Non-purulent Cellulitis Research Articles

Ticked-Off Rash

An 89-year-old female initially presented to outpatient clinic for systemic symptoms of high-grade fever, malaise and unintentional weight loss along with a rash that was presumed to be non-purulent cellulitis. After several courses of antibiotics, the patient’s symptoms worsened and was eventually hospitalized. Blood cultures resulted positive for Francisella tularensis . After more history taking the patient noted that she was bit by a tick during a camping trip that resulted with the initial rash.

THU658 My Giant Calves Gave Up My Diagnosis: An Extreme Manifestation Of A Very Rare Syndrome With A Severe Elevation Of Tsh Levels

Abstract Disclosure: E.E. Castro Feliu: None. A. Ludena De Freitas: None. A. Torres Rodríguez: None. G. Irizarry: None. Hoffmann’s Syndrome is a rare type of hypothyroidism myopathy in adults that classically presents with muscle cramps, weakness, muscle stiffness, hyporeflexia, delay deep tendon reflexes and pseudohypertrophy. This is the case of a 55-year-old male with history of poorly controlled hypothyroidism and medication non-compliance who was admitted to our institution for non-purulent cellulitis. Vital signs were within normal limits and Body Mass Index was 41.1. Upon physical examination flat affect, periorbital edema, moon facies features and macroglossia were distinguished. Skin had a doughy texture with areas of ichthyosis at upper and lower extremities. Goiter was absent. The most remarkable finding was bilateral calf hypertrophy, with measurements of 56 cm and 55.5 cm in diameter of right and left calves respectively. There was no tenderness to calf palpation and Homan’s sign was absent. Laboratories revealed dyslipidemia with a cholesterol of 308 mg/dL, triglycerides of 782 mg/dL, HDL of 26 mg/dL and LDL of 216 mg/dL with elevated inflammatory markers including sedimentation rate of 77 mm/hr and C-reactive protein of 6.45 mg/dL. Hypothyroidism was suspected therefore thyroid studies were ordered, which was compatible with severe hypothyroidism demonstrated by a record level TSH of 523 lU/ml. Other reported levels were Free T3 0.94pg/ml, total T3 0.5 ng/ml, free thyroxine <0.07 ng/dL, thyroid peroxidase <4, and thyroglobulin AB 19 IU/ml. Hoffmann’s Panel was confirmatory for this diagnosis reporting elevated levels of CPK 1509 U/L, LDH serum of 383 U/L and aldolase of 9.2 u/L. Ultrasound of the neck was non-contributory. Patient received antibiotic therapy for his skin infection and was also treated with IV Levothyroxine, which was prescribed orally upon discharge. Myopathy may be present in patients with longstanding untreated hypothyroidism in which pseudohypertrophy may occur, sometimes involving calf muscles (gastrocnemius). Hoffmann’s Syndrome is associated with changes in muscle fiber type from fast twitch type II to slow twitch type I and alteration of oxidative muscle enzyme activity with deceased calcium ATPase activity of fast twitch type II fibers leading to delayed relaxation. Biopsy of the affected muscle may reveal fiber necrosis, atrophy, hypertrophy with increased number of nuclei and increased connective tissue. Most cases of Hoffmann’s Syndrome improve after treatment with Levothyroxine, therefore, implementing this management on time can be curative. This case highlights the importance of considering this diagnosis when muscle dystrophies are studied and myopathic disorders are suspected, even in the absence of overt manifestations of hypothyroidism. Presentation: Thursday, June 15, 2023

Diagnostic methods for the confirmation of non-purulent cellulitis: a review.

Cellulitis is the most common cause for skin disease hospitalization with costs totaling over $7 billion. It can be challenging to diagnose due to clinical similarities with other inflammatory conditions and the lack of a gold-standard diagnostic test. This article reviews the different testing methods for the diagnosis of non-purulent cellulitis based on three categories (1) clinical scoring assessments, (2) in vivo imaging techniques, and (3) laboratory assessments.

