Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Harvard Combined Dermatology Residency, Harvard Medical School, Boston, Massachusetts.
JAMA Dermatol. 2018 May 1;154(5):529-536. doi: 10.1001/jamadermatol.2017.6196.
Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost.
To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis.
DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups.
Dermatology consultation within 24 hours of hospitalization.
Length of hospital stay and duration of intravenous antibiotic treatment.
Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines.
Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment.
clinicaltrials.gov Identifier: NCT01706913.
每年，蜂窝织炎导致 65 万例住院治疗，并估计在美国造成 37 亿美元的医疗费用。先前的文献表明，蜂窝织炎的误诊率很高，这导致不必要的抗生素使用和医疗费用增加。
确定皮肤科会诊是否可以缩短蜂窝织炎患者的住院时间或静脉用抗生素治疗时间。
设计、地点和参与者：这是一项于 2012 年 10 月至 2017 年 1 月在一家大型城市三级保健医院进行的随机临床试验，随访时间为 1 个月。患者被随机分为对照组（接受标准治疗，即由初级医学团队治疗）或干预组（接受皮肤科会诊）。对患者的人口统计学信息和住院情况进行了病历回顾。符合蜂窝织炎疑似诊断标准的成年住院患者符合入选条件。共筛选了 1300 名患者，排除了 1125 名患者，纳入了 175 名患者。采用统计学分析方法确定两组间的显著结局差异。
住院 24 小时内进行皮肤科会诊。
住院时间和静脉用抗生素治疗时间。
在 175 名参与者中，70 名（40%）为女性，105 名（60%）为男性。平均年龄为 58.8 岁。两组间住院时间无统计学差异。早期皮肤科会诊可显著降低静脉用抗生素治疗时间（<4 天：86.4%比 72.5%；绝对差异，13.9%；95%CI，1.9%-25.9%；P=0.04）和总抗生素治疗时间（<10 天：50.6%比 32.5%；绝对差异，18.1%；95%CI，3.7%-32.5%；P=0.01）。干预组的 2 周临床改善率明显更高（79 [89.3%]比 59 [68.3%]；绝对差异，21.0%；95%CI，9.3%-32.7%；P<0.001）。两组间 1 个月的再入院率无显著差异（4 [4.5%]比 6 [6.9%]；绝对差异，-2.4%；95%CI，-9.3%至 4.5%；P=0.54）。在干预组中，蜂窝织炎的误诊率为 30.7%（88 名参与者中的 27 名）。在整个队列中，101 名（57.7%）患者的抗生素疗程长于指南推荐的疗程。
早期皮肤科会诊可通过识别其他诊断、治疗可改变的危险因素以及缩短抗生素治疗时间，改善疑似蜂窝织炎患者的结局。
clinicaltrials.gov 标识符：NCT01706913。
