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Brown AW, Jovevski JJ, Naville-Cook CA, Roberts JL, Triboletti MD, Williams MJ, Smith CR. Cost analysis of one-time intravenous antibiotic doses in the emergency department. J Am Pharm Assoc (2003) 2024:102114. [PMID: 38705468 DOI: 10.1016/j.japh.2024.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/12/2024] [Accepted: 02/23/2020] [Indexed: 05/07/2024]
Abstract
BACKGROUND Research shows that one-time doses of intravenous (IV) antibiotics do not improve resolution of infection. However, providers continue to use them-especially in the emergency department (ED). Very few studies have aimed to quantify the cost of this practice. OBJECTIVES The primary objective was to evaluate the difference in average total cost of ED stay between patients who received a one-time dose of IV antibiotics in the ED before discharging on oral antibiotics and patients who were just discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the 2 groups, as well as the differences in adverse drug effects and need for health care contact after discharge. METHODS Chart review was conducted to identify patients who received and did not receive a one-time dose of IV antibiotics in the ED between April 30, 2020, and April 30, 2022. A microcosting approach was used to determine ED-associated costs per patient. Comparisons in primary and secondary outcomes were performed using statistical inferential tests. RESULTS A total of 102 patients were analyzed in each group. Patients who received a one-time dose of IV antibiotics in the ED before being discharged on oral antibiotics had an average length of stay of 4.55 hours, as opposed to patients who did not receive a one-time dose of IV antibiotics before being discharged on oral antibiotics who had an average length of stay of 2.82 hours (absolute difference 1.73 hours, P < 0.001). One-time dosing of IV antibiotics in the ED incurred an additional cost of approximately $556 per patient, totaling to more than $56,000 in our study cohort. CONCLUSION The use of one-time IV antibiotics in the ED did not confer any additional benefits to patients. The use of one-time doses resulted in statistically significant reduced throughput in the ED and statistically significant increased health care costs.
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St Cyr G, Jaffe J, McMahon M, Florin TA, Verre MC, Chua WJ. Management of Children With Uncomplicated Cellulitis in Emergency and Hospital Settings. Pediatr Emerg Care 2023; 39:913-917. [PMID: 38019712 DOI: 10.1097/pec.0000000000003072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
OBJECTIVE The aim of the study is to establish consensus recommendations on features used to determine the route of antibiotic administration and disposition for children with uncomplicated cellulitis. METHODS Modified Delphi methodology was performed with 2 rounds of confidential surveys of Emergency medicine and hospital medicine (HM) providers at Lurie Children's Hospital to assess cellulitis management in children (ages 6 months-18 years) without signs of sepsis or abscess formation. Using a 9-point Likert scale, emergency medicine providers ranked features by perceived level of importance when deciding initial antibiotic route and HM providers ranked features on importance when transitioning to oral antibiotics. Responses were grouped as not important (1-3), neutral (4-6), and important (7-9) and re-evaluated in the second round to reach consensus, defined as ≥70% agreement. RESULTS Emergency medicine providers (n = 17) reached consensus on 15 of 16 features (93.8%), 10 deemed important. Participants reached greatest consensus (100%) on fevers/chills, lymphangitis, and functional impairment as considerations for initiating intravenous antibiotics. HM providers (n = 15) reached consensus on 9 of 11 factors (81.8%), with 7 considered important when deciding on readiness for oral antibiotics. Providers indicated that stability, rather than reduction, of erythematous margins is sufficient to consider transition and de-escalation of therapy at less than 24 hours if all other clinical improvement criteria are met. CONCLUSIONS This study achieved consensus on important features for treatment and disposition of children with uncomplicated cellulitis in both emergency and inpatient contexts. These features have the potential to aid in decision making and improve standardization of clinical practice.
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Affiliation(s)
- Grace St Cyr
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine
| | - Jana Jaffe
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine
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Preda-Naumescu A, Elewski B, Mayo TT. Common Cutaneous Infections: Patient Presentation, Clinical Course, and Treatment Options. Med Clin North Am 2021; 105:783-797. [PMID: 34059250 DOI: 10.1016/j.mcna.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This evidence-based review highlights cutaneous infections of bacterial, viral, and fungal origin that are frequently encountered by clinicians in all fields of practice. With a focus on treatment options and management, the scope of this article is to serve as a reference for physicians, regardless of field of specialty, as they encounter these pathogens in clinical practice.
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Affiliation(s)
- Ana Preda-Naumescu
- School of Medicine, University of Alabama at Birmingham, 1670 University Blvd, Birmingham, AL 35233, USA
| | - Boni Elewski
- Department of Dermatology, University of Alabama at Birmingham, 510 20th Street South, FOT Suite 858, Birmingham, AL 35233, USA
| | - Tiffany T Mayo
- Department of Dermatology, University of Alabama at Birmingham, 510 20th Street South, FOT Suite 858, Birmingham, AL 35233, USA.
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostischer Wert von Laborparametern zur Unterscheidung zwischen Erysipel und begrenzter Phlegmone. J Dtsch Dermatol Ges 2020; 18:1417-1425. [PMID: 33373139 DOI: 10.1111/ddg.14252_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Cord Sunderkoetter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle/Saale
| | - Jan Ehrchen
- Klinik und Poliklinik für Hautkrankheiten, Universität Münster
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostic value of laboratory parameters for the discrimination between erysipelas and limited cellulitis. J Dtsch Dermatol Ges 2020; 18:1417-1424. [PMID: 33035396 DOI: 10.1111/ddg.14252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Erysipelas, caused by beta-hemolytic streptococci, and limited cellulitis, frequently caused by Staphylococcus aureus or other bacteria, are skin and soft tissue infections characterized by typical clinical signs. However, despite the therapeutical relevance they are often not differentiated (e.g in clinical trials). Erysipelas are efficiently treated with penicillin, while limited cellulitis is treated with more wide-spectrum antibiotics. This study investigates whether parameters such as CRP, blood counts or novel parameters like immature granulocytes could serve as biomarkers to distinguish between these entities. PATIENTS AND METHODS For this retrospective analysis 163 patients were included. We compared laboratory markers in patients with erysipelas (n = 68) to those with limited cellulitis (n = 41) of the leg. Both erysipelas and limited cellulitis were defined clinically, with an additional aspect for erysipelas being a prompt response to penicillin. RESULTS Erysipelas were characterized by higher levels of inflammation. CRP and leukocyte counts are the best parameters to discriminate between both infections. A CRP value ≥ 3.27 mg/dl indicated the diagnosis of erysipelas with 75 % sensitivity and 73.2 % specificity. CONCLUSIONS Our results support the thesis that erysipelas and limited cellulitis are distinct infections as defined in the German guidelines and that an assessment of CRP and leukocytes is useful for differential diagnosis.
