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Akhavan H, Habibzadeh SR, Maleki F, Foroughian M, Ahmadi SR, Akhavan R, Abbasi B, Shahi B, Kalani N, Hatami N, Mangouri A, Jamalnia S. Accuracy of CREST Guideline in Management of Cellulitis in Emergency Department; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e69. [PMID: 34870235 PMCID: PMC8628644 DOI: 10.22037/aaem.v9i1.1422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hospitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team (CREST) guideline in management of cellulitis in emergency department. Method: Studies that had evaluated cellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database, from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate Guideline Network (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AUROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriateness of antimicrobial treatment in management of cellulitis in emergency department was evaluated. Results: Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation of the rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95% confidence interval (CI): 0.06 – 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicrobial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department, OR=0.21 (95% CI: 0.009 – 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 – 0.89) showed accuracy of the CREST classification in prediction of being hospitalized more or less than 24 hours. Conclusion: CREST classification shows good accuracy in determining the duration of hospitalization or observation in ED but it could lead to inevitable over/under treatment with empirical antimicrobial agents.
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Affiliation(s)
- Hossein Akhavan
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Reza Habibzadeh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Maleki
- Department of Emergency Medicine, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Mahdi Foroughian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sayyed Reza Ahmadi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Akhavan
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Behzad Shahi
- Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Navid Kalani
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Naser Hatami
- Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Mangouri
- Division of Vascular Surgery and Endovascular Therapy, Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sheida Jamalnia
- Medical Journalism Department, Shiraz University of Medical Sciences, Shiraz, Iran
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Silverberg B. A Structured Approach to Skin and Soft Tissue Infections (SSTIs) in an Ambulatory Setting. Clin Pract 2021; 11:65-74. [PMID: 33535501 PMCID: PMC7931029 DOI: 10.3390/clinpract11010011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022] Open
Abstract
The skin is the largest, and arguably, the most vulnerable organ in the human body. Scratches and scrapes, bites and puncture wounds, impetigo and erysipelas-all these disruptions can lead to pain, swelling, and/or systemic symptoms. In this article, which is based on the Infectious Diseases Society of America's 2014 guidelines and the World Society of Emergency Surgery and Surgical Infection Society of Europe's 2018 consensus statement, a structured approach to skin and soft tissue infections (SSTIs) is reviewed, comparing treatment for suppurative and non-suppurative infections, and then discussing specific conditions commonly seen in Primary Care and Urgent Care facilities.
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Affiliation(s)
- Benjamin Silverberg
- Department of Emergency Medicine, West Virginia University, 1 Medical Center Drive, Box 9149, Morgantown, WV 26506, USA
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Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients. Epidemiol Infect 2018; 147:e68. [PMID: 30516120 PMCID: PMC6518578 DOI: 10.1017/s0950268818003291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Infectious Disease Society of America (IDSA) publishes guidelines regularly for the management of skin and soft tissue infections; however, the extent to which practice patterns follow these guidelines and if this can affect treatment failure rates is unknown. We observed the treatment failure rates from a multicentre retrospective ambulatory cohort of adult emergency department patients treated for a non-purulent skin infection. We used multivariable logistic regression to examine the role of IDSA classification and whether adherence to IDSA guidelines reduced treatment failure. A total of 759 ambulatory patients were included in the cohort with 17.4% failing treatment. Among all patients, 56.0% had received treatments matched to the IDSA guidelines with 29.1% over-treated, and 14.9% under-treated based on the guidelines. After adjustment for age, gender, infection location and medical comorbidities, patients with a moderate infection type had three times increased risk of treatment failure (adjusted risk ratio (aRR) 2.98; 95% confidence interval (CI) 1.15–7.74) and two times increased risk with a severe infection type (aRR 2.27; 95% CI 1.25–4.13) compared with mild infection types. Patients who were under-treated based on IDSA guidelines were over two times more likely to fail treatment (aRR 2.65; 95% CI 1.16–6.05) while over-treatment was not associated with treatment failure. Patients ⩾70 years of age had a 56% increased risk of treatment failure (aRR 1.56; 95% CI 1.04–2.33) compared with those <70 years. Following the IDSA guidelines for non-purulent SSTIs may reduce the treatment failure rates; however, older adults still carry an increased risk of treatment failure.
