Appeal type: Medical necessity
Decision: Overturned

Skin Disorders - Infection
Inpatient Hospital

The patient is a  female with personal and family history of methicillin-resistant staphylococcus aureus (MRSA) infection that presented to the emergency department (ED) with two-day history of fever and worsening redness in the left inguinal area. She was seen in an urgent care center the day prior to presentation and prescribed Bactrim. The area continued to worsen with apparent abscess formation. She was taken to the primary care practitioner that referred her to the ED for evaluation. She was drinking well but not eating well, she was able to ambulate with a limp following ibuprofen administration.

She was admitted to the pediatric floor for management of presumed MRSA inguinal cellulitis. Admission orders included contact isolation, maintenance intravenous (IV) fluids, vancomycin, ibuprofen and Tylenol as needed, surgery consultation, and infectious disease consultation. The surgeon recommended incision and drainage, so she was taken to the operating room (OR). The infectious disease (ID) physician made some adjustments to the vancomycin dosing. She remained clinically stable, with adequate appetite and normal urine output. The cellulitis improved with three days of vancomycin treatment. She was deemed stable for discharge to complete a ten-day course of antibiotics with clindamycin, and follow-up with both her pediatrician and the surgeon. At the time of discharge, the specific sensitivities of the wound culture were pending, and blood culture was negative. Wound culture was ultimately positive for MRSA sensitive to clindamycin. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.
MRSA causes both nosocomial and community-acquired infections. Guidelines have been developed for management of this potentially severe and debilitating condition. For skin abscesses, the first line of treatment is incision and drainage. Antibiotic therapy is generally recommended for severe disease, extensive disease, or rapidly progressive disease. Empiric therapy of outpatients with purulent cellulitis in the absence of drainable abscess involves five to ten days of therapy. Oral antibiotic choices include clindamycin, Bactrim, doxycycline, and Zyvox. For hospitalized patients with complicated infections, parenteral therapy with either vancomycin or Zyvox is recommended. The spectrum of infection caused by MRSA includes skin and soft tissue infections, pneumonia, bone and joint infections, central nervous system disease, toxic shock syndrome, sepsis, endocarditis, and bacteremia, which typically accompanies the majority of invasive cases. Severity ranges from simple abscess to life-threatening disease.

This patient with both personal and family history of MRSA infection developed redness and swelling in her left groin and was started on Bactrim in the outpatient setting. Despite the antibiotic treatment, the area of redness continued to grow, and abscess was apparent to the mother. In addition, the child was experiencing systemic effects, with fever and decreased appetite. She was limping from pain. Having failed outpatient treatment, the pediatrician referred her to the ED. Laboratory evaluation revealed significant leukocytosis with elevated inflammatory markers. She spiked fever to 38.8 while in the ED. Bedside ultrasound confirmed presence of complex abscess multiple fluid collections with the largest measuring 2x3 cm. She was appropriately admitted for parenteral antibiotics and surgical drainage, having failed reasonable outpatient treatment. Acute inpatient care was medically necessary in this case because of the rapid progression of infection and abscess, systemic manifestations, and failed outpatient management.