Management Of Cellulitis Research Articles

The effect of histopathologic analysis and tissue cultures on inpatient management of cellulitis: a randomized control trial

Background: In the absence of a gold-standard diagnostic modality for cellulitis, sterile inflammatory disorders may be misdiagnosed as cellulitis. Objective: To determine the utility of skin biopsy and tissue culture for the diagnosis and management of patients admitted with a diagnosis of presumed cellulitis. Design: Pilot single-blind parallel group randomized controlled clinical trial in 56 patients with a primary diagnosis of presumed cellulitis. In the intervention group only, skin biopsy and tissue culture results were made available to the primary care team to guide diagnosis and management. Length of hospital stay and antibiotic use were evaluated as outcome measures. Results: Length of stay showed the greatest opportunity for further study as a primary outcome (intervention: 4, IQR (2–6) vs. control: 5 IQR (3–8) days; p = 0.124). Limitations: The COVID-19 pandemic placed limitations on participant enrollment and study duration; in addition, data was collected from a single medical center. Conclusion: This study demonstrates that length of stay and anti-pseudomonal antibiotic de-escalation are endpoints that may be influenced by biopsy and tissue culture results in presumed cellulitis patients; these outcomes warrant further study.

Diagnosis and Management of Orbital Cellulitis in a Reference Center in Senegal

The severity of orbital cellulitis is the risk of blindness and cerebro-meningeal complications that can be life-threatening. The objective of our study was to report the clinical, paraclinical, therapeutic and progressive aspects of orbital cellulitis. This was a retrospective, descriptive study over 5-year, from 1st January 2017 to December 31st 2021, in the ophthalmology department of Aristide le Dantec University Hospital. We glued 102 patients. The incidence was 32.8 cases per year. The average age was 23 years, the age group from 0 to 15 years was the most representative (49%). The most frequent reason for consultation was eyelid swelling (87%). There was a predominance of preseptal cellulitis (64%). An ORL etiology was found in 21.5% of cases. Orbital-cerebral CT was performed in 57 patients. It made this possible to classify cellulite and identify sinusitis in 21.6% of cases. All patients received antibiotics and corticosteroid therapy were combined 48 hours after the start of treatment in 41 patients. The evolution was favorable in 73.5% of cases. Ten patients (9.8%) presented a complication. We aim for 3 cases of blindness. Death occurred in a patient who presented a bilateral orbital cellulitis complicated by cavernous sinus thrombophlebitis. The prognosis depends on the delay in treatment, the stage of the disease and the existence of comorbidity factors.

Cellulitis in the Emergency Department: A prospective cohort study with patient-centred follow-up.

There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to describe the demographics, clinical features (erythema, warmth, swelling and pain), patient-reported disease trajectory and medium-term follow-up for ED patients with cellulitis. Prospective observational cohort study of adults diagnosed with cellulitis in two EDs in Southeast Queensland, Australia. Patients with (peri)orbital cellulitis and abscess were excluded. Data were obtained from a baseline questionnaire, electronic medical records and follow-up questionnaires at 3, 7 and 14 days. Clinician adjudication of day 14 cellulitis cure was compared to patient assessment. Descriptive analyses were conducted. Three-hundred patients (mean age 50 years, SD 19.9) with cellulitis were enrolled, predominantly affecting the lower limb (75%). Cellulitis features showed greatest improvement between enrolment and day 3. Clinical improvement continued gradually at days 7 and 14 with persistent skin erythema (41%) and swelling (37%) at day 14. Skin warmth was the feature most likely to be resolved at each time point. There was a discrepancy in clinician and patient assessment of cellulitis cure at day 14 (85.8% vs. 52.8% cured). A clinical response of cellulitis features can be expected at day 3 with ongoing slower improvement over time. Over one third of patients had erythema or swelling at day 14. Patients are less likely than clinicians to deem their cellulitis cured at day 14. Future research should include parallel patient and clinician evaluation of cellulitis to help develop clearer definitions of treatment failure and cure.

