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Lin TL, Liu WH, Lai WH, Chen YJ, Chang PH, Chen IL, Li WF, Liu YW, Ley EJ, Wang CC. The incidence and risk factors of proximal lower extremity deep vein thrombosis without pharmacologic prophylaxis in critically ill surgical Taiwanese patients: A prospective study. J Intensive Care Soc 2024; 25:140-146. [PMID: 38737310 PMCID: PMC11086712 DOI: 10.1177/17511437231214906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background Venous thromboembolism (VTE) in critically ill patients has been well-studied in Western countries. Many studies have developed risk assessments and established pharmacological protocols to prevent deep venous thrombosis (DVT). However, the DVT rate and need for pharmacologic VTE prophylaxis in critically ill Taiwanese patients are limited. This study aimed to prospectively determine the DVT incidence, risk factors, and outcomes in critically ill Taiwanese patients who do not receive pharmacologic VTE prophylaxis. Methods We conducted a prospective study in a surgical intensive care unit (SICU) of a tertiary academic medical center in Taiwan. Adult patients admitted to SICU from March 2021 to June 2022 received proximal lower extremities DVT surveillance with venous duplex ultrasound. No patient received pharmacologic VTE prophylaxis. The outcomes were the incidence and risk factors of DVT. Results Among 501 enrolled SICU patients, 21 patients (4.2%) were diagnosed with proximal lower extremities DVT. In a multivariate regression analysis, hypoalbuminemia (odd ratio (OR) = 6.061, 95% confidence interval (CI): 1.067-34.421), femoral central venous catheter (OR = 4.515, 95% CI: 1.547-13.174), ICU stays more than 10 days (OR = 4.017, 95% CI: 1.270-12.707), and swollen leg (OR = 3.427, 95% CI: 1.075-10.930) were independent risk factors for DVT. In addition, patients with proximal lower extremities DVT have more extended ventilator days (p = 0.045) and ICU stays (p = 0.044). Conclusion Our findings indicate critically ill Taiwanese patients have a higher incidence of DVT than results from prior retrospective studies in the Asian population. Physicians who care for this population should consider the specific risk factors for DVT and prescribe pharmacologic prophylaxis in high-risk groups.
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Affiliation(s)
- Ting-Lung Lin
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Hao Liu
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Hung Lai
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Ju Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Hsun Chang
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Ling Chen
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yueh-Wei Liu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bissett B. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med 2020; 383:630-639. [PMID: 32786188 DOI: 10.1056/nejmoa1917197] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness. METHODS In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments. RESULTS A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial. CONCLUSIONS In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).
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Affiliation(s)
- Elizabeth Webb
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Teresa Neeman
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Francis J Bowden
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Jamie Gaida
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Virginia Mumford
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Bernie Bissett
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
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Thakur K, Sharma G, Singh B, Katare OP. Topical Drug Delivery of Anti-infectives Employing Lipid-Based Nanocarriers: Dermatokinetics as an Important Tool. Curr Pharm Des 2019; 24:5108-5128. [PMID: 30657036 DOI: 10.2174/1381612825666190118155843] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 01/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND The therapeutic approaches for the management of topical infections have always been a difficult approach due to lack of efficacy of conventional topical formulations, high frequency of topical applications and non-patient compliance. The major challenge in the management of topical infections lies in antibiotic resistance which leads to severe complications and hospitalizations resulting in economic burden and high mortality rates. METHODS Topical delivery employing lipid-based carriers has been a promising strategy to overcome the challenges of poor skin permeation and retention along with large doses which need to be administered systemically. The use of lipid-based delivery systems is a promising strategy for the effective topical delivery of antibiotics and overcoming drug-resistant strains in the skin. The major systems include transfersomes, niosomes, ethosomes, solid lipid nanoparticles, nanostructured lipid carriers, microemulsion and nanoemulsion as the most promising drug delivery approaches to treat infectious disorders. The main advantages of these systems include lipid bilayer structure which mimics the cell membrane and can fuse with infectious microbes. The numerous advantages associated with nanocarriers like enhanced efficacy, improvement in bioavailability, controlled drug release and ability to target the desired infectious pathogen have made these carriers successful. CONCLUSION Despite the number of strides taken in the field of topical drug delivery in infectious diseases, it still requires extensive research efforts to have a better perspective of the factors that influence drug permeation along with the mechanism of action with regard to skin penetration and deposition. The final objective of the therapy is to provide a safe and effective therapeutic approach for the management of infectious diseases affecting topical sites leading to enhanced therapeutic efficacy and patient-compliance.