High-dose cephalexin for cellulitis: a pilot randomized controlled trial

Up to 3% of all Emergency Department (ED) visits are due to skin and soft tissue infections such as non-purulent cellulitis. The current treatment failure rate is approximately 20%. Evidence is lacking regarding the optimal outpatient management of cellulitis. To evaluate the feasibility of a randomized trial comparing high-dose (1000mg) to standard-dose (500mg) cephalexin to treat ED patients with cellulitis. A parallel arm double-blind randomized controlled pilot trial conducted at two EDs in Canada. Eligible participants were adults (age ≥ 18years) presenting to the ED with non-purulent cellulitis and determined by the treating emergency physician to be eligible for outpatient management with oral antibiotics. Participants were randomized to high-dose or standard-dose cephalexin four times daily for 7days. The primary feasibility outcome was participant recruitment rate (target ≥ 35%). The preliminary primary effectiveness outcome was oral antibiotic treatment failure. Of 134 eligible participants approached for trial participation, 69 (51.5%, 95% CI 43.1 to 59.8%) were recruited and randomized. After excluding three randomized participants due to an alternate diagnosis, 33 participants were included in each arm. Nineteen eligible cases (14.2%) were missed. Loss to follow-up was 6.1%. Treatment failure occurred in four patients (12.9%) in the standard-dose arm versus one patient (3.2%) in the high-dose arm. A greater proportion had minor adverse events in the high-dose arm. No patients had an unplanned hospitalization within 14days. This pilot randomized controlled trial comparing high-dose to standard-dose cephalexin for ED patients with cellulitis demonstrated a high participant recruitment rate and that a full-scale trial is feasible. High-dose cephalexin had fewer treatment failures but with a higher proportion of minor adverse effects. The findings of this pilot will be used to inform the design of a future large trial. This trial was registered at ClinicalTrials.gov (NCT04471246).

Characterization of antibiotic overuse for common infectious disease states at hospital discharge.

To evaluate rates of and outcomes associated with antibiotic overuse at hospital discharge for patients with common infectious diseases states. Single-center, respective cohort study. A large, academic medical center in the Midwest United States. Adult patients who received antibiotics for community-acquired pneumonia (CAP), uncomplicated cystitis, or mild, non-purulent cellulitis. Patients were excluded if they did not receive antibiotic(s) upon hospital discharge, were pregnant, severely immunocompromised, had concomitant infections, died during hospitalization, or were transferred to another hospital or to an intensive care unit. Data were abstracted from the electronic medical record of ambulatory antibiotic orders for included patients based on inpatient encounters from August 1, 2021 through July 31, 2022. Of the 182 patients included in the study, antibiotic overuse was common for all three infectious disease states: CAP (n = 87/125, 69.6%), uncomplicated cystitis (n = 21/28, 75.0%), mild, non-purulent cellulitis (n = 28/29, 96.6%). The prevailing reason for overuse was excessive antibiotic duration (n = 127/182, 69.8%; mean antibiotic duration 5.39 vs. 8.32 days, p = 0.001). Antibiotic overuse was associated with approximately one additional day in the hospital (2.48 vs. 3.32 days, p = 0.001), and an increase in emergency department visits within 30 days after discharge (1 vs. 31, p = 0.001) compared to patients without antibiotic overuse at discharge. Antibiotic overuse was prevalent upon hospital discharge for these three common infectious disease states. Transitions of care should be prioritized as an area for antimicrobial stewardship intervention.

Evaluation of Dundee and ALT-70 predictive models for cellulitis in 56 patients who underwent tissue culture.

