Cellulitis risk score may help guide IV antibiotic therapy in children


By Megan Brooks

NEW YORK (Reuters Health) - Pediatricians from Australia have developed and validated a simple risk-assessment score to help guide decisions regarding antibiotic therapy for cellulitis in children.

"Cellulitis is a frequently encountered illness, yet there is no evidence-based guidance to determine which children with cellulitis should be treated with intravenous antibiotics versus which can be treated with oral antibiotics," Dr. Franz Babl of the University of Melbourne told Reuters Health by email.

"This poses risks for both under treatment and over treatment, resulting in unnecessary hospitalization," write Dr. Babl and colleagues in a paper online today in Pediatrics.

They developed the Melbourne ASSET Score based on 285 children aged six months to 18 years seen in the ED with a diagnosis of cellulitis and started either on oral (40%) or IV (60%) antibiotics. The score includes five clinical features:

- Size of the area affected, which reflects the burden of infection.

- Systemic features (fever, lethargy), which potentially reflects sepsis.

- Swelling, which reflects the severity of inflammation and can also represent induration in the early formation of abscess.

- Involvement of the eye, a vulnerable location associated with more severe morbidity.

- Tenderness, which also reflects the severity of inflammation and can be used to differentiate cellulitis from other inflammatory conditions, such as allergic reactions which typically are not tender.

The researchers correlated clinical features and outcomes to derive the Melbourne ASSET score, taking into account clinicians' opinions and practice, when appropriate.

The score has a maximum value of 7 and an area under the curve of 0.86.

Using a cutoff score of 4 to initiate IV antibiotics yielded the highest proportion of patients correctly classified at 80% (sensitivity, 60%; specificity, 93%).

The score was validated in a separate cohort of 251 children presenting to the ED with cellulitis, and it "maintained a robust" area under the curve of 0.83, the authors report.

In this cohort, a cutoff score of 4 as the threshold to start IV antibiotics had a sensitivity of 85% and a specificity of 63%, with 76% of patients correctly classified.

"The Melbourne ASSET Score is the first risk assessment scoring system for pediatric cellulitis that is proposed to aid clinicians in deciding whether to treat with IV or oral antibiotics," Dr. Babl and colleagues note in their article.

Importantly for pragmatic use, they add, the score is "simple, easy to use, applicable, and reliable. Although intended for widespread use, if limitations exist in other settings, it is designed to allow for refinement and is amenable to local impact analysis. We propose an impact analysis of this score, ideally in a different settings and population."

"We derived and internally validated the ASSET score. Prior to implementation it should be externally validated," Dr. Babl told Reuters Health.

The study had no commercial funding, and the authors declared no conflicts of interest.

SOURCE: https://bit.ly/2LOrPsF

Pediatrics 2019.

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