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Vliegenthart-Jongbloed K, Jacobs J. Not recommended fixed-dose antibiotic combinations in low- and middle-income countries - the example of Tanzania. Antimicrob Resist Infect Control 2023; 12:37. [PMID: 37076936 PMCID: PMC10116708 DOI: 10.1186/s13756-023-01238-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Fixed-dose combinations (FDC) are medicine formulations that combine two or more ingredients in fixed ratios in a single dose form. Although advantageous in tuberculosis and malaria (efficacy, adherence, protection against resistance), only a few antibiotic FDC (FDC-AB) have been developed along full microbiological, pharmacological and clinical validation and safety studies. The World Health Organization (WHO) database of Access, Watch and Reserve (AWaRe) antibiotics contains, since 2021, a list of "Not Recommended" FDC-AB (n = 103) which are rejected for use in clinical practice. BODY: The share of non-recommended FDC-AB in global antimicrobial use (2000-2015) was < 3% but substantially higher in middle income countries. The share increases over time, but recent data particular concerning sub-Saharan Africa are rare. Along three non-recommended FDC-AB listed in the Tanzanian National Essential Medicine List (ampicillin-cloxacillin, flucloxacillin-amoxicillin and ceftriaxone-sulbactam) we discuss the concerns and reasons behind use of these products. Non-recommended FDC-AB have poor rationale (ratios of both ingredients), lack evidence of efficacy (pharmacological, microbiological and clinical), have difficulties in dosing (underdosing of the single ingredients, absence of pediatric dosing) and risks of safety (additive toxicity). They are expected to fuel antimicrobial resistance (unnecessary broad spectrum coverage) and are incompatible with antimicrobial stewardship. The specific context of low- and middle-income countries contributes to their increased use: at the side of prescriber and supplier are the lack of diagnostics, poor training in antibiotic prescribing, patients' preferences, role-model of senior prescribers and pharmaceutical promotion. International market mechanisms include economic motivation for development, branding and promotion, poor access to the single antibiotic forms and weak national regulatory capacity. CONCLUSION AND IMPLICATIONS There is an urgent need for monitoring consumption of non-recommended FDC-AB in low- and middle-income countries, particular in Sub-Saharan Africa. A multinational and multisectoral antimicrobial stewardship strategy is needed in order to abolish the use of non-recommended FDC-AB.
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Affiliation(s)
- Klaske Vliegenthart-Jongbloed
- Haydom Lutheran Hospital, Haydom, United Republic of Tanzania.
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands.
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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2
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Kiely AL, Griffin M, Jeon FHK, Nolan GS, Butler PE. Phalangeal and Metacarpal Fractures in Children: A 10-Year Comparison of Factors Affecting Functional Outcomes in 313 Patients. J Hand Microsurg 2023; 15:124-132. [PMID: 37020613 PMCID: PMC10069998 DOI: 10.1055/s-0041-1730885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Introduction It is widely believed that fractures in children have excellent clinical outcomes due to their capacity to remodel. There are, however, certain fractures that require careful management to avoid long-lasting functional impairment. Functional outcomes following hand fractures in children are poorly studied. Materials and Methods We performed a retrospective cohort study of consecutive children and adolescents who had operative treatment for metacarpal and phalangeal fractures (2008-2018). Tuft fractures and replantations were excluded. Functional outcomes were measured by total active motion (TAM) scoring, where a "good" outcome = TAM > 75%. Fractures were categorized by location, classification, and by the fixation they required. Results Three hundred thirteen children were included. For proximal phalangeal fractures, those treated by manipulation under anesthesia, had a higher proportion of "good" functional outcomes than Kirschner-wire or open reduction internal fixation at discharge from hand therapy ( p = 0.043). Middle phalanx fractures had excellent functional outcomes, with no difference between fixation methods ( p = 0.81). For metacarpals, there was no statistically significant difference in functional outcomes across all managements ( p = 0.134). Fractures in the thumb had poorer postoperative function at mean 7.26 weeks than those in the long fingers ( p < 0.0001), and the data suggested a trend toward worse outcomes in the distal phalanx, pediatric Bennett fractures, Seymour fractures, and oblique fractures. Conclusions Fractures in the thumb and phalangeal fractures that require percutaneous or open fixation may need closer early postoperative monitoring in children to optimize their potential for good function.
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Affiliation(s)
- Ailbhe L. Kiely
- Department of Plastic & Reconstructive Surgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, United Kingdom
| | - Michelle Griffin
- Department of Plastic Surgery, Royal Free Hospital, Pond Street, London, United Kingdom
| | - Faith Hyun Kyung Jeon
- Department of Plastic Surgery, Royal Free Hospital, Pond Street, London, United Kingdom
| | - Grant S. Nolan
- Whiston Hospital, Warrington Road, Prescot, Merseyside, United Kingdom
| | - Peter E. Butler
- Department of Plastic Surgery, Royal Free Hospital, Pond Street, London, United Kingdom
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3
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Yadav K, Krzyzaniak N, Alexander C, Scott AM, Clark J, Glasziou P, Keijzers G. The impact of antibiotics on clinical response over time in uncomplicated cellulitis: a systematic review and meta-analysis. Infection 2022; 50:859-871. [PMID: 35593975 DOI: 10.1007/s15010-022-01842-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Antibiotic treatment of uncomplicated cellulitis is highly variable with respect to agent, dose, and route of administration. As there is uncertainty about optimal/appropriate time to reassess, we aimed to assess time to clinical response. METHODS We conducted a systematic review of randomized controlled trials reporting clinical response of uncomplicated cellulitis to antibiotic treatment over multiple timepoints. PubMed, Embase, CENTRAL, WHO ICTRP, and clinicaltrials.gov were searched from inception to June 2021 without language restrictions. The primary outcome was time to clinical response. Other outcomes were components of clinical response (pain, severity score, redness, edema measured at ≥ 2 timepoints) and the proportion of patients with treatment failure. We performed a pooled estimate of the average time to clinical response together with 95% confidence intervals using a random effects model. RESULTS We included 32 randomized controlled trials (n = 13,576 participants). The mean time to clinical response was 1.68 days (95%CI 1.48-1.88; I2 = 76%). The response to treatment for specific components was as follows: ~ 50% reduction of pain and severity score by day 5, a ~ 33% reduction in area of redness by day 2-3, and a 30-50% reduction of proportion of patients with edema by day 2-4. Treatment failure was variably defined with an overall failure rate of 12% (95%CI 9-16%). CONCLUSION The best available data suggest the optimal time to clinical reassessment is between 2 and 4 days, but this must be interpreted with caution due to considerable heterogeneity and small number of included studies.