Nonpurulent cellulitis lacks a gold standard to distinguish noninfectious sources of inflammation. Two models have been created that evaluate cellulitis. The ALT-70 model was created to reduce the overdiagnosis of cellulitis and provide clinical direction. The Dundee classification was developed to grade the severity of previously diagnosed cases of cellulitis and enhance treatment and clinical outcomes. We analyzed a dataset of 56 patients who were admitted to the OSU Wexner Medical Center with a primary admission diagnosis of cellulitis. Each patient underwent extensive tissue culture sampling to identify potential pathogens. Patients were scored using both models, then evaluated based on the positive tissue culture and skin and soft tissue infection. In both models, we found low sensitivity and specificity to predict patients with positive tissue culture cellulitis. Determination of a gold standard for classification of cellulites is important to improve future diagnosis and risk models. We recommend further study to develop a scalable consensus standard in the diagnosis of nonpurulent cellulitis.

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.

Aligning Provider Prescribing With Guidelines for Soft Tissue Infections.

Despite evidence-based guidelines, antibiotics prescribed for uncomplicated skin and soft tissue infections can involve inappropriate microbial coverage. Our aim was to evaluate the appropriateness of antibiotic prescribing practices for mild nonpurulent cellulitis in a pediatric tertiary academic medical center over a 1-year period. Eligible patients treated in the emergency department or urgent care settings for mild nonpurulent cellulitis from January 2017 to December 2017 were identified by an International Classification of Diseases, Tenth Revision, code for cellulitis. The primary outcome was appropriateness of prescribed antibiotics as delineated by adherence with the Infectious Diseases Society of America guidelines. Secondary outcomes include reutilization rate as defined by revisit to the emergency department/urgent cares within 14 days of the initial encounter. A total of 967 encounters were evaluated with 60.0% overall having guideline-adherent care. Common reasons for nonadherence included inappropriate coverage of MRSA with clindamycin (n = 217, 56.1%) and single-agent coverage with sulfamethoxazole-trimethoprim (n = 129, 33.3%). There were 29 revisits within 14 days of initial patient encounters or a reutilization rate of 3.0%, which was not significantly associated with the Infectious Diseases Society of America adherence. Our data show antibiotic prescription for nonpurulent cellulitis as a potential area of standardization and optimization of care at our center.

Cellulitis: A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis.

Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.

Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians.

Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections. The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence. Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility. In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.

Purulent and Non-Purulent Cellulitis In Hospitalized Children: Risk Factors And Outcomes

Purulent and Non-Purulent Cellulitis In Hospitalized Children: Risk Factors And Outcomes

193. quality Improvement Initiative for Non-purulent Cellulitis Management in Urgent care setting: provider-level Performance Feedback

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs). This has resulted in an 88% increase in MRSA-directed antibiotic use in emergency departments. However, the majority of cellulitis presents as non-purulent due to Group A streptococci. An unintended consequence is that many with non-purulent cellulitis receive sub-optimal antibiotics and unnecessary diagnostics. Clinical guidelines at our institution recommend beta-lactam antibiotics and discourage empiric MRSA coverage for non-purulent cellulitis. The aim of this study is to use an audit-feedback intervention to optimize urgent care providers management of mild/moderate non-purulent cellulitis.MethodsWe identified all consecutive patients presenting to our urgent care with a diagnosis of lower extremity non-purulent cellulitis using ICD coding. We conducted a prospective pre and post-intervention study from 10/2018-3/2019 and 11/2019-4/2020 respectively. Intervention included review of practice guidelines with providers and feedback from pre-intervention phase. To assess individual practitioners’ prescribing habits, a comprehensive scoring system focused on empiric antibiotic selection, antibiotic duration, and diagnostics was combined with patient demographics. Scores classified non-purulent SSTI treatment as follows: 0–2 = good, 2.5–5 = fair, and >5.5 = poor (Figure 1).Figure 1: Provider Cellulitis Management Scoring Sheet ResultsThere was statistically significant provider score improvement in the post-intervention phase with greater percentage of good cases (40% to 69%) and no poor cases (Figure 2). For IV antibiotics for mild and moderate cellulitis, there was decreased use of overly broad antibiotics (Figure 3). Antibiotic duration of greater than 7 days decreased from 68% to 52%. Combination antibiotic therapy decreased from 12% to 4%. There was also a statistically significant decrease in use of wound cultures but no change in ultrasound use.Figure 2: Overall Provider Scores Figure 3: IV Antibiotic Use ConclusionAudit-feedback intervention was effective for improving antibiotic usage and decreasing treatment duration. Providing physicians with data on their practice patterns relative to those of their peers and clinical practice guidelines can improve management of non-purulent cellulitis.Disclosures All Authors: No reported disclosures