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Affiliation(s)
- Christian Drerup
- Department of Dermatology, University of Muenster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Cord Sunderkoetter
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Jan Ehrchen
- Department of Dermatology, University of Muenster, Muenster, Germany
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Williams OM, Brindle R. Antibiotic route and duration of therapy for cellulitis: data extracted from a multi-center clinical trial. Int J Antimicrob Agents 2020; 56:106076. [DOI: 10.1016/j.ijantimicag.2020.106076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/17/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
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Cross ELA, Jordan H, Godfrey R, Onakpoya IJ, Shears A, Fidler K, Peto TEA, Walker AS, Llewelyn MJ. Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment. J Infect 2020; 81:521-531. [PMID: 32745638 DOI: 10.1016/j.jinf.2020.07.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children. METHODS We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response. PROSPERO CRD42018100602. RESULTS We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I2=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I2 = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse. CONCLUSIONS The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Harriet Jordan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Rebecca Godfrey
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annalie Shears
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Katy Fidler
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Timothy E A Peto
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. Calculated initial parenteral treatment of bacterial infections: Skin and soft tissue infections. GMS INFECTIOUS DISEASES 2020; 8:Doc11. [PMID: 32373436 PMCID: PMC7186924 DOI: 10.3205/id000055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is the ninth chapter of the guideline "Calculated Parenteral Initial Therapy of Adult Bacterial Disorders - Update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter contains the first German S2k guidelines for bacterial skin and soft tissue infections. They encompass recommendations on diagnosis and treatment of the defined entities erysipelas (caused by beta-hämolytic streptococci), limited superficial cellulitis (S. aureus), severe cellulitis, abscess, complicated skin and soft tissue infections, infections of feet in diabetic patients ("diabetic foot"), necrotizing soft tissue infection and bite injuries.
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Affiliation(s)
- Cord Sunderkötter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Karsten Becker
- Institut für Med. Mikrobiologie, Universitätsklinikum Münster, Germany
| | - Christian Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Peine, Germany
| | | | - Peter Kujath
- Chirurgische Klinik, Medizinische Universität Lübeck, Germany
| | - Helmut Schöfer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt/Main, Germany
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. S2k guidelines for skin and soft tissue infections Excerpts from the S2k guidelines for "calculated initial parenteral treatment of bacterial infections in adults - update 2018". J Dtsch Dermatol Ges 2020; 17:345-369. [PMID: 30920735 DOI: 10.1111/ddg.13790] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for "calculated initial parenteral treatment of bacterial infections" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for "complicated soft tissue infections", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.
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Affiliation(s)
- Cord Sunderkötter
- Department of Translational Dermatoinfectiology, Medical Faculty of the University of Münster, and Department of Dermatology and Venereology, University Medical Center, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, Münster University Medical Center, Münster, Germany
| | - Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Peine Medical Center, Peine, Germany
| | - Wolfgang Graninger
- Medical University of Vienna, Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Vienna General Hospital, Vienna, Austria
| | - Peter Kujath
- Department of Visceral, Vascular and Thoracic Surgery, Heide Medical Center, Heide, Germany
| | - Helmut Schöfer
- Department of Dermatology, Venereology, and Allergology, University hospital Frankfurt, Goethe-university, Frankfurt am Main, Germany
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. S2k‐Leitlinie Haut‐ und WeichgewebeinfektionenAuszug aus „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018“. J Dtsch Dermatol Ges 2019; 17:345-371. [DOI: 10.1111/ddg.13790_g] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cord Sunderkötter
- Abteilung für translationale DermatoinfektiologieMedizinische Fakultät Universität Münster und Universitätsklinik und Poliklinik für Dermatologie und VenerologieMartin‐Luther‐Universität Halle‐Wittenberg Halle (Saale)
| | - Karsten Becker
- Institut für Medizinische Mikrobiologie des Universitätsklinikums Münster
| | - Christian Eckmann
- Klinik für Allgemein‐Viszeral‐ und Thoraxchirurgie Klinikum Peine Peine
| | - Wolfgang Graninger
- Medizinische Universität WienUniversitätsklinik für Innere Medizin IKlinische Abteilung für Infektionen & TropenmedizinAllgemeines Krankenhaus Wien Wien Österreich
| | - Peter Kujath
- Klinik für Viszeral‐Gefäß‐ und ThoraxchirurgieWestküstenklinikum Heide Deutschland
| | - Helmut Schöfer
- Klinik für DermatologieVenerologie und AllergologieUniversitätsklinikum Frankfurt, Goethe‐Universität Frankfurt am Main
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Challener D, Marcelin J, Visscher S, Baddour L. Hospital costs for patients with lower extremity cellulitis: a retrospective population-based study. Hosp Pract (1995) 2017; 45:196-200. [PMID: 28944703 PMCID: PMC5935496 DOI: 10.1080/21548331.2017.1384690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Hospital admissions for non-purulent lower extremity cellulitis (NLEC) are common and can be prolonged and costly. Newer treatment options and preventive strategies are expected to result in cost savings before implementation, but few studies have quantified the cost of conventional treatment. METHODS Using the Rochester Epidemiology Project, the incidence of NLEC in Olmsted County, MN in 2013 was 176.6 per 100,000 persons. The subset of patients who required hospitalization for NLEC in 2013 was determined. Hospital admissions were analyzed retrospectively using standardized cost analysis within several relevant categories. RESULTS Thirty-four patients had an average hospital length of stay of 4.7 days. The median total inpatient cost was $7,341. The median cost per day was $2,087, with 49% due to room and board. Antibiotics administered for treatment of NLEC contributed a median cost of $75 per day of hospitalization, and laboratory and imaging test costs were $73 and $44, respectively, per day of hospitalization. CONCLUSION Hospitalizations for NLEC can be costly and prolonged with room and board accounting for much of the cost. Therefore, newer management strategies should seek to reduce hospital length of stay and/or avoid inpatient admission to reduce cost.
