Background: Cellulitis is a common emergency department (ED) presentation. Despite the fact that diagnosis remains relatively straight forward, complexity remains in management in terms of the causative agent and appropriate antibiotic regimen. Though beta-hemolytic Streptococci are the most common causative agents there is increasing prevalence of community acquired methicillin-resistant Staphylococcus aureus (MRSA). Cephalexin has long been used to treat uncomplicated cellulitis because of it’s activity against streptococci and methicillin-sensitive S. aureus (MSSA). Despite the current Infectious Disease Society of America (IDSA) recommendations against routine coverage of MRSA, trimethoprim-sulfamethoxazole (TMP-SMX) is often added to cephalexin (Stephens 2014). While there are other single options for coverage, they either have suboptimal MRSA coverage (i.e. clindamycin and doxycycline) or are more expensive (i.e. linezolid). Without reliable ways to determine which patients need MRSA coverage, it is unclear which patients with uncomplicated cellulitis need to be discharged with MRSA coverage and which will do fine with a single agent.
The Background: Nearly 50% of patients in the U.S. with cirrhotic liver disease develop ascites over a 10-year period of observation, placing them at risk for developing spontaneous bacterial peritonitis (SBP) (Runyon 2012). It is estimated that 12-25% of patients with ascites in the ED will have spontaneous bacterial peritonitis (SBP) but the classic triad of fever, abdominal pain, and worsening ascites is often absent (Borzio 2001)(Runyon 1988). With a mortality rate approaching 40%, rapid diagnosis and evidence-based treatment is critical in the management of patients presenting with SBP (Salerno 2013).
SBP is diagnosed via cell count and differential of ascitic fluid obtained by paracentesis demonstrating an elevated polymorphonuclear leukocyte (PMN) count (≥ 250 cells/mm3). Treatment focuses on appropriate antibiotic therapy. A third-generation cephalosporin is the treatment of choice as they are typically effective in covering the three most common isolates from infected ascitic fluid: Escherichia coli, Klebsiella pneumonia, and Streptococcus pneumonia (Runyon 2012). Intravenous albumin administration is often added to the management of these patients but the utility for improving morbidity and mortality is questionable. The benefit of albumin infusion in SBP is not entirely known, although multiple possible mechanisms have been identified. Albumin has been demonstrated to mitigate endotoxemia, block lipopolysaccharide-stimulated neutrophil activity, and modulate nitric oxide activity, mitigating systemic vasodilation and capillary leak (Salerno 2013)....Read More