Management of Streptococcus pyogenes Preseptal Cellulitis in Multisystem Inflammatory Syndrome in Children (MISC)

Introduction : Preseptal cellulitis were more common in children than adults. Preseptal cellulitis was an infection involving the anterior part of the orbita septum. Management of preseptal cellulitis, especially in children, were important to save visual function.
 Case Illustration : A boy, 1 year 8 months, was complained by his mother with swollen and redness on both eyes. The patient has a history of Multisystem Inflammatory Syndrome in Children (MISC) and Global Developmental Delay (GDD). Both eyes were edema, hyperemia, excoriation, bleeding, tenderness on eyelid, and conjunctival injection. Blood Culture examination results showed Streptococcus pyogenes bacteria. Patient was receiving therapy of antibiotics cefoperazone-sulbactam, amikacin, methylprednisolone intravena, enoxaparin subcutaneous injection, moxifloxacin and prednisolone asetat eye drops during hospitalization at Prof. Dr. I.G.N.G. Ngoerah General Hospital.
 Discussion : A patient with fever and respiratory tract infection was diagnosed with preseptal cellulitis. Preseptal cellulitis is a common infection of the eyelid and periorbita soft tissues characterized by acute eyelid erythema and edema. Antibiotic therapy had been started before blood culture examination. This study discusses toddler with preseptal cellulitis treated with antibiotics showing good results.
 ConclusionPreseptal cellulitis due tue multisystem inflammatory syndrome in children was an infection of the soft tissues of the eye that requires a multidisciplinary approach in management therapy. Early detection and adequate therapy have been proven to significantly improve patient survival rates and quality of life.

Management of Head and Neck Cellulitis in a Patient Immunocompetent

Head and neck cellulitis are severe infections, sometimes necrotizing, whose diagnosis is difficult at an early stage. We report the clinical observation of a 60-year-old patient who presented to the emergency room for a right laterocervical swelling associated with a deterioration in general condition. The head and neck CT scan revealed abscessed right cervical cellulitis. The patient underwent drainage and debridement in the operating room with wide necrosectomy and placement of a Delbet blade, associated with dual antibiotic therapy. The evolution was marked by an improvement in the patient's clinical condition. The aim of this work was to highlight the importance of emergency medical-surgical care, without forgetting the treatment of the portal of entry. The progression in the absence of treatment is towards sometimes fatal complications. The prognosis of these infections depends on the precocity of the treatment, its initial quality and the terrain.

Management of Children With Uncomplicated Cellulitis in Emergency and Hospital Settings.

The aim of the study is to establish consensus recommendations on features used to determine the route of antibiotic administration and disposition for children with uncomplicated cellulitis. Modified Delphi methodology was performed with 2 rounds of confidential surveys of Emergency medicine and hospital medicine (HM) providers at Lurie Children's Hospital to assess cellulitis management in children (ages 6 months-18 years) without signs of sepsis or abscess formation. Using a 9-point Likert scale, emergency medicine providers ranked features by perceived level of importance when deciding initial antibiotic route and HM providers ranked features on importance when transitioning to oral antibiotics. Responses were grouped as not important (1-3), neutral (4-6), and important (7-9) and re-evaluated in the second round to reach consensus, defined as ≥70% agreement. Emergency medicine providers (n = 17) reached consensus on 15 of 16 features (93.8%), 10 deemed important. Participants reached greatest consensus (100%) on fevers/chills, lymphangitis, and functional impairment as considerations for initiating intravenous antibiotics. HM providers (n = 15) reached consensus on 9 of 11 factors (81.8%), with 7 considered important when deciding on readiness for oral antibiotics. Providers indicated that stability, rather than reduction, of erythematous margins is sufficient to consider transition and de-escalation of therapy at less than 24 hours if all other clinical improvement criteria are met. This study achieved consensus on important features for treatment and disposition of children with uncomplicated cellulitis in both emergency and inpatient contexts. These features have the potential to aid in decision making and improve standardization of clinical practice.

A Quick Guide for Cellulitis Treatment

Cellulitis, a common bacterial skin infection, poses a clinical challenge in its management due to its varied etiology, ranging from streptococcal to staphylococcal species. This review delves into the intricate landscape of cellulitis treatment, exploring the nuances of antibiotic selection based on infection type, severity, and local epidemiology. The empirical use of antibiotics, guided by an understanding of likely pathogens, is crucial in balancing efficacy and preventing resistance. Special attention is given to the inclusion of MRSA coverage in high-risk scenarios. Tailoring antibiotic regimens to specific clinical situations, such as surgical site infections or diabetic foot complications, underscores the importance of flexibility in cellulitis management. Periodic reassessment, guided by culture results and clinical response, ensures a dynamic and effective treatment course. The review also emphasizes the critical role of antibiotic stewardship in combating resistance and sustaining effective cellulitis management.

