Primary-Secondary Care Partnership in Treatment of Severe Cellulitis Dr Alan Pithie

Background Between 500- 1000 admissions per year in Canterbury Unknown number of cases treated in primary care with oral antibiotics Wide range of presentation: Mild – life threatening Intravenous antibiotics commonly used But no clear definition of severe, no clear-cut guidelines who needs them, and similarly no validated objective measures of clinical response or when to switch from IV to oral

Home intravenous antibiotic delivery Well established, especially in US. Many programs delivered by secondary care Truly integrated program needs; Vision Leadership Willingness to change and work together Infrastructure Pathways Education for staff and patients Governance Audit

Inpatient services – general medicine Partnership Primary Care Acute Demand Service Secondary Care ED ID service Inpatient services – general medicine

Community based IV therapy for Cellulitis Severity or failure to respond to oral therapy Less than 2 SIRs criteria [temp <36, >38; pulse >90; WCC <4, >12; RR >20]. Absence of following: Overlying joint Deeper tissue involvement Blistering and necrosis Extensive involvement Severe co-morbidities

Testing the strategy [2004]

What effect has community based IV therapy for cellulitis had on hospitalisation?

Admission to Christchurch Hospital with primary cellulitis

Acute Demand From July 2009-December 2012 5029 [12% total] presentations with cellulitis

Unanswered issues Still no validated severity criteria How do we identify and select the patients who will benefit from intravenous antibiotics? Are patients being over/under treated? How can we better gauge response to therapy How can we gauge the duration of IV therapy? Can the indications be better defined, and can a wider group of patients be safely treated in the community? Are there other oral options [eg probenecid]

Australian review 6 months experience of HITH service 69 referrals for IV antibiotics 18 [26%] oral antibiotics [20% failure] 23 [33.3%] home IV [13% failure] 28 [40.6%] admitted [18.5%] The majority of initially thought to require IV abs and received oral abs did very well [subjective assessment, considerable clindamycin use]

Case 1 56 year old man with 24 hour history of fever and rigors, followed by redness of right lower leg Red line extending into groin, with tender inguinal lymphadenopathy On examination; systemically well, temp 38.6, pulse 92, RR 16, neutrophil count 10.5.

Case 1 Is the patient suitable for community based IV therapy? What would be indications for hospital admission? How would judge response to therapy? What would be indicators of poor response? How would you manage a deterioration in first 24-48 hours? Any alternative therapies?

Case 2 19 year old with sudden onset of pain and swelling over hip. 4 days after injury skiing Fever 40, pulse 110/m, RR 22. Exquisite tenderness over upper thigh. Moderate sized area of cellulitis/bruising. Very painful.

Case 2 Is this patient suitable for home IV therapy? Are there any warning symptoms or signs? Possible alternative diagnosis?

Future More research to give evidence base to our pathways and decision making Trials of IV versus oral Objective measures of severity Prospective studies Probenecid boosting