The patient in the above vignette has lower extremity cellulitis. Currently, the indications for hospital admission and treatment of cellulitis include lack of response to oral antibiotics within 24-48 hours.
Cellulitis is commonly characterized by inflammation of the skin and subcutaneous tissues, usually in response to an acute infection. A breach in the skin is often the initial inciting factor. Clinically, cellulitis presents as the acute and progressive onset of a red, sometimes painful, warm, and edematous area of skin. Along with a lack of response to oral antibiotics within 24-48 hours, systemic toxicity and excessive skin involvement would also be appropriate factors for hospital admission and treatment.
Stulberg et al. report on common bacterial skin infections. Specifically, they note that cellulitis commonly has poorly demarcated borders and is usually caused by Streptococcus or Staphylococcus species. These superficial skin infections are typically diagnosed by clinical presentation and are treated empirically. It is important to remember that children, diabetics, or patients who have immunodeficiencies are more susceptible to gram-negative infections and may require treatment with a second- or third-generation cephalosporin.
Stevens et al. of the Infectious Disease Society of America have made practice guidelines for the diagnosis and management of skin and soft tissue infections. Specifically, they recommend consideration of inpatient admission for patients with cellulitis that also have hypotension and/or elevated creatinine, elevated creatine phosphokinase level (2-3 times the upper limit of normal), CRP >13 mg/L, low serum bicarbonate, or marked left shift on the CBC with differential.
Figure A demonstrates what an initial physical exam of a patient with cellulitis may look like. Note the mild erythema without well defined borders. Figure B demonstrates the same individual that has had a progression of the cellulitis with more pronounced erythema and superficial spreading.
Answer 2: Although hospital admission would be appropriate in this clinical scenario, it is not because of the risk of compartment syndrome that the patient should be admitted.
Answer 3: Although outpatient treatment with broader antibiotic coverage may potentially benefit this patient, he currently meets admission criteria and would be better served by inpatient treatment of his cellulitis.
Answer 4: Outpatient treatment with the same antibiotic would not be appropriate, as he has not responded to it and has progressively worsened.
Answer 5: Outpatient treatment with a PICC line and antibiotics would not be the best option for this patient since he could not be closely monitored for progression or resolution of symptoms. This is not the medical norm when a patient meets inpatient criteria and would benefit from a hospital stay.
Stulberg DL, Penrod MA, Blatny RA. Common bacterial skin infections. Am Fam Physician. 2002 Jul 1;66(1):119-24. Review.
PMID:12126026 (Link to Abstract)
Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. doi: 10.1093/cid/ciu444.
PMID:24973422 (Link to Abstract)