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Affiliation(s)
| | - Jasmine Marcelin
- b Infectious Diseases , University of Nebraska Medical Center , Omaha , NE , USA
| | - Sue Visscher
- c Center for the Science of Healthcare Delivery, Mayo Clinic , Rochester , MN , USA
| | - Larry Baddour
- d Infectious Diseases , Mayo Clinic , Rochester , MN , USA
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12
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Lemaire X, Bonnet E, Castan B, Forestier E, Lescure FX, Roblot F, Pulcini C. Management of non-necrotizing cellulitis in France. Med Mal Infect 2016; 46:355-359. [PMID: 27238366 DOI: 10.1016/j.medmal.2016.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/12/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aimed to assess medical practices of French infectious disease specialists or any other relevant physicians related to the management of non-necrotizing cellulitis (NNC). METHODS We sent an online questionnaire to members of the French Infectious Diseases Society (SPILF) mailing list in September 2015. RESULTS A total of 108 specialists took part in the survey and 10% (11/107) declared to always admit NNC patients to hospital. As for the others, 18% declared to admit patients in more than 80% of cases, 49% in 50-80% of cases, 26% in 20-50% of cases, and 7% in less than 20% of cases. The most frequent criteria for hospital admission were severe sepsis/septic shock (99%), poor social conditions (99%), rapid extension of skin lesions (93%), high level of pain (86%), and failure of first-line antibiotic therapy (84%). Participants mentioned similar criteria for reasons to initiate the intravenous (IV) antibiotic therapy. Fifty-three percent of respondents declared initiating antibiotic therapy using the IV route in more than 80% of cases. Physicians declared that the usual antibiotic therapy duration were <7 days (6%), 8-10 days (57%), 11-14 days (34%), and >15 days (3%). CONCLUSION Criteria for hospital admission and use of the IV route for antibiotic therapy as well as optimal treatment duration in patients presenting with NNC need to be detailed in guidelines and evaluated in prospective studies.
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Affiliation(s)
- X Lemaire
- Service maladies infectieuses, CH de Douai, 59500 Douai, France.
| | - E Bonnet
- Unité mobile d'infectiologie, hôpital J.-Ducuing, 15, rue Varsovie, 31300 Toulouse, France
| | - B Castan
- Centre hospitalier d'Ajaccio, 20000 Ajaccio, France
| | - E Forestier
- Service de maladies infectieuses et médecine interne, centre hospitalier de Chambéry, 73011 Chambéry cedex, France
| | - F-X Lescure
- Service de maladies infectieuses et tropicales, hôpital Bichat, AP-HP, Inserm, IAME, UMR 1137, université Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| | - F Roblot
- Médecine interne et département de maladies infectieuses, Inserm U1070, université de Poitiers, 86000 Poitiers, France
| | - C Pulcini
- Université de Lorraine, université Paris Descartes, EA 4360 APEMAC, 54505 Vandœuvre-lès-Nancy cedex, France; Service de maladies infectieuses et tropicales, hôpitaux de Brabois, CHU de Nancy, 54511 Vandœuvre-lès-Nancy cedex, France
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13
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Dey SK, Das AK, Sen S, Hazra A. Comparative evaluation of 2 g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian J Pharmacol 2016; 47:365-9. [PMID: 26288467 PMCID: PMC4527055 DOI: 10.4103/0253-7613.161254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/02/2015] [Accepted: 06/25/2015] [Indexed: 11/23/2022] Open
Abstract
Objectives: Uncomplicated skin and skin structure infections (uSSSIs) are a common clinical problem. Majority are caused by staphylococci and streptococci. Different oral antibiotics are used for uSSSI, with comparable efficacy but varying treatment duration, cost, and adverse event profile. Azithromycin is used in uSSSI in adults conventionally in a dose of 500 mg once for 5 days. The extensive tissue distribution of the drug and its long elimination half-life prompted us to explore whether a single 2 g dose of the drug would produce a response in uSSSI comparable to conventional dosing. Materials and Methods: We conducted a parallel group, open-label, randomized, controlled trial (CTRI/2015/07/005969) with subjects of either sex, ≥12 years of age, presenting with uSSSI to the dermatology outpatient department. One group (n = 146) received 2 g single supervised dose while the other (n = 146) received conventional dose of 500 mg once daily for 5 days. Subjects were followed up on day 4 and day 8. Complete clinical cure implied complete healing of lesions, without residual signs or symptoms, within 7 days. Results: High cure rate was observed in both arms (97.97% and 98.63%, respectively) along with noticeable improvement in symptom profile from baseline but without statistically significant difference between groups. However, excellent adherence (defined as no tablets missed) was better in single dosing arm (98.65% vs. 86.30%). Tolerability was also comparable between groups with the majority of adverse events encountered being gastrointestinal in nature and mild. Conclusions: Single 2 g azithromycin dose achieved the same result as conventional azithromycin dosing in uSSSI with comparable tolerability but with the advantage of assured adherence. This dose can, therefore, be recommended as an alternative and administration supervised if feasible.