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Affiliation(s)
- Krishan Yadav
- Clinical Epidemiology Unit, Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, F660b, Ottawa, ON, K1Y4E9, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Charlotte Alexander
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
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4
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Ghathian K, Frimodt-Møller N. Beta-hemolytic streptococci A, C, and G are susceptible to cloxacillin. APMIS 2021; 129:314-316. [PMID: 33797809 DOI: 10.1111/apm.13134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Khaled Ghathian
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Microbiology, Rigshospital, University of Copenhagen, Copenhagen, Denmark
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5
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Mistry K, Sharma S, Patel M, Grindlay D, Janjuha R, Smart P, Levell NJ. Clinical response to antibiotic regimens in lower limb cellulitis: a systematic review. Clin Exp Dermatol 2020; 46:42-49. [PMID: 32860230 DOI: 10.1111/ced.14398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/02/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
There is variation in the treatment of lower limb cellulitis (LLC) with no agreement on the most effective antibiotic regimen. Many patients with cellulitis fail to respond to first-line antibiotics. This can negatively affect patient care and result in unnecessary hospital admissions. The aim of this systematic review was to determine the clinical response and safety of antibiotic regimens for the management of LLC. A systematic review for randomized controlled trials (RCTs) was conducted using OVID MEDLINE, Ovid Embase and Cochrane Central Register of Controlled Trials in January 2019. Outcomes of interest included the clinical response to antibiotic regimens (type, dose, route, duration) and the safety of antibiotics in LLC. Trial quality was identified using the Cochrane Risk of Bias tool. Four RCTs were included. All included studies showed no significant differences between the clinical response to different antibiotic type, administration route, treatment duration or dose. LLC may be overtreated and shorter courses of oral antibiotics, possibly with lower doses, may be more suitable. There is a lack of published data on the clinical response and safety of antibiotics in LLC. Three studies were high risk for bias overall. Further high-quality studies may help determine whether less intensive antibiotic regimens can effectively treat LLC.
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Affiliation(s)
- K Mistry
- Norwich Medical School, University of East Anglia, Norwich, UK.,Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - S Sharma
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - M Patel
- Division of Primary Care & National Institute for Health Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - D Grindlay
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - R Janjuha
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - P Smart
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - N J Levell
- Norwich Medical School, University of East Anglia, Norwich, UK.,Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
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6
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. Calculated initial parenteral treatment of bacterial infections: Skin and soft tissue infections. GMS INFECTIOUS DISEASES 2020; 8:Doc11. [PMID: 32373436 PMCID: PMC7186924 DOI: 10.3205/id000055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is the ninth chapter of the guideline "Calculated Parenteral Initial Therapy of Adult Bacterial Disorders - Update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter contains the first German S2k guidelines for bacterial skin and soft tissue infections. They encompass recommendations on diagnosis and treatment of the defined entities erysipelas (caused by beta-hämolytic streptococci), limited superficial cellulitis (S. aureus), severe cellulitis, abscess, complicated skin and soft tissue infections, infections of feet in diabetic patients ("diabetic foot"), necrotizing soft tissue infection and bite injuries.
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Affiliation(s)
- Cord Sunderkötter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Karsten Becker
- Institut für Med. Mikrobiologie, Universitätsklinikum Münster, Germany
| | - Christian Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Peine, Germany
| | | | - Peter Kujath
- Chirurgische Klinik, Medizinische Universität Lübeck, Germany
| | - Helmut Schöfer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt/Main, Germany
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7
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. S2k guidelines for skin and soft tissue infections Excerpts from the S2k guidelines for "calculated initial parenteral treatment of bacterial infections in adults - update 2018". J Dtsch Dermatol Ges 2020; 17:345-369. [PMID: 30920735 DOI: 10.1111/ddg.13790] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for "calculated initial parenteral treatment of bacterial infections" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for "complicated soft tissue infections", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.
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Affiliation(s)
- Cord Sunderkötter
- Department of Translational Dermatoinfectiology, Medical Faculty of the University of Münster, and Department of Dermatology and Venereology, University Medical Center, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, Münster University Medical Center, Münster, Germany
| | - Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Peine Medical Center, Peine, Germany
| | - Wolfgang Graninger
- Medical University of Vienna, Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Vienna General Hospital, Vienna, Austria
| | - Peter Kujath
- Department of Visceral, Vascular and Thoracic Surgery, Heide Medical Center, Heide, Germany
| | - Helmut Schöfer
- Department of Dermatology, Venereology, and Allergology, University hospital Frankfurt, Goethe-university, Frankfurt am Main, Germany
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8
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York JA, Varadarajan M, Barlow G. When are combinations of antibiotics clinically useful? Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32097069 DOI: 10.12968/hmed.2019.0348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antimicrobial resistance is a global crisis. Prescribing antibacterial combinations may be one way of reducing the development of resistance in target pathogens, as in the treatment of tuberculosis. Combinations may be useful for ascertaining synergy, broadening antimicrobial cover to reduce the risk of non-susceptibility, antimicrobial stewardship reasons, and immune modulation. The current research literature and/or prevailing global standards of clinical care suggest that combination therapy may be advantageous in: severe community-acquired pneumonia; severe hospital-acquired or ventilator-associated pneumonia or when there is a high risk of resistance in hospital-acquired or ventilator-associated pneumonia; multi-drug or extensively drug-resistant Gram-negative infections; and severe group A streptococcal infections. In other situations, combinations may be harmful. Overall, outside of tuberculosis, combination antibacterial therapy is likely to improve outcomes only in specific circumstances and there is little evidence to suggest that this prevents the development of bacterial resistance. Further high-quality research is essential.
