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There is a lack of evidence-based guidance for management of cellulitis and use of outpatient parenteral antimicrobial therapy (OPAT) in children. The only published guidelines for skin infections are for adults.1 Lack of standardised guidelines for children can result in variation in paediatricians’ practice, with implications on care and resources.2 Our aim was to understand hospital paediatricians’ opinions about cellulitis management, important in reducing variation in care, regarding: (1) indications for using intravenous antibiotics, (2) indications for hospitalisation and (3) barriers to OPAT.
This web-based anonymous survey was undertaken over 4 weeks at The Royal Children’s Hospital in Melbourne. Acute care paediatricians who diagnose and manage cellulitis were surveyed. Questions related to a clinical scenario (box 1), and none were mandatory.
A 3-year-old previously well girl presents to the emergency department with swelling and tenderness on her left shin after grazing her leg in the park when she fell. On examination, she has a temperature of 38.5°C but is systemically well, with an area of erythema, swelling and tenderness measuring 20×10 cm on her lower left shin. She has tracking lymphangitis going up 10 cm to above knee level. She can weight bear but has a limp.
There were 106/138 (77%) responses. All participants classified the scenario as moderate/severe, and 97/98 (99%) would use intravenous antibiotics, with clinical features used to determine treatment route (see table 1). Seventy out of 104 (67%) physicians responded that a clinical score to guide route would be useful to decrease variation; among trainee doctors, this was 31/40 (78%). Trainees were more likely than senior clinicians to organise investigations (92% vs 71%, OR 4.6 95% CI 1.3 to 15.8, p=0.02). Sixty per cent of physicians would take a blood culture, although there was wide variation in perceived risk of bacteraemia: 46% believed it to be ≤5% and 15% to be >50%.
Regarding location of intravenous antibiotic treatment, a similar proportion chose home with OPAT 51/98 (52%) as hospital admission 46/98 (47%). The reasons for choosing hospitalisation in preference to OPAT were frequently the same as for choosing intravenous antibiotics over oral, although there were several differences (table 1). Potential barriers to OPAT were identified (table 2). Despite this, 81/96 (84%) physicians believed more than 60% parents would prefer home treatment. Sixty-six out of 92 (72%) clinicians would accept 10%–30% (median 20%) patients on OPAT re-presenting to hospital.
From this survey, it appears that most physicians would choose intravenous antibiotics for moderate/severe cellulitis. Where the decision for antibiotic route is less clear, the new Melbourne ASSET score for cellulitis in children aims to guide between intravenous and oral antibiotics.3 When prescribing intravenous antibiotics, only half of physicians would choose home treatment despite cellulitis having low morbidity, low bacteraemia rate and studies showing safe treatment at home.4 Lymphangitis and fever were more likely to affect choosing intravenous treatment than choosing hospitalisation suggesting that clinicians were receptive to treating patients with more severe features via OPAT as long they received intravenous treatment. In contrast, family preference was not relevant in choosing route, although it was considered a factor in choosing location. This suggests that while physicians consider route to be a medical decision, location choice can have non-medical input. Considering the risks associated with hospitalisation, we believe clinicians should consider treatment location a medical decision. Supporting this, physicians were willing to accept a 20% risk of patients re-presenting to hospital while receiving OPAT and still consider this a valuable pathway. Barriers identified for the OPAT pathway are amenable to education and should inform future endeavours to address physician hesitance.
We are grateful to all the physicians for their participation in the survey.
Contributors LFI conceptualised, designed and coordinated the study, contacted participants, drafted the initial manuscript and approved the final manuscript as submitted. PAB, FEB and SMH were involved in the design of the study, data analysis, reviewed and revised the manuscript and approved the final draft. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding This study was funded in part by grants from The Royal Children’s Hospital (RCH) Foundation, the Murdoch Children’s Research Institute (MCRI), the Victorian Department of Health, Melbourne, Australia. LFI was supported in part by a scholarship from AVANT Mutual Group Ltd, Melbourne, the Melbourne Children’s Campus Postgraduate Health Research Scholarship and the Doctor Nicholas Collins Fellowship. PAB was in part supported by a Melbourne Campus Clinician Scientist Fellowship, Melbourne, Australia. FEB was supported in part by a grant from the RCH Foundation and a Melbourne Campus Clinician Scientist Fellowship, Melbourne, Australia, and a National Health and Medical Research Council (NHMRC) Practitioner Fellowship, Canberra, Australia. The emergency research group, MCRI, is in part supported by an NHMRC Centre for Research Excellence Grant for Paediatric Emergency Medicine, Canberra, Australia, and the Victorian government infrastructure support programme.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.