AYURVEDIC MANAGEMENT OF CELLULITIS BY JALAUKAVACHARANA: A CASE STUDY

Cellulitisis an acute inflammatory condition of the skin that is characterized by localized pain, erythema, swelling and heat.[1] It is a common bacterial skin infection affecting the dermal and subcutaneous tissues, and poses significant challenges to modern medical treatments due to its recurrent nature and potential complications. In this case study, we explore the efficacy of Ayurvedic interventions in the management of cellulitis, presenting a comprehensive analysis of a single patient's experience. "Vranashoph" is the term from Ayurveda that refers to the inflammation or swelling of wounds or injuries. In Ayurvedic terminology, "Vrana" means wound or injury, and "Shotha" means swelling or inflammation. Here a case of a 32-year-old patient has been presented having cellulitis changes over left lower extremity. The patient had history of Accident 4 years back and after that inflammation and pain and difficulty in movement have been recurrent features. Jalaukavacharan was the choice of treatment .The procedure was done over 8 weeks which reduced the signs and improved the discoloration of the affected part. The case will be discussed here in detail.

Diagnosis and management of cellulitis in a primary care setting

Diagnosis and management of cellulitis in a primary care setting

Microbial patterns and culture utility in orbital cellulitis

To determine the prevalence and types of pathogens found in children with orbital cellulitis and to evaluate the utility of nonoperative cultures. This was a retrospective cohort study of children with imaging-confirmed orbital cellulitis over a period of 8 years. Outcomes included prevalence and types of organisms, polymicrobial infection, mixed aerobic-anaerobic infection, effect of age, and culture utility. Of 220 children with orbital cellulitis, 112 (51%) had cultures taken; 69 (31%) had surgical intervention. Culture sources for the 112 children with cultures included blood (57 patients [51%]), sinus (53 [47%]), orbit (42 [38%]), brain (6 [5%]), and skin/conjunctiva/lacrimal sac (6 [5%]). Streptococcus anginosus group strains grew in cultures from 19 children (17%); methicillin-sensitive Staphylococcus aureus (MSSA), in 15 (13%); Streptococcus pyogenes, in 12 (11%); methicillin-resistant Staphylococcus aureus (MRSA), in 6 (5%); anaerobic/facultative gram negative rods, in 8 (7%); anaerobic Gram-positive cocci, other Viridans group streptococci, and Streptococci pneumoniae, in 3 (3%) each; and normal respiratory/skin flora, in 23 (21%). Polymicrobial infection (P = 0.08) and anaerobic organisms (P=0.58) did not differ by age (range, 0.1-16.8 years). In all 220 (100%) children, nonoperative cultures were either not obtained (108 [49%]), not helpful in avoiding surgery (69 [31%]), showed no growth (39 [18%]), or grew an organism that did not change management from empiric therapy (4 [2%]). While many organisms may be cultured from children with orbital cellulitis, Streptococcus and MSSA were the most common in our study cohort. MRSA is uncommon, so initial empiric coverage is not necessary. Rates of polymicrobial and anaerobic infection were similar across ages. Our results indicate that nonoperative cultures are not indicated in the initial medical management of orbital cellulitis; in our cohort, they neither resulted in treatment changes nor helped avoid surgery.

Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single-centre audit of cellulitis outcomes.