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Affiliation(s)
- Joshua A York
- Hull York Medical School, York, UK.,Department of Infection, Hull University Teaching Hospitals, Hull, UK
| | - Maithili Varadarajan
- Department of Infection, Hull University Teaching Hospitals, Hull, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | - Gavin Barlow
- Hull York Medical School, York, UK.,Department of Infection, Hull University Teaching Hospitals, Hull, UK
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9
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Karakonstantis S. Is coverage of S. aureus necessary in cellulitis/erysipelas? A literature review. Infection 2019; 48:183-191. [PMID: 31845187 DOI: 10.1007/s15010-019-01382-7] [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: 08/27/2019] [Accepted: 12/06/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Empirical treatment of patients with cellulitis/erysipelas usually targets both streptococci and methicillin-sensitive S. aureus (MSSA). However, the recommendation to empirically cover MSSA is weak and based on low-quality evidence. METHODS AND OBJECTIVE A systematic review was conducted in PubMed and clinical trial registries to assess the role of S. aureus in cellulitis/erysipelas and the need for empirical MSSA coverage. RESULTS Combined microbiological and serological data, and response to penicillin monotherapy suggest that streptococci are responsible for the vast majority of cases of cellulitis/erysipelas. However, most cases are non-culturable and the specificity of microbiological and serological studies is questionable based on recent studies using molecular techniques. According to epidemiological data and three randomized controlled trials, empirical coverage of methicillin-resistant S. aureus (MRSA) is not recommended for most patients, despite the high prevalence of MRSA in many areas. If MRSA is indeed not an important cause of uncomplicated cellulitis/erysipelas, then the same may apply to MSSA. Based on indirect comparison of data from clinical studies, cure rates with penicillin monotherapy (to which most MSSA are resistant) are comparable to the cure rates reported in many studies using wider-spectrum antibiotics. CONCLUSION Considering the limitations of microbiological studies in identifying the pathogens responsible for cellulitis/erysipelas, treatment needs to be guided by clinical trials. Trials comparing penicillin or amoxicillin monotherapy to MSSA-covering regimens are needed to definitively answer whether empirical coverage of MSSA is needed and to identify the subset of patients that can be safely treated with penicillin or amoxicillin monotherapy.
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Affiliation(s)
- Stamatis Karakonstantis
- Infectious Diseases Unit, School of Medicine, University of Crete, Voutes, Heraklion, Postal code 71110, Greece.
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10
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Brindle R, Williams OM, Barton E, Featherstone P. Assessment of Antibiotic Treatment of Cellulitis and Erysipelas: A Systematic Review and Meta-analysis. JAMA Dermatol 2019; 155:1033-1040. [PMID: 31188407 DOI: 10.1001/jamadermatol.2019.0884] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance The optimum antibiotic treatment for cellulitis and erysipelas lacks consensus. The available trial data do not demonstrate the superiority of any agent, and data are limited on the most appropriate route of administration or duration of therapy. Objective To assess the efficacy and safety of antibiotic therapy for non-surgically acquired cellulitis. Data Sources The following databases were searched to June 28, 2016: Cochrane Central Register of Controlled Trials (2016, issue 5), Medline (from 1946), Embase (from 1974), and Latin American and Caribbean Health Sciences Information System (LILACS) (from 1982). In addition, 5 trials databases and the reference lists of included studies were searched. Further searches of PubMed and Google Scholar were undertaken from June 28, 2016, to December 31, 2018. Study Selection Randomized clinical trials comparing different antibiotics, routes of administration, and treatment durations were included. Data Extraction and Synthesis For data collection and analysis, the standard methodological procedures of the Cochrane Collaboration were used. For dichotomous outcomes, the risk ratio and its 95% CI were calculated. A summary of findings table was created for the primary end points, adopting the GRADE approach to assess the quality of the evidence. Main Outcomes and Measures The primary outcome was the proportion of patients cured, improved, recovered, or symptom-free or symptom-reduced at the end of treatment, as reported by the trial. The secondary outcome was any adverse event. Results A total of 43 studies with a total of 5999 evaluable participants, whose age ranged from 1 month to 96 years, were included. Cellulitis was the primary diagnosis in only 15 studies (35%), and in other studies the median (interquartile range) proportion of patients with cellulitis was 29.7% (22.9%-50.3%). Overall, no evidence was found to support the superiority of any 1 antibiotic over another, and antibiotics with activity against methicillin-resistant Staphylococcus aureus did not add an advantage. Use of intravenous antibiotics over oral antibiotics and treatment duration of longer than 5 days were not supported by evidence. Conclusions and Relevance In this systematic review and meta-analysis, only low-quality evidence was found for the most appropriate agent, route of administration, and duration of treatment for patients with cellulitis; future trials need to use a standardized set of outcomes, including severity scoring, dosing, and duration of therapy.
