Clinical Question: Can cellulitis requiring intravenous antibiotics be treated effectively at home, and does this practice lead to greater patient satisfaction?

Setting: Outpatient (primary care)

Study Design: Randomized controlled trial (single-blinded)

Allocation: Concealed

Synopsis: Investigators enrolled 200 patients presenting to an emergency department for whom intravenous antibiotic therapy was necessary. Patients with two or more signs of sepsis, severe cellulitis, or serious comorbidities were excluded. After enrollment, patients were assigned to home or in-hospital treatment. Before leaving, patients in the home treatment group received cefazolin in an initial dose of 2 g in the emergency department, which was followed by a dosage of 2 g twice daily at home (this same regimen was used in the hospital). A visiting nurse administered the antibiotic and the patients were visited daily by a primary care physician. Although this study was performed in New Zealand, where home visits are common, additional study is prudent to determine whether nurses who visit the home twice daily can serve the same clinical monitoring function in countries in which home visits are not common.

The primary outcome was the turnaround time (i.e., the number of days to no advancement of cellulitis), which was similar in both treatment groups (1.50 days in home versus 1.49 days in hospital). With regard to secondary outcomes, the number of days of intravenous therapy, the number of days to discharge (from treatment or hospital), and the number of days on oral antibiotics also were similar between the two groups.

After one week, all patients were surveyed about their care; scores were similar in both groups. Significantly more patients receiving home care reported being “very or quite” satisfied with the location of their treatment (93 versus 66 percent; P < .0001; number needed to treat = four) and only 5 percent of patients treated at home expressed a preference for hospital care, while 35 percent of hospitalized patients would have preferred at-home care (P < .0001). One in eight patients treated at home required hospitalization. The study had the power (at 80 percent) to find a two-day difference in turnaround time, if such a difference truly existed.

Bottom Line: Patients requiring parenteral antibiotics for the treatment of cellulitis can be treated successfully at home, although some eventually will require hospitalization. In this study, all patients had a telephone, were visited daily by their primary care physician, and were visited twice daily by a nurse. (Level of Evidence: 1b)