Cellulitis is a common acute skin and soft tissue infection that causes substantial morbidity and healthcare costs. To audit the impact on cellulitis management, regimen tolerability and outcomes of switching from outpatient parenteral antimicrobial therapy (OPAT) using intravenous (i.v.) cefazolin once daily plus probenecid to oral beta-lactam therapy (OBLT) using oral flucloxacillin plus probenecid. We undertook a retrospective audit on cellulitis management, regimen tolerability and outcomes at the Dunedin Public Hospital Emergency Department (ED) before and after a change of the local outpatient cellulitis treatment pathway from OPAT using i.v. cefazolin once daily plus probenecid to OBLT using oral flucloxacillin plus probenecid. OPAT was used in 97/123 (78.9%) patients with cellulitis before compared to 1/70 (1.4%) after the pathway change (odds ratio (OR), 0.04, P < 0.01). OBLT was used in 26/123 (21.1%) patients with cellulitis before and 69/70 (98.6%) after (OR, 218.8, P < 0.01). Antimicrobial change due to intolerance occurred in 4/123 (3.2%) patients with cellulitis before and 4/70 (5.7%) after (OR, 1.8, P, not significant (NS)) the pathway change. Inpatient admission within 28 days occurred in 15/123 (12.2%) cellulitis patients before and 9/70 (12.9%) after (OR, 1.1, P, NS) the pathway change. Implementation of a change in outpatient cellulitis treatment pathway resulted in a significant change in prescribing practice. Our findings suggest that OBLT was both tolerable and had similar outcomes to OPAT.

The management of acute cellulitis in individuals with lymphoedema: a case study

British Journal of Community NursingVol. 28, No. Sup4 Clinical CommentThe management of acute cellulitis in individuals with lymphoedema: a case studyRebecca ElwellRebecca ElwellE-mail Address: [email protected]Macmillan Lymphoedema Advanced Nurse Practitioner, Royal Stoke University Hospital; British Lymphology Society TrusteeSearch for more papers by this authorRebecca ElwellPublished Online:29 Mar 2023https://doi.org/10.12968/bjcn.2023.28.Sup4.S6AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Brindle R, Williams OM, Barton E, Featherstone P. Assessment of antibiotic treatment of cellulitis and erysipelas: a systematic review and meta-analysis. JAMA Dermatol. 2019;155(9):1033-1040. https://doi.org/10.1001/jamadermatol.2019.0884 Crossref, Medline, Google ScholarBritish Lymphology SocietyLS consensus doc 2022. Guidelines on the management of cellulitis in lymphoedema. 2022. https://www.thebls.com/documents-library/guidelines-on-the-management-of-cellulitis-in-lymphoedema (accessed 6 March 2023) Google ScholarKilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;2010(6):CD004299. https://doi.org/10.1002/14651858.cd004299.pub2 Medline, Google ScholarSawai J, Hasegawa T, Kamimura T, et al.. Growth phase-dependent effect of clindamycin on production of exoproteins by Streptococcus pyogenes. Antimicrob Agents Chemother. 2007;51(2):461-467. https://doi.org/10.1128%2FAAC.00539-06 Crossref, Medline, Google ScholarVignes S, Poizeau F, Dupuy A. Cellulitis risk factors for patients with primary or secondary lymphedema. J Vasc Surg Venous Lymphat Disord. 2022;10(1):179-185.e1. https://doi.org/10.1016/j.jvsv.2021.04.009 Crossref, Medline, Google ScholarWounds UK. Patients presenting with ‘red legs’: differential diagnosis and the role of compression. 2022. https://www.woundsme.com/uploads/resources/97f654a22b9afbac3bc6c9dac73e49d3.pdf (accessed 6 March 2023) Google Scholar FiguresReferencesRelatedDetails 1 April 2023Volume 28Issue Sup4ISSN (print): 1462-4753ISSN (online): 2052-2215 Metrics History Accepted 1 December 2022 Published online 29 March 2023 Published in print 1 April 2023 Information© MA Healthcare LimitedPDF download

Epidemiology and Management of Orbital Cellulitis Complicated by Cerebrospinal Disease

Orbital cellulitis is defined as an inflammation of the cellulo-fatty tissue of the orbit. Consecutive to an attack by an infectious agent, they are responsible for serious ocular, venous and especially cerebral complications. Cerebral or intracranial complications are responsible for 5 to 25% of mortality cases. The objective was to reveal the seriousness of cerebral complications of orbital cellulitis to contribute to better patient care in our context. Observation: We report three cases of orbital cellulitis received in ophthalmological consultation whose evolution was marked by the occurrence of cerebral complications which involved the functional and vital prognosis of patients. Discussion: Brain damage from orbital cellulitis is rare but remains the most serious complication. Computed tomography confirms the diagnosis. Their management is multidisciplinary and requires close collaboration between ophthalmologists, radiologists, otolaryngologists, and neurosurgeons. It must be rapid and adapted because the delay in consultations and patient care explains the evolution of the pathology towards these fatal outcomes. Orbital cellulitis is an ophthalmological emergency whose medical management should not suffer from any delay. Conclusion: Orbital cellulitis are rare but serious pathologies and responsible for many complications, particularly cerebral. Antibiotic therapy associated with rapid surgical management can considerably improve the vital and functional prognosis.

