[Severe Streptococcus pyogenes cutaneous infections]

Outpatient management of moderate cellulitis in children using high-dose oral cephalexin

Objectives

To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.

Methods

In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.

Results

A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).

Conclusions

With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.

[Clinical symptoms and therapy of necrotizing skin and soft tissue infections]

Skin and soft tissue infections are among the most common diseases requiring surgical treatment. The presentation of patients varies from folliculitis to severe necrotizing infections with a fatal outcome. The diagnosis of a necrotizing infection is often difficult. The correct diagnosis is often made after deterioration of the patient's condition in the rapid course of the disease. The early and correct diagnosis and immediate surgery are decisive for the prognosis. Treatment at a specialized intensive care unit and the administration of a broad spectrum antibiotic are pivotal for the survival of individual patients.

Sudden Unexpected Death in a Child With Varicella Caused by Necrotizing Fasciitis and Streptococcal Toxic Shock Syndrome

A 4-year-old child with chickenpox infection for 5 days prior to death complained of swelling and pain in his right leg that required medical assistance in the emergency department. Radiologic study was normal, and analgesic and bandage of the leg were prescribed. Some hours later, he presented cyanosis, dizziness, and vomiting and collapsed. A complete forensic autopsy was performed 12 hours after death. External examination of the body showed numerous crusty varicella skin lesions, especially over the trunk, and swelling and reddening of his right leg. The brain was swollen, with cerebellar herniation, and both adrenal glands were hemorrhagic.Microscopically, neutrophilic infiltration and muscle fiber necrosis were observed in soft tissues of his right leg, and fibrin microthrombus were numerous in capillaries of the plexus choroideus, larynx, lungs, and adrenals. Bacterial emboli were present in most of the tissues. Microbiologic cultures of blood and cerebrospinal fluid showed group A beta-hemolytic streptococcus (Streptococcus pyogenes). Death was attributed to fulminant streptococcal toxic shock syndrome, with necrotizing fasciitis as a complication of varicella.

Évaluation du traitement ambulatoire de la varicelle de l’enfant

BACKGROUND

Varicella, an almost compulsory affection in children, is complicated in 2% of cases. Some treatments such as powders and non-steroidial anti-inflammatories (NSAIs) may favorise or worsen infectious complications.

OBJECTIVE

To assess out-patient prescriptions in children presenting with varicella.

METHODS

Three methods were used. Collection of the out-patient prescriptions in children (n=122) subsequently presenting with varicella in one of the hospitals in the North of France conducted from January to May 2003. A telephone survey was made among 50 general practitioners in the same area in March 2003. This collected not only the prescription of the last case reported, but also the intended prescriptions when confronted with a simulated case of the disease.

RESULTS

Powders were prescribed in 44 to 54% of cases, NSAIs in 14 to 16%, aspirin in 2 to 4%, and oral acyclovir in 4%. The three assessment methods did not reveal any differences in the prescription of antibiotics, more frequent in the children subsequently visiting the hospital (25 vs. 6%), and the prescriptions of paracetamol. Only 38% of the prescriptions during clinical cases corresponded to the guidelines.

CONCLUSION

It is crucial that practitioners be informed on the treatment of varicella and the risks of severe cutaneous surinfections enhanced by certain prescriptions.