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Affiliation(s)
- Richard Brindle
- Department of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - O Martin Williams
- Public Health England Microbiology Services Bristol, Bristol, United Kingdom.,University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Edward Barton
- North Cumbria University Hospitals NHS Trust, Carlisle, United Kingdom
| | - Peter Featherstone
- Acute Medicine Unit, Queen Alexandra Hospital, Portsmouth Hospitals, Portsmouth, United Kingdom
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11
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Kiely A, Elwahab SA, McDonnell D, Tully R, Randles M, Hickey M, Ofori-Kuma F, Ivanovski I, Khan S, Schmidt K, Mealy K. Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines. Ir J Med Sci 2019; 189:245-249. [DOI: 10.1007/s11845-019-02065-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 07/13/2019] [Indexed: 11/28/2022]
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12
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. S2k‐Leitlinie Haut‐ und WeichgewebeinfektionenAuszug aus „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018“. J Dtsch Dermatol Ges 2019; 17:345-371. [DOI: 10.1111/ddg.13790_g] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cord Sunderkötter
- Abteilung für translationale DermatoinfektiologieMedizinische Fakultät Universität Münster und Universitätsklinik und Poliklinik für Dermatologie und VenerologieMartin‐Luther‐Universität Halle‐Wittenberg Halle (Saale)
| | - Karsten Becker
- Institut für Medizinische Mikrobiologie des Universitätsklinikums Münster
| | - Christian Eckmann
- Klinik für Allgemein‐Viszeral‐ und Thoraxchirurgie Klinikum Peine Peine
| | - Wolfgang Graninger
- Medizinische Universität WienUniversitätsklinik für Innere Medizin IKlinische Abteilung für Infektionen & TropenmedizinAllgemeines Krankenhaus Wien Wien Österreich
| | - Peter Kujath
- Klinik für Viszeral‐Gefäß‐ und ThoraxchirurgieWestküstenklinikum Heide Deutschland
| | - Helmut Schöfer
- Klinik für DermatologieVenerologie und AllergologieUniversitätsklinikum Frankfurt, Goethe‐Universität Frankfurt am Main
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13
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Ortiz-Lazo E, Arriagada-Egnen C, Poehls C, Concha-Rogazy M. An Update on the Treatment and Management of Cellulitis. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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14
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An Update on the Treatment and Management of Cellulitis. ACTAS DERMO-SIFILIOGRAFICAS 2018; 110:124-130. [PMID: 30390916 DOI: 10.1016/j.ad.2018.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/17/2018] [Accepted: 07/15/2018] [Indexed: 12/20/2022] Open
Abstract
Cellulitis and erysipelas are local soft tissue infections that occur following the entry of bacteria through a disrupted skin barrier. These infections are relatively common and early diagnosis is essential to treatment success. As dermatologists, we need to be familiar with the clinical presentation, diagnosis, and treatment of these infections. In this article, we provide a review of the literature and update on clinical manifestations, predisposing factors, microbiology, diagnosis, treatment, and complications. We also review the current situation in Chile.
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15
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Yassaie E, Kelly M, Tan ST. Review of empiric antibiotic use in plastic and reconstructive surgery. ANZ J Surg 2018; 88:531-533. [PMID: 29864261 DOI: 10.1111/ans.14406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/19/2017] [Accepted: 01/02/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Emily Yassaie
- Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital, Wellington, New Zealand
| | - Matthew Kelly
- Department of Medicine, Hutt Hospital, Wellington, New Zealand
| | - Swee T Tan
- Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital, Wellington, New Zealand.,Gillies McIndoe Research Institute, Wellington, New Zealand
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16
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Abstract
Cellulitis is a frequently encountered condition, but remains a challenging clinical entity. Under and overtreatment with antimicrobials frequently occurs and mimics cloud the diagnosis. Typical presentation, microbiology and management approaches are discussed.
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Affiliation(s)
| | - Eoghan de Barra
- Beaumont Hospital, Dublin
- The Royal College of Surgeons in Ireland, Dublin, Ireland
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17
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McKean AR, Aggarwal D, Torres-Grau J, Welman T, Moore LSP, Jones I. Is flucloxacillin monotherapy sufficient for the treatment of skin and soft tissue infections in plastic surgery? J Plast Reconstr Aesthet Surg 2018; 71:919-920. [PMID: 29477266 DOI: 10.1016/j.bjps.2018.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Andrew R McKean
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom.
| | - Dinesh Aggarwal
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom; North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, United Kingdom
| | - Jana Torres-Grau
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Ted Welman
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom; North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, United Kingdom; Imperial College London, South Kensington, London, SW7 2AZ, United Kingdom
| | - Isabel Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
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Quirke M, Curran EM, O'Kelly P, Moran R, Daly E, Aylward S, McElvaney G, Wakai A. Risk factors for amendment in type, duration and setting of prescribed outpatient parenteral antimicrobial therapy (OPAT) for adult patients with cellulitis: a retrospective cohort study and CART analysis. Postgrad Med J 2017; 94:25-31. [PMID: 28874503 DOI: 10.1136/postgradmedj-2017-134968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/11/2017] [Accepted: 07/16/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE OF THE STUDY To measure the percentage rate and risk factors for amendment in the type, duration and setting of outpatient parenteral antimicrobial therapy (OPAT) for the treatment of cellulitis. STUDY DESIGN A retrospective cohort study of adult patients receiving OPAT for cellulitis was performed. Treatment amendment (TA) was defined as hospital admission or change in antibiotic therapy in order to achieve clinical response. Multivariable logistic regression (MVLR) and classification and regression tree (CART) analysis were performed. RESULTS There were 307 patients enrolled. TA occurred in 36 patients (11.7%). Significant risk factors for TA on MVLR were increased age, increased Numerical Pain Scale Score (NPSS) and immunocompromise. The median OPAT duration was 7 days. Increased age, heart rate and C reactive protein were associated with treatment prolongation. CART analysis selected age <64.5 years, female gender and NPSS <2.5 in the final model, generating a low-sensitivity (27.8%), high-specificity (97.1%) decision tree. CONCLUSIONS Increased age, NPSS and immunocompromise were associated with OPAT amendment. These identified risk factors can be used to support an evidence-based approach to patient selection for OPAT in cellulitis. The CART algorithm has good specificity but lacks sensitivity and is shown to be inferior in this study to logistic regression modelling.
