Penicillin to prevent recurrent leg cellulitis.

Penicillin to prevent recurrent leg cellulitis.

May 2013

Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR, Nasr IS, Brindle RJ, English J, Meredith SK,Reynolds NJ, de Berker D, Mortimer PS, Williams HC; U.K. Dermatology Clinical Trials Network's PATCH I Trial Team.

Collaborators (146)

Source

Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom.

Abstract

BACKGROUND:

Cellulitis of the leg is a common bacterial infection of the skin and underlying tissue. We compared prophylactic low-dose penicillin with placebo for the prevention of recurrent cellulitis.

METHODS:

We conducted a double-blind, randomized, controlled trial involving patients with two or more episodes of cellulitis of the leg who were recruited in 28 hospitals in the United Kingdom and Ireland. Randomization was performed according to a computer-generated code, and study medications (penicillin [250 mg twice a day] or placebo for 12 months) were dispensed by a central pharmacy. The primary outcome was the time to a first recurrence. Participants were followed for up to 3 years. Because the risk of recurrence was not constant over the 3-year period, the primary hypothesis was tested during prophylaxis only.

RESULTS:

A total of 274 patients were recruited. Baseline characteristics were similar in the two groups. The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence, as compared with 51 of 138 participants in the placebo group (37%) (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P=0.01), yielding a number needed to treat to prevent one recurrent cellulitis episode of 5 (95% CI, 4 to 9). During the no-intervention follow-up period, there was no difference between groups in the rate of a first recurrence (27% in both groups). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 vs. 164, P=0.02 for trend). There was no significant between-group difference in the number of participants with adverse events (37 in the penicillin group and 48 in the placebo group, P=0.50).

CONCLUSIONS:

In patients with recurrent cellulitis of the leg, penicillin was effective in preventing subsequent attacks during prophylaxis, but the protective effect diminished progressively once drug therapy was stopped. (Funded by Action Medical Research; PATCH I Controlled-Trials.com number, ISRCTN34716921.).

PubMed

http://www.ncbi.nlm.nih.gov/pubmed/23635049 (or)

NEJM

http://www.nejm.org/doi/full/10.1056/NEJMoa1206300

A rare case of endogenous Streptococcus group C endophthalmitis associated with cellulitis

Sept 2011

A Ebneter,^1,* L Goold,¹ and J S Gilhotra¹

Sir,

Group C Streptococci are part of the human flora¹ and rarely cause opportunistic infections. Here we report a case of endophthalmitis presumably caused by a cellulitis of the arm.

Case Report:

A 59-year-old woman with non-insulin-dependent diabetes mellitus had been given an influenza vaccination into her left arm with chronic lymph oedema. Two days later she developed painful swelling of the arm. Another 24h later she noticed decreased visual acuity of the right eye and pain. On presentation, the patient was febrile and a cellulitis involving the entire left arm with marked swelling was present. Systemic therapy with penicillin 2.4g every 4h and flucloxacillin 1g every 6h had already been started. The visual acuity was hand movements. The cornea showed mild exposure keratopathy due to a lagophthalmos of 2mm secondary to a pre-existing facial nerve palsy. The pupil was mid-dilated and non-reactive. A hypopyon was present and visualization of the posterior segment was not possible owing to dense vitritis. Vitreous and anterior chamber taps were done and ceftazidime (2.25mg/0.1ml) and vancomycin (1mg/0.1ml) were injected intravitreally. Gram staining of the aqueous tap featured Gram-positive cocci growing in chains, which were later identified as group C Streptococci. The B-scan showed an attached retina and dense vitreous debris. Blood cultures (taken after commencement of systemic antibiotics) did not grow any microorganisms. One day later the visual acuity further deteriorated to perception of light. Owing to corneal stromal opacity it was not possible to safely perform a vitrectomy. Topical prednisolone hourly and 50mg oral prednisone were added to the antibiotic treatment. Despite three more intravitreal injections of antibiotics over the following 10 days there was no improvement. Surgery involving keratoprosthesis, lensectomy, and vitrectomy was now offered to the patient, who declined this approach. The eye eventually became phthisical.

Comment:

Streptococcal endophthalmitis is exogenous in the vast majority of cases and is caused by organisms from the viridians group (50%), followed by Enterococcus (27%), Streptococcus pneumoniae (12.5%), and beta-haemolytic Streptococci (10.5%).² Endogenous Streptococcalendophthalmitis is uncommon, and we could only find two case reports in which group C Streptococcus was the causative microorganism.^3, 4 Our case highlights the importance of early recognition and the poor prognosis of endogenous Streptococcal endophthalmitis.

NIH