Mid-Level Providers

Mid-Level Providers

Who they are, what they do, and why they’re changing emergency medicine

How to make sense of the puzzle and improve your practice.

When Patients Lie

When Patients Lie

How to Spot Deception, What You Can Do, and Why it Matters

Accusing anyone of lying is serious business, but when that person is your patient, the stakes are even higher. 

Raves and Saves

Raves and Saves

Advanced Emergency Management at Mass Gatherings

EM is crucial at drug-fueled electronic dance festivals, like this month’s Electric Zoo in New York.  

Transfusion Confusion

Transfusion Confusion

Knowing the Real Risks of Blood Transfusion

This routine procedure bears real risks and should be handled accordingly.

The ABCs (and T) of Rural EM

The ABCs (and T) of Rural EM

Situational Awareness is Key

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing…

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

Debunking 5 Fallacies

Improve your EOL care and communicate more effectively.

Through the Looking Glass

Through the Looking Glass

Three Novel Use Cases for Google Glass in the ED

How might augmented reality change your practice?

Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Frontpage Slideshow | Copyright © 2006-2014 JoomlaWorks Ltd.
Print
E-mail
Reprint
Review by Jose Vega, MD
Column Organized by Evan Schwarz, MD
Division of Emergency Medicine
Washington Univeristy
Mills AM. Chen EH.  Are Blood Cultures Necessary in Adults with Cellulitis?  Ananls of Emergency Mediicne May 2005; 45 (5) 548-549.
 
Cellulitis is a common soft tissue infection that extends into the dermis and subcutaneous tissues.  Microorganisms, typically gram-positive bacteria, invade disrupted skin leading to clinically apparent infection.  The hallmark physical findings include pain, redness, swelling, warmth and lymphangitis if the infection is within the lymphatic system.  Systemic antibiotic therapy is routinely used to treat cellulitis. However, identifying a specific pathogen is often not possible on clinical grounds. Therefore, antibiotic therapy with activity against group A Streptococcus and Staphylococcus aureus is usually selected empirically.  Ideally, blood culture susceptibility would direct antimicrobial therapy.  Mills and Chen reviewed 5 original published research articles that specifically addressed the utility of blood cultures in adult cellulitis. 
 
Perl et al performed a retrospective study of 757 patients that were admitted for community acquired cellulitis, of which 553 had blood cultures performed.  A specific microbial strain was isolated in 11 cases and 9 cases grew gram-positive organisms and were already treated with appropriate antimicrobial therapy.  The other 2 cases had risk factors for a more complicated infection such as an indwelling catheter.  Contaminant organisms were seen in 20 cases.  Hook et al conducted a prospective study that evaluated the diagnostic value of cultures from primary site infections, aspirates from the advancing edge erythema, skin biopsy specimens and blood cultures from 50 adults with cellulitis.  Blood cultures were positive in 2 patients, Group A streptococci was isolated from one and staph from the other.  Bottom Line:  blood cultures are of little value in determining the microbial origin of acute cellulitis and no patient required change in antimicrobial therapy based on culture results in either study.
 
Kulthanan et al performed a retrospective study of 150 patient charts that were admitted for adult cellulitis.  Blood cultures were obtained from 116 patients and compared between immunocompetent and immunocompromised patients.  Blood cultures were positive in 3 immunocompetent patients and 17 immunocompromised patients; however, no statistical significance was shown between the two groups.  The organisms isolated in the immunocompetent group were gram-positive, while in the immunocompromised group only half of the organisms were gram-positive.  Ho et al performed a retrospective study of blood and wound cultures obtained from healthy adult patients admitted for acute cellulitis.  Of the 110 patients that were included, 66 had blood cultures and only 1 set of blood cultures was positive (Group A streptococcus).  Bottom Line:  both studies concluded that blood cultures are not necessary in acute adult cellulitis without serious underlying disease and no patient required a change in antimicrobial therapy based on culture results in either study.
 
Lutomski et al enrolled 25 nondiabetic adult patients with cellulitis.  All patients had 2 sets of blood cultures drawn before the initiation of antimicrobial therapy.  Blood cultures were positive in four and all contained gram-positive organisms.  The authors concluded that empiric therapy with penicillinase resisitant penicillins or 1st generation cephalosporins are adequate coverage for gram-positive organisms.  No mention was made if the culture results changed the initial antimicrobial therapy.  Of note concerning the antibiotic recommendations, three of the five studies were published before 1990 and all were published before the year 2000.  The antibiotic recommendations predate wide-spread community associated MRSA and are probably no longer adequate.
 
The LLSA article suggests that blood cultures rarely alter the treatment in the management of cellulitis in the normal host.  Furthermore, the Perl et al study demonstrated that contaminated blood cultures (false positives) were twice as likely as true positives.  These findings could lead to unnecessary tests and increased costs.  All five studies demonstrated that empiric treatment of uncomplicated cellulitis in the normal host should be directed against Group A streptococci and Staph aureus.  Blood cultures are of little value in determining the microbial origin of acute cellulitis in immunocompetent patients, unless the clinician suspects exposure to unusual organisms or potentially complicated cellulitis.
 

Add comment

Security code
Refresh

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Subscribe to EPM