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Single-Dose Oritavancin Treatment of Acute Bacterial Skin and Skin Structure Infections: SOLO Trial Efficacy by Eron Severity and Management Setting. Infect Dis Ther 2016; 5:353-61. [PMID: 27370913 PMCID: PMC5019975 DOI: 10.1007/s40121-016-0119-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Indexed: 11/04/2022] Open
Abstract
Introduction Introduction of new antibiotics enabling single-dose administration, such as oritavancin may significantly impact site of care decisions for patients with acute bacterial skin and skin structure infections (ABSSSI). This analysis compared the efficacy of single-dose oritavancin with multiple-dose vancomycin in patients categorized according to disease severity via modified Eron classification and management setting. Methods SOLO I and II were phase 3 studies evaluating single-dose oritavancin versus 7–10 days of vancomycin for treatment of ABSSSI. Patient characteristics were collected at baseline and retrospectively analyzed. Study protocols were amended, allowing outpatient management at the discretion of investigators. In this post hoc analysis, patients were categorized according to a modified Eron severity classification and management setting (outpatient vs. inpatient) and the efficacy compared. Results Overall, 1910 patients in the SOLO trials were categorized into Class I (520, 26.5%), II (790, 40.3%), and III (600, 30.6%). Of the 767 patients (40%) in the SOLO trials who were managed entirely in the outpatient setting 40.3% were categorized as Class II and 30.6% were Class III. Clinical efficacy was similar between oritavancin and vancomycin treatment groups, regardless of severity classification and across inpatient and outpatient settings. Class III patients had lower response rates (oritavancin 73.3%, vancomycin 76.6%) at early clinical evaluation when compared to patients in Class I (82.6%) or II (86.1%); however, clinical cure rates at the post-therapy evaluation were similar for Class III patients (oritavancin 79.8%, vancomycin 79.9%) when compared to Class I and II patients (79.1–85.7%). Conclusion Single-dose oritavancin therapy results in efficacy comparable to multiple-dose vancomycin in patients categorized according to modified Eron disease severity classification regardless of whether management occurred in the inpatient or outpatient setting. Funding The Medicines Company, Parsippany, NJ, USA. Trial registration ClinicalTrials.gov identifiers, NCT01252719 (SOLO I) and NCT01252732 (SOLO II).
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Costa JF, Marques JP, Marques M, Quadrado MJ. Endogenous endophthalmitis secondary to erysipelas. BMJ Case Rep 2015; 2015:bcr-2014-209252. [PMID: 26123459 DOI: 10.1136/bcr-2014-209252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
A 64-year-old woman with chronic right arm lymphoedema presented with progressive and painful vision loss in the right eye following diagnosis of erysipelas in the ipsilateral arm. Visual acuity was light perception. Biomicroscopy revealed marked conjunctival injection, decreased corneal transparency and an inflammatory mass in the anterior chamber, which precluded fundoscopy. The ocular ultrasonography features were consistent with acute endophthalmitis, and the patient was admitted to the hospital. A systemic evaluation, including complete physical examination, echocardiography and blood tests, ruled out other sources of infection besides the cutaneous site. Blood cultures were positive for group A Streptococcus. A diagnosis of unilateral acute endophthalmitis due to group A Streptococcus bacteraemia secondary to erysipelas was made and successfully treated with optimal medical care, including prompt intravitreal and systemic antibiotic administration. Despite resolution of the infectious process, visual acuity did not improve.