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Affiliation(s)
- Sudipta Kumar Dey
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Amal Kanti Das
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sumit Sen
- Department of Dermatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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14
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Sunderkötter C, Becker K. Frequent bacterial skin and soft tissue infections: diagnostic signs and treatment. J Dtsch Dermatol Ges 2016; 13:501-24; quiz 525-6. [PMID: 26018361 DOI: 10.1111/ddg.12721] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2015] [Indexed: 12/13/2022]
Abstract
Skin and soft tissue infections rank among the most frequent infections worldwide. Classic erysipelas is defined as a non-purulent infection by beta-hemolytic streptococci. The typical signs are tender, warm, bright erythema with tongue-like extensions and early systemic symptoms such as fever or at least chills. Erysipelas always and best responds to penicillin. Limited soft tissue infection or limited cellulitis are the terms we have introduced for infections frequently caused by S. aureus and often originating from chronic wounds or acute trauma. Clinically, they are marked by tender, erythematous swelling which, unlike erysipelas, exhibit a darker red hue and is not always accompanied by fever or chills at onset. Severe cellulitis is a purulent, partially necrotic infection extending to the fascia, with general symptoms of infection, requiring surgical management in addition to antibiotics. It often fulfils criteria of so-called complicated soft tissue infections according to the definition of the FDA, due to their frequent association with e.g. severe diabetes mellitus, peripheral arterial occlusive disease or severe immunosuppression. In contrast, the rare necrotizing skin and soft tissue infections represent a distinct entity, characterized by rapid progression to ischemic necroses and shock due to special bacterial toxins. Limited cellulitis should be treated with cephalosporins group 1 or 2, or, when S.aureus is the isolated or highly likely causative agent, isoxazolyl-penicillins (exploiting their minimal selection pressure on other bacteria). For severe cellulitis, initial antibiotic treatment (mostly iv) includes - depending on the location - agents also active against gram-negative and/or anaerobic bacteria. (e.g. clindamycine, aminopeniclilline with inhibitors of betalaktamase, fluochinolons, cephalosporines group 4). For cutaneous abscesses, drainage presents the therapy of choice. Only under certain conditions additional antibiotic therapy is required. Adherence to the diagnostic criteria and to evidence-based or consensus-derived treatment recommendations as presented herein should allow for an antibiotic therapy with a good balance of efficacy, tolerability by patients and low selection pressure for highly resistant bacteria.
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Affiliation(s)
- Cord Sunderkötter
- Department of Dermatology, University Hospital Münster and Division of Infectious Diseases in Dermatology, University of Münster
| | - Karsten Becker
- Institute for Medical Microbiology, University Hospital Münster
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Sunderkötter C, Becker K. Häufige bakterielle Infektionen der Haut- und Weichgewebe: Klinik, Diagnostik und Therapie. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12721_suppl] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Cord Sunderkötter
- Klinik für Hautkrankheiten des Universitätsklinikums Münster und Abteilung für translationale Dermatoinfektiologie der Universität Münster
| | - Karsten Becker
- Institut für Medizinische Mikrobiologie des Universitätsklinikums Münster
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Aboltins CA, Hutchinson AF, Sinnappu RN, Cresp D, Risteski C, Kathirgamanathan R, Tacey MA, Chiu H, Lim K. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. J Antimicrob Chemother 2014; 70:581-6. [PMID: 25336165 DOI: 10.1093/jac/dku397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials. METHODS A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910). RESULTS Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups. CONCLUSIONS Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.
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Affiliation(s)
- Craig A Aboltins
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Victoria, Australia Northwest Academic Centre, The University of Melbourne, Epping, Melbourne, Victoria, Australia
| | - Anastasia F Hutchinson
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia School of Nursing & Midwifery, Deakin University, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Rabindra N Sinnappu
- Hospital In The Home, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Damian Cresp
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Chrissie Risteski
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia
| | | | - Mark A Tacey
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia Department of Medicine, The University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Herman Chiu
- Emergency Department, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Kwang Lim
- Northwest Academic Centre, The University of Melbourne, Epping, Melbourne, Victoria, Australia Department of Medicine, Northern Health, Epping, Melbourne, Victoria, Australia
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Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue
Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147-59. [DOI: 10.1093/cid/ciu296] [Citation(s) in RCA: 1187] [Impact Index Per Article: 118.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.
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Affiliation(s)
- Dennis L. Stevens
- Division of Infectious Diseases, Department of Veterans Affairs, Boise, Idaho
| | - Alan L. Bisno
- Medical Service, Miami Veterans Affairs Health Care System, Florida
| | | | | | - Ellie J. C. Goldstein
- University of California, Los Angeles, School of Medicine, and R. M. Alden Research Laboratory, Santa Monica, California
| | | | - Jan V. Hirschmann
- Medical Service, Puget Sound Veterans Affairs Medical Center, Seattle, Washington
| | - Sheldon L. Kaplan
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - James C. Wade
- Geisinger Health System, Geisinger Cancer Institute, Danville, Pennsylvania
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Chon SY, Doan HQ, Mays RM, Singh SM, Gordon RA, Tyring SK. Antibiotic overuse and resistance in dermatology. Dermatol Ther 2012; 25:55-69. [PMID: 22591499 DOI: 10.1111/j.1529-8019.2012.01520.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Antibiotics have a significant role in dermatology, treating a wide range of diseases, including acne, rosacea, inflammatory skin conditions and skin structure infections, such as cellulitis, folliculitis, carbuncles, and furuncles. Because of their consistent use, utility, and availability, antibiotics are susceptible to overuse within the medical practice, and, specific to this discussion, in the dermatologic setting. The issue of continuously increasing risk of antibiotic resistance remains an important concern to the dermatologist. The scope of this review will be to provide an overview of the common antibiotics used in the dermatologic setting with an emphasis on identifying areas of overuse, reported bacterial resistance, and discussion of clinical management aimed at decreasing antibiotic resistance.
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Affiliation(s)
- Susan Y Chon
- Department of Dermatology, University of Texas Medical School at Houston, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Lower limb cellulitis and its mimics. J Am Acad Dermatol 2012; 67:163.e1-12; quiz 175-6. [DOI: 10.1016/j.jaad.2012.03.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 12/17/2022]
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Cross L. The classification and management of skin and soft tissue infections. Int Emerg Nurs 2012; 21:84-8. [PMID: 23615514 DOI: 10.1016/j.ienj.2012.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/29/2012] [Accepted: 03/31/2012] [Indexed: 01/22/2023]
Abstract
Skin and soft tissue infections (SSTIs) are a common problem in patients presenting to the emergency department, varying from mild local inflammation to necrotizing fasciitis. SSTI were the 2nd most common indication for antibiotic use in Europe in 2006. Currently, the National Institute of Clinical Excellence (a UK based independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health) has not published any guidelines for the classification and management of these patients. This is a review of the evidence around attempts at developing classification systems for SSTI and their management. It also considers the financial implications for both the patient and the healthcare system and the personal ramifications for patients.
