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Huang YF, Tang HJ, Hsu HL. The Impact of Monthly Prophylactic Antibiotics Use in Patients with Recurrent Cellulitis: A 20-Year Population-Based Cohort Study in a Medical Center. Infect Drug Resist 2023; 16:3819-3827. [PMID: 37342433 PMCID: PMC10278657 DOI: 10.2147/idr.s393919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/08/2023] [Indexed: 06/22/2023] Open
Abstract
Purpose The vicious cycle of recurrent cellulitis ultimately results in a high risk of relapse, which facilitates the use of antibiotic prophylaxis with monthly intramuscular benzathine penicillin G (BPG) to prevent recurrence. However, several clinical situations hinder the guideline recommendations in daily practice. Therefore, intramuscular clindamycin has been used as an alternative in our institution for years. This study aims to elucidate the effectiveness of monthly intramuscular antibiotics in preventing further cellulitis recurrence and evaluate the applicability of intramuscular clindamycin as an alternative to BPG. Patients and Methods A retrospective cohort study was conducted at a medical center in Taiwan from January 2000 to October 2020. Adult patients with recurrent cellulitis were enrolled to receive monthly intramuscular antibiotic prophylaxis (including 1.2-2.4MU BPG or 300-600mg intramuscular clindamycin) or to be observed without prophylaxis. The decision to administer prophylaxis or observe was made at the discretion of the examining infectious disease specialists. Cox proportional-hazards regressions were performed to estimate hazard ratios (HR) and adjust for variables between groups. The Kaplan-Meier method was used to estimate survival curves. Results Enrollment in the study consisted of 426 patients, with 222 receiving BPG, 106 receiving intramuscular clindamycin, and 98 being observed without prophylaxis. Both types of antibiotics resulted in a significantly lower recurrence rate than observation alone (27.9% for BPG, 32.1% for intramuscular clindamycin, and 82.7% for observation, P < 0.001). After adjusting for multiple variables, antibiotic prophylaxis continued to significantly reduce the risk of cellulitis recurrence by 82% (HR 0.18, 95% CI 0.13 to 0.26), by 86% (HR 0.14, 95% CI 0.09 to 0.20) with BPG, and by 77% (HR 0.23, 95% CI 0.14 to 0.38) with intramuscular clindamycin. Conclusion Monthly intramuscular antibiotic prophylaxis was demonstrated to be effective in reducing cellulitis recurrence. Moreover, in the real-world practice, intramuscular clindamycin may serve as a reasonable alternative option to BPG.
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Affiliation(s)
- Yu-Fen Huang
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Jen Tang
- Division of Infectious Disease, Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Lin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
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2
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Peghin M, Graziano E, Rovelli C, Grossi PA. Prevention and treatment of recurrent cellulitis. Curr Opin Infect Dis 2023; 36:95-101. [PMID: 36853755 DOI: 10.1097/qco.0000000000000903] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Recurrent cellulitis is a challenging clinical condition affecting up to 47% of patients after the first episode, especially those with predisposing risk factors. The purpose of this review is to describe the state of the art of literature evidence and to highlight recent developments in its management. RECENT FINDINGS Recurrent cellulitis can occur after successful treatment of cellulitis. Conditions that commonly increase the risk of cellulitis include local and systemic modifiable and nonmodifiable factors. A rigorous approach to the management of risk factors and treatment of acute infection is important as the risk of recurrence rises with repeated episodes. Risk factors, if present, need to be targeted in association with antibiotic prophylaxis. Penicillin V is the preferred antibiotic for prevention but other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure. SUMMARY Recurrent cellulitis is associated with short term and long-term morbidity as well as significant healthcare costs. Management of underlying predisposing conditions is crucial to prevent recurrence in addition with evaluation of pharmacological measures, but specialized and multidisciplinary skills are needed. More efforts are needed to prevent and treat this underestimated problem.
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Affiliation(s)
- Maddalena Peghin
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
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3
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Webb E, Bissett B, Neeman T, Bowden F, Preston E, Mumford V. Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema. Lymphat Res Biol 2022; 21:160-168. [PMID: 35997601 PMCID: PMC10125391 DOI: 10.1089/lrb.2022.0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.
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Affiliation(s)
- Elizabeth Webb
- Physiotherapy Department, Calvary Public Hospital Bruce, Canberra, Australia.,Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Teresa Neeman
- Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine, Australian National University, Canberra, Australia
| | - Francis Bowden
- Medical School, Australian National University, Canberra, Australia
| | - Elisabeth Preston
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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4
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Ong BS, Dotel R, Ngian VJJ. Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis? Int J Gen Med 2022; 15:6561-6572. [PMID: 35983462 PMCID: PMC9379124 DOI: 10.2147/ijgm.s326459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
Abstract
Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.
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Affiliation(s)
- Bin S Ong
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Ravindra Dotel
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Vincent Jiu Jong Ngian
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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5
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Bednarska A, Sosińska-Bryła I, Grąbczewski P, Podlasin R, Paciorek M, Bursa D, Hackiewicz M, Makowiecki M, Horban A. The effectiveness of erysipelas prophylaxis depends on the cumulative dose of benzathine penicillin G. Dermatol Reports 2022; 14:9429. [PMID: 36199905 PMCID: PMC9527694 DOI: 10.4081/dr.2022.9429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Erysipelas is an acute infection due to S. pyogenes and is characterized by a high risk of relapses. The number of patients suffering from one or more recurrences varied depending on the study and accounted for between 16% and 47% of the total number of those affected. Antibiotic prophylaxis with the use of penicillin can reduce the risk of recurrence by 47%. Methods: A number of 873 patients with erysipelas treated at the Hospital for Infectious Diseases in Warsaw from 2010 to 2018 was enrolled in the study. Benzathine-penicillin G was given intramuscularly at a dose of 1.2 MU or 2.4 MU or 3.6 MU. The earliest moment that prophylactic treatment was administered was the first episode of erysipelas recurrence. The decision to administer the antibiotic and the dose to use was discretionally made by the examining physician. Results: Altogether 104 (11.9%) persons experienced at least one episode of erysipelas recurrence during the study period. A total of 2976 doses of benzathine-penicillin G (BP) were administered. The most common dose was that of 2.4 MU (2380, 80 %). The dose of 1.2 MU was given 567 times (19 %). The highest dose, i.e. 3.6 MU, was administered to only 5 patients (8 applications, 0.2%). No effect was shown by either the number of benzathine-penicillin G administered doses (p=0.07) or the median dose (p=0.65), whereas patients without relapse received a statistically higher cumulative dose of the antibiotic (p=0.047). Age was a risk factor of recurrence only in the group of diabetic patients (p=0.03). Conclusion: Benzathine penicillin G given in an appropriate cumulative dose is effective in preventing erysipelas recurrence.
