Burden of illness of bacterial cellulitis and erysipelas of the leg in the Netherlands

Fungal infections of the feet in patients with erysipelas of the lower limb: is it a significant clinical problem?

BACKGROUND

Erysipelas is a bacterial infection of the superficial layers of the skin usually caused by Group A Streptococci, often seen in clinical practice. Fungal infections of the feet and elderly age are some of the most significant risk factors for the infection. The aim of the study was to evaluate the frequency of fungal infections from different regions of the feet in patients with erysipelas.

METHODS

56 patients with clinically diagnosed erysipelas and 56 healthy individuals were clinically examined and tested for fungal infection in three locations: toenails, interdigital space, and soles. The collected samples were evaluated under a microscope and then mycological cultures on Sabouraud's medium were prepared. After 4 weeks of incubation, the cultures were analysed with the identification of particular pathogens.

RESULTS

42.9% (24/56) of the patients with erysipelas had positive mycological cultures. Toenails and interdigital spaces (both 62.5%) were the most frequently affected areas, followed by soles (37.5%). The most common pathogen was T. rubrum (43.18%), followed by Candida spp. (27.27%), and T. mentagrophytes var.interdigitale (13.63%). Only 14.3% (8/56) of the samples taken from the control group were positive and T.rubrum was the only type of fungus cultured.

CONCLUSIONS

Fungal infections of the feet are important risk factors for the first episode as well as recurrent erysipelas. Prevention and early treatment of fungal infections, especially in elderly people, can significantly reduce the incidence of erysipelas.

Factors associated with sepsis development in 606 Spanish adult patients with cellulitis

Background

Cellulitis, a frequent cause of admission of adult patients to medical wards, occasionally evolves to sepsis. In this study we analyze the factors related to sepsis development.

Methods

Prospective and observational study of 606 adult patients with cellulitis admitted to several Spanish hospitals. Comorbidities, microbiological, clinical, lab, diagnostic, and treatment data were analyzed. Sepsis was diagnosed according to the criteria of the 2016 International Sepsis Definitions Conference. Multiple logistic regression modelling was performed to determine the variables independently associated with sepsis development.

Results

Mean age was 63.4 years and 51.8% were men. Overall 65 (10.7%) patients developed sepsis, 7 (10.8%) of whom died, but only 4 (6.2%) due to cellulitis. Drawing of blood (P < 0.0001) or any (P < 0.0001) culture, and identification of the agent (P = 0.005) were more likely among patients with sepsis. These patients had also a longer duration of symptoms (P = 0.04), higher temperature (P = 0.03), more extensive cellulitis (P = 0.02), higher leukocyte (P < 0.0001) and neutrophil (P < 0.0001) counts, serum creatinine (P = 0.001), and CRP (P = 0.008) than patients without sepsis. Regarding therapy, patients with sepsis were more likely to undergo changes in the initial antimicrobial regimen (P < 0.0001), received more antimicrobials (P < 0.0001), received longer intravenous treatment (P = 0.03), and underwent surgery more commonly (P = 0.01) than patients without sepsis. Leukocyte counts (P = 0.002), serum creatinine (P = 0.003), drawing of blood cultures (P = 0.004), change of the initial antimicrobial regimen (P = 0.007) and length of cellulitis (P = 0.009) were independently associated with sepsis development in the multivariate analysis.

Conclusions

Increased blood leukocytes and serum creatinine, blood culture drawn, modification of the initial antimicrobial regimen, and maximum length of cellulitis were associated with sepsis in these patients.

Colonization of β-hemolytic streptococci in patients with erysipelas-a prospective study

Erysipelas is a common skin infection causing significant morbidity. At present there are no established procedures for bacteriological sampling. Here we investigate the possibility of using cultures for diagnostic purposes by determining the perianal colonization with beta-hemolytic streptococci (BHS) in patients with erysipelas. Patients with erysipelas and a control group of patients with fever without signs of skin infection were prospectively included and cultures for BHS were taken from the tonsils, the perianal area, and wounds. BHS were grouped according to Lancefield antigen, species-determined, and emm-typed. Renewed cultures were taken after four weeks from patients with erysipelas and a positive culture for BHS. 25 patients with erysipelas and 25 with fever were included. In the group with erysipelas, 11 patients (44%) were colonized with BHS, ten patients were colonized in the perianal area, and one patient in the throat. In contrast, only one patient in the control group was colonized (p = 0.005 for difference). All of the patients with erysipelas colonized with BHS had an erythema located to the lower limb. The BHS were then subjected to MALDI-TOF MS and most commonly found to be Streptococcus dysgalactiae. Renewed cultures were taken from nine of the 11 patients with BHS and three of these were still colonized. Streptococcus dysgalactiae colonizes the perianal area in a substantial proportion of patients with erysipelas. The possibility of using cultures from this area as a diagnostic method in patients with erysipelas seems promising.