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Affiliation(s)
- Kanika Thakur
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Gajanand Sharma
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Bhupindar Singh
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Om Prakash Katare
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
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4
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Webb E, Neeman T, Gaida J, Bowden FJ, Mumford V, Bissett B. Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol. BMJ Open 2019; 9:e029225. [PMID: 31420389 PMCID: PMC6701661 DOI: 10.1136/bmjopen-2019-029225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Cellulitis represents a significant burden to patients' quality of life (QOL) and cost to the healthcare system, especially due to its recurrent nature. Chronic oedema is a strong risk factor for both an initial episode of cellulitis and cellulitis recurrence. Expert consensus advises compression therapy to prevent cellulitis recurrence in individuals with chronic oedema, however, there is little supporting evidence. This research aims to determine if the management of chronic oedema using compression therapy effectively delays the recurrence of lower limb cellulitis. METHODS AND ANALYSIS A randomised controlled trial with cross-over will be used to assess the impact of compression therapy on clinical outcomes (time to next episode of cellulitis, rate of cellulitis-related hospital presentations, QOL and leg volume). Using concealed allocation, 162 participants will be randomised into the intervention (compression) or control (no compression) group. Randomisation will be stratified by prophylactic antibiotic use. Participants will be followed up at 6 monthly intervals for up to 3 years or until 45 episodes of cellulitis occur across the cohort. Following an episode of recurrent cellulitis, control group participants will cross-over to the intervention group. Survival analysis will be undertaken to assess the primary outcome measure of time to cellulitis recurrence. The hypotheses are that compression therapy to control lower limb chronic oedema will delay recurrent lower limb cellulitis, reduce the rate of associated hospitalisations, minimise affected limb volume and improve the QOL of this population. ETHICS AND DISSEMINATION Ethics approval has been obtained from the ethics committees of all relevant institutions. Results will be disseminated through relevant peer-reviewed journal articles and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12617000412336; Pre-results. The ICTOC trial is currently in progress. Participant recruitment started in May 2017 and is expected to continue until December 2019.
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Affiliation(s)
- Elizabeth Webb
- Department of Physiotherapy, Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Teresa Neeman
- Biological Data Science Institute, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jamie Gaida
- University of Canberra Research Institute for Sport and Exercise (UC-RISE), University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Francis J Bowden
- Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
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5
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Ebob-Anya BA, Bassah N, Palle JN. Management of cellulitis and the role of the nurse: a 5-year retrospective multicentre study in Fako, Cameroon. BMC Res Notes 2019; 12:452. [PMID: 31337435 PMCID: PMC6651919 DOI: 10.1186/s13104-019-4497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022] Open
Abstract
Objective This was a 5 year retrospective study of patients’ hospital records to find out how patients with cellulitis are managed and the care provided by nurses to these patients in some hospitals in Fako, Cameroon. Results Of the 236 cases of cellulitis identified from a study of hospital records, 202 were included in the study. Most of the participants (55%) were female and the mean (SD) age was 43 (1.1) years. Cellulitis accounted for 2.3% of admissions in this study. The predisposing factors identified were; the presence of trauma (60.5%), HIV infection (18.6%), alcohol consumption (8.4%) and tobacco use (4.8%). Commonly recorded complications were necrosis (32.2%), sepsis (23%), abscess formation (19.5%), and ulcer development (19.5%). Medical management was with antibiotic therapy, including mostly penicillin (26.5%), aminoglycoside (22.1%), nitroimidazole (20.2%) and cephalosporin (19.6%). Debridement (46.7%), and incision and drainage (44.4%) were the most implemented surgical interventions. Nursing care, as found in patients’ hospital records were predominantly on medication administration (98.0%), vital signs assessment (90.5%) and patient assessment (53%). Cellulitis therefore was found among a substantial number of patients and management was predominantly with combination antibiotics therapy and inadequate nursing care. Electronic supplementary material The online version of this article (10.1186/s13104-019-4497-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bachi-Ayukokang Ebob-Anya
- Department of Nursing, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, South-West Region, Cameroon
| | - Nahyeni Bassah
- Department of Nursing, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, South-West Region, Cameroon.
| | - John Ngunde Palle
- Department of Nursing, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, South-West Region, Cameroon.,Saint Luke's Medical Center Buea, Buea, Cameroon
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6
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Nijenhuis-Rosien L, Kleefstra N, van Dijk PR, Wolfhagen MJHM, Groenier KH, Bilo HJG, Landman GWD. Laser therapy for onychomycosis in patients with diabetes at risk for foot ulcers: a randomized, quadruple-blind, sham-controlled trial (LASER-1). J Eur Acad Dermatol Venereol 2019; 33:2143-2150. [PMID: 30920059 DOI: 10.1111/jdv.15601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers. OBJECTIVE The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy. METHODS In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up. RESULTS From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe. CONCLUSION At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.