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Williams HC, McPhee M, Layfield C. Celebrating 20 years of the
UK
Dermatology Clinical Trials Network: Part 1 – developing and delivering high quality independent clinical trials. Clin Exp Dermatol 2022; 47:1048-1059. [PMID: 35199857 PMCID: PMC9322597 DOI: 10.1111/ced.15140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
The UK Dermatology Clinical Trials Network (UK DCTN) was formed in 2002 with the aim of developing and supporting high‐quality independent national clinical trials that address prioritized research questions for people with skin disease. Its philosophy is to democratize UK dermatological clinical research and to tackle important clinical questions that industry has no incentive to answer. The network also plays a key role in training and capacity development. Its membership of over 1000 individuals includes dermatology consultants, trainees, dermatology nurses, general practitioners, methodologists and patients. Its organizational structures are lean and include a co‐ordinating team based at the Centre of Evidence‐Based Dermatology in Nottingham, and an executive with independent members to ensure probity and business progression. A prioritization panel and steering group enable a pipeline of projects to be prioritized and refined for external funding from independent sources. The UK DCTN has supported and completed 12 national clinical trials, attracting investment of over £15 million into UK clinical dermatology research. Trials have covered a range of interventions from drugs such as doxycycline (BLISTER), silk clothing for eczema (CLOTHES) and surgical interventions for hidradenitis suppurativa (THESEUS). Trial results are published in prestigious journals and have global impact. Genuine partnership with patients and carers has been a strong feature of the network since its inception. The UK DCTN is proud of its first 20 years of collaborative work, and aims to remain at the forefront of independent dermatological health technology assessment, as well as expanding into areas including diagnostics, artificial intelligence, efficient studies and innovative designs.
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Affiliation(s)
- Hywel C. Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Margaret McPhee
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Carron Layfield
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
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7
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Layfield CP, Williams HC. Celebrating 20 years of the UK Dermatology Clinical Trials Network: Part 2 - education, training and capacity building. Clin Exp Dermatol 2022; 47:1060-1067. [PMID: 35150144 PMCID: PMC9320955 DOI: 10.1111/ced.15132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
In Part 1 of this 2‐part review of the 20th anniversary of the UK Dermatology Clinical Trials Network (UK DCTN), we described its role in developing and supporting clinical trial proposals, elaborating on structure, process and clinical trials activity. This review describes the diverse educational and training activities that the UK DCTN supports. Although not primarily set up as an educational organization, an education and training function emerged organically as the network grew. Education and training also embodies the democratization principle that drove the formation of the UK DCTN, allowing participation from a much wider group of individuals than just senior academics. Far from being a sideline, education and training has now become a major component of the UK DCTN that evolves constantly through changing training curricula and trial methodology developments. Formal UK DCTN training opportunities started in 2007 with competitively awarded annual fellowships for dermatology trainees, followed by similar schemes for general practitioners, Staff and Associate Specialist clinicians and dermatology nurses. These were followed in 2013 by larger groups of trainees who work up specific trial proposals with senior mentors. Finally, a virtual journal club emerged during the pandemic in 2020 in order to reach trainees with little access to academic training. Focused activities with dermatological nurses and patients/carers also take place. Such activities require considerable organization and volunteerism from the co‐ordinating centre and former fellows. Education and training has become an essential component for capacity building to develop clinical trials and succession planning for the UK DCTN.
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Affiliation(s)
- Carron P Layfield
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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8
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Duane TM, Huston JM, Collom M, Beyer A, Parli S, Buckman S, Shapiro M, McDonald A, Diaz J, Tessier JM, Sanders J. Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections. Surg Infect (Larchmt) 2021; 22:383-399. [PMID: 33646051 DOI: 10.1089/sur.2020.436] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.
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Affiliation(s)
| | - Jared M Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | | | - Adam Beyer
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sara Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Sara Buckman
- Department of Surgery, Washington University, St. Louis, Missouri, USA
| | - Mark Shapiro
- Acute Care Surgery, Portsmouth, New Hampshire, USA
| | - Amy McDonald
- Department of Veterans Affairs, Cleveland, Ohio, USA
| | - Jose Diaz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Jeffrey M Tessier
- Division of Infectious Diseases, University of Texas Southwestern, Dallas Texas, USA
| | - James Sanders
- Department of Pharmacy and Division of Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
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9
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Confidence of recurrent cellulitis self-diagnosis among people with lymphoedema: a qualitative interview study. Br J Gen Pract 2020; 70:e130-e137. [PMID: 31848202 DOI: 10.3399/bjgp19x707909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cellulitis can sometimes be challenging for healthcare professionals to diagnose, with no validated diagnostic criteria available. Supporting healthcare professionals to make a more accurate diagnosis of cellulitis in different groups, such as those with lymphoedema, is a cellulitis research priority. However, to the authors knowledge, no previous studies have looked at the involvement of non-healthcare professionals in the diagnostic process. AIM To explore the experience of people with lymphoedema and recurrent cellulitis in the diagnosis of lower-limb cellulitis. DESIGN AND SETTING Single, semi-structured, qualitative interviews carried out between 29 October and 19 December 2018. METHOD Adults with a suspected episode of cellulitis who had been diagnosed in the last 12 months or had a history of recurrent cellulitis were interviewed. RESULTS Three key themes emerged: the recurrent nature of cellulitis symptoms, participants' experience of getting a cellulitis diagnosis, and participants' suggestions of how cellulitis diagnosis might be improved. Generally, people with lymphoedema experienced similar clinical features during each of their own recurrent cellulitis episodes and were confident that they could make a self-diagnosis of cellulitis. This is also reflected in the participants' perceived trust from the healthcare professional in being able to make a self-diagnosis. A diagnostic checklist and educational resources were suggested as methods to improve diagnosis. CONCLUSION Selected people with lymphoedema who have recurrent cellulitis are confident in self-diagnosing their own recurrent cellulitis episodes. There may be a role for greater involvement of people with lymphoedema in their cellulitis diagnosis.
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Brindle RJ, O’Neill LA, Williams OM. Risk, Prevention, Diagnosis, and Management of Cellulitis and Erysipelas. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00287-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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The use of benzathine penicillin in streptococcal erythema nodosum: May it reduce recurrence? Presse Med 2019; 48:1180-1182. [DOI: 10.1016/j.lpm.2018.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/17/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
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Webb E, Neeman T, Gaida J, Bowden FJ, Mumford V, Bissett B. Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol. BMJ Open 2019; 9:e029225. [PMID: 31420389 PMCID: PMC6701661 DOI: 10.1136/bmjopen-2019-029225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Cellulitis represents a significant burden to patients' quality of life (QOL) and cost to the healthcare system, especially due to its recurrent nature. Chronic oedema is a strong risk factor for both an initial episode of cellulitis and cellulitis recurrence. Expert consensus advises compression therapy to prevent cellulitis recurrence in individuals with chronic oedema, however, there is little supporting evidence. This research aims to determine if the management of chronic oedema using compression therapy effectively delays the recurrence of lower limb cellulitis. METHODS AND ANALYSIS A randomised controlled trial with cross-over will be used to assess the impact of compression therapy on clinical outcomes (time to next episode of cellulitis, rate of cellulitis-related hospital presentations, QOL and leg volume). Using concealed allocation, 162 participants will be randomised into the intervention (compression) or control (no compression) group. Randomisation will be stratified by prophylactic antibiotic use. Participants will be followed up at 6 monthly intervals for up to 3 years or until 45 episodes of cellulitis occur across the cohort. Following an episode of recurrent cellulitis, control group participants will cross-over to the intervention group. Survival analysis will be undertaken to assess the primary outcome measure of time to cellulitis recurrence. The hypotheses are that compression therapy to control lower limb chronic oedema will delay recurrent lower limb cellulitis, reduce the rate of associated hospitalisations, minimise affected limb volume and improve the QOL of this population. ETHICS AND DISSEMINATION Ethics approval has been obtained from the ethics committees of all relevant institutions. Results will be disseminated through relevant peer-reviewed journal articles and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12617000412336; Pre-results. The ICTOC trial is currently in progress. Participant recruitment started in May 2017 and is expected to continue until December 2019.
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Affiliation(s)
- Elizabeth Webb
- Department of Physiotherapy, Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Teresa Neeman
- Biological Data Science Institute, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jamie Gaida
- University of Canberra Research Institute for Sport and Exercise (UC-RISE), University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Francis J Bowden
- Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
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Rodriguez JR, Hsieh F, Huang CT, Tsai TJ, Chen C, Cheng MH. Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema. J Surg Oncol 2019; 121:25-36. [PMID: 31264724 DOI: 10.1002/jso.25525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.
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Affiliation(s)
- Jose R Rodriguez
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Frank Hsieh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Tai Huang
- Department of Infectious Diseases, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tai-Jung Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Courtney Chen
- Medical Doctor Candidate, UC San Diego School of Medicine, San Diego, California
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Rochlin DH, Inchauste S, Zelones J, Nguyen DH. The role of adjunct nanofibrillar collagen scaffold implantation in the surgical management of secondary lymphedema: Review of the literature and summary of initial pilot studies. J Surg Oncol 2019; 121:121-128. [PMID: 31209884 DOI: 10.1002/jso.25576] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 12/27/2022]
Abstract
Secondary lymphedema is a worldwide affliction that exacts a significant public health burden. This review examines the etiology, presentation, and management of secondary lymphedema. In addition, emerging adjunctive strategies are explored, specifically evidence from animal and pilot human studies regarding implantation of a collagen nanofibrillar scaffold (BioBridge™; Fibralign Corporation, Union City, CA) in promoting lymphangiogenesis, preventing and treating lymphedema, and enhancing outcomes with lymphaticovenous anastomosis and vascularized lymph node transfer.
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Affiliation(s)
- Danielle H Rochlin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Suzanne Inchauste
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Justin Zelones
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dung H Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Teasdale E, Lalonde A, Muller I, Chalmers J, Smart P, Hooper J, El‐Gohary M, Thomas K, Santer M. Patients' understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care. Br J Dermatol 2019; 180:810-820. [PMID: 30451281 PMCID: PMC6487809 DOI: 10.1111/bjd.17445] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately one-third of cases. The only proven strategy to reduce the risk of recurrence is long-term, low-dose antibiotics. Given current concerns about antibiotic resistance and the pressure to reduce antibiotic prescribing, other prevention strategies are needed. OBJECTIVES To explore patients' views about cellulitis and different ways of preventing recurrent episodes. METHODS Adults aged ≥ 18 years with a history of first-episode or recurrent cellulitis were invited through primary care, hospitals and advertising to complete a survey, take part in an interview or both. RESULTS Thirty interviews were conducted between August 2016 and July 2017. Two hundred and forty surveys were completed (response rate 17%). Triangulation of quantitative and qualitative data showed that people who have had cellulitis have wide-ranging beliefs about what can cause cellulitis and are often unaware of risk of recurrence or potential strategies to prevent recurrence. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were more popular potential strategies than the use of compression stockings or long-term antibiotics. Participants expressed caution about long-term oral antibiotics, particularly those who had experienced only one episode of cellulitis. CONCLUSIONS People who have had cellulitis are keen to know about possible ways to prevent further episodes. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were generally viewed to be more acceptable, feasible strategies than compression or antibiotics, but further research is needed to explore uptake and effectiveness in practice.
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Affiliation(s)
- E.J. Teasdale
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - A. Lalonde
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - I. Muller
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - J. Chalmers
- Centre for Evidence Based DermatologyUniversity of NottinghamNottinghamU.K
| | | | | | - M. El‐Gohary
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - K.S. Thomas
- Centre for Evidence Based DermatologyUniversity of NottinghamNottinghamU.K
| | - M. Santer
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
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16
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Smith E, Patel M, Thomas KS. Which outcomes are reported in cellulitis trials? Results of a review of outcomes included in cellulitis trials and a patient priority setting survey. Br J Dermatol 2018; 178:1028-1034. [PMID: 29222939 DOI: 10.1111/bjd.16235] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is an emerging need to develop consistent outcomes in clinical trials to allow effective comparison of treatment effects. No systematic review has previously looked at the reporting of outcome measures used in randomized controlled trials (RCTs) on the treatment and prevention of cellulitis (erysipelas). OBJECTIVES The primary aim of this review was to describe the breadth of outcomes reported from RCTs on cellulitis treatment and prevention. The secondary aim was to identify outcome themes from patients' and healthcare professionals' feedback from a cellulitis Priority Setting Partnership (PSP). METHODS We conducted a review of all outcome measures used in RCTs from two recent Cochrane reviews. Free-text responses from a cellulitis priority setting survey were used to understand the perspectives of patients and healthcare professionals. RESULTS Outcomes from 42 RCTs on treatment of cellulitis and six RCTs on prevention of cellulitis were reviewed. Only 28 trials stated their primary outcome. For trials assessing treatment of cellulitis, clinical response to treatment was categorized in 25 different ways. Five of these trials used an outcome that was in accordance with FDA guidance and only four trials incorporated either quality of life or patient satisfaction. For trials assessing prevention of cellulitis, recurrence was the key outcome measure. From the cellulitis PSP, prevention of recurrence, clinical features and long-term disease impact were the most important outcome themes for patients. CONCLUSIONS We have shown that in cellulitis treatment and prevention research, there is significant heterogeneity in clinical outcomes, inadequate focus on patient-reported outcomes, and a disparity between what is currently measured and what patients and healthcare professionals feel is important. We recommend that future cellulitis treatment trials consider the use of longer-term outcomes to capture recurrence and long-term morbidity, as well as short-term resolution of acute infection.
