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.

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.

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.

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.

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.

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.

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.

The costs of interdigital phlegmon in four loose-housed Finnish dairy herds.

BACKGROUND: The aim of the study was to provide detailed herd level cost information about an outbreak of interdigital phlegmon (IP), which has been an emerging problem with enlarged loose house barns in Finland in recent years. During enlargement, the farmer's financial situation is sensitive because of the large investments to the farm business and unexpected costs can risk the farm's survival. RESULTS: The University of Helsinki research herd and three commercial herds having outbreaks of IP in 2012 or 2013 were visited to collect detailed information about the costs and economic impact of the outbreaks. The majority of the costs came from the discarded milk due to the antibiotic treatments. In Finland IP is usually treated with parental benzylpenicillin for 5 days which result in discarded milk for a total of 11 days. Third generation cephalosporins, widely used in other countries, have no milk withdrawal time. However, the use of these antibiotics is not recommended in Finland since these antimicrobials are critically important for human health. Herd-level costs varied between 4560 and 28,386 € depending on the herd size, the frequency of the infected cows, the antibiotics used and other costs involved. The average cost per infected cow was 489 €. CONCLUSIONS: The outbreaks of IP cause severe economic losses to dairy farms and the costs are lower if cows are treated with antibiotics with no withdrawal time. However, other costs, such as involuntary culling, reduced production and fertility also produce substantial costs to the farms. Early detection of sick animals, rapid treatment and control measures to limit the outbreak of IP can lower the costs. Because of the high costs farms should concentrate on preventing the disease.

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes.

BACKGROUND: Cellulitis is a common infection with wide variation of clinical care. OBJECTIVE: To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis. DESIGN: A retrospective observational pre-/postintervention study was performed. SETTING: University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. PATIENTS: All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis. INTERVENTION: Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians. MEASUREMENTS: Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs. RESULTS: A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively. CONCLUSION: The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

Longitudinal discharge trends and outcomes after hospitalization for mouth cellulitis and Ludwig angina.

OBJECTIVE: Objective is to provide longitudinal discharge trends and hospitalization outcomes in patients hospitalized because of mouth cellulitis or Ludwig angina. METHODS: Nationwide Inpatient Sample for years 2004 to 2010 was used. All hospitalizations with primary diagnosis of cellulitis or Ludwig angina were selected. Discharge trends were examined. RESULTS: A total of 29,228 hospitalizations occurred as a result of mouth cellulitis/Ludwig angina; 55% of all hospitalizations were male patients; 68% were aged 21 to 60 years. Non-whites comprised close to 40%. The uninsured comprised 22.3%. Ninety-nine patients died in hospitals. The total hospitalization charges across the entire United States over the study period was $772.57 million. Factors associated with increased hospitalization charges included, age, co-morbid burden, insurance status, race, teaching status of hospital, and geographic location. CONCLUSIONS: Uninsured non-whites, those with high co-morbid burden, and those aged 21 to 60 years tended to be hospitalized consistently over the study period.

Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials.

BACKGROUND: Cellulitis (erysipelas) is a recurring and debilitating bacterial infection of the skin and underlying tissue. We assessed the cost-effectiveness of prophylactic antibiotic treatment to prevent the recurrence of cellulitis using low dose penicillin V in patients following a first episode (6 months prophylaxis) and more recurrent cellulitis (12 months prophylaxis, or 6 months in those declining 12 months). METHODS: Within-trial cost-effectiveness analysis was conducted using the findings of two randomised placebo-controlled multicentre trials (PATCH I and PATCH II), in which patients recruited in the UK and Ireland were followed-up for up to 3 years. Incremental cost, reduction in recurrence, cost per recurrence prevented and cost/QALY were estimated. National unit and reference costs for England in 2010 were applied to resource use, exploring NHS and societal perspectives. A total of 397 patients from the two trials contributed to the analysis. RESULTS: There was a 29% reduction in the number of recurrences occurring within the trial (IRR: 0.71 95%CI: 0.53 to 0.90, p = 0.02), corresponding to an absolute reduction of recurrence of 0.31 recurrences/patient (95%CI: 0.05 to 0.59, p = 0.02). Incremental costs of prophylaxis suggested a small cost saving but were not statistically significant, comparing the two groups. If a decision-maker is willing to pay up to £25,000/QALY then there is a 66% probability of antibiotic prophylaxis being cost-effective from an NHS perspective, rising to 76% probability from a secondary, societal perspective. CONCLUSION: Following first episode or recurrent cellulitis of the leg, prophylactic low dose penicillin is a very low cost intervention which, on balance, is effective and cost-effective at preventing subsequent attacks. Antibiotic prophylaxis reduces cellulitis recurrence by nearly a third but is not associated with a significant increase in costs.

