Cellulitis: Misdiagnoses Common and Costly

Beth Skwarecki

November 07, 2016

One third of patients admitted to the hospital for cellulitis were discharged with a different diagnosis, according to a new single-center retrospective analysis. The researchers estimate that misdiagnosis of other conditions as cellulitis results in 50,000 to 130,000 unnecessary hospitalizations and from $195 million to $515 million in avoidable health costs each year.

"Our study serves as a call to arms for improving the care of patients with suspected lower extremity cellulitis," Qing Yu Weng, MD, from the Department of Dermatology at Massachusetts General Hospital, Boston, and colleagues write. The study was published online November 2 in JAMA Dermatology.

"Dermatologists need to consult on these cases because cellulitis of the lower extremity has many mimics that can make diagnosis challenging, particularly for nondermatologists," Sotonye Imadojemu, MD, and Misha Rosenbach, MD, write in an accompanying editorial.

"Objective diagnostic modalities for cellulitis, such as blood and skin cultures (including needle aspiration and biopsies) are rarely revealing, and diagnosis is usually made by medical history and physical examination alone," Dr Weng and colleagues explain.

Misdiagnosing other conditions as cellulitis also leads to higher antibiotic use; in this study, 92.3% of patients who were misdiagnosed received unnecessary antibiotics.

The investigators examined the medical records of all adult patients who were admitted to the hospital from the emergency department with a diagnosis of lower extremity cellulitis between June 2010 and December 2012. They excluded patients with an abscess, trauma, surgery, or recent intravenous antibiotics. Of the 259 patients included in the study, 30.5% had their diagnosis changed before discharge or within the following month.

Of the misdiagnosed patients, 85% did not require hospitalization, and 92% received unnecessary antibiotics. The mean hospital stay for these patients was 4.3 days (standard deviation, 3.7 days). After patients without cellulitis were discharged, 32% had a complication such as drug eruption, diarrhea, or gastrointestinal distress related to their treatment.

To determine how many patients are affected nationwide, the investigators used an estimate of $12,656.90 for a 4.3-day hospital stay from the Medical Expenditure Panel Survey. From a review of other literature, they estimated that 15,000 to 40,000 unnecessary hospitalizations result from cellulitis misdiagnosis each year, for a total of $195 million to $515 million, not counting the costs of antibiotics or subsequent healthcare visits. The authors believe their estimates are conservative and that the true number may be higher.

According to rates of antibiotic prescribing for these patients, the team calculated that the results of unnecessary antibiotics could lead to 617 to 1628 nosocomial infections, 437 to 5551 cases of Clostridium difficile colitis, and one to seven cases of anaphylaxis each year.

"We applaud the authors' efforts to quantify this common, expensive, and harmful practice gap," Dr Imadojemu and Dr Rosenbach write. Dermatologists' services are underused in EDs, they say, despite the specialty's expertise in distinguishing between cellulitis and similar-appearing skin conditions such as inflammatory venous stasis, deep vein thrombosis, and allergic or irritant contact dermatitis.

The study authors are working on a predictive model that could help providers assess which cases of skin inflammation are true cellulitis. Dr Imadojemu and Dr Rosenbach agree that this could help reduce the incidence of misdiagnosis. "Some may argue that the prospect of consulting dermatology for all suspected cellulitis cases is too large a task. The development of diagnostic algorithms (for instance, if there is bilateral erythema, no fever, and a normal white blood cell count, the diagnosis is unlikely to be cellulitis) and teledermatology may offer ways to mitigate that challenge."

The authors, Dr Imadojemu, and Dr Rosenbach have disclosed no relevant financial relationships.

JAMA Dermatol. Published online November 2, 2016. Article full text, Editorial extract

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