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Affiliation(s)
- E Smith
- Centre of Evidence Based Dermatology, The University of Nottingham, Nottingham, U.K
| | - M Patel
- Division of Primary Care, The University of Nottingham, Nottingham, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, The University of Nottingham, Nottingham, U.K
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17
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Jones D, Meijer EFJ, Blatter C, Liao S, Pereira ER, Bouta EM, Jung K, Chin SM, Huang P, Munn LL, Vakoc BJ, Otto M, Padera TP. Methicillin-resistant Staphylococcus aureus causes sustained collecting lymphatic vessel dysfunction. Sci Transl Med 2018; 10:eaam7964. [PMID: 29343625 PMCID: PMC5953194 DOI: 10.1126/scitranslmed.aam7964] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/20/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of morbidity and mortality worldwide and is a frequent cause of skin and soft tissue infections (SSTIs). Lymphedema-fluid accumulation in tissue caused by impaired lymphatic vessel function-is a strong risk factor for SSTIs. SSTIs also frequently recur in patients and sometimes lead to acquired lymphedema. However, the mechanism of how SSTIs can be both the consequence and the cause of lymphatic vessel dysfunction is not known. Intravital imaging in mice revealed an acute reduction in both lymphatic vessel contractility and lymph flow after localized MRSA infection. Moreover, chronic lymphatic impairment is observed long after MRSA is cleared and inflammation is resolved. Associated with decreased collecting lymphatic vessel function was the loss and disorganization of lymphatic muscle cells (LMCs), which are critical for lymphatic contraction. In vitro, incubation with MRSA-conditioned supernatant led to LMC death. Proteomic analysis identified several accessory gene regulator (agr)-controlled MRSA exotoxins that contribute to LMC death. Infection with agr mutant MRSA resulted in sustained lymphatic function compared to animals infected with wild-type MRSA. Our findings suggest that agr is a promising target to preserve lymphatic vessel function and promote immunity during SSTIs.
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Affiliation(s)
- Dennis Jones
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Eelco F J Meijer
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Cedric Blatter
- Harvard Medical School, Boston, MA 02115, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Shan Liao
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
| | - Ethel R Pereira
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Echoe M Bouta
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Keehoon Jung
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Shan Min Chin
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Peigen Huang
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Lance L Munn
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Benjamin J Vakoc
- Harvard Medical School, Boston, MA 02115, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Michael Otto
- Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20814, USA
| | - Timothy P Padera
- Edwin L. Steele Laboratory, Department of Radiation Oncology, MGH Cancer Center, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA.
- Harvard Medical School, Boston, MA 02115, USA
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18
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Kim SY. Ethical issues in pragmatic trials of "standard-of-care" interventions in learning health care systems. Learn Health Syst 2018; 2:e10045. [PMID: 31245574 PMCID: PMC6508815 DOI: 10.1002/lrh2.10045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/07/2017] [Accepted: 10/12/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Learning health care systems (LHS) hold the promise of improving medical care by systematically and continuously integrating the delivery of medical services with clinical research. One important type of integration would involve embedding trials that compare interventions that are already commonly in use (as "accepted" or "standard of care") into the clinical setting-trials that could cost-effectively improve care. But the traditional requirement of informed consent for clinical trials stands in tension with the conduct of such trials. METHOD Narrative analysis. RESULTS Although some have suggested that the idea of LHS makes the distinction between research and ordinary clinical care obsolete, the distinction remains ethically relevant even when it comes to randomized clinical trials (RCTs) that compare standard-of-care interventions. This paper presents an ethical framework for analyzing standard-of-care RCTs in resolving the tension between such trials and traditional requirements of research ethics. CONCLUSION It is important not to treat all standard-of-care RCTs as a monolithic category of special ethical status. Close attention to ethical issues in specific standard-of-care RCTs is crucial if the LHS movement is to avoid ethical lapses that could be counterproductive to its long term vision.
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Affiliation(s)
- Scott Y.H. Kim
- Department of BioethicsClinical Center, National Institutes of HealthBethesdaMaryland
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19
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Sutherland M, Parent A. Diagnosis and management of cellulitis: a dermatology perspective. Br J Community Nurs 2017; 22:272-275. [PMID: 28570111 DOI: 10.12968/bjcn.2017.22.6.272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie Sutherland
- Dermatology Sister and Specialist Nurse in Cellulitis and Lymphoedema management, Norfolk and Norwich University Hospital
| | - Annmarie Parent
- Dermatology Staff Nurse, Norfolk and Norwich University Hospital
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20
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Lee ASW, Levell NJ. Dermatology-led lower-limb cellulitis service: analysis of 1579 referrals (2007-15). Br J Dermatol 2017; 177:596-597. [PMID: 28386995 DOI: 10.1111/bjd.15553] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A S W Lee
- Department of Dermatology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR7 4UY, U.K
| | - N J Levell
- Department of Dermatology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR7 4UY, U.K
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21
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Dalal A, Eskin‐Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L, Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database Syst Rev 2017; 6:CD009758. [PMID: 28631307 PMCID: PMC6481501 DOI: 10.1002/14651858.cd009758.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. OBJECTIVES To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. SEARCH METHODS We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. SELECTION CRITERIA Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. MAIN RESULTS We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. AUTHORS' CONCLUSIONS In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.
