Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is a young male child with unremarkable medical history. He was well until five days prior to presentation, when he was noted to have a wound near his left knee. He was taken to Urgent Care, where he was given Bactrim for possible MRSA (methicillin-resistant Staphylococcus aureus) infection (mother was taking Bactrim and clindamycin at the time for an MRSA infection). He remained symptomatic, so he was taken to the pediatrician the day prior to presentation, where he was given an IM (intramuscular) dose of clindamycin. The mother no longer noted purulent drainage and thought it appeared somewhat improved, but the child remained febrile and there was swelling below the knee. Maximum fever was 103. He was refusing to bear weight. 

The patient's vital signs included temperature 99.8, heart rate 120, respiratory rate 25, and saturation 100% in room air. Examination was significant for no distress, moist oral mucosa, strong pulses, clear lungs, benign abdomen, 3 mm wound on the left knee with surrounding erythema and warmth around the entire knee, no drainage or fluctuance, erythema tracking up the left lateral aspect of the leg, swelling below the left calf, refusal to bear weight, and non-focal neurologic exam. With concerns for cellulitis and possible septic knee, x-rays were obtained and Orthopedic Surgery was consulted. The x-ray revealed marked soft tissue swelling without osseous abnormality. Orthopedic Surgery had low suspicion for septic knee, and made recommendations for additional labs, Infectious Disease consultation, pain control, and continuation of antibiotics. 

Laboratory evaluation revealed normal WBC (white blood cell) count (12.0K) with 70% neutrophils, mild hyponatremia (sodium 134), normal lactate (1.4), elevated CRP (C-reactive protein) (7.543), and elevated ESR (erythrocyte sedimentation rate) (51). He was treated with normal saline bolus and vancomycin prior to being admitted for further management and failed outpatient care of cellulitis. 

Admission orders included vancomycin, antipyretics, MRI the next day, regular diet, and follow-up cultures. The first night, the patient continued to have fevers and refused to ambulate. Ceftriaxone was added for Kingella coverage. MRI was done and showed no osteomyelitis or abscess. 

By the day of discharge, the patient had no fevers and was able to play and bear weight. Infectious Disease made antibiotic recommendations, and coverage was changed from vancomycin and ceftriaxone to clindamycin and cephalexin. Blood cultures remained negative. He was subsequently deemed stable for discharge.  

This young child developed cellulitis from a small wound to the left knee that rapidly progressed, with erythema tracking up his leg and edema below the knee. He was febrile to 103 and refused to walk. He was initially treated with Bactrim in the outpatient setting, and when he failed to improve, was given an IM injection of clindamycin. Having failed this second line of treatment, he presented to the ED and was subsequently admitted for parenteral therapy. Because of his clinical presentation and failure to respond to outpatient therapy twice, acute inpatient admission was medically necessary and appropriate. He could not have been safely managed at a lower level of care.