Case 4: An Obese Patient With Red Legs
Is it cellulitis or stasis dermatitis? A 78-year-old woman presents to the ED with severe left-sided chest pain after a coughing spell. She has no other symptoms. On physical examination, severe point tenderness is discovered over the sixth rib on the left side. The patient is morbidly obese with marked leg edema and redness from ankles to knees that is not warm or tender. A chest x-ray reveals severe osteoporosis, with multiple old healed rib fractures. Doppler venous ultrasonography is negative for deep vein thrombosis.
After admission to the hospital, the patient was started on vancomycin and levofloxacin. The case was reviewed by the AST on hospital day 2. An infectious disease consult was obtained at the request of the AST. The patient had a history of bilateral leg redness for several weeks. Her PCT level was < 0.05 ng/mL. Assessment revealed chronic stasis dermatitis. The antibiotics were discontinued, and the patient was discharged on pain medication for the cracked rib.
Stasis dermatitis can mimic cellulitis; however, the gradual onset; lack of fever, chills, or exquisite tenderness; and the presence of symmetric lesions on both legs make this diagnosis unlikely.
If cellulitis were present, is broad-spectrum antibiotic therapy recommended?
Even in the era of methicillin-resistant Staphylococcus aureus (MRSA), the microbiology of uncomplicated cellulitis without abscess has changed little. Beta-hemolytic streptococci are proven to cause 79% of cases of cellulitis (excluding bites; groin wounds; and perineal abscesses, furuncles, or ulcers). These organisms remain completely sensitive to penicillin and first-generation cephalosporins. Response rates to cefazolin or oxacillin are >90% for uncomplicated cellulitis. Empiric overage for MRSA and gram-negative bacilli is generally unnecessary.
Acute Bronchitis
In 1995, an editorial titled, What Will It Take to Stop Physicians From Prescribing Antibiotics for Acute Bronchitis? was published in The Lancet. This question is just as germane today! Acute bronchitis has been known for decades to be a viral infection. Yet recent articles on ED care continue to show that the antibiotic treatment rate for bronchitis remains at 68%-74%.