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Affiliation(s)
- Adam Dalal
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Marina Eskin‐Schwartz
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Daniel Mimouni
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Walford Days
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Emmilia Hodak
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine EKaplan StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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22
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Rob F, Hercogová J. Benzathine penicillin G once-every-3-week prophylaxis for recurrent erysipelas a retrospective study of 132 patients. J DERMATOL TREAT 2017; 29:39-43. [DOI: 10.1080/09546634.2017.1329507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Filip Rob
- Dermatovenereology Department, Na Bulovce Hospital, 2nd Medical Faculty Charles University, Prague, Czech Republic
| | - Jana Hercogová
- Dermatovenereology Department, Na Bulovce Hospital, 2nd Medical Faculty Charles University, Prague, Czech Republic
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23
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Jain SR, Hosseini-Moghaddam SM, Dwek P, Gupta K, Elsayed S, Thompson GW, Dagnone R, Hutt K, Silverman M. Infectious diseases specialist management improves outcomes for outpatients diagnosed with cellulitis in the emergency department: a double cohort study. Diagn Microbiol Infect Dis 2017; 87:371-375. [PMID: 28162827 DOI: 10.1016/j.diagmicrobio.2016.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/27/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Abstract
Three hospital emergency rooms (ERs) routinely referred all cases of cellulitis requiring outpatient intravenous antibiotics, to a central ER-staffed cellulitis clinic. We performed a retrospective cohort study of all patients seen by the ER clinic in the last 4months preceding a policy change (ER management cohort [ERMC]) (n=149) and all those seen in the first 3months of a new policy of automatic referral to an infectious disease (ID) specialist-supervised cellulitis clinic (ID management cohort [IDMC]) (n=136). Fifty-four (40%) of 136 patients in the IDMC were given an alternative diagnosis (noncellulitis), compared to 16 (11%) of 149 in the ERMC (P<0.0001). Logistic regression-demonstrated rates of disease recurrence were lower in the IDMC than the ERMC (hazard ratio [HR], 0.06; P=0.003), as were rates of hospitalization (HR, 0.11; P=0.01). There was no significant difference in mortality. Automatic ID consultation for cellulitis was beneficial in differentiating mimickers from true cellulitis, reducing recurrence, and preventing hospital admissions.
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Affiliation(s)
- Shilpa R Jain
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada.
| | - Seyed M Hosseini-Moghaddam
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Philip Dwek
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Kaveri Gupta
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Sameer Elsayed
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Guy W Thompson
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Robert Dagnone
- Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Kelly Hutt
- Division of Infectious Diseases, St Joseph's Hospital, London, ON N6A 4V2, Canada
| | - Michael Silverman
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
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24
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Kwak YG, Choi SH, Kim T, Park SY, Seo SH, Kim MB, Choi SH. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother 2017; 49:301-325. [PMID: 29299899 PMCID: PMC5754343 DOI: 10.3947/ic.2017.49.4.301] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Indexed: 12/17/2022] Open
Abstract
Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommendations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipelas and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets community-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline.
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Affiliation(s)
- Yee Gyung Kwak
- The Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Seong Ho Choi
- The Korean Society for Chemotherapy, Seoul, Korea.,Department of Internal Medicine, Chung Ang University College of Medicine, Seoul, Korea
| | - Tark Kim
- The Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicne, SoonChunHyang University Bucheon Hospital, Buchon, Korea
| | - Seong Yeon Park
- The Korean Society for Chemotherapy, Seoul, Korea.,Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Soo Hong Seo
- The Korean Dermatological Association, Seoul, Korea.,Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Min Bom Kim
- The Korean Orthopaedic Association, Seoul, Korea.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Ho Choi
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea.,Department of Infectious Diseases, Ulsan University College of Medicine, Seoul, Korea.
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25
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Chen SC, Kim SY. A framework for analysis of research risks and benefits to participants in standard of care pragmatic clinical trials. Clin Trials 2016; 13:605-611. [PMID: 27365010 DOI: 10.1177/1740774516656945] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Standard of care pragmatic clinical trials that compare treatments already in use could improve care and reduce costs, but there is considerable debate about the research risks of standard of care pragmatic clinical trials and how to apply informed consent regulations to such trials. We sought to develop a framework integrating the insights from opposing sides of the debate. METHODS We developed a formal risk-benefit analysis framework for standard of care pragmatic clinical trials and then applied it to key provisions of the US federal regulations. RESULTS Our formal framework for standard of care pragmatic clinical trial risk-benefit analysis takes into account three key considerations: the ex ante estimates of risks and benefits of the treatments to be compared in a standard of care pragmatic clinical trial, the allocation ratios of treatments inside and outside such a trial, and the significance of some participants receiving a different treatment inside a trial than outside the trial. The framework provides practical guidance on how the research ethics regulations on informed consent should be applied to standard of care pragmatic clinical trials. CONCLUSION Our proposed formal model makes explicit the relationship between the concepts used by opposing sides of the debate about the research risks of standard of care pragmatic clinical trials and can be used to clarify the implications for informed consent.
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Affiliation(s)
- Stephanie C Chen
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Scott Yh Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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26
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Chang CY, Lin HJ, Li BR, Li YK. A Novel Metallo-β-Lactamase Involved in the Ampicillin Resistance of Streptococcus pneumoniae ATCC 49136 Strain. PLoS One 2016; 11:e0155905. [PMID: 27214294 PMCID: PMC4877090 DOI: 10.1371/journal.pone.0155905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/08/2016] [Indexed: 12/28/2022] Open
Abstract
Streptococcus pneumoniae, a penicillin-sensitive bacterium, is recognized as a major cause of pneumonia and is treated clinically with penicillin-based antibiotics. The rapid increase in resistance to penicillin and other antibiotics affects 450 million people globally and results in 4 million deaths every year. To unveil the mechanism of resistance of S. pneumoniae is thus an important issue to treat streptococcal disease that might consequently save millions of lives around the world. In this work, we isolated a streptococci-conserved L-ascorbate 6-phosphate lactonase, from S. pneumoniae ATCC 49136. This protein reveals a metallo-β-lactamase activity in vitro, which is able to deactivate an ampicillin-based antibiotic by hydrolyzing the amide bond of the β-lactam ring. The Michaelis parameter (Km) = 25 μM and turnover number (kcat) = 2 s(-1) were obtained when nitrocefin was utilized as an optically measurable substrate. Through confocal images and western blot analyses with a specific antibody, the indigenous protein was recognized in S. pneumoniae ATCC 49136. The protein-overexpressed S. pneumonia exhibits a high ampicillin-tolerance ability in vivo. In contrast, the protein-knockout S. pneumonia reveals the ampicillin-sensitive feature relative to the wild type strain. Based on these results, we propose that this protein is a membrane-associated metallo-β-lactamase (MBL) involved in the antibiotic-resistant property of S. pneumoniae.