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Affiliation(s)
- L Nijenhuis-Rosien
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Innofeet, Zwolle, The Netherlands
| | - N Kleefstra
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands.,University of Groningen, Groningen, The Netherlands.,Medical Research Group Langerhans, Ommen, The Netherlands
| | - P R van Dijk
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M J H M Wolfhagen
- Laboratory of Medical Microbiology and Infectious Diseases, Isala, Zwolle, The Netherlands
| | | | - H J G Bilo
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands.,University of Groningen, Groningen, The Netherlands
| | - G W D Landman
- Medical Research Group Langerhans, Ommen, The Netherlands.,Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
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7
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Teasdale E, Lalonde A, Muller I, Chalmers J, Smart P, Hooper J, El‐Gohary M, Thomas K, Santer M. Patients' understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care. Br J Dermatol 2019; 180:810-820. [PMID: 30451281 PMCID: PMC6487809 DOI: 10.1111/bjd.17445] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately one-third of cases. The only proven strategy to reduce the risk of recurrence is long-term, low-dose antibiotics. Given current concerns about antibiotic resistance and the pressure to reduce antibiotic prescribing, other prevention strategies are needed. OBJECTIVES To explore patients' views about cellulitis and different ways of preventing recurrent episodes. METHODS Adults aged ≥ 18 years with a history of first-episode or recurrent cellulitis were invited through primary care, hospitals and advertising to complete a survey, take part in an interview or both. RESULTS Thirty interviews were conducted between August 2016 and July 2017. Two hundred and forty surveys were completed (response rate 17%). Triangulation of quantitative and qualitative data showed that people who have had cellulitis have wide-ranging beliefs about what can cause cellulitis and are often unaware of risk of recurrence or potential strategies to prevent recurrence. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were more popular potential strategies than the use of compression stockings or long-term antibiotics. Participants expressed caution about long-term oral antibiotics, particularly those who had experienced only one episode of cellulitis. CONCLUSIONS People who have had cellulitis are keen to know about possible ways to prevent further episodes. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were generally viewed to be more acceptable, feasible strategies than compression or antibiotics, but further research is needed to explore uptake and effectiveness in practice.
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Affiliation(s)
- E.J. Teasdale
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - A. Lalonde
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - I. Muller
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - J. Chalmers
- Centre for Evidence Based DermatologyUniversity of NottinghamNottinghamU.K
| | | | | | - M. El‐Gohary
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
| | - K.S. Thomas
- Centre for Evidence Based DermatologyUniversity of NottinghamNottinghamU.K
| | - M. Santer
- Primary Care and Population ScienceFaculty of MedicineUniversity of SouthamptonSouthamptonU.K
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Patients' understanding of cellulitis and their information needs: a mixed-methods study in primary and secondary care. Br J Gen Pract 2019; 69:e279-e286. [PMID: 30858335 PMCID: PMC6428464 DOI: 10.3399/bjgp19x701873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/14/2018] [Indexed: 12/01/2022] Open
Abstract
Background Cellulitis is a painful infection of the skin and underlying tissues, commonly affecting the lower leg. Approximately one-third of people experience recurrence. Patients’ ability to recover from cellulitis or prevent recurrence is likely to be influenced by their understanding of the condition. Aim To explore patients’ perceptions of cellulitis, and their information needs. Design and setting Mixed-methods study comprising semi-structured, face-to-face interviews and a cross-sectional survey, recruiting through primary and secondary care, and advertising. Method Adults aged ≥18 years with a history of cellulitis were invited to take part in a survey, qualitative interview, or both. Results In all, 30 interviews were conducted between August 2016 and July 2017. Qualitative data highlighted a low awareness of cellulitis before the first episode, uncertainty about when it had been diagnosed, concern/surprise at the severity of cellulitis, and a perceived insufficient information provision. People were surprised that they had never heard of cellulitis and that they had not received advice or leaflets giving self-care information. Some sought information from the internet and found this confusing. A total of 240 surveys were completed (response rate 17%). These showed that, although many participants had received information on the treatment of cellulitis (60.0%, n = 144), they often reported receiving no information about causes (60.8%, n = 146) or prevention of recurrence (73.3%, n = 176). Conclusion There is a need to provide information for people with cellulitis, particularly in regard to naming their condition, the management of acute episodes, and how to reduce the risk of recurrences.
