Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis and lymphangitis 
Treatment: Inpatient admission 
The inpatient admission was not medically necessary. 

The patient is a preteen male with medical history significant for asthma, constipation, and recent lower extremity cellulitis treated with parenteral clindamycin for three days in the hospital followed by enteral clindamycin (on day 6-7/10) and mupirocin and two doses of Augmentin. He presented to the ED around midnight with pain and swelling from an insect bite. The patient reported possible insect bite to the right hand two days prior that progressed to swelling and redness and streaking to the upper arm. He had no fevers or other systemic symptoms. 

The patient's vital signs included temperature 98.8, heart rate 95, respiratory rate 20, and blood pressure 94/66. Examination was significant for no distress, well-appearing, moist oral mucosa, clear lungs, benign abdomen, good pulses, moderate swelling to the dorsum of the right hand from fingers to wrist, able to make a fist with pain, erythema over the right hand streaking up the arm past the elbow warm to touch, and non-focal neurologic exam. Laboratory evaluation revealed unremarkable CBC (complete blood count), with culture pending. He was treated with ibuprofen, Benadryl, and vancomycin prior to admitting for further management. 

Admission diagnosis was made of cellulitis with possible lymphangitis. Admitting orders included vancomycin, follow-up blood culture, Orthopedic Surgery consultation to evaluate for fasciitis, and Infectious Disease consultation if no further improvement. Orthopedic Surgery had no surgical recommendations. 

By the next day, the patient had improved significantly, with improved range of motion and decreased swelling and redness. He remained afebrile with stable vital signs. Additional labs revealed unremarkable CRP (C-reactive protein) and mildly elevated ESR (erythrocyte sedimentation rate). Cultures remained negative. He had one mildly elevated blood pressure that was attributed to anxiety over being in the hospital. He was subsequently deemed stable for discharge home, to complete a course of Keflex and Bactrim. 

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. 

This male child presented to the ED with signs and symptoms consistent with cellulitis complicated by lymphangitis. This infection developed while he was taking clindamycin for a lower extremity cellulitis, with an additional two doses of Augmentin. He failed outpatient treatment. In the ED, he was afebrile and stable, with no evidence of impending sepsis or necrotizing fasciitis. Because of the rapid progression of this infection, it was reasonable and appropriate to monitor him overnight in the hospital after initiation of antibiotics to make sure he was responding appropriately without further decompensation. However, he was overall hemodynamically stable, with no clinical indication of fasciitis or impending sepsis. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care such as observation.