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

2. 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

3. 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

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

5. 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

6. Testing the strategy [2004]

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

11. Admission to Christchurch Hospital with primary cellulitis

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

14. 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]

15. 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]

16. 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.

18. 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 hours?
Any alternative therapies?

19. 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.

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

22. 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