Comorbidities as Risk Factors for Acute and Recurrent Erysipelas

BACKGROUND:

Erysipelas is a common infectious skin disease. A typical feature of erysipelas, especially on the lower limbs, is the tendency to reoccur and the study aimed to define the comorbidities associated with it.

AIM:

We aimed to investigate systemic and local comorbidities in patients diagnosed with erysipelas on the lower limbs.

MATERIAL AND METHODS:

We conducted a retrospectively-prospective, population-based cohort study which included all patients diagnosed with erysipelas on the lower limbs, during two years. Patients were divided into two groups: patients with first episode and patients with recurrent erysipelas. These two groups were compared, with particular emphasis on systemic and local comorbidities.

RESULTS:

The study included 313 patients, of which 187 with the first episode of erysipelas and 126 with a recurrent. Regarding the analyzed systemic risk factors, the recurrent erysipelas was significantly associated with obesity (p < 0.0001), insulin dependent diabetes mellitus (p = 0.0015), history of malignant disease (p = 0.02) and tonsillectomy (p = 0.000001). For a p-value < 0.0001, significantly more frequent finding of peripheral arterial occlusive disease, chronic oedema/lymphoedema, fungal infections of the affected leg and chronic ulcer was confirmed in recurrent erysipelas. Neuropathy had 23% of the recurrent cases and 8.6% in patients without recurrence, and the difference was found to be significant for p = 0.0003. The only dissection of the lymph nodes was found more frequently in recurrent erysipelas (p = 0.017), but no associations with other analysed local surgery on the affected leg. Patients with recurrent erysipelas had ipsilateral coexisting dermatitis p = 0.00003 significantly more frequent. Minor trauma often preceded the first episode of erysipelas p = 0.005.

CONCLUSION:

Identification and treatment of modifiable risk factors are expected to reduce the risk of a subsequent episode of erysipelas on the lower limbs.

Intracellular Streptococcal Uptake and Persistence: A Potential Cause of Erysipelas Recurrence

Erysipelas is a severe streptococcal infection of the skin primarily spreading through the lymphatic vessels. Penicillin is the treatment of choice. The most common complication consists in relapses which occur in up to 40% or more of patients despite appropriate antibiotic treatment. They cause lymphatic damage resulting in irreversible lymphedema and ultimately elephantiasis nostras and lead to major health restrictions and high socio-medical costs. Prevention of relapses is an unmet need, because even long-term prophylactic penicillin application does eventually not reduce the risk of recurrence. In this article we assess risk factors and causes of erysipelas recurrence. A systematic literature search for clinical studies addressing potential causes and measures for prevention of erysipelas recurrence was combined with a review of experimental and clinical data assessing the ability and clinical relevance of streptococci for intracellular uptake and persistence. The literature review found that venous insufficiency, lymphedema, and intertrigo from fungal infections are considered to be major risk factors for recurrence of erysipelas but cannot adequately explain the high recurrence rate. As hitherto unrecognized likely cause of erysipelas relapses we identify the ability of streptococci for intracellular uptake into and persistence within epithelial and endothelial cells and macrophages. This creates intracellular streptococcal reservoirs out of reach of penicillins which do not reach sufficient bactericidal intracellular concentrations. Incomplete streptococcal elimination due to intracellular streptococcal persistence has been observed in various deep tissue infections and is considered as cause of relapsing streptococcal pharyngitis despite proper antibiotic treatment. It may also serves as endogenous infectious source of erysipelas relapses. We conclude that the current antibiotic treatment strategies and elimination of conventional risk factors employed in erysipelas management are insufficient to prevent erysipelas recurrence. The reactivation of streptococcal infection from intracellular reservoirs represents a plausible explanation for the frequent occurrence erysipelas relapses. Prevention of erysipelas relapses therefore demands for novel antibiotic strategies capable of eradicating intracellular streptococcal persistence.

Evaluation of Antibiotic Treatment on the Duration of Hospitalization of Patients with Erysipelas and Bacterial Cellulitis

Introduction

Erysipelas and bacterial cellulitis are two of the most common infectious skin diseases. They are usually caused by the β-hemolytic group of Streptococcus, and less frequently by other bacteria. The objective of the study was to assess the factors affecting the length of stay of patients admitted to hospital with erysipelas or bacterial cellulitis.

