Analysis of empiric antimicrobial strategies for cellulitis in the era of methicillin-resistant Staphylococcus aureus.
Analysis of empiric antimicrobial strategies for cellulitis in the era of methicillin-resistant Staphylococcus aureus.1: Ann Pharmacother. 2007 Jan;41(1):13-20. Epub 2007 Jan 2.
Phillips S,
MacDougall C,
Holdford DA.
Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
BACKGROUND:
The rise in community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections potentially complicates the empiric management of cellulitis. The threshold at which drugs active against MRSA, such as clindamycin and trimethoprim/sulfamethoxazole (TMP/SMX), should be incorporated into empiric therapy is unknown.
OBJECTIVE:
To evaluate the cost-effectiveness of using cephalexin, TMP/SMX, or clindamycin for outpatient empiric therapy of cellulitis, given various likelihoods of infection due to MRSA.
METHODS:
A decision analysis of the empiric treatment of cellulitis was performed from the perspective of a third-party payer. The model included initial therapy with cephalexin, clindamycin, or TMP/SMX, followed by treatment with linezolid in cases of clinical failure. Probability and cost estimates were obtained from clinical trials, epidemiologic data, and publicly available cost data and were subjected to sensitivity analysis.
RESULTS:
Under the base-case scenario (37% probability of infection by S. aureus and a 27% MRSA prevalence), cephalexin was the most cost-effective option. Clindamycin became a more cost-effective therapy at MRSA probabilities from 41-80% when the probability of staphylococcal infection was greater than 40%. TMP/SMX was cost-effective only at very high likelihoods of MRSA infection. Variables with the most influence in the model were probability of S. aureus being methicillin-resistant, cost of linezolid, probability of a cure with cephalexin for a non-MRSA infection, and probability of infection due to S. aureus.
CONCLUSIONS:
Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels. Cephalexin was the most cost-effective choice over most of the modeled range of probabilities, with clindamycin becoming more cost-effective at high likelihoods of MRSA infection. TMP/SMX is unlikely to be cost-effective for treatment of simple cellulitis. Further studies of the microbiology of cellulitis, the epidemiology of MRSA, and the clinical effectiveness of clindamycin and TMP/SMX in skin and soft tissue infections are needed.
Key Words: cellulitis, cost-effectiveness, methicillin-resistant Staphylococcus aureus
Full Text Article
Bullous eosinophilic cellulitis succession with eosinophilic pustular folliculitis without eosinophilia.
Bullous eosinophilic cellulitis succession with eosinophilic pustular folliculitis without eosinophilia.1: J Dermatol. 2007 Jan;34(1):80-85.
Ercan ARCA
Osman KÖSE
Yildirim KARSLIOĞLU Halis Bülent TAŞTAN Murat DEMİRİZ
Departments of 1Dermatology and 2Pathology, Gülhane School of Medicine, Ankara, TurkeyCorrespondence: Osman Köse, M.D., Associate Professor, Gülhane School of Medicine, Department of Dermatology, 06018 Ankara, Turkey. Email: okose@gata.edu.tr
Eosinophilic cellulitis is characterized clinically by an acute dermatitis resembling cellulitis with unknown etiology. Eosinophilic pustular folliculitis is also a rare inflammatory dermatosis characterized by recurrent crops of erythematous follicular papulopustules that coalesce to form annular plaques with unclear etiopathogenesis. We describe a 20-year-old white male who had vesiculobullous and plaque-like lesions on the hands and feet and was diagnosed with bullous eosinophilic cellulitis clinically and histologically without any etiological agents. Following therapy with oral corticosteroid and oral tetracycline capsules, the lesions disappeared. After a 2-month asymptomatic period, the patient developed pruritic follicular papules and pustules on the lower and upper extremities and upper back. Stool examination revealed Gierdia intestinalis eggs. The patient had complete clearance with treatment of ornidazol for 2 weeks and indomethacin for 2 months. This is the first report of bullous eosinophilic cellulitis coexisting with eosinophilic pustular folliculitis without eosinophilia in the English published work.
Abstract
Summer Infections and Cellulitis
Look out for Skin Infections this Summer!
Friday, 12 January 2007, 11:02 am
Press Release: Well Child Look out for Skin Infections this Summer!
January 12, 2007
In recent years hospitalisations for the treatment of serious skin infections have been increasing in New Zealand and none more so than during summer when children are prone to grazes, cuts and insect bites.
Dr Teuila Percival, a paediatrician at Kidz First Children’s Hospital, sees first-hand the effects of serious skin infections which have been left untreated.
“We see a lot of skin infections at Kidz First with cellulitis being the most common. It affects all ages, both children and adults and is an infection that comes on very rapidly,” says Dr Percival.