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Affiliation(s)
- Michael Quirke
- Emergency Care Research Unit (ECRU),Royal College of Surgeons Ireland (RCSI), Dublin, Ireland
| | - Emma May Curran
- Department of Medicine, RCSI, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Statistics, Renal Medicine Unit,Beaumont Hospital, Dublin, Ireland
| | - Ruth Moran
- VHI Homecare, Waverly Business Park, Dublin, Ireland
| | - Eimear Daly
- VHI Homecare, Waverly Business Park, Dublin, Ireland
| | | | - Gerry McElvaney
- Department of Medicine, RCSI, Beaumont Hospital, Dublin, Ireland
| | - Abel Wakai
- Emergency Care Research Unit (ECRU),Royal College of Surgeons Ireland (RCSI), Dublin, Ireland.,Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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Brindle R, Williams OM, Davies P, Harris T, Jarman H, Hay AD, Featherstone P. Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis. BMJ Open 2017; 7:e013260. [PMID: 28314743 PMCID: PMC5372109 DOI: 10.1136/bmjopen-2016-013260] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis. DESIGN Parallel, double-blinded, randomised controlled trial. SETTING Emergency department attendances and general practice referrals within 20 hospitals in England. INTERVENTIONS Flucloxacillin, at a minimum of 500 mg 4 times per day for 5 days, with clindamycin 300 mg 4 times per day for 2 days given orally versus flucloxacillin given alone. MAIN OUTCOME MEASURES The primary outcome was improvement at day 5. This was defined as being afebrile with either a reduction in affected skin surface temperature or a reduction in the circumference of the affected area. Secondary outcomes included resolution of systemic features, resolution of inflammatory markers, recovery of renal function, reduction in the affected area, decrease in pain, return to work or normal activities and the absence of increased side effects. RESULTS 410 patients were included in the trial. No significant difference was seen in improvement at day 5 for flucloxacillin with clindamycin (136/156, 87%) versus flucloxacillin alone (140/172, 81%)-OR 1.55 (95% CI 0.81 to 3.01), p=0.174. There was a significant difference in the number of patients with diarrhoea at day 5 in the flucloxacillin with clindamycin allocation (34/160, 22%) versus flucloxacillin alone (16/176, 9%)-OR 2.7 (95% CI 1.41 to 5.07), p=0.002. There was no clinically significant difference in any secondary outcome measures. There was no significant difference in the number of patients stating that they had returned to normal activities at the day 30 interview in the flucloxacillin with clindamycin allocation (99/121, 82%) versus flucloxacillin alone (104/129, 81%)-adjusted OR 0.90 (95% CI 0.44 to 1.84). CONCLUSIONS The addition of a short course of clindamycin to flucloxacillin early on in limb cellulitis does not improve outcome. The addition of clindamycin doubles the likelihood of diarrhoea within the first few days. TRIAL REGISTRATION NUMBER NCT01876628, Results.
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Affiliation(s)
- Richard Brindle
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - O Martin Williams
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - Paul Davies
- General Practice Support Unit, Bristol Royal Infirmary, Bristol, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Heather Jarman
- Department of Emergency Medicine, St George's University Hospitals, London, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Davis JS, Mackrow C, Binks P, Fletcher W, Dettwiller P, Marshall C, Day J, Pratt W, Tong SYC. A double-blind randomized controlled trial of ibuprofen compared to placebo for uncomplicated cellulitis of the upper or lower limb. Clin Microbiol Infect 2017; 23:242-246. [PMID: 28274772 DOI: 10.1016/j.cmi.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Cellulitis is a common skin infection resulting in inflammation that may take weeks to resolve despite appropriate antibiotics. It is unclear whether the adjunctive use of nonsteroidal anti-inflammatory drugs hastens the resolution of inflammation in patients with cellulitis. METHODS We conducted a double-blind, randomized controlled trial comparing ibuprofen 400 mg three times daily for 5 days with identical placebo in adults with uncomplicated cellulitis of the upper or lower limb who were treated with intravenous cefazolin via an outpatient parenteral antibiotic treatment service at one of two Australian hospitals. Participants were assessed twice daily by a study nurse. The primary outcome measure was the proportion of patients with regression of inflammation 48 hours after the first effective dose of parenteral antibiotics (trial registration ANZCTR 12611000515998). RESULTS Fifty-one patients were enrolled; 48 had sufficient data available to be included in the modified intention-to-treat analysis. Inflammation had begun to regress at 48 hours in 20 participants (80%) in the ibuprofen group compared to 15 (65%) in the placebo group (absolute risk difference +15%; 95% confidence interval -10 to +40; p >0.05). There was no significant difference in any secondary outcome. Ibuprofen appeared safe, with no patients developing renal impairment or necrotizing fasciitis. CONCLUSIONS This trial demonstrated no significant benefit of adjunctive ibuprofen in adults with uncomplicated cellulitis. The trial was powered to detect a large effect, and hence it is unclear whether the 15% absolute increase in the primary end point in the ibuprofen group was attributable to chance.