Methods

The study was based on the retrospective analysis of medical records of patients diagnosed with erysipelas or bacterial cellulitis. Selected clinical features of the disease, the results of additional tests, the treatment used, and the time of hospitalization were analyzed. Among an initial group of 78 pre-identified patients, 59 subjects aged from 32 to 89 years were included in the final analysis. The time spent in the hospital and the number of antibiotics necessary to cure the patient were chosen as the parameters of treatment efficacy.

Results

The average duration of stay in a hospital was 7.0 ± 2.9 days and was slightly longer for women than for men. Patients with chills on admission, with coexisting chronic venous insufficiency of the lower limbs, and with anemia were hospitalized for a significantly longer period than those without these conditions. A combination therapeutic regimen of amoxicillin + clavulanic acid was the most commonly used treatment option, and this therapy was linked with shortest duration of stay in the hospital; the length of hospital stay was significantly longer for those patients receiving cephalosporins or clindamycin as treatment. The combination therapy of amoxicillin + clavulanic acid as treatment option was also least often associated with the need to use other antibacterial agents.

Conclusions

Based on our evaluation of 59 subjects with either erysipelas or bacterial cellulitis, combination therapy with amoxicillin + clavulanic acid appears to be linked with the shortest stay in the hospital. We suggest that this combination therapy should be considered as a first-line treatment for patients hospitalized due to erysipelas or bacterial cellulitis, if other factors did not preclude the use of this therapy.

Cellulitis in adult patients: A large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment

Background

Cellulitis is a frequent cause of hospital admission of adult patients. Increasing prevalence of multiresistant microorganisms, comorbidities, predisposing factors and medical and surgical therapies might affect cellulitis response and recurrence rate.

Methods

Prospective and observational study of 606 adult patients with cellulitis admitted to several Spanish hospitals. Comorbidities, microbiological, clinical, diagnostic, treatment (surgical and antibiotic) data were analyzed according to the cellulitis response. Good response implied cure. Poor response implied failure to cure or initial cure but relapse within 30 days of hospital discharge.

Results

Mean age was 63.3 years and 51.8% were men. Poor responses were significantly associated with age, previous episodes of cellulitis, prior wounds and skin lesions, venous insufficiency, lymphedema, immunosuppression and lower limbs involvement. No differences in ESR or CRP blood levels, leukocyte counts, pus or blood cultures positivity or microbiological or imaging aspects were observed in those with good or poor responses. Regarding antimicrobials, no differences in previous exposition before hospital admission, treatment with single or more than one antibiotic, antibiotic switch, days on antimicrobials or surgical treatment were observed regarding good or poor cellulitis response. Prior episodes of cellulitis (P = 0.0001), venous insufficiency (P = 0.004), immunosuppression (P = 0.03), and development of sepsis (P = 0.05) were associated with poor treatment responses, and non-surgical trauma (P = 0.015) with good responses, in the multivariate analysis.

Conclusions

Prior episodes of cellulitis, non-surgical trauma, venous insufficiency, sepsis and immunosuppression were independently associated with treatment response to cellulitis, but not the causative microorganism, the number of antimicrobials administered or its duration.

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

BACKGROUND

Cellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code "other cellulitis and abscess" accounts for 1.4% of all admissions and $5.5 billion in annual costs. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis and to ascertain if the rate is comparable to the rate for low risk patients with community acquired pneumonia that are currently recommended for outpatient management.

METHODS

A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random effects model. Heterogeneity was estimated using the I² statistic.

RESULTS

Eighteen studies met inclusion criteria. The overall worldwide mortality rate was 1.1% (95% confidence interval (CI), 0.7-1.8). For studies from the USA, the rate was 0.5% (95% CI 0.3-0.9). The actual cause of death was generally poorly described, and only one third of deaths appeared to be due to infection.

DISCUSSION

The estimated mortality rate for patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that are recommended for outpatient management by the Pneumonia Severity Index and CURB65 prediction models and strongly endorsed by major infectious disease societies. Outpatient management of these patients could result in large cost savings and may be much preferred by patients.

Interventions for the prevention of recurrent erysipelas and cellulitis

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.

Sepsis, parenteral vaccination and skin disinfection

ASBSTRACT Disinfection should be required for all skin penetrative procedures including parenteral administration of vaccines. This review analyses medically attended infectious events following parenteral vaccination in terms of their microbiological aetiology and pathogenesis. Like 'clean' surgical site infections, the major pathogens responsible for these events were Staphylococcal species, implicating endogenous con-tamination as a significant source of infection. As 70% isopropyl alcohol swabbing has been shown to effectively disinfect the skin, it would be medico-legally difficult to defend a case of sepsis with the omission of skin disinfection unless the very low risk of this event was adequately explained to the patient and documented prior to vaccination. There was a significant cost-benefit for skin disinfection and cellulitis. Skin disinfection in the context of parenteral vaccination represents a new paradigm of medical practice; the use of a low cost intervention to prevent an event of very low prevalence but of significant cost.

