急诊门诊单纯性蜂窝织炎患者经验性门诊抗生素治疗失败的预测因素。
Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis.
机构信息
The Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario.
出版信息
Acad Emerg Med. 2014 May;21(5):526-31. doi: 10.1111/acem.12371.
BACKGROUND
Despite several expert panel recommendations and cellulitis treatment guidelines, there are currently no clinical decision rules to assist clinicians in deciding which emergency department (ED) patients should be treated with oral antibiotics and which patients require intravenous (IV) therapy at first presentation of cellulitis amenable to outpatient treatment.
OBJECTIVES
The objective was to determine risk factors associated with adult patients presenting to the ED with cellulitis who fail initial antibiotic therapy as outpatients and require a change of antibiotics or admission to hospital.
METHODS
This was a prospective cohort study of patients 18 years of age or older presenting with cellulitis to one of two tertiary care EDs (combined annual census 140,000). Patients were excluded if they had been treated with antibiotics for the cellulitis before presenting to the ED, if they were admitted to the hospital, or if they had an abscess only. Trained research personnel administered a questionnaire at the initial ED visit with telephone follow-up 2 weeks later. Multivariable logistic regression models determined predictor variables independently associated with treatment failure (failed initial antibiotic therapy and required a change of antibiotics or admission to hospital).
RESULTS
A total of 598 patients were enrolled, 52 were excluded, and 49 were lost to follow-up. The mean (±standard deviation [SD]) age was 53.1 (±18.4) years and 56.4% were male. A total of 185 patients (37.2%) were given oral antibiotics, 231 (46.5%) were given IV antibiotics, and 81 patients (16.3%) received both oral and IV antibiotics in the ED. A total of 102 (20.5%, 95% confidence [CI] = 17.2% to 24.2%) patients had treatment failures. Fever (temperature > 38°C) at triage (odds ratio [OR] = 4.3, 95% CI = 1.6 to 11.7), chronic leg ulcers (OR = 2.5, 95% CI = 1.1 to 5.2), chronic edema or lymphedema (OR = 2.5, 95% CI = 1.5 to 4.2), prior cellulitis in the same area (OR = 2.1, 95% CI = 1.3 to 3.5), and cellulitis at a wound site (OR = 1.9, 95% CI = 1.2 to 3.0) were independently associated with treatment failure.
CONCLUSIONS
These risk factors should be considered when initiating empiric antibiotic therapy for ED patients with cellulitis amenable to outpatient treatment.
背景
尽管有几个专家小组的建议和蜂窝织炎治疗指南，但目前尚无临床决策规则来帮助临床医生决定哪些急诊（ED）患者应接受口服抗生素治疗，哪些患者在初次就诊时需要静脉（IV）治疗适合门诊治疗的蜂窝织炎。
目的
确定与成年患者相关的风险因素，这些患者在初次就诊时接受门诊治疗，接受初始抗生素治疗后出现失败，并需要改变抗生素治疗或住院治疗。
方法
这是一项对两家三级保健 ED 就诊的 18 岁或以上蜂窝织炎患者进行的前瞻性队列研究（总年度普查为 140,000 人）。如果患者在就诊前已接受抗生素治疗蜂窝织炎、住院或仅患有脓肿，则将其排除在外。经过培训的研究人员在初次就诊时进行问卷调查，并在 2 周后进行电话随访。多变量逻辑回归模型确定与治疗失败（初始抗生素治疗失败并需要改变抗生素或住院治疗）独立相关的预测变量。
结果
共纳入 598 例患者，其中 52 例被排除，49 例失访。平均（±标准差[SD]）年龄为 53.1（±18.4）岁，56.4%为男性。共有 185 例（37.2%）患者给予口服抗生素，231 例（46.5%）给予 IV 抗生素，81 例（16.3%）患者在 ED 中同时接受口服和 IV 抗生素治疗。共有 102 例（20.5%，95%置信区间[CI] = 17.2%至 24.2%）患者发生治疗失败。分诊时发热（体温>38°C）（比值比[OR] = 4.3，95%CI = 1.6 至 11.7）、慢性腿部溃疡（OR = 2.5，95%CI = 1.1 至 5.2）、慢性水肿或淋巴水肿（OR = 2.5，95%CI = 1.5 至 4.2）、同一部位先前的蜂窝织炎（OR = 2.1，95%CI = 1.3 至 3.5）和伤口部位的蜂窝织炎（OR = 1.9，95%CI = 1.2 至 3.0）与治疗失败独立相关。
结论
在为适合门诊治疗的 ED 蜂窝织炎患者开始经验性抗生素治疗时，应考虑这些危险因素。
Zotero 插件