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    ALT-70 Score for Cellulitis

    Predicts likelihood of lower extremity cellulitis over other diagnoses.
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    INSTRUCTIONS

    Use in adult patients presenting to the ED with a red leg and clinical concern for cellulitis. Do not use if: visible abscess/fluctuance, penetrating trauma, burn, diabetic ulcer, hardware/device, post-operative patient, or recent (within 48 hrs) IV antibiotic use.

    When to Use
    Pearls/Pitfalls
    Why Use

    • Adult patients presenting to the ED with a red leg and clinical concern for cellulitis.

    • Do not use if any of the following:

      • Visible abscess/fluctuance.

      • Penetrating trauma.

      • Burn.

      • Diabetic ulcer.

      • Implanted hardware/device.

      • Post-operative patient.

      • Recent (within 48 hours) IV antibiotic use.

    • Developed to assist with evaluation of lower extremity redness, which may be inappropriately diagnosed as cellulitis (versus mimickers, or “pseudocellulitis”).  

    • Most patients with cellulitis have acute onset, unilateral involvement (usually one leg), and are sick with an elevated white blood cell count, tachycardia, and/or a fever.

    • Validated in a small cohort of 67 patients (Li 2018).

    • Cellulitis is the most common skin and soft tissue infection, with a high cost. No gold-standard diagnostic test exists, and clinical signs of redness, edema, warmth, and tenderness are nonspecific.

    • At least 30% of patients with presumed cellulitis are misdiagnosed, leading to unnecessary admissions, overuse of antibiotics, and missed alternative diagnoses.  

    • Factors previously used to determine likelihood of true cellulitis (e.g. past medical and skin history, prior cellulitis, ulcers, barrier disruption, tinea, lymphedema, venous disease, malignancy, and underlying dermatitis) have not been shown to be statistically significant risk factors for cellulitis.

    • May also help indicate appropriate subspecialty consultation to identify pseudocellulitis/mimickers.

    No
    0
    Yes
    +3
    No
    0
    Yes
    +2
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    • Scores 5-7 indicate likely cellulitis (>82.2% likelihood), and patients should receive appropriate therapy. This may vary based on comorbidities or underlying diseases, history of resistant organisms, prior culture data or prior antibiotic use, and/or whether there is a clear trigger or portal of entry.

    • Scores 3-4 indicate uncertainty, and consultation may be appropriate. Dermatology consultation may assist in the evaluation and can help identify alternative etiologies or explanations; if not available, ID consultation may be appropriate. Examples of alternative etiologies include:

      • Vascular inflammation, stasis dermatitis.

      • Inflammatory skin conditions.

      • Alternate infections (e.g. Lyme).

      • Chemotherapeutic reactions.

      • Contact dermatitis.

    • Scores 0-2 suggest patients are unlikely to have true cellulitis (likelihood of pseudocellulitis >83.3%) and should be reassessed to have the differential diagnosis reconsidered. Very common mimickers include:

      • Bilateral redness without tachycardia/leukocytosis in a patient with edema and/or heart failure, suggestive of stasis dermatitis.

      • Pruritic, geometric patch with serous drainage in someone using a topical agent who may have developed allergic contact dermatitis.

    Management

    • Patients with true cellulitis should be treated with standard-of-care management, which varies based on their underlying disease state, recent antibiotics or previously documented microbial culture data, and local antibiotic resistant patterns.  This may include oral or IV antibiotics.

    • Patients with pseudocellulitis (mimickers) should be treated appropriately for the identified alternate diagnosis.

    Critical Actions

    • Patients with septic physiology may require more immediate attention and aggressive intervention.  

    • Patients with fluctuant lesions/abscesses may require imaging and/or surgical intervention.

    Formula

    Addition of the selected points:

    Variable

    Points

    Asymmetric

    +3

    Age ≥70 years

    +2

    WBC in ED ≥10,000/µL

    +1

    HR in ED ≥90 bpm

    +1

    Facts & Figures

    Interpretation:

    ALT-70 Score

    Recommendation

    0-2

    Reassess (>83.3% likelihood of pseudocellulitis)

    3-4

    Consult dermatology and/or infectious disease

    5-7

    Treat (>82.2% likelihood of true cellulitis)

    Literature

    Other References

    Research PaperLevell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol. 2011;164(6):1326-8.Research PaperArakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatol. 2014;150(10):1056-61.Research PaperStrazzula L, Cotliar J, Fox LP, et al. Inpatient dermatology consultation aids diagnosis of cellulitis among hospitalized patients: A multi-institutional analysis. J Am Acad Dermatol. 2015;73(1):70-5.Research PaperRaff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-37.Research PaperWeng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016.Research PaperLi DG, Xia FD, Khosravi H, et al. Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis. JAMA Dermatol. 2018;154(5):537-543.Research PaperKo LN, Garza-mayers AC, St john J, et al. Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial. JAMA Dermatol. 2018;154(5):529-536.
    Dr. Adam B. Raff

    About the Creator

    Adam B. Raff, MD, PhD, is a dermatologist at Harvard Medical School. He is also an instructor in dermatology at Massachusetts General Hospital. Dr. Raff’s primary research is focused on infectious skin diseases, skin cancer, and eczema.

