今日の臨床サポート

丹毒

著者: 北薗英隆 Springfield Regional Medical Center

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2021/11/24
参考ガイドライン:
  1. 米国感染症学会(IDSA): Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections:2014 Update by the Infectious Disease Society of America.
  1. UpToDate:Cellulitis and skin abscess:Epidemiology, microbiology, clinical manifestations, and diagnosis.
  1. UpToDate:Cellulitis and skin abscess in adults:Treatment.
患者向け説明資料

概要・推奨   

  1. 丹毒の診断は基本的には病歴と身体所見からつけられる。境界明瞭でやや膨隆した、圧痛を伴う非化膿性病変が特徴的である。なお、発熱がしばしばみられる(推奨度1)
  1. 軽症例では必ずしも血液培養は必要ないが、悪寒戦慄やバイタルサインの異常を認める患者には行われるよう推奨される(推奨度2)
  1. 丹毒の原因菌のほとんどβ血連鎖球beta hemolytic Streptococcus)り、まれに黄色ブドウ球菌もみられる。グラム陰性桿菌は非常に稀な起因菌である(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要と
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
北薗英隆 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 新規の文献、ガイドラインのアップデートはないが、より臨床に即した内容に改訂した。
  1. 起因菌の大半をA群溶連菌からβ溶血連鎖球菌に変更した。

病態、疫学、診察

疾患情報  
  1. 丹毒の原因菌のほとんどはβ溶血連鎖球菌(beta hemolytic Streptococcus)であり、まれに黄色ブドウ球菌もみられる。グラム陰性桿菌は非常に稀な起因菌である(推奨度1)。
  1. 下肢が多く、次いで顔面が好発部位である。
  1. 視診による診断がすべてである。境界明瞭な発赤、疼痛、圧痛があり、非化膿性で、境界内の病変部は1~2mm盛り上がってみえる。
  1. 皮疹の境界が明瞭でない場合は蜂窩織炎とまずは評価することが多い。
問診・診察のポイント  
  1. 危険因子には糖尿病とその他の免疫不全状態、肥満、静脈のうっ滞、外傷や術後のリンパ浮腫が挙げられる。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: 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
雑誌名: 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.
PMID 24973422  Clin Infect Dis. 2014 Jul 15;59(2):e10-52. doi: 10.1093・・・
著者: A L Bisno, D L Stevens
雑誌名: N Engl J Med. 1996 Jan 25;334(4):240-5. doi: 10.1056/NEJM199601253340407.
Abstract/Text
PMID 8532002  N Engl J Med. 1996 Jan 25;334(4):240-5. doi: 10.1056/NE・・・
著者: B Perl, N P Gottehrer, D Raveh, Y Schlesinger, B Rudensky, A M Yinnon
雑誌名: 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.

PMID 10585800  Clin Infect Dis. 1999 Dec;29(6):1483-8. doi: 10.1086/31・・・
著者: P Bernard, C Bedane, M Mounier, F Denis, G Catanzano, J M Bonnetblanc
雑誌名: 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.

PMID 2658843  Arch Dermatol. 1989 Jun;125(6):779-82.
著者: Sally A Kilburn, Peter Featherstone, Bernie Higgins, Richard Brindle
雑誌名: 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.

PMID 20556757  Cochrane Database Syst Rev. 2010 Jun 16;(6):CD004299. d・・・
著者: Taiji Ogawa, Yutaka Terao, Hiroshi Sakata, Hisashi Okuni, Keiko Ninomiya, Kazunori Ikebe, Yoshinobu Maeda, Shigetada Kawabata
雑誌名: 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.
PMID 21362024  FEMS Microbiol Lett. 2011 May;318(2):143-51. doi: 10.11・・・
著者: P I Bergkvist, K Sjöbeck
雑誌名: 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.

PMID 9730318  Scand J Infect Dis. 1998;30(2):206-7.
著者: P I Bergkvist, K Sjöbeck
雑誌名: 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.

PMID 9360253  Scand J Infect Dis. 1997;29(4):377-82.
著者: 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
雑誌名: Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
PMID 16231249  Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1・・・
著者: Matthew J Hepburn, David P Dooley, Peter J Skidmore, Michael W Ellis, William F Starnes, William C Hasewinkle
雑誌名: 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.

PMID 15302637  Arch Intern Med. 2004 Aug 9-23;164(15):1669-74. doi: 10・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから