Variability of antimicrobial prescribing in patients with acute cellulitis.

Mar 2012

Davies MS, Robertson MB, Brown SH, Saunders B, Waring WS.

Source

Acute Medical Unit, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK.

Abstract

PURPOSE:

Clinical guidelines concerning treatment of infection are incorporated into prescribing formularies and antimicrobial stewardship policies. The extent to which these influence prescribing is uncertain. In this study, we sought to examine antimicrobial prescribing patterns in patients with cellulitis.

METHODS:

Consecutive adults admitted to hospital due to acute cellulitis between 2008 and 2010 were studied. Data collected were clinical and laboratory markers of sepsis, antimicrobial agent, route of administration, number of i.v. dosages, duration of antimicrobial treatment, and hospital length of stay. Three groups were defined by prescribing that was (i) identical to formulary, (ii) modified appropriately due to microbiological data or prior drug allergy, and (iii) nonformulary prescribing. Comparisons were made between groups using Mann-Whitney tests.

RESULTS:

There were 306 patients: 167 men (54.6%), median age 66 (range 18-100) years. Prescribing was consistent with formulary recommendations in 253 (82.7%), modified appropriately in 24 (7.8%), and nonformulary in 29 (9.5%). Median [interquartile range (IQR)] duration of hospital stay was 5 (3-8), 7 (5-9, P = 0.026), and 7 (5-14, P = 0.0006) days, and overall duration of antimicrobial therapy was 12 (9-16), 13 (8-15), and 15 (12-19, P = 0.0479) days, respectively. No differences were observed in clinical or laboratory markers of sepsis.

CONCLUSIONS:

Prescribing patterns accorded with prevailing guidelines in the majority of patients. Nonetheless, there was nonformulary prescribing in 10% of patients, and this could not be explained by clinical or laboratory measures of disease severity. Further work is needed to explore the factors that contribute to nonformulary prescribing in this group of patients.

SpringerLink

Swollen, red leg calls for immediate treatment

Feb 28, 2012

BY PAUL G. DONOHUE, M.D.

DEAR DR. DONOHUE: Recently my left leg has swollen from below the knee down to the ankle and foot. There also is some redness of the skin. Did I get a spider bite, or what? What is the remedy? -- D.Z.

ANSWER: I suppose it could be a spider bite, but the first thought that comes to mind is cellulitis, an infection of the skin and the tissues beneath the skin. The leg is one of the prime sites where this happens. It's a condition that calls for prompt antibiotic treatment. I hope you have seen a doctor before waiting for this to appear in the paper.

Another possibility is a blood clot in one of the leg veins, thrombophlebitis (THROM-boh-flea-BITE-us). It, too, is an emergency situation.

A third cause is obstruction or inflammation of lymph vessels. Lymph is fluid that circulates between cells and tissues. Lymph vessels, also called lymphatics, vacuum up the fluid and return it to the circulation.

The rupture of a Baker's cyst, a behind-the-knee bulge, causes similar signs. It's very painful, and I am sure you wouldn't hesitate to see a doctor if this happened.

I'm not suggesting any treatment because all of these diagnoses are serious and need quick attention. I hope you have gotten it.

Read more: Yuma Sun

Generally, cellulitis is caused by a bacterial agent. It can however, be caused by a fungus as well as this abstracts states:

Invasive Mycoleptodiscus fungal cellulitis and myositis.

Koo S, Sutton DA, Yeh WW, Thompson EH, Sigler L, Shearer JF, Hofstra DE, Wickes BL, Marty FM.

Source

* Division of Infectious Diseases, Brigham & Women's Hospital , Boston.

Abstract

We report progressive necrotizing fungal cellulitis and myositis in the leg of a patient with glioblastoma multiforme treated with temozolomide and corticosteroids. While the morphologic appearance of the isolate and its ability to grow at temperatures greater than 32°C were suggestive of Mycoleptodiscus indicus, some of the conidia were atypical for this species in that they had single septa and occasional lateral appendages. Furthermore, the isolate was different from M. indicus based on the sequencing analysis of two rDNA regions. This is the first case of Mycoleptodiscus invasive fungal disease in which the causative agent could not be resolved at the species level because of inconsistencies between morphological and molecular data.

Informa

Direct laryngoscopy should be procedure of choice in the airway management of patients with dental cellulitis.

Feb 2012

Boccheciampe N, Hell-Remy C, Le Manach Y, Andrieu G, Riou B, Bertolus C, Langeron O.

Source

From the Department of Anaesthesiology and Critical Care (NB, YLM CHR, GA, OL), Department of Emergency Medicine and Surgery (BR) and Department of Maxillofacial Surgery (CB), CHU Pitié-Salpêtrière, Paris, France.

Abstract

CONTEXT:

Airway management of patients with dental cellulitis can be difficult due to laryngeal deviation and oedema. Awake fibre-optic intubation has been recommended.

