Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Sheldon L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014 Jul 15;59(2):e10-52. doi: 10.1093/cid/ciu444.
Abstract/Text
A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
A L Bisno, D L Stevens
Streptococcal infections of skin and soft tissues.
N Engl J Med. 1996 Jan 25;334(4):240-5. doi: 10.1056/NEJM199601253340407.
Abstract/Text
B Perl, N P Gottehrer, D Raveh, Y Schlesinger, B Rudensky, A M Yinnon
Cost-effectiveness of blood cultures for adult patients with cellulitis.
Clin Infect Dis. 1999 Dec;29(6):1483-8. doi: 10.1086/313525.
Abstract/Text
To assess the cost-effectiveness of blood cultures for patients with cellulitis, a retrospective review was conducted of clinical and microbiological data for all 757 patients admitted to a medical center because of community-acquired cellulitis during a 41-month period. Blood cultures were performed for 553 patients (73%); there were a total of 710 blood samples (i.e., a mean of 1.3 cultures were performed per patient). In only 11 cases (2.0%) was a significant patient-specific microbial strain isolated, mainly beta-hemolytic streptococci (8 patients [73%]). An organism that was considered a contaminant was isolated from an additional 20 culture bottles (3. 6%). The cost of laboratory workup of the 710 culture sets was $36, 050. Isolation of streptococci led to a change from empirical treatment with cefazolin to penicillin therapy for 8 patients. All patients recovered. In conclusion, the yield of blood cultures is very low, has a marginal impact on clinical management, and does not appear to be cost-effective for most patients with cellulitis.
P Bernard, C Bedane, M Mounier, F Denis, G Catanzano, J M Bonnetblanc
Streptococcal cause of erysipelas and cellulitis in adults. A microbiologic study using a direct immunofluorescence technique.
Arch Dermatol. 1989 Jun;125(6):779-82.
Abstract/Text
We prospectively studied 42 adult patients with acute dermis and soft-tissue infections (27 with erysipelas and 15 with acute cellulitis) involving the lower limb in all except one case. Streptococcus organisms (groups A, C, D, and G) were researched in skin biopsy specimens by a direct immunofluorescent (DIF) technique using commercially available antibodies. Our results showed that DIF gives a sensitivity of 0.70 for the in situ detection of streptococci in cases of erysipelas and cellulitis. With the obvious contribution of this DIF technique, streptococcal pathogens could be detected in situ and grouped in 19 of 27 cases of erysipelas (group A, 13; group B, 1; group C, 1; and group G, 4) and in ten of 15 cases of cellulitis (group A, 9; group B, 1). Combined data, including conventional cultures, DIF studies, and serologic findings, established that Streptococcus organisms, especially Streptococcus pyogenes (A), were, in nearly all cases, responsible for both erysipelas (26/27 cases) and acute cellulitis (11/15 cases) involving the lower limb in adults.
Sally A Kilburn, Peter Featherstone, Bernie Higgins, Richard Brindle
Interventions for cellulitis and erysipelas.
Cochrane Database Syst Rev. 2010 Jun 16;(6):CD004299. doi: 10.1002/14651858.CD004299.pub2. Epub 2010 Jun 16.
Abstract/Text
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.
Taiji Ogawa, Yutaka Terao, Hiroshi Sakata, Hisashi Okuni, Keiko Ninomiya, Kazunori Ikebe, Yoshinobu Maeda, Shigetada Kawabata
Epidemiological characterization of Streptococcus pyogenes isolated from patients with multiple onsets of pharyngitis.
FEMS Microbiol Lett. 2011 May;318(2):143-51. doi: 10.1111/j.1574-6968.2011.02252.x. Epub 2011 Mar 11.
