What about in the immunocompromised population. The guidelines say to admint anyone who is immunocompromised for IV antibiotics. Is there any evidence to try an outpatient course of abx on your ESRD on dialysis diabetic with good return instructions if they are not systemically sick? Thanks!
Great question. I am not aware of any studies looking specifically at immunocompromised patients. Judgement is always going to be a huge part of evidence based medicine. I am of two minds. On the one hand, at the physiological level, I don’t think there is any reason to think that IV would be better than PO in this group. Furthermore, this is a group of patients at high risk for iatrogenic infections with an admission. On the other hand, they are also at high risk of unresponsive or aggressive cellulitis. The final answer will probably depend a lot of the patient and your system. If the patient prefers outpatient treatment, is reliable, can return easily, and has early follow up, I don’t see any reason an admission is necessary. But that’s a lot of ifs, and erring on the side of caution also makes sense. These tough calls are what medicine is all about, but I find they are a lot easier when you discuss your thinking with the patient - they will often make the decision for you.
As a practicing family physician in the early days of the century and full time ED for the last ten years I have observed that most PO antibiotic "treatment failures" in cellulitis follow a stereotypical presentation. The patient has a lower extremity infection (less often distal upper extremity), goes home on appropriate or possibly overzealous broad-spectrum drug with simple QD/BID/QID instruction, then returns to the office/ED 3-5 days later with either worse local symptoms or early systemic symptoms. They almost universally have one thing in common: no one discussed the timing of antibiotic dosing and the need to keep the affected limb at least level with the torso if not slightly elevated. They dosed most often in the morning and around supper time and kept the limb in a dependent position for several hours thereafter. The relative decrease in circulation to downhill limbs seems to be enough to condemn these individuals to the need to revisit a prescriber. I have counseled patients about dosing at bedtime for QD drugs and at bedtime and some time +/- 12 hrs later when they are free to spend 2 hrs with the diseased limb in a slightly elevated posture relative to the heart, thus increasing the flow of antibiotic-rich blood to the place of need. When patient's know this from the initial prescription, I have only very rarely seen a return visit for persistent/worsening infection. I have taught this to all the PA/NPs in the department and they have seen fewer bounce backs. Hope you find this helpful. Keep up the good work!
So, with the information you have laid out, what are strong indications for admission FOR iv abx? do you send everyone home unless they obviously cant be discharged (ie toxic appearance etc)? thanks!
Krishna - this is tough to say. True failure of oral antibiotics, obviously patients with signs of bacteremia or sepsis would come in. There's some literature that states that patients with ulcerations in the affected area (but not necessarily an infected ulcer) and recurrent cellulitis in the same location do poorly with oral antibiotics so those are patients I would consider keeping. Any patient with a poorly working gut (i.e. diabetic gastroparesis, short gut, absorption abnormalities) I would start on IV as well.
Agree with Swami. In my mind, the admission decision and the IV antibiotic decision are completely separate. (In both Canada and New Zealand you can get IV antibiotics as an outpatient.) My big criteria for admission are septic, social issues, or major comorbidities that require management. I think it is appropriate to admit patients who need it and still use oral antibiotics. (I know it is a harder sell, but it also focuses attention where it is needed. Rather than "this patient needs to come in for IV antibiotics", it is "this patient needs to come in because they are homeless and need social work", which makes it more likely that patient will get the services they need.) My big criteria for IV antibiotics are critically ill patients (where 20 minutes of absorption might be a big differences) and concern about GI issues, like short gut, or shock and malperfused intestines.
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Erin C. - January 29, 2019 11:55 AM
What about in the immunocompromised population. The guidelines say to admint anyone who is immunocompromised for IV antibiotics. Is there any evidence to try an outpatient course of abx on your ESRD on dialysis diabetic with good return instructions if they are not systemically sick? Thanks!
Justin M. - January 31, 2019 1:06 AM
Great question. I am not aware of any studies looking specifically at immunocompromised patients. Judgement is always going to be a huge part of evidence based medicine. I am of two minds. On the one hand, at the physiological level, I don’t think there is any reason to think that IV would be better than PO in this group. Furthermore, this is a group of patients at high risk for iatrogenic infections with an admission. On the other hand, they are also at high risk of unresponsive or aggressive cellulitis.
The final answer will probably depend a lot of the patient and your system. If the patient prefers outpatient treatment, is reliable, can return easily, and has early follow up, I don’t see any reason an admission is necessary. But that’s a lot of ifs, and erring on the side of caution also makes sense.
These tough calls are what medicine is all about, but I find they are a lot easier when you discuss your thinking with the patient - they will often make the decision for you.
William G. - February 8, 2019 10:51 PM
As a practicing family physician in the early days of the century and full time ED for the last ten years I have observed that most PO antibiotic "treatment failures" in cellulitis follow a stereotypical presentation. The patient has a lower extremity infection (less often distal upper extremity), goes home on appropriate or possibly overzealous broad-spectrum drug with simple QD/BID/QID instruction, then returns to the office/ED 3-5 days later with either worse local symptoms or early systemic symptoms. They almost universally have one thing in common: no one discussed the timing of antibiotic dosing and the need to keep the affected limb at least level with the torso if not slightly elevated. They dosed most often in the morning and around supper time and kept the limb in a dependent position for several hours thereafter. The relative decrease in circulation to downhill limbs seems to be enough to condemn these individuals to the need to revisit a prescriber. I have counseled patients about dosing at bedtime for QD drugs and at bedtime and some time +/- 12 hrs later when they are free to spend 2 hrs with the diseased limb in a slightly elevated posture relative to the heart, thus increasing the flow of antibiotic-rich blood to the place of need. When patient's know this from the initial prescription, I have only very rarely seen a return visit for persistent/worsening infection. I have taught this to all the PA/NPs in the department and they have seen fewer bounce backs. Hope you find this helpful. Keep up the good work!
Krishna P. - May 7, 2019 1:38 AM
So, with the information you have laid out, what are strong indications for admission FOR iv abx? do you send everyone home unless they obviously cant be discharged (ie toxic appearance etc)? thanks!
Anand S. - May 7, 2019 6:10 AM
Krishna - this is tough to say. True failure of oral antibiotics, obviously patients with signs of bacteremia or sepsis would come in. There's some literature that states that patients with ulcerations in the affected area (but not necessarily an infected ulcer) and recurrent cellulitis in the same location do poorly with oral antibiotics so those are patients I would consider keeping. Any patient with a poorly working gut (i.e. diabetic gastroparesis, short gut, absorption abnormalities) I would start on IV as well.
Justin M. - May 9, 2019 4:05 PM
Agree with Swami.
In my mind, the admission decision and the IV antibiotic decision are completely separate. (In both Canada and New Zealand you can get IV antibiotics as an outpatient.)
My big criteria for admission are septic, social issues, or major comorbidities that require management. I think it is appropriate to admit patients who need it and still use oral antibiotics. (I know it is a harder sell, but it also focuses attention where it is needed. Rather than "this patient needs to come in for IV antibiotics", it is "this patient needs to come in because they are homeless and need social work", which makes it more likely that patient will get the services they need.)
My big criteria for IV antibiotics are critically ill patients (where 20 minutes of absorption might be a big differences) and concern about GI issues, like short gut, or shock and malperfused intestines.