OBJECTIVE:

The aim of this study was to assess our routine procedure which is based mainly on direct laryngoscopy.

DESIGN:

This was a prospective observational study.

SETTING:

In a single centre between February 2008 and February 2009.

PATIENTS:

All patients suffering from dental cellulitis and requiring emergency surgery were included except pregnant women and patients under 18 years.

INTERVENTION:

Nasotracheal intubation by direct laryngoscopy under general anaesthesia was performed unless the supine position was not tolerated, or difficult mask ventilation or intubation was anticipated, when awake nasotracheal fibre-optic intubation was indicated. In the case of failure at the first attempt, orotracheal intubation by direct laryngoscopy was attempted. If failure persisted, tracheotomy was then performed.

MAIN OUTCOME MEASURES:

The principal endpoint was the incidence of difficult mask ventilation which was expected to be less than 5%. Secondary endpoints were the incidence of difficult tracheal intubation and tracheotomy.

RESULTS:

We included 127 consecutive patients (mouth opening 20 ± 10 mm). One did not tolerate the supine position and was successfully intubated using the fiberscope. Among the 126 remaining, difficult mask ventilation did not occur [0%, 95% confidence interval (CI) 0-3%], 124 (98%) patients were intubated by direct laryngoscopy and two (2%) required tracheotomy. Retrognathia (odds ratio 8.2, 95% CI 1.3-50.1) and extension to oral floor (odds ratio 15.1, 95% CI 1.8-129.5) were significantly associated with the prediction of intubation failure at the first attempt.

CONCLUSION:

Most patients with dental cellulitis can be safely intubated through direct laryngoscopy even if mouth opening is limited.

European Journal of Anesthesiology

Pemetrexed-induced cellulitis: A rare toxicity in non-small cell lung cancer treatment.

Feb 10, 2012

Katsenos S, Psara A, Panagou C.

Source

Department of Pneumonology, Army General Hospital of Athens, Athens, Greece.

Abstract

Pemetrexed is indicated for locally advanced or metastatic non-squamous non-small-cell lung cancer as an initial treatment in combination with cisplatin or after prior chemotherapy as a single agent. It is generally a well-tolerated drug.

The most common adverse reactions (incidence ≥20%) with single-agent use are fatigue, nausea, and anorexia. Additional common side effects when used in combination with cisplatin include vomiting, neutropenia, leukopenia, anemia, stomatitis/pharyngitis, thrombocytopenia, and constipation. Peripheral edema with associated erythema has rarely been described as an adverse effect. Herein, we report a patient with advanced non-small-cell lung cancer who experienced bilateral peripheral edema after pemetrexed administration.

Discontinuation of pemetrexed and corticosteroids use completely resolved peripheral edema.

PubMed

Ambulatory Intravenous Antibiotic Therapy for Children With Preseptal Cellulitis.

Feb 2012

Brugha RE, Abrahamson E.

Source

From the Paediatric Emergency Department, Chelsea and Westminster NHS Trust, London, United Kingdom.

Abstract

OBJECTIVE:

This study aimed to compare the use of outpatient ambulatory care versus admission for intravenous antibiotics in the management of preseptal cellulitis.

METHODS:

This is a retrospective consecutive cohort study of children younger than 16 years presenting to an Inner London Paediatric Emergency Department with signs and symptoms of preseptal cellulitis.

RESULTS: A total of 94 cases were identified during a 17-month period. Of them, 30 children were prescribed oral antibiotics. One child did not receive treatment. Of the 63 children prescribed with intravenous antibiotics, 42 were managed on an ambulatory basis and 21 were admitted. There was no significant difference in duration of treatment in days between those on ambulatory management and those admitted (2.79 ± 0.8 vs 2.76 ± 1.9, P = 0.94) or in the rate of complications. The net cost saving was $205,924 (£131,065; (euro)147,578) overall, equal to $4900 (£3120; (euro)3513) per patient.

CONCLUSIONS:

Ambulatory intravenous antibiotics with daily review are a safe and cost-effective alternative to inpatient admission in simple preseptal cellulitis for children in our population who require parenteral antibiotics.

PubMed

A systematic review of bacteremias in cellulitis and erysipelas.

Feb 2012

Gunderson CG, Martinello RA.

Source

Department of Internal Medicine and VA Connecticut Health Care System, Yale School of Medicine, 950 Campbell Avenue, West Haven CT 06516, USA; Veterans Health Administration, Public Health, 950 Campbell Avenue, West Haven CT 06516, USA.

Abstract

OBJECTIVES:

Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.

METHODS:

OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.

RESULTS:

For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. Forcellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.

CONCLUSIONS:

Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis and erysipelas in terms of the relative proportion of infections due to S. aureus.

Elsevier-sciVerse