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Affiliation(s)
- J S Davis
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia; Department of Infectious Diseases, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, Australia.
| | - C Mackrow
- Hospital in the Home Program, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - P Binks
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - W Fletcher
- Hospital in the Home Program, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - P Dettwiller
- Katherine Rural Clinical School, Flinders University, Katherine, Northern Territory, Australia
| | - C Marshall
- Hospital in the Home Program, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - J Day
- Hospital in the Home Program, Shoalhaven Hospital, Nowra, New South Wales, Australia
| | - W Pratt
- Hospital in the Home Program, Shoalhaven Hospital, Nowra, New South Wales, Australia
| | - S Y C Tong
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia; Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and the University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Williams OM, Brindle RJ. Audit of guidelines for antimicrobial management of cellulitis across English NHS hospitals reveals wide variation. J Infect 2016; 73:291-3. [PMID: 27321116 DOI: 10.1016/j.jinf.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/05/2016] [Indexed: 11/29/2022]
Affiliation(s)
- O Martin Williams
- Public Health England Laboratory Bristol, Bristol Royal Infirmary, Bristol, UK; University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, UK.
| | - Richard J Brindle
- Public Health England Laboratory Bristol, Bristol Royal Infirmary, Bristol, UK; University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, UK
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Obaitan I, Dwyer R, Lipworth AD, Kupper TS, Camargo CA, Hooper DC, Murphy GF, Pallin DJ. Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis. Am J Emerg Med 2016; 34:1645-52. [PMID: 27344098 DOI: 10.1016/j.ajem.2016.05.064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 05/21/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The objectives of the study are to quantify trial-to-trial variability in antibiotic failure rates, in randomized clinical trials of cellulitis treatment and to provide a point estimate for the treatment failure rate across trials. METHODS We conducted a structured search for clinical trials evaluating antibiotic treatment of cellulitis, indexed in PubMed by August 2015. We included studies published in English and excluded studies conducted wholly outside of developed countries because the pathophysiology of cellulitis is likely to be different in such settings. Two authors reviewed all abstracts identified for possible inclusion. Of studies identified initially, 5% met the selection criteria. Two reviewers extracted data independently, and data were pooled using the Freeman-Tukey transformation under a random-effects model. Our primary outcome was the summary estimate of treatment failure across intent-to-treat and clinically evaluable participants. RESULTS We included 19 articles reporting data from 20 studies, for a total of 3935 patients. Treatment failure was reported in 6% to 37% of participants in the 9 trials reporting intent-to-treat results, with a summary point estimate of 18% failing treatment (95% confidence interval, 15%-21%). In the 15 articles evaluating clinically evaluable participants, treatment failure rates ranged from 3% to 42%, and overall, 12% (95% confidence interval, 10%-14%) were designated treatment failures. CONCLUSIONS Treatment failure rates vary widely across cellulitis trials, from 6% to 37%. This may be due to confusion of cellulitis with its mimics and perhaps problems with construct validity of the diagnosis of cellulitis. Such factors bias trials toward equivalence and, in routine clinical care, impair quality and antibiotic stewardship. Objective diagnostic tools are needed.
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Affiliation(s)
- Itegbemie Obaitan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Richard Dwyer
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Adam D Lipworth
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA
| | - Thomas S Kupper
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - David C Hooper
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
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Sunderkötter C, Becker K. Frequent bacterial skin and soft tissue infections: diagnostic signs and treatment. J Dtsch Dermatol Ges 2016; 13:501-24; quiz 525-6. [PMID: 26018361 DOI: 10.1111/ddg.12721] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2015] [Indexed: 12/13/2022]
Abstract
Skin and soft tissue infections rank among the most frequent infections worldwide. Classic erysipelas is defined as a non-purulent infection by beta-hemolytic streptococci. The typical signs are tender, warm, bright erythema with tongue-like extensions and early systemic symptoms such as fever or at least chills. Erysipelas always and best responds to penicillin. Limited soft tissue infection or limited cellulitis are the terms we have introduced for infections frequently caused by S. aureus and often originating from chronic wounds or acute trauma. Clinically, they are marked by tender, erythematous swelling which, unlike erysipelas, exhibit a darker red hue and is not always accompanied by fever or chills at onset. Severe cellulitis is a purulent, partially necrotic infection extending to the fascia, with general symptoms of infection, requiring surgical management in addition to antibiotics. It often fulfils criteria of so-called complicated soft tissue infections according to the definition of the FDA, due to their frequent association with e.g. severe diabetes mellitus, peripheral arterial occlusive disease or severe immunosuppression. In contrast, the rare necrotizing skin and soft tissue infections represent a distinct entity, characterized by rapid progression to ischemic necroses and shock due to special bacterial toxins. Limited cellulitis should be treated with cephalosporins group 1 or 2, or, when S.aureus is the isolated or highly likely causative agent, isoxazolyl-penicillins (exploiting their minimal selection pressure on other bacteria). For severe cellulitis, initial antibiotic treatment (mostly iv) includes - depending on the location - agents also active against gram-negative and/or anaerobic bacteria. (e.g. clindamycine, aminopeniclilline with inhibitors of betalaktamase, fluochinolons, cephalosporines group 4). For cutaneous abscesses, drainage presents the therapy of choice. Only under certain conditions additional antibiotic therapy is required. Adherence to the diagnostic criteria and to evidence-based or consensus-derived treatment recommendations as presented herein should allow for an antibiotic therapy with a good balance of efficacy, tolerability by patients and low selection pressure for highly resistant bacteria.