Counts of Damage Assessed following Head and Neck Cellulitis of Oral Origin

Introduction: Cellulite is an inflammatory process of bacterial origin of cellulo-adipose tissue. Its evolution and management can be marked by complications that can induce sequelae to patients. The purpose of the study was to determine the counts of harm assessed following surgical management of head and neck cellulitis of oral origin in three hospitals in Yaounde. Methodology: A descriptive and retrospective study was conducted in three hospitals in the city of Yaounde during 2021 for 7 months. Included in our research were patients surgically treated for head and neck cellulitis from January 2010 to December 2018. The data collection was done with a pre-designed sheet and the analysis of the results obtained using the EPI info 7.2.2.6 software. Results: Out of 352 patients collected, male accounted for 63% of cases with a sex ratio of 1.69. The average age was 32.52 ± 11.4 years with extremes ranging from 1 to 73 years. About 46.88% worked in the informal sector. The main functional sequelae were edentulism (68.75%), and the average permanent functional deficit (PFD) was 1.61% ±1.15 with extremes between 0 and 7%. Permanent aesthetic damage (PEP) was mostly very mild, rated at 1/7 in 86.65% of cases. The suffering endured (SE) was mainly very mild, at 1/7 in 91.19% of cases. Conclusion: The counts of harm assessed following odontogenic head and neck cellulitis were aesthetic harm, suffering endured and permanent functional deficit.

Comprehensive Management of Preseptal Cellulitis with Massive Palpebral Abscess in 72-year-old Man

Introduction: Infectious inflammation of the periorbital and orbital soft tissue can be classified as preseptal (periorbital) or postseptal (orbital) cellulitis. Eyelid abscess, an accumulation of pus in the palpebral tissue, can occur in isolation or in association with preseptal cellulitis. Preseptal cellulitis is nearly three times more common than orbital cellulitis. Case Presentation: The patient, in this case, was admitted with a complaint of swollen left eyelid ten days before being admitted. Swollen eyelid with the inability to open the left eye was accompanied by pus discharge five days before coming to the hospital. Current complaints include eyelid pain, swelling, and discharge of thick yellow fluid. Massive abscess with active pus and crust was present in the left superior and inferior eyelid and frontotemporal area. A head CT scan revealed a soft tissue mass in the left sub galea soft tissue, left frontal region, left orbit, and left temporal region. Multi-department consultations and several workups were done to reveal the etiology and plan the appropriate management of this condition. Conclusion: A comprehensive assessment must be done to distinguish preseptal and orbital cellulitis. Ophthalmology examination and imaging are crucial to detect any extension of the palpebral abscess beyond the orbital septum. Examining an immunocompromised state and focal infection is crucial in determining proper treatment.

RISK FACTORS FOR DEVELOPING UPPER LIMB CELLULITIS AFTER BREAST CANCER TREATMENT

Cellulitis is one of the most important troubling complications of breast cancer treatment. Therefore, elucidating the risk factors for cellulitis in patients that have undergone breast cancer treatment is crucial. This is a retrospective medical record study among 523 patients who had received breast cancer treatment and were referred to the Lymphedema Clinic. Data on age, height, weight, BMI (body mass index), education level, arm dominance, history of previous surgery, axillary lymph node dissection, radiotherapy, and chemotherapy were noted. The time between operation and onset of lymphedema, duration of lymphedema, history of cellulitis, and number of cellulitis attacks were recorded. Circumference measurements were taken at four points on the upper limb. Univariate analysis showed that longer duration of lymphedema, larger circumference of the unaffected arm and larger circumference of the arm with lymphedema were associated with higher risk of cellulitis (p=0.008, p=0.007, p< 0.001, respectively). The incidence of cellulitis was higher in patients with lymphedema than patients who had no lymphedema (p< 0.001). Moreover, the frequency of cellulitis was higher in patients with lower education level (p=0.015). It was deter-mined that patients with cellulitis needed more compression garments (p< 0.001) and multi-layered bandage therapy (p< 0.001) than those without. Regression analysis revealed that presence of lymphedema (p=0.036), duration of lymphedema (p=0.048), radiotherapy (p=0.01) and educational level (0.019) are significantly associated with developing upper extremity cellulitis. It is important to consider these risk factors for the prevention and management of cellulitis in patients who undergo treatment for breast cancer. Early detection and treatment of lymphedema also remains essential for these patients.