    To view Dr. Adam B. Raff's publications, visit PubMed

    Dr. Arash Mostaghimi

    From the Creator

    Why did you develop the ALT-70? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    The inspiration for the ALT-70 came from our experiences as consultative dermatologists specialized in the care of inpatients. We found that we were being consulted for patients who had failed "cellulitis" therapy who in reality had other diseases. Patients who had languished in the hospital for days were able to improve rapidly and be discharged on the correct therapy.

    Cellulitis is not a disease commonly seen by dermatologists—it is a front-line clinician disease, taken care of mostly by primary care physicians and emergency room physicians. Dermatologists can help identify mimickers, but only when they are aware of patients with possible misdiagnosis.

    The goal of the ALT-70 was to provide an objective tool to emergency department physicians that would help alert them of times when dermatology consultation or broadening of the differential to consider other diagnoses would be beneficial. Our hope was to identify potential misdiagnosis early in the course of hospitalization to get patients on the right path of treatment as soon as possible.

    What pearls, pitfalls and/or tips do you have for users of the ALT-70? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    Like every diagnostic test, the ALT-70's performance depends on the situation where it is used. Different pre-test probabilities of cellulitis will of course impact the predictive values of the test. The testing and validation of the ALT-70 was done in an urban academic center, and these patients may fundamentally differ from patients in other care settings.

    The ALT-70 is meant for use at the time of presentation in patients with suspected lower extremity cellulitis in an emergency room. Patients who have already been treated with antibiotics, had penetrating injuries, burns, diabetic ulcer, known hardware at the cellulitis site, or a history of osteomyelitis were excluded and the test should not be applied to them.

    There is emerging evidence that for admitted patients the performance of the ALT-70 may be maintained at 24 and 48 hours. The use of the ALT-70 in this setting has not been validated yet.

    We do not yet know the performance of the ALT-70 in other settings such a primary care offices or urgent care clinics.

    What recommendations do you have for doctors once they have applied the ALT-70? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    Over time, we find that most people are using higher scores (5-7) to confirm treatment for cellulitis and obtaining consultations for everything with a score of 4 and below. This increases consultation rates but may lead to improved outcomes for patients. Since the publication of the ALT-70, we and others have identified that earlier dermatology consultation in general leads to better outcomes for patients with suspected cellulitis:

    1) “Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis

    2) “Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial

    How do you use the ALT-70 in your own clinical practice? Can you give an example of a scenario in which you use it?

    At Brigham & Women's, we have developed new clinical pathways for patients admitted from the emergency department with suspected cellulitis. The ALT-70 is part of the screening process we use to identify patients at risk for possible misdiagnosis.

    Any other research in the pipeline that you’re particularly excited about?

    One of the challenges of the ALT-70 is that many places do not have access to timely dermatology consultation for patients at risk. We are currently evaluating the potential for teledermatology to assist in assessing patients with suspected cellulitis in places where in-person dermatology assessment is unavailable.

    We've also been working on developing alternative diagnostic tests to create better objective measures for cellulitis diagnosis. Stay tuned!

    About the Creator

    Arash Mostaghimi, MD, MPA, MPH, is the director of Dermatology Inpatient Service and co-director of the Complex Medical Dermatology Fellowship Program at Brigham and Women's Hospital. He is also an associate professor at Harvard Medical School. Dr. Mostaghimi’s primary research is focused on severe drug reactions, cutaneous oncology, and medical dermatology.

    To view Dr. Arash Mostaghimi's publications, visit PubMed

    Dr. Qing Yu Christina Weng

    About the Creator

    Qing Yu Christina Weng, MD, is a dermatology resident at the Harvard Combined Dermatology Residency training program. Her research is in melanocyte biology, which she began in the laboratory of David Baltimore at the California Institute of Technology and continued in the laboratory of David Fisher during medical school at Harvard. Dr. Weng completed a research fellowship supported by the Howard Hughes Medical Institute and is currently in the accelerated research track in residency, with a research and clinical focus on melanoma and pigment biology.

    To view Dr. Qing Yu Christina Weng's publications, visit PubMed

    Content Contributors
    • Misha Rosenbach, MD
    Content Contributors
    • Misha Rosenbach, MD