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Affiliation(s)
- Cord Sunderkötter
- Department of Dermatology, University Hospital Münster and Division of Infectious Diseases in Dermatology, University of Münster
| | - Karsten Becker
- Institute for Medical Microbiology, University Hospital Münster
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Sunderkötter C, Becker K. Häufige bakterielle Infektionen der Haut- und Weichgewebe: Klinik, Diagnostik und Therapie. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12721_suppl] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Cord Sunderkötter
- Klinik für Hautkrankheiten des Universitätsklinikums Münster und Abteilung für translationale Dermatoinfektiologie der Universität Münster
| | - Karsten Becker
- Institut für Medizinische Mikrobiologie des Universitätsklinikums Münster
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26
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Sunderkötter C, Becker K. [Systemic therapy with antibiotics. Overview of important antibiotics in dermatology]. Hautarzt 2014; 65:113-24. [PMID: 24549482 DOI: 10.1007/s00105-013-2743-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Systemic antibiotics are used in a targeted fashion, i.e. according to antibiogram whenever possible, otherwise in a calculated or empiric way. The pathogen to be treated can be identified sometimes by the clinical symptoms (e.g. in classical erysipelas) or by microbiological analysis. The latter requires adequate sampling methods. Due to the demographic development, which entails age-related multimorbidity and polypharmacy, criteria for the selection of the correct antibiotic not only encompass the pathogen spectrum and the tissue penetration of the drug, but also the risks for adverse events and unwanted interactions with other drugs. AIM In this review article the mode of action, mechanisms of resistance, pharmacokinetics, adverse events, and drug interactions of the dermatologically important antibiotics are summarized, as are some relevant indications for their appropriate use in dermatology. RESULTS For most bacterial skin and soft tissue infections beta-lactam antibiotics represent the first line therapy. They are efficacious, their adverse events are well known and defined, and they are mostly cost-effective. Penicillins G and V are recommended for classical erysipelas (caused by hemolytic streptococci). For uncomplicated soft tissue infections originating from wounds, which are mostly due to Staphylococcus aureus, the first line therapy are cephalosporins group 1 and 2, or isoxazoyl penicillins. The use of broad-spectrum antibiotics is indicated only for complicated soft tissue infections when a different spectrum of bacterial pathogens is suspected or when (multi-) resistant bacteria are supposed to be the causative organism.
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Affiliation(s)
- C Sunderkötter
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland,
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Aboltins CA, Hutchinson AF, Sinnappu RN, Cresp D, Risteski C, Kathirgamanathan R, Tacey MA, Chiu H, Lim K. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. J Antimicrob Chemother 2014; 70:581-6. [PMID: 25336165 DOI: 10.1093/jac/dku397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials. METHODS A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910). RESULTS Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups. CONCLUSIONS Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.
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Affiliation(s)
- Craig A Aboltins
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Victoria, Australia Northwest Academic Centre, The University of Melbourne, Epping, Melbourne, Victoria, Australia
| | - Anastasia F Hutchinson
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia School of Nursing & Midwifery, Deakin University, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Rabindra N Sinnappu
- Hospital In The Home, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Damian Cresp
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Chrissie Risteski
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia
| | | | - Mark A Tacey
- Northern Clinical Research Centre, Northern Health, Epping, Melbourne, Victoria, Australia Department of Medicine, The University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Herman Chiu
- Emergency Department, Northern Health, Epping, Melbourne, Victoria, Australia
| | - Kwang Lim
- Northwest Academic Centre, The University of Melbourne, Epping, Melbourne, Victoria, Australia Department of Medicine, Northern Health, Epping, Melbourne, Victoria, Australia
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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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29
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Lower limb cellulitis and its mimics. J Am Acad Dermatol 2012; 67:163.e1-12; quiz 175-6. [DOI: 10.1016/j.jaad.2012.03.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 12/17/2022]
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White B, Seaton RA. Complicated skin and soft tissue infections: literature review of evidence for and experience with daptomycin. Infect Drug Resist 2011; 4:115-27. [PMID: 21753891 PMCID: PMC3132872 DOI: 10.2147/idr.s13808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Indexed: 11/23/2022] Open
Abstract
Skin and soft tissue infections (SSTIs) are the second most common infection encountered in hospitals. Management decisions have become increasingly complex due to the prevalence of resistant pathogens, the wide array of licensed antimicrobials and the availability of potent oral agents and of out-patient parenteral antibiotic therapy. Daptomycin is one of the newer therapeutic agents licensed for complex SSTI management. Rapid cidality, good soft tissue penetration, once daily IV bolus administration and activity against resistant Gram-positive infections make daptomycin an attractive option both in hospitalized and community treated patients. A comprehensive review of the evidence for and experience with daptomycin and its use in SSTIs is presented.
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Affiliation(s)
- Beth White
- Brownlee Center, Gartnavel General Hospital, Glasgow, Scotland
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Krasagakis K, Valachis A, Maniatakis P, Krüger-Krasagakis S, Samonis G, Tosca AD. Report: Analysis of epidemiology, clinical features and management of erysipelas. Int J Dermatol 2010; 49:1012-7. [DOI: 10.1111/j.1365-4632.2010.04464.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore) 2010; 89:217-226. [PMID: 20616661 DOI: 10.1097/md.0b013e3181e8d635] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Staphylococcus aureus and beta-hemolytic streptococci (BHS) are the 2 main types of bacteria causing soft-tissue infections. Historically, BHS were believed to be the primary cause of diffuse, nonculturable cellulitis. However, with the recent epidemic of community-associated methicillin-resistant S aureus (MRSA) causing culturable soft-tissue infections, it is currently unclear what role either of these bacteria has in cases where the cellulitis is diffuse and nonculturable. This uncertainty has led to broad-spectrum and haphazard use of antibiotics for this infection type, which has led to increased risk of adverse drug reactions, health care costs, and emergence of resistance in bacteria. To investigate this issue, we conducted a prospective investigation between December 2004 and June 2007, enrolling all adult patients admitted to the inpatient service at the Olive View-UCLA Medical Center, a county hospital of Los Angeles, with diffuse, nonculturable cellulitis. Acute and convalescent serologies for anti-streptolysin-O and anti-DNase-B antibodies were obtained. Patient data were analyzed for response to beta-lactam antibiotics. The primary outcome was the proportion of these cases caused by BHS, as diagnosed by serologies and/or blood cultures, and the secondary outcome was the response rate of patients to beta-lactam antibiotics. Of 248 patients enrolled, 69 were dropped from analysis because of loss to follow-up or exclusion criteria. Of the 179 remaining patients, 73% of nonculturable cellulitis cases were caused by BHS. Analysis of outcomes to beta-lactam antibiotic treatment revealed that patients diagnosed with BHS had a 97% (71/73) response, while those who did not have BHS had a 91% (21/23) response, with an overall response rate of 95.8% (116/121). Results of this large, prospective study show that diffuse, nonculturable cellulitis is still mainly caused by BHS, despite the MRSA epidemic, and that for this infection type, treatment with beta-lactam antibiotics is still effective. A cost-effective, evidence-based algorithm can be useful for the empiric management of uncomplicated soft-tissue infections based on the presence or absence of a culturable source.