Socioeconomic implications of pediatric cervical methicillin-resistant Staphylococcus aureus infections.

OBJECTIVE: To study cervical methicillin-resistant Staphylococcus aureus (MRSA) infections using a national database with the goal of providing normative data and identifying variations in resource utilization. DESIGN: Retrospective review using a pediatric national data set (Kids' Inpatient Database 2009). SUBJECTS: Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for both MRSA and specific neck and pharyngeal infections. RESULTS: There were 26,829 admissions with MRSA; 3571 included a head and neck infection. The mean (SE) age at admission was 7.72 (0.20) years. Most patients (65.0%) were in the lower 2 socioeconomic quartiles; the most common payer was Medicaid (53.3%). The mean total charge per admission was $20,442. The mean (SE) length of stay (LOS) was 4.39 (0.15) days; there were significant differences among age (P < .001) and racial (P < .001) groups. A total of 1671 children underwent at least 1 surgical drainage procedure; there were statistically significant differences among racial (P < .001), age (P < .001), and socioeconomic (P = .048) groups. There were no regional variations in resource utilization when LOS, number of procedures, and total hospital charges were compared. CONCLUSIONS: Cervical MRSA infections have a large socioeconomic impact across the nation. There are differences among the various races in resource utilization. Younger children have longer hospitalizations, are more likely to need surgery, and require more intubations. Children from the lowest socioeconomic group require surgery more frequently, but their LOS is not statistically different when compared with the other 3 groups. Knowledge of such characteristics for cervical MRSA infections in children can facilitate targeted clinical interventions to improve care of affected populations.

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.

Burden of facial cellulitis: estimates from the Nationwide Emergency Department Sample.

OBJECTIVE: Multitude of maxillofacial infections from odontogenic and nonodontogenic origins can progress to facial cellulitis, which may require an emergency department (ED) visit for appropriate care. The aim of this study was to investigate national prevalence of ED visits attributed primarily to facial cellulitis, to quantify the associated hospital charges, and to identify a cohort of population presenting to the ED with facial cellulitis. STUDY DESIGN: The Nationwide Emergency Department Sample (NEDS) for the year 2007, a component database of the health care cost and utilization project was used for this study. All ED visits that had a primary diagnosis of facial cellulitis (ICD-9-CM code 682.0) were selected for analysis. All estimates were projected to national levels using the discharge weight variables. RESULTS: In 2007, a total of 302,507 ED visits were attributed primarily to facial cellulitis in the USA. The average age of the patients was 35.0 years. The mean hospital charge for each ED visit was $1,024, with a total charge of $241,541,694. A total of 17.8% of ED visits were admitted into the same hospital for inpatient care, and 78.5% of ED visits were discharged routinely; 67.6% of ED visits occurred on weekdays. Private insurance payers comprised the largest proportion (31.6%). CONCLUSIONS: This study highlights the prevalence of hospital-based ED visits primarily due to facial cellulitis in the USA in year 2007, its significant associated hospital resource utilization for treatment, and characteristics of the patient population who are likely to visit a hospital-based ED for treatment of facial cellulitis.