Abstract/Text
Streptococcus pyogenes causes a broad spectrum of acute infections and is the bacterium most frequently isolated from patients with pharyngitis. A number of antibiotics including penicillin have been shown to be effective, although antibiotic treatment failure in cases of streptococcal pharyngitis have been reported. Herein, we aimed to elucidate the features of recurrent strains using clinical isolates. Ninety-three S. pyogenes organisms were obtained from Japanese patients with recurrent pharyngitis. Following genetic characterization, M-type isolates from patients with recurrent pharyngitis differed from those obtained at initial onset in 11 of 49 episodes, and pulsed field gel electrophoresis analysis showed different patterns in those cases. Additionally, spe genotyping revealed that the Spe type of the strains obtained at secondary onset corresponded with those from the initial onset in 22 cases. Furthermore, antibiotic susceptibility testing revealed that more than half of the strains were resistant to macrolides and lincosamides, which was a much greater ratio as compared with the strains obtained from initial onsets in previous studies. Our results suggest that recurrence and reinfection are often confused during the diagnosis of repetitive and persistent streptococcal pharyngitis. Moreover, the present S. pyogenes organisms were less susceptible to antibiotics, which raises caution about their appropriate use in clinical practice.
© 2011 Federation of European Microbiological Societies. Published by Blackwell Publishing Ltd. All rights reserved.
P I Bergkvist, K Sjöbeck
Relapse of erysipelas following treatment with prednisolone or placebo in addition to antibiotics: a 1-year follow-up.
Scand J Infect Dis. 1998;30(2):206-7.
Abstract/Text
Of 112 patients with erysipelas, who were randomized to treatment with 8 d of either prednisolone or placebo in addition to antibiotics, 103 were followed-up for 12 months after they had been cured. The results of the period from 3 weeks up to 1 y after the day of cure are presented. 52 patients came from the prednisolone group and 6 of them had further episodes of erysipelas, whereas 13/51 patients from the placebo group relapsed. The difference is not statistically significant.
P I Bergkvist, K Sjöbeck
Antibiotic and prednisolone therapy of erysipelas: a randomized, double blind, placebo-controlled study.
Scand J Infect Dis. 1997;29(4):377-82.
Abstract/Text
112 patients admitted to hospital with a diagnosis of erysipelas, were randomized to 8 days treatment with prednisolone or placebo in addition to antibiotics. 108 patients received the study drugs and were evaluated for time to cure, which was the primary end-point. The median healing time was significantly shorter in the prednisolone group, 5 days, vs 6 days in the placebo group (p < 0.01). The 90th percentile healing time was 10.0 days in the prednisolone group vs 14.6 days in the control group. The prednisolone-treated patients had a median length of hospital stay (secondary end-point) of 5 days vs 6 for the placebo-treated (p < 0.01). The median treatment time with intravenous antibiotics (secondary end-point) was 4 days in the placebo group, which was 1 day longer than in the prednisolone group (p < 0.05). 13 patients, 7 of whom received placebo, relapsed during the observation period of 3 weeks. The frequency of side effects attributable to the study drug was not higher in the prednisolone group.
Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Dale Everett, Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Edward L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
Practice guidelines for the diagnosis and management of skin and soft-tissue infections.
Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
Ahmed Babiker, Xiaobai Li, Yi Ling Lai, Jeffrey R Strich, Sarah Warner, Sadia Sarzynski, John P Dekker, Robert L Danner, Sameer S Kadri
Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study.
Lancet Infect Dis. 2021 May;21(5):697-710. doi: 10.1016/S1473-3099(20)30523-5. Epub 2020 Dec 14.
Abstract/Text
BACKGROUND: Clindamycin is strongly recommended as an adjunctive treatment to β-lactam antibiotics in patients with severe invasive group A β-haemolytic streptococcal (iGAS) infections. However, there is little evidence of a benefit in the use of clindamycin in humans, and its role, if any, in treating patients with invasive non-group A/B β-haemolytic streptococcal (iNABS) infections is unclear.