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Affiliation(s)
- Chia-Yu Chang
- Department of Applied Chemistry, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
| | - Hui-Jen Lin
- Department of Applied Chemistry, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
| | - Bor-Ran Li
- Institute of Biomedical Engineering, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
- Center for Interdisciplinary Science, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
| | - Yaw-Kuen Li
- Department of Applied Chemistry, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
- Center for Interdisciplinary Science, National Chiao Tung University, 1001 University Road, Hsinchu, Taiwan
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Bundy DG, Muschelli J, Clemens GD, Strouse JJ, Thompson RE, Casella JF, Miller MR. Preventive Care Delivery to Young Children With Sickle Cell Disease. J Pediatr Hematol Oncol 2016; 38:294-300. [PMID: 26950087 PMCID: PMC4842129 DOI: 10.1097/mph.0000000000000537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Preventive services can reduce the morbidity of sickle cell disease (SCD) in children but are delivered unreliably. We conducted a retrospective cohort study of children aged 2 to 5 years with SCD, evaluating each child for 14 months and expecting that he/she should receive ≥75% of days covered by antibiotic prophylaxis, ≥1 influenza immunization, and ≥1 transcranial Doppler ultrasound (TCD). We used logistic regression to quantify the relationship between ambulatory generalist and hematologist visits and preventive services delivery. Of 266 children meeting the inclusion criteria, 30% consistently filled prophylactic antibiotic prescriptions. Having ≥2 generalist, non-well child care visits or ≥2 hematologist visits was associated with more reliable antibiotic prophylaxis. Forty-one percent of children received ≥1 influenza immunizations. Children with ≥2 hematologist visits were most likely to be immunized (62% vs. 35% among children without a hematologist visit). Only 25% of children received ≥1 TCD. Children most likely to receive a TCD (42%) were those with ≥2 hematologist visits. One in 20 children received all 3 preventive services. Preventive services delivery to young children with SCD was inconsistent but associated with multiple visits to ambulatory providers. Better connecting children with SCD to hematologists and strengthening preventive care delivery by generalists are both essential.
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Affiliation(s)
- David G. Bundy
- Division of General Pediatrics, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - John Muschelli
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gwendolyn D. Clemens
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - John J. Strouse
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - James F. Casella
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marlene R. Miller
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Oh CC. Cellulitis and erysipelas: prevention. BMJ CLINICAL EVIDENCE 2015; 2015:1708. [PMID: 26580894 PMCID: PMC4651026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Cellulitis is a common problem caused by spreading bacterial inflammation of the skin, with redness, pain, and lymphangitis. Up to 40% of affected people have systemic illness. Erysipelas is a form of cellulitis with marked superficial inflammation, typically affecting the lower limbs and the face. The most common pathogens in adults are streptococci and Staphylococcus aureus. Cellulitis and erysipelas can result in local necrosis and abscess formation. Around one quarter of affected people have more than one episode of cellulitis within 3 years. METHODS AND OUTCOMES We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments to prevent recurrence of cellulitis and erysipelas? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2015 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS At this update, searching of electronic databases retrieved 323 studies. After deduplication and removal of conference abstracts, 184 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 170 studies and the further review of 14 full publications. Of the 14 full articles evaluated, one systematic review was added at this update. We performed a GRADE evaluation for one PICO combination. CONCLUSIONS In this systematic overview, we categorised the efficacy for two interventions based on information about to the effectiveness and safety of antibiotics and treatment of predisposing factors.
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Affiliation(s)
- Choon Chiat Oh
- Singapore General Hospital, Singapore, Republic of Singapore
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29
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Developing a Dermatology Clinical Trials Network for Improved Therapeutics and Clinical Outcomes Research. CURRENT DERMATOLOGY REPORTS 2015. [DOI: 10.1007/s13671-015-0100-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Elwell R, Craven N. A glossary of terms to assist the recognition and diagnosis of skin conditions associated with lower-limb chronic oedema. Br J Community Nurs 2015; Suppl:S14-8, S20. [PMID: 25950393 DOI: 10.12968/bjcn.2015.20.sup4.s14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There are a number of recognised skin conditions associated with chronic oedema, but the lack of agreed definitions and terminology often leads to poor recognition and a delay in treatment. Many patients are given a diagnostic 'label' (e.g. varicose eczema) that often turns out to be incorrect, leading to an interruption in the patient pathway. Every skin condition can be described in a variety of ways and each professional group adheres to certain phrases and words that, within each discipline, are recognised, but when making onward referral or working between professions, it helps to have clear and concise definitions. This article aims is to standardise the terminology used to describe skin conditions of the lower limbs among health professionals, removing some of the discrepancy, and to develop a glossary to aid recognition, definition and hence diagnosis to ensure prompt and appropriate management is implemented.
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Affiliation(s)
- Rebecca Elwell
- Macmillan Lymhoedema Clinical Nurse Specialist, University Hospitals of North Midlands NHS Trust
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Karppelin M, Siljander T, Aittoniemi J, Hurme M, Huttunen R, Huhtala H, Kere J, Vuopio J, Syrjänen J. Predictors of recurrent cellulitis in five years. Clinical risk factors and the role of PTX3 and CRP. J Infect 2015; 70:467-73. [DOI: 10.1016/j.jinf.2014.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 09/22/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Tay EY, Fook-Chong S, Oh CC, Thirumoorthy T, Pang SM, Lee HY. Cellulitis Recurrence Score: A tool for predicting recurrence of lower limb cellulitis. J Am Acad Dermatol 2015; 72:140-5. [DOI: 10.1016/j.jaad.2014.08.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 07/30/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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van Zuuren EJ, Fedorowicz Z, Alper B, Mitsuma SF. Penicillin to prevent recurrent leg cellulitis: a critical appraisal. Br J Dermatol 2014; 171:1300-3. [PMID: 25523263 DOI: 10.1111/bjd.13461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E J van Zuuren
- Department of Dermatology, B1-Q, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, the Netherlands.