Serious skin infections like cellulitis (an acute bacterial infection of the soft tissues of the skin) and abscesses (a cavity containing pus, which may also incorporate cellulitis), are largely cause by bacteria that gets past the protective layer of skin.
A skin infection may simply start out as a mosquito bite that the child then scratches. Bacteria can enter the skin causing an infection. If left untreated, complications can arise.
It’s a good thing most skin infections are preventable, or easily treated if detected early. Untreated skin infections can affect your blood, kidneys, bones, joints, lymph nodes and brain, and sometimes people need to be hospitalised for treatment. Deeper abscesses can form in the lungs, kidneys, joints, muscles, bone and brain.
What puts children at risk of skin infections?
Children are more at risk when living in an environment where bacteria are passed easily from person to person. This may happen in over-crowded houses where some amenities are lacking, for example, hot water, washing machine or drier, first aid supplies, linen and towels; or when there is poor access to adequate nutrition and medical care.
Children who have eczema and other breaks in the skin are more susceptible to skin infections. 90% of sufferers already carry the bacteria Staphylococcus aureus on their skin, and the dryness, cracking, itching and scratching that eczema causes, increases the chance of the bacteria breaking through the skin.
Article
Deadly new superbug hits Wales (Can cause Cellulitis)
Deadly new superbug hits Wales (Can cause Cellulitis)Jan 10 2007
Madeleine Brindley, Western Mail
A PATIENT has been admitted to a Welsh hospital suffering from the new, potentially lethal superbug PVL-positive MRSA.
This is the same bug that killed a nurse and a patient in the West Midlands last year, and is thought to be one of the first cases of its kind in Wales.
The patient is being treated at Prince Charles Hospital in Merthyr Tydfil. It is understood that the patient, who has not been named, acquired the bug in the community - there is no evidence currently that it was caught in a healthcare setting.
The PVL toxin destroys white blood cells. PVL-positive MRSA commonly causes skin infections, such as cellulitis (inflammation of layers under the skin) and pus-producing conditions like abscesses, boils and carbuncles.
On very rare occasions it can lead to more severe infections, such as septic arthritis, blood poisoning or necrotising pneumonia - a severe, life-threatening form of pneumonia.
A joint statement from Paul Hollard, interim chief executive of North Glamorgan NHS Trust, and the National Public Health Service for Wales, last night said, "A patient with community-acquired Panton-Valentine Leukocidin (PVL)-positive MRSA has been admitted to Prince Charles Hospital, Merthyr Tydfil.
"The trust has liaised with the Health Protection Agency and the National Public Health Service for Wales and the appropriate infection control procedures have been put in place.
"The patient is comfortable and receiving appropriate treatment."
PVL is a toxin that is carried by about 2% of Staphylococcus aureus bacteria, including the antibiotic-resistant strains MRSA (methicillin-resistant Staphylococcus aureus) and MSSA (methicillin-sensitive Staphylococcus aureus).
But unlike MRSA and MSSA, with which the public have become familiar as the number of cases in hospitals has risen over the years, PVL-producing strains can affect previously healthy young children and young adults. People tend to become infected in the community.
This is in stark contrast to so-called hospital-associated MRSA and MSSA strains, which do not produce PVL, and affect more elderly and debilitated patients.
Dr Eleri Davies, director of the Welsh Healthcare Associated Infection Programme for the National Public Health Service for Wales, said, "The rate of transmission is the same for PVL-producing strains as it is for other Staphylococcus aureus infections - some infections will be caused by our own bacteria getting into a breach in the skin, such as a graze or a picked spot, or through transmission between close family members."
Until recently most cases of PVL-related infections were caused by PVL-positive strains of MSSA, which was common in hospitals in the 1950s and 1960s.
But experts have recently become aware of a small number of cases, like the one at Prince Charles Hospital, of PVL-positive MRSA infections.
It is thought that these new strains have evolved from PVL-positive MSSA.
The Health Protection Agency is aware of seven deaths in England and Wales associated with PVL-positive MRSA in the last two years, including the two deaths at the University Hospital of North Staffordshire last year.
The West Midlands cases were unique in that they were the first cases of PVL-positive MRSA that had been transmitted in a hospital or healthcare setting in the UK. Nine other people, including another patient, were infected in the same outbreak.
In most of the other deaths attributed to PVL-positive MRSA, the infections were caught in the community.
Last month six babies in a hospital neonatal unit in Norfolk tested positive for a strain of PVL-positive MSSA. One of the babies, who was born very premature and was extremely sick, died after contracting the infection.
The HPA website states, "While PVL-producing MRSA can cause more serious infection, we have no evidence to suggest it is more dangerous than some other types of MRSA.
"Indeed, some previous and more recent data suggests that the PVL gene may not be the main virulence factor even in PVL strains.
