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    ALT-70 Score for Cellulitis

    Predicts likelihood of lower extremity cellulitis over other diagnoses.

    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.

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    Next Steps
    Evidence
    Creator Insights
    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

    Are you Dr. Adam B. Raff? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    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

    Are you Dr. Qing Yu Christina Weng? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Misha Rosenbach, MD
    About the Creator
    Dr. Adam B. Raff
    Are you Dr. Adam B. Raff?
    Dr. Arash Mostaghimi
    Dr. Qing Yu Christina Weng
    Are you Dr. Qing Yu Christina Weng?
    Content Contributors
    • Misha Rosenbach, MD