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Affiliation(s)
- Louise Cross
- Emergency Department, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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Cutaneous Manifestations of Infectious Diseases. ATLAS OF DERMATOLOGY IN INTERNAL MEDICINE 2012. [PMCID: PMC7178861 DOI: 10.1007/978-1-4614-0688-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Skin infections account for a significant portion of dermatologic diseases. Infections of the skin and subcutaneous tissues are highly diverse in respect to incidence, etiologic organisms, and clinical manifestations. Most cases are potentially treatable, thus, it is vital for the clinician to become familiar with the cutaneous expression of local and systemic processes. This chapter covers the clinical presentation, diagnosis, and treatment of the most common bacterial, viral, and fungal mucocutaneous infections encountered in internal medicine.
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Koerner R, Johnson AP. Changes in the classification and management of skin and soft tissue infections. J Antimicrob Chemother 2010; 66:232-4. [PMID: 21123287 DOI: 10.1093/jac/dkq443] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used 'Eron classification' is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) 'Guidelines on the Management of Cellulitis in Adults' have not been validated in clinical trials. In the current issue of JAC, investigators at Ninewells Hospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.
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Affiliation(s)
- Roland Koerner
- Department of Microbiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK.
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Marwick C, Broomhall J, McCowan C, Phillips G, Gonzalez-McQuire S, Akhras K, Merchant S, Nathwani D, Davey P. Severity assessment of skin and soft tissue infections: cohort study of management and outcomes for hospitalized patients. J Antimicrob Chemother 2010; 66:387-97. [PMID: 20926396 DOI: 10.1093/jac/dkq362] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are caused by bacterial invasion of the skin and underlying soft tissues and can present with a wide spectrum of signs, symptoms and illness severity. They are a common indication for antimicrobial therapy. However, there are few data on treatment outcomes or the validity of clinical severity scores. METHODS Two hundred and five adult patients admitted to Ninewells Hospital, Scotland in 2005, and treated with antibiotics for SSTI, were identified. They were stratified into four classes of severity (class IV = most severe) based on sepsis, co-morbidity and their standardized early warning score (SEWS). Empirical antimicrobial therapy by severity class was compared with the recommendations of a UK guideline. RESULTS Thirty-five different empirical antimicrobial regimens were prescribed. Overall, 43% of patients were over-treated, this being particularly common in the lowest severity class I (65% patients). Thirty-day mortality was 9% (18/205) and 17 patients (8%) died during their index admission. Mortality (30 day) and inadequate therapy increased with severity class: I, no sepsis or co-morbidity (45% patients, 1% mortality, 14% therapy inadequate); II, significant co-morbidity but no sepsis (32% patients, 11% mortality, 39% therapy inadequate); III, sepsis but SEWS <4 (17% of patients, 17% mortality, 39% therapy inadequate); and IV, sepsis plus SEWS ≥ 4 (6% of patients, 33% mortality, 92% therapy inadequate). CONCLUSIONS SSTI in hospital is associated with significant mortality. Choice of empirical therapy is not evidence based, with significant under-treatment of severely ill patients.
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Affiliation(s)
- Charis Marwick
- Quality, Safety and Informatics Research Group, Division of Clinical and Population Sciences and Education, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, Scotland, UK.
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Krasagakis K, Valachis A, Maniatakis P, Krüger-Krasagakis S, Samonis G, Tosca AD. Report: Analysis of epidemiology, clinical features and management of erysipelas. Int J Dermatol 2010; 49:1012-7. [DOI: 10.1111/j.1365-4632.2010.04464.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
BACKGROUND Cellulitis and erysipelas are now usually considered manifestations of the same condition, a skin infection associated with severe pain and systemic symptoms. A range of antibiotic treatments are suggested in guidelines. OBJECTIVES To assess the efficacy and safety of interventions for non-surgically-acquired cellulitis. SEARCH STRATEGY In May 2010 we searched for randomised controlled trials in the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and the ongoing trials databases. SELECTION CRITERIA We selected randomised controlled trials comparing two or more different interventions for cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS We included 25 studies with a total of 2488 participants. Our primary outcome 'symptoms rated by participant or medical practitioner or proportion symptom-free' was commonly reported. No two trials examined the same drugs, therefore we grouped similar types of drugs together.Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98).Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99, 95% CI 0.68 to 1.43).Six trials which included 538 people that compared different generations of cephalosporin, showed no difference in treatment effect (RR 1.00, 95% CI 0.94 to1.06).We found only small single studies for duration of antibiotic treatment, intramuscular versus intravenous route, the addition of corticosteroid to antibiotic treatment compared with antibiotic alone, and vibration therapy, so there was insufficient evidence to form conclusions. Only two studies investigated treatments for severe cellulitis and these selected different antibiotics for their comparisons, so we cannot make firm conclusions. AUTHORS' CONCLUSIONS We cannot define the best treatment for cellulitis and most recommendations are made on single trials. There is a need for trials to evaluate the efficacy of oral antibiotics against intravenous antibiotics in the community setting as there are service implications for cost and comfort.