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Ortiz-Lazo E, Arriagada-Egnen C, Poehls C, Concha-Rogazy M. An Update on the Treatment and Management of Cellulitis. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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10
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Impact of health care-associated community-onset cellulitis in Korea: a multicenter study. Eur J Clin Microbiol Infect Dis 2019; 38:545-552. [PMID: 30680560 DOI: 10.1007/s10096-018-03456-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
Abstract
We conducted a multicenter study to determine the clinical and microbiological characteristics of health care-associated (HCA) cellulitis in Korea. We retrospectively reviewed the medical records of patients who had been diagnosed with community-onset cellulitis. Of the 2208 cellulitis patients, 232 (10.5%) had HCA cellulitis, 1243 (56.3%) patients were hospitalized, and 15 (0.7%) died in hospital. Compared with community-acquired (CA) cellulitis, patients with HCA cellulitis were older and more frequently presented with comorbidity and septic shock. A total of 355 microorganisms were isolated from 314 patients (14.2%). Staphylococcus aureus (134 isolates) was the most common organism, followed by Streptococcus spp. (86 isolates) and Gram-negative fermenters (58 isolates). Methicillin-resistant S. aureus (MRSA) accounted for 29.1% (39/134) of S. aureus infections. None of the Gram-negative fermenters were resistant to carbapenem. The antibiotic susceptibility pattern of isolated microorganisms was not different between HCA and CA cellulitis. In patients with HCA cellulitis, S. aureus (11.2% [26/232] vs. 5.5% [108/1976], p = 0.001), including MRSA (4.3% [10/232] vs. 1.5% [29/1976], p = 0.003) and Gram-negative fermenters (6.0% [14/232] vs. 2.3% [44/1976], p = 0.002), were more common causative organisms than in CA-cellulitis patients. Age ≥ 65 years, septic shock, and HCA infection were statistically significant factors associated with in-hospital mortality.
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11
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An Update on the Treatment and Management of Cellulitis. ACTAS DERMO-SIFILIOGRAFICAS 2018; 110:124-130. [PMID: 30390916 DOI: 10.1016/j.ad.2018.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/17/2018] [Accepted: 07/15/2018] [Indexed: 12/20/2022] Open
Abstract
Cellulitis and erysipelas are local soft tissue infections that occur following the entry of bacteria through a disrupted skin barrier. These infections are relatively common and early diagnosis is essential to treatment success. As dermatologists, we need to be familiar with the clinical presentation, diagnosis, and treatment of these infections. In this article, we provide a review of the literature and update on clinical manifestations, predisposing factors, microbiology, diagnosis, treatment, and complications. We also review the current situation in Chile.
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12
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Gunderson CG, Cherry BM, Fisher A. Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis. J Gen Intern Med 2018; 33:1553-1560. [PMID: 30022408 PMCID: PMC6108983 DOI: 10.1007/s11606-018-4546-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/29/2018] [Accepted: 06/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code "other cellulitis and abscess" accounts for 1.4% of all admissions and $5.5 billion in annual costs. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis and to ascertain if the rate is comparable to the rate for low risk patients with community acquired pneumonia that are currently recommended for outpatient management. METHODS A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random effects model. Heterogeneity was estimated using the I2 statistic. RESULTS Eighteen studies met inclusion criteria. The overall worldwide mortality rate was 1.1% (95% confidence interval (CI), 0.7-1.8). For studies from the USA, the rate was 0.5% (95% CI 0.3-0.9). The actual cause of death was generally poorly described, and only one third of deaths appeared to be due to infection. DISCUSSION The estimated mortality rate for patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that are recommended for outpatient management by the Pneumonia Severity Index and CURB65 prediction models and strongly endorsed by major infectious disease societies. Outpatient management of these patients could result in large cost savings and may be much preferred by patients.
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Affiliation(s)
- Craig G Gunderson
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, West Haven, CT, USA.
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
| | - Benjamin M Cherry
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, West Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Ann Fisher
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
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Dalal A, Eskin‐Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L, Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database Syst Rev 2017; 6:CD009758. [PMID: 28631307 PMCID: PMC6481501 DOI: 10.1002/14651858.cd009758.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. OBJECTIVES To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. SEARCH METHODS We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. SELECTION CRITERIA Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. MAIN RESULTS We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. AUTHORS' CONCLUSIONS In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.
