Evaluation of Crest Guideline Validity for Diagnosis of Non-Facial Cellulites

Cellulitis is an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, usually complicating a wound, ulcer, or dermatosis. Inappropriate diagnosis of cellulitis is a problem and would need prospective rather than retrospective studies to quantify the extent. There is one national guideline for the m anagement of patients with cellulitis. The aim of this study is to determine the validity of Crest guideline in th e patients with non-facial cellulitis. This prospective cohort study was conducted on all Adult patients with cell ulites who were admitted at Resole-Akram and Sina emergency department between November 2013 and Jan uary 2014. Based on admission duration, the patients were randomly divided into two groups including primar y and secondary outcome, <24-hours or >24-hours admission, respectively. Out of 89 admitted patients, 5 5% were hospitalized over 24 hours and 20% of them had significant systemic symptoms. The most patients (n= 42) had either systemically ill or systemically well or class II followed by classes I (n=28), III (n=18), an d IV (n=1). There was significant relevancy between age, fever, PR, infected organ, leukocytosis, diabetes m ellitus, IUDA, human bite, and primary outcome. In conclusion, factors associated with admission were age, presence of multiple comorbid conditions, diabetes mellitus, human bite, IUDA, infected organ, leukocytosis and fever. These results showed that the de cision in the emergency department was mostly the same as Crest guideline and the prospection of admission and discharge of these patients was almost according to the educations of Crest guideline. Corresponding author: Dr. Samaneh Abiri, Department of Emergency, Iran University of Medical University, Tehran, Iran. samaneh.abiri@gmail.com Tel: 0098216653234 Fax: 0098216653230


Introduction
Cellulitis is an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, usually complicating a wound, ulcer, or dermatosis. It is a common medical condition taking up a large number of occupied bed days in acute hospitals [1].
Streptococcus pneumonia is the most common germ of cellulites [2]. Cellulitis must be differentiated from oedema with blisters, lower leg eczema, acute venous problems including thrombophlebitis, deep venous thrombosis, and liposclerosis, and vasculitis [3,4]. Inappropriate diagnosis of cellulitis is a problem and would need prospective rather than retrospective studies to quantify the extent. The distinctive features, including the anatomical location of cellulitis and the patient's medical and exposure history, should guide appropriate treatment [1]. There is one national guideline for the management of patients with cellulitis.
The Clinical Resource Efficiency Support Team (CREST) guideline present to evaluate patient with cellulites, the guideline indicators have been changed over the times [5]. These guidelines have been published by the CREST, which is a small team of health care professionals established under the auspices of the Central Medical Advisory Committee in 1988. The aims of CREST are to promote clinical efficiency in the Health Service, while ensuring the highest possible standard of clinical practice is maintained [5].
There is a relative lack of observational studies look at the effects of treating predisposing factors on the recurrence of cellulitis. Even though the Crest guidelines are much easier to apply in clinical practice, their validity has never been proven by a clinical study.
Revise this guideline seems valuable because of the most frequency of cellulites and the large amount of expenditure on this issue. Because of higher frequency of cellulites, higher Health system expenses, and the complications, the aim of this study is evaluation of Crest guideline in the patients with cellulitis and provide a valid criteria to admit or discharge of patients with cellulites in emergency department and improve the disease outcome using them, and decreasing the complications and patient expenses and finally the Health system expenses.

Material and Methods
The Ethics Committee of Iran University of Medical Sciences approved the study and author group collected written informed consent from all patients. collected. All clinical variables were independently recorded by two data abstractors. Based on admission duration, the patients were randomly divided into two groups including primary and secondary outcome, <24hours or >24-hours admission, respectively. All patients initially discharged home were tracked for 7 days within our hospital and clinic health system to assess for repeat ED visits related to the initial presentation.
Patient data were analyzed using STAT13 analyzer and analyzer was blind to patient outcome. Severity was assessed and compared with a CREST guideline for the management of cellulitis in adults [5].  Table 4). The area under the receiver operating characteristic curve was 89%. Ki-square and logistic regression were done and significantly relevance between primary outcome and Crest guideline criteria was confirmed (Fig 1).

Discussion
The primarily aim of this study was to determine the validity of Crest guideline in the patients with nonfacial cellulitis. Patients with facial cellulitis were excluded due to the potential complexity of these infections, proximity to the brain and vital structures, and difference in clinical management relative to soft tissue infections in other body regions [6].