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Affiliation(s)
- Sally A Kilburn
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, Hampshire, UK, PO1 2FR
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Infecciones de piel y partes blandas. Med Clin (Barc) 2009; 133:552-64. [DOI: 10.1016/j.medcli.2008.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 11/26/2008] [Indexed: 01/22/2023]
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Abstract
Introduction Lymphoedema (LE) is a disorder characterized by persistent swelling caused by impaired lymphatic drainage because of various aetiologies, including lymphatic injury and congenital functional or anatomical defects. Objective Literature review and expert opinion about diagnosis and treatment of LE in children. Results LE is rare in children, with a prevalence of about 1.15/100,000 persons, 20 years old. The management of LE in children differs considerably from adults in terms of origin, co-morbidity and therapeutic approach. The objective of this presentation is to discuss practical issues related to clinically relevant information on the diagnosis, aetiology, work-up and treatment of LE in children. In contrast to adults, who usually experience secondary LE because of acquired lymphatic failure, most cases in children have a primary origin. The diagnosis can be made mainly on the basis of careful personal and family history, and physical examination. LE in children can be part of a syndrome if there are other concomitant phenotypic abnormalities and if a genetic defect is recognizable. Treatment of LE is mostly conservative utilizing decongestive LE therapy including compression therapy, directed exercises, massage and skincare. In the neonate, initial observation alone may be sufficient, as delayed lymphatic development and maturation can result in spontaneous improvement. The role of parents is crucial in providing the necessary input. Conclusion We present a review emphasizing a practical approach to treating a child with LE according to current publications and our own experience.
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Affiliation(s)
- R J Damstra
- Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital Drachten, The Netherlands
| | - P S Mortimer
- Department of Cardiac and Vascular Sciences (Dermatology), St George's Hospital Medical School, University of London, London, UK
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Damstra RJ, van Steensel MAM, Boomsma JHB, Nelemans P, Veraart JCJM. Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg. Br J Dermatol 2008; 158:1210-5. [PMID: 18363756 DOI: 10.1111/j.1365-2133.2008.08503.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erysipelas is a common skin infection that is usually caused by beta-haemolytic group A streptococci. After having had erysipelas in an extremity, a significant percentage of patients develops persistent swelling or suffers from recurrent erysipelas. We hypothesize that in cases of erysipelas without a clear precipitating agent, subclinical pre-existing congenital or acquired disturbances in the function of the lymphatic system are present. The persistent swelling after erysipelas is then most likely caused by lymphoedema. OBJECTIVES We designed a study to examine if erysipelas of unknown origin is associated with a pre-existent insufficiency of the lymphatic system. If our hypothesis is correct, patients with erysipelas of unknown cause without previously evident lymphoedema should have evidence of disturbed lymphatic transport in the unaffected extremity. METHODS A prospective study, in which lymphoscintigraphy of both legs was performed in patients 4 months after presenting with an episode of erysipelas only in one leg. No patient had any known risk factor for erysipelas, such as diabetes mellitus, chronic venous insufficiency or clinical signs of lymphoedema. Lymphoscintigraphy was performed in 40 patients by subcutaneous injection of Tc-99m-labelled human serum albumin in the first web space of both feet. After 30 and 120 min, quantitative and qualitative scans were performed using a computerized gamma camera. During the lymphoscintigraphy, the patients performed a standardized exercise programme. Lymph drainage was quantified as the percentage uptake of Tc-99m-labelled human serum albumin in the groin nodes at 2 h after injection. Groin uptake of < 15% is pathological; uptake between 15-20% is defined as borderline, and uptake of > 20% as normal. RESULTS The mean +/- SD percentage uptake in the groin nodes in the affected limbs was 9.6 +/- 8.5% vs. 12.1% +/- 8.9% in the nonaffected limbs. The mean paired difference in uptake between the nonaffected vs. affected side was 2.5% (95% confidence interval 1.1-3.9%). This indicates that lymphatic drainage in the nonaffected limb was only slightly better than in the affected limb despite the infectious event in the latter. Of 33 patients with objective impairment of lymph drainage in the affected limb, 26 (79%) also had impaired lymph drainage in the nonaffected limb. Agreement in qualitative measurements between affected and nonaffected leg was less pronounced: 21 patients had abnormal qualitative results in the affected leg of whom nine also had impairment of the nonaffected leg (43%). CONCLUSIONS Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology.
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Affiliation(s)
- R J Damstra
- Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, 9202 NN Drachen, The Netherlands.
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Sendi P, Johansson L, Norrby-Teglund A. Invasive Group B Streptococcal Disease in Non-pregnant Adults. Infection 2008; 36:100-11. [DOI: 10.1007/s15010-007-7251-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 09/19/2007] [Indexed: 01/22/2023]
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Goettsch WG, Bouwes Bavinck JN, Herings RMC. Burden of illness of bacterial cellulitis and erysipelas of the leg in the Netherlands. J Eur Acad Dermatol Venereol 2007; 20:834-9. [PMID: 16898907 DOI: 10.1111/j.1468-3083.2006.01657.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Information on the prevalence of bacterial cellulitis (BC) and erysipelas (ER) of the leg (BCERL) is sparse and dependent on the definitions used. There is no information available on the number of hospitalized and non-hospitalized patients with BCERL, and related treatment costs. OBJECTIVE The purpose of this study was to assess the burden of illness for BCERL in the Netherlands in 2001. METHODS Data were obtained from different linked databases. Hospital information was obtained from the National Morbidity Registration (known in the Netherlands as the LMR), which includes all Dutch citizens, using ICD-9-CM codes. The number of patients not admitted to hospital was estimated using a subsample with data from general practitioners (GPs) (N = 50,000). These data were extrapolated using age/gender and disease-specific standardization. The subsample was used to assess the location of the infection. Reimbursement costs were available for all resources. RESULTS In 2001, approximately 28,000 patients presented with either BC or ER of the leg. Of these patients, 2,200 were admitted to the hospital and 4-6% had two or more episodes of ER/BC in 2001. The average costs per hospitalization for BCERL were 5,346 euros, accumulating to more than 14 million euros in 2001. Although only 7% of all patients were hospitalized, 83% of the total treatment costs could be attributed to hospitalization. CONCLUSIONS BCERL are common and serious infections in the Netherlands. Hospitalization occurs in only one in 14 patients but contributes more than 80% of the total costs, which accumulate to 17 million euros a year.
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Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005; 41:1373-406. [PMID: 16231249 DOI: 10.1086/497143] [Citation(s) in RCA: 926] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Accepted: 07/14/2005] [Indexed: 01/11/2023] Open
Affiliation(s)
- Dennis L Stevens
- Infectious Diseases Section, Veterans Affairs Medical Center, Boise, Idaho 83702, USA.