18. Durations of Antibiotic Therapy and Factors Associated with Longer Than Recommended Durations for Common Ambulatory Infections in an Integrated Healthcare System

BackgroundDuration of antibiotic therapy is an important focus for antibiotic stewardship, but the extent and drivers of excessive durations are not well understood. This project aimed to describe durations of therapy prescribed for common infections across the ambulatory care settings of an integrated healthcare system and identify factors associated with longer than recommended durations.MethodsThis was a retrospective, cross-sectional evaluation conducted from July 1, 2018 to June 30, 2019. We identified antibiotic prescriptions for adults age 18 years or older presenting to a Denver Health ambulatory care facility (urgent care, emergency department, family medicine clinic, or internal medicine clinic) for an infection with a recommended duration of therapy of 5 days or less based on institutional guidance. Infections included purulent and non-purulent cellulitis, uncomplicated subcutaneous abscess, acute bacterial sinusitis (ABS), acute otitis media (AOM), community acquired pneumonia, cystitis, and pyelonephritis treated with an indicated fluoroquinolone. Prescriptions for more than 5 days were classified as longer than recommended. We evaluated whether the following factors were associated with longer than recommended prescriptions: location of visit, type of infection, patients’ age, race/ethnicity, sex, infection type, and prescribing provider typeResults5331 prescriptions met inclusion criteria. Of those, the duration of therapy was longer than recommended for 2095 (39%) (Table 1). Durations varied significantly across locations (p< 0.0001). In the sub-group analysis family medicine clinics had the highest proportion of longer than recommended durations (46%). Durations also varied significantly by type of infection. For cellulitis, ABS, and AOM, the duration was longer than recommended in 50%, 54%, and 75% of cases, respectively. Other factors associated with longer than recommended durations included male sex (p< 0.0001) and prescriptions by advanced practice providers (p = 0.0008).Table 1: Antibiotic Duration of Therapy for Common Outpatient InfectionsConclusionCare locations, infection types, and both patient and prescriber factors were associated with longer than recommended prescriptions suggesting specific opportunities to prevent excessive durations of therapy. Disclosures All Authors: No reported disclosures

A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship.

The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.

MP52: Effectiveness of an outpatient parenteral antibiotic therapy clinic for adults with non-purulent cellulitis

Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age &gt;=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p &lt; 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were &lt;2% and adverse events were &lt;5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.

A Multicenter Evaluation of Vancomycin-Associated Acute Kidney Injury in Hospitalized Patients with Acute Bacterial Skin and Skin Structure Infections.