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Affiliation(s)
- José F Costa
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Pedro Marques
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Marco Marques
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maria João Quadrado
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Faculty of Medicine, Coimbra University, Coimbra, Portugal
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Claeys KC, Lagnf AM, Patel TB, Jacob MG, Davis SL, Rybak MJ. Acute Bacterial Skin and Skin Structure Infections Treated with Intravenous Antibiotics in the Emergency Department or Observational Unit: Experience at the Detroit Medical Center. Infect Dis Ther 2015; 4:173-86. [PMID: 26055392 PMCID: PMC4471063 DOI: 10.1007/s40121-015-0069-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction Acute bacterial skin and skin structure infections (ABSSSIs) are frequently treated in emergency departments (EDs) or observation units (OUs) initially with intravenous (IV) antibiotics before discharge on oral therapy. This study aims to describe ABSSSI patients discharged directly from EDs/OUs. Methods This is a retrospective cohort study of patients with ABSSSIs treated in EDs/OUs of the Detroit Medical Center from 2012 to 2014. Adults with less than 24 h of IV antibiotics without hospital admission were included. Demographics, clinical characteristics, and severity were compared between ED and OU patients. Resource utilization, including tissue and blood cultures, and use of radiographic analysis was also collected. The primary outcome was 96-h ED revisit/hospitalization. Results Analysis included 308 patients; 219 ED and 89 OU. OU patients were significantly more likely to be obese, have COPD/asthma, be diagnosed with cellulitis, and meet at least one systemic inflammatory response syndrome (SIRS) criterion. Tissue cultures were obtained in 21.7% of abscesses in the ED; 67.9% were in uncomplicated abscesses. In the OU tissue cultures were obtained in 48.8% of abscesses and 37.5% were uncomplicated cases. Blood cultures were drawn in 18.3% of ED patients and 56.2% of OU patients, not significantly associated with the presence of SIRS criteria. Radiology was used in the diagnosis of ABSSSIs in 33.5% of ED versus 69.5% OU patients (p < 0.001), Plain film radiograph being the most common. Thirty patients revisited the ED or required hospitalization within 96 h, 23 from the ED (p = 0.479). Prior history of ABSSSI (adjusted odds ratio [aOR] = 2.382, 95% confidence interval [CI] 1.264–6.346) and location on torso/buttocks (aOR = 2.355, 95% CI 1.067–5.197) were independent predictors. Conclusions The low rate of ED revisit/hospitalization supports the use of OUs for low acuity ABSSSIs requiring initial IV therapy. Resource utilization within EDs/OUs for the management of ABSSSIs needs to be evaluated for unnecessary testing/procures. Electronic supplementary material The online version of this article (doi:10.1007/s40121-015-0069-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimberly C Claeys
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, 48201, USA
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Talan DA, Salhi BA, Moran GJ, Mower WR, Hsieh YH, Krishnadasan A, Rothman RE. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. West J Emerg Med 2014; 16:89-97. [PMID: 25671016 PMCID: PMC4307734 DOI: 10.5811/westjem.2014.11.24133] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/10/2014] [Accepted: 11/17/2014] [Indexed: 01/22/2023] Open
Abstract
Introduction Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI. Methods We conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI in which physicians were surveyed as to reason(s) for admission, and clinical characteristics were correlated with disposition. We employed chi-square binary recursive partitioning to assess independent predictors of admission. Serious adverse events were recorded. Results Among 619 patients, median age was 38.7 years. The median duration of symptoms was 4.0 days, 96 (15.5%) had a history of fever, and 46 (7.5%) had failed treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0–7.0). Upon presentation, 39 (6.3%) had temperature >38°C, 81 (13.1%) tachycardia, 35 (5.7%), tachypnea, and 5 (0.8%) hypotension; at the time of the ED disposition decision, these findings were present in 9 (1.5%), 11 (1.8%), 7 (1.1%), and 3 (0.5%) patients, respectively. Ninety-four patients (15.2%) were admitted, 3 (0.5%) to the intensive care unit (ICU). Common reasons for admission were need for intravenous antibiotics in 80 (85.1%; the only reason in 41.5%), surgery in 23 (24.5%), and underlying disease in 11 (11.7%). Hospitalization was significantly associated with the following factors in decreasing order of importance: history of fever (present in 43.6% of those admitted, and 10.5% discharged; maximal length of erythema >10cm (43.6%, 11.3%); history of failed treatment (16.1%, 6.0%); any co-morbidity (61.7%, 27.2%); and age >65 years (5.4%, 1.3%). Two patients required amputation and none had ICU transfer or died. Conclusion ED SSTI patients with fever, larger lesions, and co-morbidities tend to be hospitalized, almost all to non-critical areas and rarely do they suffer serious complications. The most common reason for admission is administration of intravenous antibiotics, which is frequently the only reason for hospitalization. With the increasing outpatient intravenous antibiotic therapy options, these results suggest that many hospitalized patients with SSTI could be managed safely and effectively as outpatients.