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Abstract
Erysipelas is an acute bacterial infection of the dermis and hypodermis that is associated with clinical inflammation. It is a specific clinical type of cellulitis and, as such, it should be studied as a specific entity. Erysipelas is generally caused by group A streptococci; it is highly probable that streptococcal toxins also play a role, which could, in part, help explain the clinical inflammation. Erysipelas of the leg is the main clinical type encountered. The face, arm, and upper thigh are the other most common sites for the occurrence of erysipelas. After a sudden onset, areas of erythema and edema characteristically enlarge with well-defined margins. Athlete's foot is the most common portal of entry for the disease. Erysipelas is generally associated with high fever, and adenopathy and lymphangitis are sometimes present. At the time of diagnosis, it is important to look for clinical markers of severity (local signs and symptoms, general signs and symptoms, co-morbidity, social context) which would necessitate hospitalization. There are many differential diagnoses, particularly in the case of atypical dermo-hypodermitis. Some bacterial infections may have specific clinical aspects or may lead to a diagnosis of cellulitis. Necrotizing cellulitis or fasciitis are life-threatening diseases and a rapid diagnosis is important. Other noninfectious types of cellulitis have been reported in many diseases, both localized or generalized. The biology of typical erysipelas is of little value in diagnosis and a laboratory workup is usually not required. There are few local complications associated with erysipelas; abscess can occur in some patients and septicemia is rare. Recurrence is the more distressing complication. Treatment of patients with erysipelas has been evaluated in a small number of studies. In most of them, erysipelas has been included in therapeutic studies of 'severe cutaneous infections'. This is not justified as in fact erysipelas is usually sensitive to penicillin G. Amoxicillin and macrolides are also effective. However, comparative, cost-analysis studies need to be performed to determine the best therapeutic option. Bed rest with the leg elevated is also important. Anticoagulants are indicated in patients at risk of venous thromboembolism. The portal of entry will also require treatment. Long-term antibacterial therapy is required for patients with recurrence.
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Bernard P, Chosidow O, Vaillant L. Oral pristinamycin versus standard penicillin regimen to treat erysipelas in adults: randomised, non-inferiority, open trial. BMJ 2002; 325:864. [PMID: 12386036 PMCID: PMC129632 DOI: 10.1136/bmj.325.7369.864] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2002] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of oral pristinamycin versus intravenous then oral penicillin to treat erysipelas in patients in hospital. DESIGN Multicentre, parallel group, open labelled, randomised non-inferiority trial. SETTING 22 French hospitals. PARTICIPANTS 289 adults admitted to hospital with erysipelas. RESULTS At follow up (day 25-45) the cure rate (primary efficacy end point) for the per protocol populations was 81% (83/102) for pristinamycin and 67% (68/102) for penicillin. The planned interim analysis (global one sided type I error 5%) showed that the one sided 97.06% confidence interval of the observed difference (pristinamycin-penicillin) between cure rates (3.3% to infinity ) exceeded the -10% non-inferiority threshold. For the intention to treat populations the cure rate at follow up was 65% (90/138) for pristinamycin and 53% (79/150) for penicillin, with the one sided 97.06% confidence interval of the observed difference between cure rates (1.7% to infinity ) exceeding the -10% non-inferiority threshold. That the lower limit of the confidence interval exceeded the -10% threshold and was also >0 supports the hypothesis that pristinamycin is significantly superior at the 5% level. More adverse events related to treatment, as assessed by the investigators, were reported in the pristinamycin group than in the penicillin group. Most adverse events involved the gastrointestinal tract (nausea, vomiting, and diarrhoea) but were minor and usually did not require discontinuation of treatment. CONCLUSION Pristinamycin could be an alternative to the standard intravenous then oral penicillin regimen used to treat erysipelas in adults in hospital, with the advantages of oral first line therapy.
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Affiliation(s)
- Philippe Bernard
- Department of Dermatology, Hôpital Robert-Debré, 51092 Reims, France.
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Marie-Cardine A, Mallet E, Billiemaz K, Boulesteix J, Bourrillon A, Dechamps C, Duhamel JF, Garnier JM, Gaudelus J, Gendrel D, Jeannot E, Küpfer I, Labbé A, Lagardère B, Meunier M, Olivier C, Reinert P. [Severe cutaneous Streptococcus pyogenes infections in the child: results of a multicenter survey]. Arch Pediatr 2001; 8:1325-32. [PMID: 11811027 DOI: 10.1016/s0929-693x(01)00653-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
UNLABELLED To assess pediatric cases of severe cutaneous infections due to Streptococcus pyogenes. Since the beginning of 1980, the incidence of cellulitis and necrotizing fasciitis due to S. pyogenes has increased in adults. Serotyping of obtained isolates are in most cases M1, M3 or M5 protein. PATIENTS AND METHOD A retrospective (1990-2000) survey was carried out in pediatric hospital centers. RESULTS Three cases of necrotizing fasciitis and 15 of cellulitis were observed. In 30% of the cases, vancella lesions were associated; in the other cases, minor wounds were the site of the infection. Bacteriologic diagnosis was made by local samples in 14 cases; blood cultures were positive in four cases. In 11 cases, initial intravenous treatment consisted of third generation cephalosporin, in six cases of penicillin M or G and in one case of fusidic acid. In the second time, penicillin M was perfused in the majority of the cases. Mean duration of intravenous antibiotics perfusion was 15 days. There were no sequelae or death in this survey. CONCLUSIONS Despite this study had limited epidemiological characteristics, it confirms that these two infections are rare. The frequency is probably underestimated, due to the difficulty in performing a diagnosis. The major site of infection was the varicella lesion. These two infections are so similar that it is frequent to mistake one infection for the other. Nonsteroidal anti-inflammatory drugs and site of infections did not influence prognosis. The treatment of cellulitis is penicillinotherapy whereas in necrotizing fasciitis early major surgery is often correlated with the rate of survival.