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Thomas K. Author response to van Zuuren et al., Penicillin to prevent recurrent cellulitis: a critical appraisal. Br J Dermatol 2014; 171:1303-4. [DOI: 10.1111/bjd.13554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K.S. Thomas
- Centre of Evidence Based Dermatology; University of Nottingham; Nottingham NG7 2NR U.K
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Pastushenko I, Martin-Gorgojo A. Antibiotic Therapy With Low Doses of Penicillin for the Secondary Prevention of Recurrent Lower Extremity Cellulitis. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2014.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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RF-antibioterapia con bajas dosis de penicilina en prevención secundaria de episodios de celulitis de extremidad inferior. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:793-4. [DOI: 10.1016/j.ad.2014.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/15/2014] [Indexed: 11/22/2022] Open
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Brodell LA, Brodell JD, Brodell RT. Recurrent lymphangitic cellulitis syndrome: A quintessential example of an immunocompromised district. Clin Dermatol 2014; 32:621-7. [PMID: 25160103 DOI: 10.1016/j.clindermatol.2014.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recurrent lymphangitic cellulitis syndrome (RLCS) occurs when a disordered lymphatic system renders a leg vulnerable to recurrent infection. The underlying immunologic defect is the result of accidental or iatrogenic penetrating wounds on the medial aspect of the thigh or lower limb overlying the greater saphenous vein, because the primary lymphatic drainage vessels are adjacent to this structure. Cracking/fissuring of the skin associated with chronic fungal infection of the feet ("athlete's foot"), most commonly mixed bacterial/fungal interdigital involvement, provides a portal of entry for opportunistic organisms. Bacteria and their products are cleared more slowly in the lymphatic-disrupted and therefore immunologically impaired limb, producing broad areas of dermatitis and around the scars quite distinct from other forms of superficial infection. This rarely develop in otherwise normal limbs. The dermatitis of RLCS and its systemic effects clear with antibiotics but recur intermittently until the tinea pedis is eradicated. The contralateral limb with normal lymphatic structures never develops clinical evidence of infection even though bilateral tinea infection is almost always present. This confirms the central role of an anatomically induced immunocompromised district (ICD) in this syndrome.
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Affiliation(s)
- Lindsey Ann Brodell
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - James David Brodell
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Thomas Brodell
- Department of Dermatology, Department of Pathology, University of Mississippi School of Medicine, Jackson, Mississippi; University of Rochester School of Medicine and Dentistry, Rochester, New York.
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Oh CC, Ko HCH, Lee HY, Safdar N, Maki DG, Chlebicki MP. Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis. J Infect 2014; 69:26-34. [DOI: 10.1016/j.jinf.2014.02.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/29/2014] [Accepted: 02/18/2014] [Indexed: 11/15/2022]
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Chlebicki MP, Oh CC. Recurrent Cellulitis: Risk Factors, Etiology, Pathogenesis and Treatment. Curr Infect Dis Rep 2014; 16:422. [DOI: 10.1007/s11908-014-0422-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
This project was developed to set up a nurse-led service based on the needs of patients diagnosed with 'red legs'. These patients are often wrongly admitted into hospital for treatment of cellulitis. Representatives from the specialties involved in caring for those individuals with red legs were invited to participate with patients to create a stakeholder group whose purpose was to develop integrated care pathways focused on referral criteria, diagnostics and treatment to inform a new nurse-led service. There was a commitment to utilising a number of facilitation techniques and practice-development methods in the progression of the project with the support of the Foundation of Nursing Studies. Much of the prescribed care can be carried out by the patients at home and only 25% patients have required a follow-up appointment within the new service. The service has now been fully commissioned and a secondment opportunity has been developed to lead the new service. Significant savings have been demonstrated and regular revision of the integrated care pathways with all groups, including the patients, will take place.
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Rubegni P, Cevenini G, Lamberti A, Bruni F, Tiezzi R, Verzuri A, Barbini P, Manzi P, Fimiani M. Dermatological conditions presenting at the Emergency Department in Siena University Hospital from 2006 to 2011. J Eur Acad Dermatol Venereol 2014; 29:164-8. [PMID: 24754355 DOI: 10.1111/jdv.12513] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 03/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Published studies on emergency dermatology consultations are few because there are few dermatology emergency units in the world. No study has yet described the Italian situation. OBJECTIVES To quantify and characterize patients evaluated in our dermatology emergency unit from 2006 to 2011. METHODS We studied personal details, diagnosis, annual trend of cases, emergency level and hospitalization of dermatology cases over the 6-year period. RESULTS A total of 12,226 patients were evaluated. The most numerous diagnostic group was infections (27.1%), followed by non-specific and descriptive diagnosis (22.5%), skin conditions caused by mechanical or physical agents (13.1%), eczematous diseases (10.5%), insect bites (9.5%) and urticaria/angio-oedema (8.8%). The most common indications for admission to hospital were skin conditions caused by mechanical or physical agents (33.3%), infections (27.5%), drug eruption (15.9%) and autoimmune or inflammatory disorders (7.4%). Emergency dermatology cases followed a variable annual trend, with more consultations in the summer months. CONCLUSION This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful quantitative and qualitative information on cases for physicians and the national health system for the purposes of improving patient care and cost-effectiveness.
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Affiliation(s)
- P Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, Siena University Hospital, Siena, Italy
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Mason JM, Thomas KS, Crook AM, Foster KA, Chalmers JR, Nunn AJ, Williams HC. Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials. PLoS One 2014; 9:e82694. [PMID: 24551029 PMCID: PMC3925077 DOI: 10.1371/journal.pone.0082694] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/04/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cellulitis (erysipelas) is a recurring and debilitating bacterial infection of the skin and underlying tissue. We assessed the cost-effectiveness of prophylactic antibiotic treatment to prevent the recurrence of cellulitis using low dose penicillin V in patients following a first episode (6 months prophylaxis) and more recurrent cellulitis (12 months prophylaxis, or 6 months in those declining 12 months). METHODS Within-trial cost-effectiveness analysis was conducted using the findings of two randomised placebo-controlled multicentre trials (PATCH I and PATCH II), in which patients recruited in the UK and Ireland were followed-up for up to 3 years. Incremental cost, reduction in recurrence, cost per recurrence prevented and cost/QALY were estimated. National unit and reference costs for England in 2010 were applied to resource use, exploring NHS and societal perspectives. A total of 397 patients from the two trials contributed to the analysis. RESULTS There was a 29% reduction in the number of recurrences occurring within the trial (IRR: 0.71 95%CI: 0.53 to 0.90, p = 0.02), corresponding to an absolute reduction of recurrence of 0.31 recurrences/patient (95%CI: 0.05 to 0.59, p = 0.02). Incremental costs of prophylaxis suggested a small cost saving but were not statistically significant, comparing the two groups. If a decision-maker is willing to pay up to £25,000/QALY then there is a 66% probability of antibiotic prophylaxis being cost-effective from an NHS perspective, rising to 76% probability from a secondary, societal perspective. CONCLUSION Following first episode or recurrent cellulitis of the leg, prophylactic low dose penicillin is a very low cost intervention which, on balance, is effective and cost-effective at preventing subsequent attacks. Antibiotic prophylaxis reduces cellulitis recurrence by nearly a third but is not associated with a significant increase in costs.