METHODS: For this retrospective multicentre cohort study, we used a dataset from patients in the Cerner Health Facts database, which contains electronic health-based data from 233 US hospitals. We queried the Cerner Health Facts database for inpatients (no age restriction) admitted to hospital in 2000-15, with any clinical cultures positive for β-haemolytic streptococcal taxa of interest, and who had received β-lactam antibiotics within 3 days either side of culture sampling. This group of patients was then queried for those who had also received intravenous or oral clindamycin within 3 days either side of culture sampling. Patients were excluded if they had polymicrobial growth or clindamycin non-susceptible isolates, received linezolid, or had missing variable data needed for analysis. Patients were categorised by Lancefield group (iGAS or iNABS); β-lactam antibiotic-treated patients who had received clindamycin were propensity-matched (1:2) to those who did not receive clindamycin separately for iGAS and iNABS cohorts, and logistic regression was then used to account for residual confounding factors. The primary outcome was the adjusted odds ratio (aOR) of in-hospital mortality in propensity-matched patients treated with adjunctive clindamycin versus those not treated with clindamycin in the iGAS and iNABS infection cohorts.
FINDINGS: We identified 1956 inpatients with invasive β-haemolytic streptococcal infection who had been treated with β-lactam antibiotics across 118 hospitals (1079 with iGAS infections and 877 with iNABS infections). 459 (23·4%) of these patients had received adjunctive clindamycin treatment (343 [31·7%] patients with iGAS infections and 116 [13·2%] patients with iNABS infections). The effect of adjunctive clindamycin therapy on in-hospital mortality differed significantly and showed the opposite trend in iGAS and iNABS infection cohorts (p=0·013 for an interaction). In the iGAS cohort, in-hospital mortality in propensity-matched patients who received adjunctive clindamycin (18 [6·5%] of 277 patients) was significantly lower than in those who did not (55 [11·0%] of 500 patients; aOR 0·44 [95% CI 0·23-0·81]). This survival benefit was maintained even in patients without shock or necrotising fasciitis (six [2·6%] of 239 patients treated with adjunctive clindamycin vs 27 [6·1%] of 422 patients not treated with adjunctive clindamycin; aOR 0·40 [0·15-0·91]). By contrast, in the iNABS infection cohort, in-hospital mortality in propensity-matched patients who received adjunctive clindamycin (ten [9·8%] of 102) was higher than in those who did not (nine [4·6%] of 193), but this difference was not significant (aOR 2·60 [0·94-7·52]). Several subset analyses found qualitatively similar results.
INTERPRETATION: Real-world data suggest that increased use of adjunctive clindamycin for invasive iGAS infections, but not iNABS infections, could improve outcomes, even in patients without shock or necrotising fasciitis.
FUNDING: Intramural Research Program of the National Institutes of Health Clinical Center and the National Institute of Allergy and Infectious Disease.
Copyright © 2021 Elsevier Ltd. All rights reserved.
Matthew J Hepburn, David P Dooley, Peter J Skidmore, Michael W Ellis, William F Starnes, William C Hasewinkle
Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis.
Arch Intern Med. 2004 Aug 9-23;164(15):1669-74. doi: 10.1001/archinte.164.15.1669.
Abstract/Text
BACKGROUND: Cellulitis is a condition routinely encountered in the primary care setting. No previous study has compared a short (5 days) vs standard (10 days) course of therapy of the same antibiotic in patients with uncomplicated cellulitis.
METHODS: We performed a randomized, double-blind, placebo-controlled trial to determine if 5 days of therapy has equal efficacy to 10 days of therapy for patients with cellulitis. Of 121 enrolled subjects evaluated after 5 days of therapy for cellulitis, 43 were randomized to receive 5 more days of levofloxacin therapy (10 days total antibiotic treatment), and 44 subjects to receive 5 more days of placebo therapy (5 days of total antibiotic treatment). Levofloxacin was given at a dose of 500 mg/d. Subjects were not randomized if they had worsening cellulitis, a persistent nidus of infection, a lack of any clinical improvement, or abscess formation within the first 5 days of therapy. The main outcome measure was resolution of cellulitis at 14 days, with absence of relapse by 28 days, after study enrollment.
RESULTS: Eighty-seven subjects were randomized and analyzed by intention to treat. There was no significant difference in clinical outcome between the 2 courses of therapy (success in 42 [98%] of 43 subjects receiving 10 days of antibiotic, and 43 [98%] of 44 subjects receiving 5 days of antibiotic) at both 14 and 28 days of therapy.
CONCLUSION: In patients with uncomplicated cellulitis, 5 days of therapy with levofloxacin appears to be as effective as 10 days of therapy.