BackgroundWe sought to determine the real-world incidence of and risk factors for vancomycin-associated acute kidney injury (V-AKI) in hospitalized adults with acute bacterial skin and skin structure infections (ABSSSI).MethodsRetrospective, observational, cohort study at ten U.S. medical centers between 2015 and 2019. Hospitalized patients treated with vancomycin (≥ 72 h) for ABSSSI and ≥ one baseline AKI risk factor were eligible. Patients with end-stage kidney disease, on renal replacement therapy or AKI at baseline, were excluded. The primary outcome was V-AKI by the vancomycin guidelines criteria.ResultsIn total, 415 patients were included. V-AKI occurred in 39 (9.4%) patients. Independent risk factors for V-AKI were: chronic alcohol abuse (aOR 4.710, 95% CI 1.929–11.499), no medical insurance (aOR 3.451, 95% CI 1.310–9.090), ICU residence (aOR 4.398, 95% CI 1.676–11.541), Gram-negative coverage (aOR 2.926, 95% CI 1.158–7.392) and vancomycin duration (aOR 1.143, 95% CI 1.037–1.260). Based on infection severity and comorbidities, 34.7% of patients were candidates for oral antibiotics at baseline and 39.3% had non-purulent cellulitis which could have been more appropriately treated with a beta-lactam. Patients with V-AKI had significantly longer hospital lengths of stay (9 vs. 6 days, p = 0.001), higher 30-day readmission rates (30.8 vs. 9.0%, p < 0.001) and increased all-cause 30-day mortality (5.1 vs. 0.3%, p = 0.024)ConclusionsV-AKI occurred in approximately one in ten ABSSSI patients and may be largely prevented by preferential use of oral antibiotics whenever possible, using beta-lactams for non-purulent cellulitis and limiting durations of vancomycin therapy.Electronic supplementary materialThe online version of this article (10.1007/s40121-019-00278-1) contains supplementary material, which is available to authorized users.

463. Evaluation of Trimethoprim-Sulfamethoxazole Utilization for Skin and Soft-Tissue Infections During Emergency Department Visits at Two Community Teaching Hospitals

BackgroundIncreasing trimethoprim/sulfamethoxazole (TMP/SMX) resistance has been noted among inpatient and outpatient isolates of methicillin-resistant S. aureus (MRSA) at two community teaching hospitals in Northern New Jersey. The purpose of the study is to evaluate the indications for TMP/SMX prescriptions for adult Emergency Department (ED) discharges. In addition, since IDSA guidelines for the management of skin and soft-tissue infections (SSTIs) do not recommend the use of anti-MRSA antibiotics for non-purulent SSTIs, we chose to determine guideline concordance of antibiotic selection for non-purulent SSTIs.MethodsTMP/SMX susceptibility data for S. aureus from 2014 to 2018 at two community teaching hospitals were compiled. A retrospective chart review was then conducted of all adult patients who were discharged from the ED with an antibiotic prescription from January to March 2019. Antibiotic indications were extracted based on ED diagnosis and review of the medical record. In patients treated for non-purulent cellulitis, antibiotic prescription information and antibiotic allergies were collected and assessed for guideline concordance. Guideline-concordance for non-purulent cellulitis was defined as treatment with B-lactams or clindamycin.ResultsTMP/SMX susceptibility against S. aureus is displayed in Figure 1. Of 338 patients discharged with a prescription for TMP/SMX, 60% were treated for SSTIs, 30% were treated for urinary tract infections, and 10% were treated for other indications. Among 203 patients treated with a TMP/SMX-containing regimen for SSTIs, 76% had purulent or wound-related infection. Of 137 patients treated for non-purulent cellulitis, 68% of antibiotic regimens were guideline-concordant. In addition, 19% of antibiotic regimens for non-purulent cellulitis contained TMP/SMX.ConclusionA substantial reduction in TMP/SMX susceptibility among MRSA, but not MSSA, isolates has been observed. Opportunities to improve utilization of TMP/SMX for SSTIs exist at our institutions. Additional studies are warranted to determine the factors associated with increasing TMP/SMX resistance in MRSA. Disclosures All authors: No reported disclosures.