Erysipelas, a large retrospective study of aetiology and clinical presentation

Background

Erysipelas is a common and severe infection where the aetiology and optimal management is not well-studied. Here, we investigate the clinical features, bacteriological aetiology, and treatment of erysipelas.

Methods

Episodes of erysipelas in a seven-years period in our institution were studied retrospectively using a pre-specified protocol and is presented with descriptive and comparative statistics.

Results

1142 episodes of erysipelas were identified in 981 patients. Patients had a median age of 61 years, 59 % were male, a majority had underlying diseases or predisposing conditions, and the leg was most often affected. Wound cultures were taken in 343 episodes and 56 grew group A streptococci (GAS), 53 grew group G streptococci (GGS), 11 grew group C streptococci (GCS), and 153 grew Staphylococcus aureus. Blood cultures were drawn in 49 % of episodes and 50 cultures were positive with GGS as the most common finding (21 cultures) followed by GAS in 13, group B streptococci in 5, S. aureus in 4, and GCS in 3 cultures. In 45 % of episodes, patients received antibiotics with activity against S. aureus.

Conclusions

GGS is the most common streptococcus isolated in erysipelas and the role of S. aureus in erysipelas remains elusive.

Recurrent erysipelas--risk factors and clinical presentation

Background

Erysipelas is a common infection that often recurs, but the impact of specific risk factors for reoccurrence remains elusive. In the present study we aimed at clarifying predisposing conditions for reoccurrence.

Methods

Medical records were reviewed from all patients ≥18 years of age diagnosed with erysipelas at the Department of Infectious Diseases at Skåne University Hospital, Sweden, from January 2007 to February 2011. 502 patients were included, of which 357 were single episode erysipelas and 145 had recurrent erysipelas. These two groups were compared regarding underlying conditions and clinical presentation.

Results

Erysipelas in the lower limbs had the greatest propensity of recurrence. The associations between underlying conditions and recurrence were largely depending on the site of erysipelas. Overall, the most prominent risk factor for recurrence was lymphedema and other conditions causing a chronic impairment of the defence against microbes. Conditions temporarily disrupting the skin barrier (e.g. a local wound or toe web intertrigo), although likely being risk factors for erysipelas per se, did not seem to predispose to repeated episodes. Individuals with recurrent erysipelas tended to seek medical attention earlier, and were less likely to be hospitalized or receive intravenous antibiotics, but there was no evidence of any difference in inflammatory reaction when taking confounding factors into account.

Conclusions

In this large cross-sectional study of over 500 patients with erysipelas, lymphedema was the most prominent risk factors for recurrence although the distribution of predisposing conditions varies depending on the site of erysipelas.

Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials

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.

Oral flucloxacillin and phenoxymethylpenicillin versus flucloxacillin alone for the emergency department outpatient treatment of cellulitis: study protocol for a randomised controlled trial

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

Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial

BACKGROUND

Cellulitis (erysipelas) of the leg is a common, painful infection of the skin and underlying tissue. Repeat episodes are frequent, cause significant morbidity and result in high health service costs.

OBJECTIVES

To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes.

METHODS

Double-blind, randomized controlled trial including patients recently treated for an episode of leg cellulitis. Recruitment took place in 20 hospitals. Randomization was by computer-generated code, and treatments allocated by post from a central pharmacy. Participants were enrolled for a maximum of 3 years and received their randomized treatment for the first 6 months of this period.

RESULTS

Participants (n=123) were randomized (31% of target due to slow recruitment). The majority (79%) had suffered one episode of cellulitis on entry into the study. The primary outcome of time to recurrence of cellulitis included all randomized participants and was blinded to treatment allocation. The hazard ratio (HR) showed that treatment with penicillin reduced the risk of recurrence by 47% [HR 0·53, 95% confidence interval (CI) 0·26-1·07, P=0·08]. In the penicillin V group 12/60 (20%) had a repeat episode compared with 21/63 (33%) in the placebo group. This equates to a number needed to treat (NNT) of eight participants in order to prevent one repeat episode of cellulitis [95% CI NNT(harm) 48 to ∞ to NNT(benefit) 3]. We found no difference between the two groups in the number of participants with oedema, ulceration or related adverse events.

CONCLUSIONS

Although this trial was limited by slow recruitment, and the result failed to achieve statistical significance, it provides the best evidence available to date for the prevention of recurrence of this debilitating condition.