Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines

  • Ailbhe KielyEmail author
  • Sami Abd Elwahab
  • Declan McDonnell
  • Roisin Tully
  • Maria Randles
  • Mary Hickey
  • Felix Ofori-Kuma
  • Ivan Ivanovski
  • Suhail Khan
  • Karl Schmidt
  • Kenneth Mealy
Original Article



Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy.


A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)).


Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy.


There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.


Admissions Antimicrobial stewardship Benzylpenicillin Cellulitis Flucloxacillin Guidelines 



The authors would like to thank Mr. Grant Nolan for his great assistance with formatting and editing. Some statistical information was attained from the HIPE office at the Wexford General Hospital, Newtown Rd., Wexford. The authors would also like to thank Ms. Maisy Doyle, Surgical Administration, Wexford General Hospital, Newtown Rd., Wexford, for providing surgical audit information across five years.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Royal Academy of Medicine in Ireland 2019

Authors and Affiliations

  • Ailbhe Kiely
    • 1
    • 2
    Email author
  • Sami Abd Elwahab
    • 2
  • Declan McDonnell
    • 2
  • Roisin Tully
    • 2
  • Maria Randles
    • 3
  • Mary Hickey
    • 4
  • Felix Ofori-Kuma
    • 2
  • Ivan Ivanovski
    • 2
  • Suhail Khan
    • 2
  • Karl Schmidt
    • 2
  • Kenneth Mealy
    • 2
  1. 1.Department of Plastic SurgerySt Thomas’s HospitalLondonUK
  2. 2.Department of SurgeryWexford General HospitalWexfordIreland
  3. 3.Antimicrobial PharmacologistWexford General HospitalWexfordIreland
  4. 4.Department of Microbiology, Southeast Health BoardUniversity Hospital WaterfordWaterfordIreland

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