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Affiliation(s)
- Arthur Jeng
- From Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, California
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Abstract
BACKGROUND Cellulitis and erysipelas are now usually considered manifestations of the same condition, a skin infection associated with severe pain and systemic symptoms. A range of antibiotic treatments are suggested in guidelines. OBJECTIVES To assess the efficacy and safety of interventions for non-surgically-acquired cellulitis. SEARCH STRATEGY In May 2010 we searched for randomised controlled trials in the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and the ongoing trials databases. SELECTION CRITERIA We selected randomised controlled trials comparing two or more different interventions for cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS We included 25 studies with a total of 2488 participants. Our primary outcome 'symptoms rated by participant or medical practitioner or proportion symptom-free' was commonly reported. No two trials examined the same drugs, therefore we grouped similar types of drugs together.Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98).Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99, 95% CI 0.68 to 1.43).Six trials which included 538 people that compared different generations of cephalosporin, showed no difference in treatment effect (RR 1.00, 95% CI 0.94 to1.06).We found only small single studies for duration of antibiotic treatment, intramuscular versus intravenous route, the addition of corticosteroid to antibiotic treatment compared with antibiotic alone, and vibration therapy, so there was insufficient evidence to form conclusions. Only two studies investigated treatments for severe cellulitis and these selected different antibiotics for their comparisons, so we cannot make firm conclusions. AUTHORS' CONCLUSIONS We cannot define the best treatment for cellulitis and most recommendations are made on single trials. There is a need for trials to evaluate the efficacy of oral antibiotics against intravenous antibiotics in the community setting as there are service implications for cost and comfort.
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Affiliation(s)
- Sally A Kilburn
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, Hampshire, UK, PO1 2FR
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Risk stratification and outcome of cellulitis admitted to hospital. J Infect 2010; 60:431-9. [DOI: 10.1016/j.jinf.2010.03.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/17/2010] [Accepted: 03/19/2010] [Indexed: 01/22/2023]
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Ayre S, Walters G. Are therapeutic decisions made on the medical admissions unit any more evidence-based than they used to be? J Eval Clin Pract 2009; 15:1180-6. [PMID: 20367724 DOI: 10.1111/j.1365-2753.2009.01345.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To determine whether inpatients in a medical admissions unit in a UK district general hospital received evidence-based therapies in 2008. METHODS The diagnoses of and therapies received by inpatients at the George Eliot Hospital National Health Service Trust in Nuneaton were recorded. A clinical librarian searched the literature (Clinical Knowledge Summaries, Cochrane Library, Medline and Embase) for the best evidence for each diagnosis-therapy pair. Evidence was graded on the following scale: systematic review, randomized controlled trial, non-experimental evidence and no or contrary evidence. RESULTS One hundred and two patients generated 150 diagnosis-therapy pairs. Of these 61 (41%) had systematic review level evidence supporting them, 17 (11%) randomized controlled trial evidence, 48 (32%) non-experimental evidence and 24 (16%) no evidence. CONCLUSIONS Results were comparable with previous studies. Care in a medical admissions unit in 2008 is still evidence-based, but, despite the vast growth in medical literature, no more than it was. The process was a useful collaboration between medical and library staff to audit the quality of patient care.
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Affiliation(s)
- Stephen Ayre
- Clinical Librarian, George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK.
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Morris AD. Cellulitis and erysipelas. BMJ CLINICAL EVIDENCE 2008; 2008:1708. [PMID: 19450336 PMCID: PMC2907977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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 a quarter of affected people have more than one episode of cellulitis within 3 years. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for cellulitis and erysipelas? 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 May 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, comparative effects of different antibiotic regimens, duration of antibiotics, and treatment of predisposing factors.
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Tan R, Newberry DJ, Arts GJ, Onwuamaegbu ME. The design, characteristics and predictors of mortality in the North of England Cellulitis Treatment Assessment (NECTA). Int J Clin Pract 2007; 61:1889-93. [PMID: 17764455 DOI: 10.1111/j.1742-1241.2007.01422..x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Cellulitis is a common cause of acute medical admissions in UK hospitals. The factors that determine susceptibility to an acute admission or to mortality following hospital admission are poorly defined. METHODS We studied a retrospective cohort of 568 patients with a diagnosis of cellulitis between 1 January 2001 and 31 December 2003 in the north-east of England to see whether we could determine these factors. We collected data on the factors that were associated with acute hospital admissions and survival. We used a primary end-point of deaths within 1 year of admission for cellulitis. RESULTS The characteristics that identified patients at high risk of mortality were present in 39.9% of the cohort studied. The four most common of these characteristics were lower limb oedema 30.1% (95% CI: -26.0 to 34.1), ulceration 24% (95% CI: -20.2 to 27.8), previous myocardial infarction (MI) 19.9% (95% CI: -16.3 to 23.4) and blunt injury 18.7% (95% CI: -15.3 to 22.2). Significant predictors of mortality were: patient's age (p < 0.001), presence of penetrating injury (p < 0.001), previous MI (p < 0.001), presence of liver disease (p = 0.003), presence of lower limb oedema (p = 0.01) and long-term use of drugs that caused sodium and water retention (p < 0.001). Treatment with i.v. flucloxacillin was found to be a significant predictor of survival (odds ratio = 3.43, z =3.42. p < 0.001) at 360 days. CONCLUSION Our results show that cellulitis as a cause of an acute medical admission may present with a variety of clinical features. Some of these clinical features can be used to predict mortality within 360 days of an acute hospital admission.
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Affiliation(s)
- R Tan
- Department of Medicine for the Elderly, Addenbrookes Hospital, Cambridge, UK
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