Ana Coelho Estevens Lopes Vaz, John Sadlier, Odhran Ryan, Mark Donnelly, Cian Davis, Julie Clifford, Ola Ahmed, Talal Almukhlifi, Naomi Fearon, Helen Heneghan
Background: Cellulitis is a common, acute, bacterial infection that causes inflammation of the deep dermis and surrounding subcutaneous tissue. It accounts for 1.2–3% of emergency department (ED) presentations in Ireland and the UK. Necrotising soft tissue infection (NSTI) is a rare, but serious complication of cellulitis, with an estimated mortality of up to 30%. Early operative debridement is a major determinant of outcome, however, the majority of mortality is due to inappropriate antibiotics and uncontrolled sepsis. Identifying which patients with cellulitis may progress to NSTI, and require surgical intervention is paramount.
Methods: A cross-sectional, retrospective review of all patients admitted in ED of St. Vincent’s University Hospital with a diagnosis of cellulitis over a 12-month period was performed. Clinical data were recorded. Risk stratification using scoring systems was done to assess severity of disease and probability of requiring surgical intervention due to NSTI. Clinical Resource Efficiency Support Team (CREST) guidelines were used to evaluate suitability of the surgical referral.
Results: In total, 128 patients were included, 1.4:1 female to male ratio, with a mean age of 63.55±18.78 years. Approximately, 72% suffered from at least one co-morbidity, and the mean length of stay was 10.05±13.25 days. Risk stratification for progression to NSTI was performed, with only 9.38%, 6.2%, and 0.78% of patients being evaluated as high risk of developing NSTI according to Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), NSTI assessment score (NAS) and Site Other Than Lower Limb, Immunosuppression, Age, Renal Impairment, and Inflammatory Markers (SIARI) scores respectively. Overall, 97% (N=125) were admitted under Surgery but none progressed to requiring surgical intervention.
Conclusions: There are reliable scoring systems with a very high negative predicative value to rule-out progression of NSTI. These could be more widely used to facilitate more appropriate referrals in ED, as rarely do patients require surgical intervention, and admission under medical teams may be more appropriate.
Keywords: Cellulitis; Clinical Resource Efficiency Support Team (CREST); Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC); necrotising soft tissue infection (NSTI); Site Other Than Lower Limb, Immunosuppression, Age, Renal Impairment, and Inflammatory Markers (SIARI)