"PVL-positive MRSA has not been shown to spread more rapidly than any of the usual hospital-associated MRSA organisms.
"There is no indication that current PVL-positive MRSA strains are more transmissible than other MRSA strains."
Persons with recurrent skin infections - spreading inflammation [cellulitis], boils and abscesses - should seek medical advice.
"Standard treatment and infection control measures are highly effective."
PVL-positive MRSA can be treated with antibiotics, even though it is resistant to methicillin. But the HPA said it was important that the infection is diagnosed early.
As with MRSA, good hygiene is important to stop the infection spreading to other patients and hospital staff.
"The HPA said thorough hand-washing and drying, and the use of alcoholic hand rubs are the most important measures in reducing cross-infection in both the community and the hospital.
Its website also states, "The infection control measures used to prevent the spread of PVL-positive MRSA are the same as for any type of MRSA infection.
"Standard infection control measures are effective and the most important first line of defence."
Article
Analysis of Empiric Antimicrobial Strategies for Cellulitis in the Era of Methicillin-Resistant Staphylococcus aureus
Analysis of Empiric Antimicrobial Strategies for Cellulitis in the Era of Methicillin-Resistant Staphylococcus aureusJan 2 2007
Phillips S,
Macdougall C,
Holdford DA.
Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, VA.* To whom correspondence should be addressed. E-mail: macdougallc@pharmacy.ucsf.edu
BACKGROUND:
The rise in community-onset methicillin-resistant Staphylococcus aureus(MRSA) infections potentially complicates the empiric management of cellulitis. The threshold at which drugs active against MRSA, such as clindamycin and trimethoprim/sulfamethoxazole (TMP/SMX), should be incorporated into empiric therapy is unknown.
OBJECTIVE:
To evaluate the cost-effectiveness of using cephalexin, TMP/SMX, or clindamycin for outpatient empiric therapy of cellulitis, given various likelihoods of infection due to MRSA. METHODS: A decision analysis of the empiric treatment of cellulitis was performed from the perspective of a third-party payer. The model included initial therapy with cephalexin, clindamycin, or TMP/SMX, followed by treatment with linezolid in cases of clinical failure. Probability and cost estimates were obtained from clinical trials, epidemiologic data, and publicly available cost data and were subjected to sensitivity analysis. RESULTS: Under the base-case scenario (37% probability of infection by S.aureus and a 27% MRSA prevalence), cephalexin was the most cost-effective option. Clindamycin became a more cost-effective therapy at MRSA probabilities from 41-80% when the probability of staphylococcal infection was greater than 40%. TMP/SMX was cost-effective only at very high likelihoods of MRSA infection. Variables with the most influence in the model were probability of S. aureus being methicillin-resistant, cost of linezolid, probability of a cure with cephalexin for a non-MRSA infection, and probability of infection due to S. aureus. CONCLUSIONS: Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels. Cephalexin was the most cost-effective choice over most of the modeled range of probabilities, with clindamycin becoming more cost-effective at high likelihoods of MRSA infection. TMP/SMX is unlikely to be cost-effective for treatment of simple cellulitis. Further studies of the microbiology of cellulitis, the epidemiology of MRSA, and the clinical effectiveness of clindamycin and TMP/SMX in skin and soft tissue infections are needed.Key Words: cellulitis, cost-effectiveness, methicillin-resistant Staphylococcus aureus.The Annals of Pharmacotherapy
Risk factors for recurrent lower extremity cellulitis in a u.s. Veterans medical center population.
Risk factors for recurrent lower extremity cellulitis in a u.s. Veterans medical center population.Am J Med Sci. 2006 DecLewis SD,
Peter GS,
Gomez-Marin O,
Bisno AL. From the University of Miami Miller School of Medicine and Miami Veterans Affairs Medical Center, Miami, Florida.BACKGROUND:Despite the frequency of recurrent acute cellulitis of the lower extremities, factors associated with this infection have not been previously assessed in a case-control study among patients admitted to U.S. hospitals. METHODS:We compared the clinical characteristics of 47 patients with those of 94 age- and sex-matched control subjects admitted to the Miami Veterans Affairs Medical Center. RESULTS: In a multivariate analysis, two physical factors, lower extremity edema and body mass index, one behavioral factor, smoking, and one demographic factor, homelessness, were significantly and independently associated with recurrent cellulitis. The latter two factors have not previously been reported to be independently associated with cellulitis. CONCLUSIONS: Our results suggest that increased emphasis on weight loss, smoking cessation, and improved foot hygiene in the homeless might decrease recurrences of lower extremity cellulitis.PubMedRelated AbstractsRisk factors for acute cellulitis of the lower limb: a prospective case-control study.Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up.Lower limb cellulitis: features associated with length of hospital stay.