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Affiliation(s)
- A Marie-Cardine
- Service de réanimation pédiatrique, centre hospitalier universitaire de Saint-Etienne, avenue A.-Raimond, 42055 Saint-Etienne, France
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Becq-Giraudon B. L’érysipèle: prévention primaire et secondaire. Med Mal Infect 2000. [DOI: 10.1016/s0399-077x(01)80027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Érysipèle: quelle prise en charge? Med Mal Infect 2000. [DOI: 10.1016/s0399-077x(01)80019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Dupuy A. Épidémiologie descriptive et connaissance des facteurs de risque de l’érysipèle. Med Mal Infect 2000. [DOI: 10.1016/s0399-077x(01)80016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Sjöblom AC, Eriksson B, Jorup-Rönström C, Karkkonen K, Lindqvist M. Antibiotic prophylaxis in recurrent erysipelas. Infection 1993; 21:390-3. [PMID: 8132369 DOI: 10.1007/bf01728920] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Recurrences of erysipelas are especially prevalent in patients suffering from local impairment of circulation and intervention might thus be of benefit. Therefore a prospective, randomized, open study was undertaken to evaluate whether daily antibiotic prophylaxis would reduce the risk of recurrence. Patients with venous insufficiency or lymphatic congestion who had suffered two or more episodes of erysipelas during the previous 3 years and were admitted to the Infectious Disease Department at Roslagstull Hospital, Stockholm, Sweden, between November 1988 and November 1991 were included. Fourty patients, 20 on prophylaxis and 20 controls were followed according to a life table analysis during a median time of 15 months. Phenoxymethylpenicillin was prescribed as daily prophylaxis (while erythromycin was given to patients allergic to penicillin). Recurrences of erysipelas appeared to be reduced by daily antibiotic prophylaxis but the effect was not dramatic (p = 0.06). Only in patients with a high recurrence rate continuous antibiotic prophylaxis against erysipelas is indicated.
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Affiliation(s)
- A C Sjöblom
- Dept. of Infectious Diseases, Huddinge Hospital, Sweden
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Affiliation(s)
- E M Grosshans
- Dermatology Clinic, Faculty of Medicine, Louis Pasteur University, Strasbourg, France
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Sjöblom AC, Bruchfeld J, Eriksson B, Jorup-Rönström C, Karkkonen K, Malmborg AS, Lindqvist M. Skin concentrations of phenoxymethylpenicillin in patients with erysipelas. Infection 1992; 20:30-3. [PMID: 1563809 DOI: 10.1007/bf01704891] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 45 patients hospitalized with febrile erysipelas that had been treated with oral penicillin, punch biopsies of infected skin were performed and analysed for phenoxymethylpenicillin (pcV) concentrations. The curves for the concurrent serum and tissue levels followed the same course, indicating a rapid diffusion of pcV from serum into tissue. Penicillin concentrations in infected skin exceeded the minimal inhibitory concentrations (MIC) of the streptococci isolated for the first 4 h after tablet ingestion. Venous insufficiency was highly prevalent and pcV concentrations in affected patients were slightly but not significantly higher. A theoretical basis for the successful treatment of erysipelas with oral penicillin is therefore at hand.
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Affiliation(s)
- A C Sjöblom
- Dept. of Infectious Diseases, Roslagstull Hospital, Stockholm, Sweden
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Affiliation(s)
- C Chartier
- Dermatology Clinic, Faculty of Medicine, Louis Pasteur University, Strasbourg, France
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45
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Jorup-Rönström C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection 1987; 15:105-6. [PMID: 3110071 DOI: 10.1007/bf01650206] [Citation(s) in RCA: 71] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
After an average follow-up time of three years, recurrent erysipelas was observed in 29% of 143 patients admitted primarily with erysipelas. Nineteen patients (13%) had two or more recurrences during this period. The predisposing factor with the highest recurrence rate was venous insufficiency. Regular prophylaxis with phenoxymethylpenicillin (or erythromycin in penicillin allergics) after the second recurrence may be cost-effective. This antibiotic prophylaxis is only recommended in patients with predisposing factors who have suffered severe attacks.
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Fredlund H, Bodin L, Bäck E, Holmberg H, Krook A, Rydman H. Antibiotic therapy in pneumonia: a comparative study of parenteral and oral administration of penicillin. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1987; 19:459-66. [PMID: 3118453 DOI: 10.3109/00365548709021679] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
An open, randomized study of treatment of radiologically verified community-acquired pneumonia is described. 33 patients were treated with phenoxymethylpenicillin orally in an average dose of 2 g every 8 h, and 36 patients were treated intravenously with benzylpenicillin 3 g every 8 h. When temperature was normalized the antibiotic dose was reduced in both groups to oral phenoxymethylpenicillin in an average dose of 1 g every 8 h. 24 and 26 patients in respective groups completed 10 days of therapy. No statistically significant differences between the two groups were found when compared for duration of fever, hospital stay, CRP, ESR, leukocyte counts and X-ray normalization. In spite of the low number of patients included in this study it gives a clear indication that treatment of pneumonia with penicillin by the oral route results in the same outcome as parenteral treatment when patients suffering from vomiting, diarrhoea and severe illness with respiratory distress are excluded. In addition, oral treatment is cheaper than parenteral and more simple to manage.
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Affiliation(s)
- H Fredlund
- Department of Infectious Diseases, Orebro Medical Center Hospital, Sweden
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Jorup-Rönström C. Epidemiological, bacteriological and complicating features of erysipelas. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1986; 18:519-24. [PMID: 3810046 DOI: 10.3109/00365548609021656] [Citation(s) in RCA: 98] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
233 patients with erysipelas, admitted to the Department of Infectious Diseases, Danderyd Hospital, during a 2-year period were analysed for epidemiological, bacteriological and complicating features. Erysipelas was defined clinically as a febrile skin infection with a sudden onset of a red indurated expanding plaque with a distinct border. Common predisposing factors were alcohol abuse, diabetes mellitus and venous insufficiency, and complications were more common among such patients. No seasonal variation was found. 5% of patients with blood culture had streptococcemia (7/149). Erysipelas emerging from an infected ulcer was seen in 52% (122/233) and in 46% of these streptococci were isolated (57/122), 67% of which were of type A (38/57). Staphylococcus aureus was isolated from 59% of ulcerative cases (72/122) and in 3 of them staphylococci were found in the blood.
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