Generally speaking, the diagnosis of cellulitis is a fairly straightforward clinical evaluation – even in the Emergency Department. This article, however, says “we’re doing it wrong!” to the tune of $225M of waste on the inpatient side.
These authors retrospectively reviewed 183 patients admitted through their hospital system for a diagnosis of cellulitis, with a focus on imaging and blood cultures obtained. Of these, 83 (45%) underwent at least one form of imaging, with a handful a greater number, with 8 identifying an important additional or alternative diagnosis. Then, 60 (33%) received blood cultures, one of whom had conclusive culture growth – although the authors do not characterize whether it changed or narrowed antibiotic therapy. They ultimately conclude, in these otherwise non-toxic patients, these tests are of low value and ought be severely curtailed.
As much as I generally agree with the various Less is More-themed articles in this vein, I’m not sure this one entirely hits the mark. These 183 patients are inpatient hospitalizations, with progressive disease or significant comorbid disease – a far cry from the uncomplicated cellulitis representing the majority of our throughput. While these statistics may look grim, and they absolutely reflect generally low-value practice, this is a heterogenous cohort of patients in whom some of these tests were reasonable based on clinical examination and a reasonable pretest likelihood of a clinical important alternative entity. There is prudence and value to be found in reflecting on the assessment of cellulitis – but $225M might be a little bit of hyperbole.
“Clinical Usefulness of Imaging and Blood Cultures in Cellulitis Evaluation”
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2676998
fyi typo:
“The is prudence and value”
Thx.