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Affiliation(s)
- James M. Mason
- Durham Clinical Trials Unit, Durham University, Queen’s Campus, Stockton-on-Tees, United Kingdom
| | - Kim S. Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Katharine A. Foster
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Joanne R. Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Andrew J. Nunn
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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Nguyen L, Rowland K. Low-dose penicillin for recurrent cellulitis? THE JOURNAL OF FAMILY PRACTICE 2014; 63:E10-E12. [PMID: 24475469 PMCID: PMC3890441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Giving patients with leg cellulitis low-dose penicillin helps prevent recurrence, this study shows—but optimal dose and duration are still unknown.
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Oral flucloxacillin and phenoxymethylpenicillin versus flucloxacillin alone for the emergency department outpatient treatment of cellulitis: study protocol for a randomised controlled trial. Trials 2013; 14:164. [PMID: 23732051 PMCID: PMC3679880 DOI: 10.1186/1745-6215-14-164] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 05/17/2013] [Indexed: 11/25/2022] Open
Abstract
Background Oral flucloxacillin, either alone or in combination with phenoxymethylpenicillin, is a commonly prescribed antibiotic for the treatment of cellulitis, particularly in Ireland and the United Kingdom. This study aims to establish the non-inferiority of oral monotherapy (flucloxacillin alone) to dual therapy (flucloxacillin and phenoxymethylpenicillin) for the outpatient treatment of cellulitis in adults. Methods/design This study is a multicentre, randomised, double-blind, placebo-controlled trial of adults who present to the emergency department (ED) with cellulitis that is deemed treatable on an outpatient basis with oral antibiotics. After fulfilling specified inclusion and exclusion criteria, informed consent will be taken. Patients will be given a treatment pack containing 7 days of treatment with flucloxacillin 500 mg four times daily and placebo or flucloxacillin 500 mg four times daily and phenoxymethylpenicillin 500 mg four times daily. The primary outcome measure under study is the proportion of patients in each group in which there is greater than or equal to a 50% reduction in the area of diameter of infection from the area measured at enrolment at the end-of-treatment visit (7 to 10 days). Secondary endpoints include a health-related quality of life measurement as rated by the SF-36 score and the Extremity Soft Tissue Infection Score (not validated), compliance and adverse events. Patients will be followed up by telephone call at 3 days, end-of-treatment visit (EOT) at 7 to 10 days and test-of-cure (TOC) visit at 30 days. To achieve 90% power, a sample size of 172 patients per treatment arm is needed. This assumes a treatment success rate of 85% with oral flucloxacillin and phenoxymethylpenicillin, an equivalence threshold Δ = 12.5% and an α = 0.025. Non-inferiority will be assessed using a one-sided confidence interval on the difference of proportions between the two groups. Standard analysis including per-protocol and intention-to-treat will be performed. Discussion This trial aims to establish the non-inferiority of flucloxacillin monotherapy to dual therapy in the treatment of uncomplicated cellulitis among ED patients. In doing so, this trial will bridge a knowledge gap in this understudied and common condition and will be relevant to clinicians across several different disciplines. Trial registration EudraCT Number
2008-006151-42
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Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR, Nasr IS, Brindle RJ, English J, Meredith SK, Reynolds NJ, de Berker D, Mortimer PS, Williams HC. Penicillin to prevent recurrent leg cellulitis. N Engl J Med 2013; 368:1695-703. [PMID: 23635049 DOI: 10.1056/nejmoa1206300] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cellulitis of the leg is a common bacterial infection of the skin and underlying tissue. We compared prophylactic low-dose penicillin with placebo for the prevention of recurrent cellulitis. METHODS We conducted a double-blind, randomized, controlled trial involving patients with two or more episodes of cellulitis of the leg who were recruited in 28 hospitals in the United Kingdom and Ireland. Randomization was performed according to a computer-generated code, and study medications (penicillin [250 mg twice a day] or placebo for 12 months) were dispensed by a central pharmacy. The primary outcome was the time to a first recurrence. Participants were followed for up to 3 years. Because the risk of recurrence was not constant over the 3-year period, the primary hypothesis was tested during prophylaxis only. RESULTS A total of 274 patients were recruited. Baseline characteristics were similar in the two groups. The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence, as compared with 51 of 138 participants in the placebo group (37%) (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P=0.01), yielding a number needed to treat to prevent one recurrent cellulitis episode of 5 (95% CI, 4 to 9). During the no-intervention follow-up period, there was no difference between groups in the rate of a first recurrence (27% in both groups). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 vs. 164, P=0.02 for trend). There was no significant between-group difference in the number of participants with adverse events (37 in the penicillin group and 48 in the placebo group, P=0.50). CONCLUSIONS In patients with recurrent cellulitis of the leg, penicillin was effective in preventing subsequent attacks during prophylaxis, but the protective effect diminished progressively once drug therapy was stopped. (Funded by Action Medical Research; PATCH I Controlled-Trials.com number, ISRCTN34716921.).
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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Lam ML, Patel AN, Ferguson AD. Review of the 92nd Annual Meeting of the British Association of Dermatologists, 3-5 July 2012, Birmingham, U.K. Br J Dermatol 2013; 168:32-8. [PMID: 23278558 DOI: 10.1111/bjd.12172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This is a synopsis of the main research and clinical findings presented at the 92nd Annual Meeting of the British Association of Dermatologists, held on 3-5 July 2012 in Birmingham, U.K. The conference highlighted the biological, epidemiological and therapeutic advances that have been made recently in the field of dermatology. This synopsis is a selection of the major findings from the meeting; it is not intended to be a substitute for reading the conference proceedings and related references quoted in this article.
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Affiliation(s)
- M L Lam
- Department of Dermatology, Queen's Medical Centre, Derby Road, Nottingham NG7 2UH, U.K.
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De Mozzi P, Alexandroff A, Johnston G. Updates from the British Association of Dermatologists 91st Annual Meeting, 5-7 July 2011, London, U.K. Br J Dermatol 2012; 167:232-9. [DOI: 10.1111/j.1365-2133.2012.11080.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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50
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Chosidow O, Le Cleach L. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg. A commentary. Br J Dermatol 2011; 166:6. [DOI: 10.1111/j.1365-2133.2011.10740.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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