Skin Infections in Indiana Nursing Homes

Background and Hypothesis: OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality, &amp; Improving Symptoms: Transforming Institutional Care) is a CMS (Centers for Medicare and Medicaid Services) demonstration project that aims to improve nursing home care. CMS provides enhanced reimbursement to nursing homes in the project when they are able to treat six conditions in the facility rather than being transferred to a hospital, one of which being skin infections. The purpose of this study is to examine the diagnosis, treatments, and outcomes of skin infections of residents in nursing homes enrolled in OPTIMISTIC.&#x0D; Experimental Design or Project Methods: A chart review of 26 cases was conducted using data from nursing home medical records of nine OPTIMISTIC facilities. Cases were randomly selected from billing episodes between November 2018 and May 2019. Data was entered into an Excel extraction tool created for the project and analyzed.&#x0D; Results: Of the randomly selected skin infections, 46.2% were diagnosed as non-purulent cellulitis and 23.1% as purulent cellulitis. Other infections included abscesses, infected pressure injuries, and shingles. Doxycycline was the most common antibiotic prescribed, used in 42.3% of the total skin infections. For non-purulent cellulitis, cephalexin was the next most used antibiotic (41.7%). Twelve of the skin infections were recurrent, and the most common antibiotic used for those infections was doxycycline. Of the twenty-six cases, twenty-three were resolved in the facility, one was recertified for a longer length of time, one was transferred to the hospital, and one was transferred to hospice.&#x0D; Conclusion and Potential Impact: This project provides a unique opportunity to examine diagnosis and treatment patterns of skin infections in nursing homes. The results of this study will be used to bolster and augment future efforts at nursing home care improvement for patients diagnosed with skin infections in the facility.

Evaluation of Efficacy of Standard Treatment of Non-Purulent Cellulitis

Backgound: Cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, a process usually related to acute infection that does not involve the fascia or muscles. Cellulitis is characterized by localized pain, swelling, tenderness, erythema, and warmth, cellulitis has been classically considered to be an infection without formation of abscess (nonpurulent), purulent drainage, or ulceration. Objective: The aim of the current work was to evaluate the efficacy of standard treatment for cases of cellulitis and identify other treatment options if needed in local community. Patients and methods: This prospective study was conducted at Department of General Surgery, Al-Azhar university hospitals (Al-Hussin & Said Galal hospitals). This study carried out on 100 consecutive patients with non-purulent cellulitis from 23/2/2017 to 1/5/2018 to allow a minimum follow-up period of at least 4 months for the last case follow upon. Clinical response to dicloxacillin, amoxicillin, and cephalexin was evaluated. Results: Age, sex, presentation, sit of non purulent cellulitis and result were recorded. Cellulitis was found to be more common in geriatric patients and slightly more in females. Most patients had lower limb cellulitis, and only little patients had an additional sit as orbit, hand and genitalia. 83 cases have good clinical response and 17 cases have poor clinical response within 7 days to dicloxacillin, amoxicillin, and cephalexin. Conclusion: Dicloxacillin, amoxicillin, or cephalexin are effective in most cases of cellulitis with gram positive organisms as Streptococcal and staphylococcal species.

Evaluation of Efficacy of Standard Treatment of Non-Purulent Cellulitis

Backgound: Cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, a process usually related to acute infection that does not involve the fascia or muscles. Cellulitis is characterized by localized pain, swelling, tenderness, erythema, and warmth, cellulitis has been classically considered to be an infection without formation of abscess (nonpurulent), purulent drainage, or ulceration. Objective: The aim of the current work was to evaluate the efficacy of standard treatment for cases of cellulitis and identify other treatment options if needed in local community. Patients and methods: This prospective study was conducted at Department of General Surgery, Al-Azhar university hospitals (Al-Hussin & Said Galal hospitals). This study carried out on 100 consecutive patients with non-purulent cellulitis from 23/2/2017 to 1/5/2018 to allow a minimum follow-up period of at least 4 months for the last case follow upon. Clinical response to dicloxacillin, amoxicillin, and cephalexin was evaluated. Results: Age, sex, presentation, sit of non purulent cellulitis and result were recorded. Cellulitis was found to be more common in geriatric patients and slightly more in females. Most patients had lower limb cellulitis, and only little patients had an additional sit as orbit, hand and genitalia. 83 cases have good clinical response and 17 cases have poor clinical response within 7 days to dicloxacillin, amoxicillin, and cephalexin. Conclusion: Dicloxacillin, amoxicillin, or cephalexin are effective in most cases of cellulitis with gram positive organisms as Streptococcal and staphylococcal species.