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Affiliation(s)
- David A Talan
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Bisan A Salhi
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Gregory J Moran
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - William R Mower
- Ronald Reagan Medical Center, University of California at Los Angeles, Department of Emergency Medicine, Los Angeles, California
| | - Yu-Hsiang Hsieh
- Johns Hopkins Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Anusha Krishnadasan
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Richard E Rothman
- Johns Hopkins Medical Center, Department of Emergency Medicine, Baltimore, Maryland
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Lazzarini L, Pellizzer G. Erysipelas-Cellulitis of the Leg: Impact of the Application of a Guideline in an Infectious Diseases Unit. J Chemother 2013; 23:378. [DOI: 10.1179/joc.2011.23.6.378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Cutaneous infections, good use of antibiotics and diagnostic accuracy. Med Mal Infect 2012; 42:495-500. [DOI: 10.1016/j.medmal.2012.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 03/26/2012] [Accepted: 07/22/2012] [Indexed: 11/20/2022]
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Muthaiyan A, Biswas D, Crandall PG, Wilkinson BJ, Ricke SC. Application of orange essential oil as an antistaphylococcal agent in a dressing model. Altern Ther Health Med 2012; 12:125. [PMID: 22894560 PMCID: PMC3522527 DOI: 10.1186/1472-6882-12-125] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 08/08/2012] [Indexed: 11/12/2022]
Abstract
Background Staphylococcus aureus is the pathogen most often and prevalently involved in skin and soft tissue infections. In recent decades outbreaks of methicillin-resistant S. aureus (MRSA) have created major problems for skin therapy, and burn and wound care units. Topical antimicrobials are most important component of wound infection therapy. Alternative therapies are being sought for treatment of MRSA and one area of interest is the use of essential oils. With the increasing interest in the use and application of natural products, we screened the potential application of terpeneless cold pressed Valencia orange oil (CPV) for topical therapy against MRSA using an in vitro dressing model and skin keratinocyte cell culture model. Methods The inhibitory effect of CPV was determined by disc diffusion vapor assay for MRSA and vancomycin intermediate-resistant S. aureus (VISA) strains. Antistaphylococcal effect of CPV in an in vitro dressing model was tested on S. aureus inoculated tryptic soya agar plate. Bactericidal effect of CPV on MRSA and VISA infected keratinocyte cells was examined by enumeration of extra- and intra-cellular bacterial cells at different treatment time points. Cytotoxic effects on human skin cells was tested by adding CPV to the keratinocyte (HEK001) cells grown in serum free KSFM media, and observed by phase-contrast microscope. Results CPV vapour effectively inhibited the MRSA and VISA strains in both disc diffusion vapour assay and in vitro dressing model. Compared to untreated control addition of 0.1% CPV to MRSA infected keratinocyte decreased the viable MRSA cells by 2 log CFU/mL in 1 h and in VISA strain 3 log CFU/mL reduction was observed in 1 h. After 3 h viable S. aureus cells were not detected in the 0.2% CPV treatment. Bactericidal concentration of CPV did not show any cytotoxic effect on the human skin keratinocyte cells in vitro. Conclusions At lower concentration addition of CPV to keratinocytes infected with MRSA and VISA rapidly killed the bacterial cells without causing any toxic effect to the keratinocytes. Therefore, the results of this study warrant further in vivo study to evaluate the potential of CPV as a topical antistaphylococcal agent.
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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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Dryden M, Saeed K, Townsend R, Winnard C, Bourne S, Parker N, Coia J, Jones B, Lawson W, Wade P, Howard P, Marshall S. Antibiotic stewardship and early discharge from hospital: impact of a structured approach to antimicrobial management. J Antimicrob Chemother 2012; 67:2289-96. [DOI: 10.1093/jac/dks193] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ahluwalia R, Mills A, Cuthbertson D. An ‘Avatar’ infection: associated cellulitis in a type 2 diabetes patient following decorative tattooing. PRACTICAL DIABETES 2011. [DOI: 10.1002/pdi.1617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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