The spectrum, management and outcome of cellulitis in subtropical South Africa.

This study aimed to ascertain the microbiology, severity stratification, and clinical outcomes of cellulitis based on our current management for comparison with international reports. A retrospective chart review was conducted of all patients with cellulitis treated by the department of surgery at Ngwelezana Hospital over an 18-month period. Severity of cellulitis was graded, and a comparison was made of the Eron and Modified Dundee classifications. Superficial swabs were taken for culture on patients who had cellulitis with open wounds or blisters. Culture results, antibiotics used, need for surgical intervention, and length of hospital stay were documented and analysed. One hundred and thirty-four patients had cellulitis. Severity grading for classes I-IV in the Eron classification was 3%, 57%, 39% and 1%, respectively, and for the Modified Dundee classification, 47%, 11%, 38%, and 4%, respectively. Co-amoxiclav was the most used antibiotic (73%). Superficial skin swabs were taken from 49 patients and 34 cultured 44 specific organisms. The most common organism identified was Staphylococcus aureus (30%). Several gram-negative and anaerobic organisms were cultured. Fifty-three patients required surgical debridement of the infected area and one patient required an above-knee amputation. Mean hospital stay for patients who did not receive surgical intervention was 6 days (IQR 3) and 7 days (IQR 4) for those who did. There were no deaths. The Dundee classification triages fewer patients as class 2 severity than the Eron system and its use has the potentail to reduce the number of patients hospitalised. Gram-positive organisms predominated in those cultured, but gram-negative cultures were frequent compared to other reported series. Co-amoxiclav is effective as first-line antimicrobial therapy in our environment.

Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?

Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.

A Rare Case of Orbital Cellulitis with Tolosa-Hunt Syndrome Caused by Methicillin-Resistant Staphylococcus aureus (MRSA): a Case Report

Background: Orbital cellulitis is an active infection of the orbital soft tissue posterior to the orbital septum, which can cause Tolosa-Hunt Syndrome (THS) complication. Purpose: We reported a child with orbital cellulitis with THS complication caused by methicillin-resistant Staphylococcus aureus (MRSA). Case: A two-year-old girl complained of swelling and pain in the left eye accompanied by fever. In nasal region and left eye showed multiple erythema patches with geographic shape, size 1x2cm - 4x5cm, unclear border, erosion with sizes 0.5x1cm - 1x1.5 cm size covered with blackish crusts. After several days of hospitalization, she complained of proptosis and pain in moving her eye. We did the magnetic resonance imaging (MRI) scan examination, which showed a mass size of 2.2 x1.1 x 0.9 cm in a left intraconal orbital and dilation of the left-sided cavernous sinus. The blood culture showed MRSA bacteria. She was diagnosed with orbital cellulitis with THS complication and showed a good response with Meropenem, Methylprednisolone, cendo lyteers eye drops, levofloxacin eye drops, and gentamicin eye ointment. Discussion: Orbital cellulitis presents as ill-defined erythema, edema, warmth, and pain around the nasal and the orbital region and is more often found in children. The THS complication is characterized by ophthalmoplegia, unilateral orbital or periorbital pain, unilateral headache, and leukocytosis. Orbital cellulitis management includes antibiotic intravenous, corticosteroid, and eye care. Conclusion: THS is a rare complication of orbital cellulitis. Early diagnosis and management of orbital cellulitis are essential to prevent THS complication.

Performance of infectious diseases specialists, hospitalists, and other internal medicine physicians in antimicrobial case-based scenarios: Potential impact of antimicrobial stewardship programs at 16 Veterans' Affairs medical centers.

As part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing. An online survey explored attitudes toward antimicrobial use and assessed respondents' management of four clinical scenarios: cellulitis, community-acquired pneumonia, non-catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria. This study was conducted across 16 Veterans' Affairs (VA) medical centers in 2017. Physicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine. Scenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and -1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA). Overall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non-catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12). Significant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.