51) in 2000 to 10.5% (2/19) and 5.2% (1/19) in 2002. The total costs (excluding antibiotics, staffing and surgery) for those treated with Silvazine were US$ 109,357 and those treated with Acticoat were US$ 78,907, demonstrating a saving of US$ 30,450 with the new treatment. The average length of stay (LOS) in hospital was 17.25 days for the Silvazine group and 12.5 days for the Acticoat group-a difference of 4.75 days. These audits demonstrate that Acticoat results in a reduced incidence of burn wound cellulitis, antibiotic use and overall cost compared to Silvazine in the treatment of early burn wounds.