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Affiliation(s)
- Adam Dalal
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Marina Eskin‐Schwartz
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Daniel Mimouni
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Walford Days
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Emmilia Hodak
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine EKaplan StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Jain SR, Hosseini-Moghaddam SM, Dwek P, Gupta K, Elsayed S, Thompson GW, Dagnone R, Hutt K, Silverman M. Infectious diseases specialist management improves outcomes for outpatients diagnosed with cellulitis in the emergency department: a double cohort study. Diagn Microbiol Infect Dis 2017; 87:371-375. [PMID: 28162827 DOI: 10.1016/j.diagmicrobio.2016.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/27/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Abstract
Three hospital emergency rooms (ERs) routinely referred all cases of cellulitis requiring outpatient intravenous antibiotics, to a central ER-staffed cellulitis clinic. We performed a retrospective cohort study of all patients seen by the ER clinic in the last 4months preceding a policy change (ER management cohort [ERMC]) (n=149) and all those seen in the first 3months of a new policy of automatic referral to an infectious disease (ID) specialist-supervised cellulitis clinic (ID management cohort [IDMC]) (n=136). Fifty-four (40%) of 136 patients in the IDMC were given an alternative diagnosis (noncellulitis), compared to 16 (11%) of 149 in the ERMC (P<0.0001). Logistic regression-demonstrated rates of disease recurrence were lower in the IDMC than the ERMC (hazard ratio [HR], 0.06; P=0.003), as were rates of hospitalization (HR, 0.11; P=0.01). There was no significant difference in mortality. Automatic ID consultation for cellulitis was beneficial in differentiating mimickers from true cellulitis, reducing recurrence, and preventing hospital admissions.
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Affiliation(s)
- Shilpa R Jain
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada.
| | - Seyed M Hosseini-Moghaddam
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Philip Dwek
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Kaveri Gupta
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Sameer Elsayed
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Guy W Thompson
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Robert Dagnone
- Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
| | - Kelly Hutt
- Division of Infectious Diseases, St Joseph's Hospital, London, ON N6A 4V2, Canada
| | - Michael Silverman
- Department of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, London, ON N6A 5C1, Canada
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15
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Abstract
The management of chronic oedema often consists of a programme of compression bandaging to reduce swelling and improve skin changes and limb shape, followed by patient self-care management in compression hosiery. Occasionally, patients experience rebound swelling and require further episodes of bandaging. In such cases, a thorough assessment of the causes of the rebound swelling should be carried out so that they can be eliminated. By evidencing three case studies, this article demonstrates that Haddenham Custom Goldpunkt garments can be useful in preventing rebound swelling, making it a cost- and resource-effective method of managing stubborn chronic oedema and lymphoedema.
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Affiliation(s)
- Marie Todd
- Clinical Nurse Specialist in Lymphoedema, Glasgow Specialist Lymphoedema Service
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16
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Elwell R, Craven N. A glossary of terms to assist the recognition and diagnosis of skin conditions associated with lower-limb chronic oedema. Br J Community Nurs 2015; Suppl:S14-8, S20. [PMID: 25950393 DOI: 10.12968/bjcn.2015.20.sup4.s14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There are a number of recognised skin conditions associated with chronic oedema, but the lack of agreed definitions and terminology often leads to poor recognition and a delay in treatment. Many patients are given a diagnostic 'label' (e.g. varicose eczema) that often turns out to be incorrect, leading to an interruption in the patient pathway. Every skin condition can be described in a variety of ways and each professional group adheres to certain phrases and words that, within each discipline, are recognised, but when making onward referral or working between professions, it helps to have clear and concise definitions. This article aims is to standardise the terminology used to describe skin conditions of the lower limbs among health professionals, removing some of the discrepancy, and to develop a glossary to aid recognition, definition and hence diagnosis to ensure prompt and appropriate management is implemented.
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Affiliation(s)
- Rebecca Elwell
- Macmillan Lymhoedema Clinical Nurse Specialist, University Hospitals of North Midlands NHS Trust
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17
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Nijenhuis-Rosien L, Kleefstra N, Wolfhagen MJ, Groenier KH, Bilo HJG, Landman GWD. Laser therapy for onychomycosis in patients with diabetes at risk for foot complications: study protocol for a randomized, double-blind, controlled trial (LASER-1). Trials 2015; 16:108. [PMID: 25872590 PMCID: PMC4381488 DOI: 10.1186/s13063-015-0622-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/27/2015] [Indexed: 11/25/2022] Open
Abstract
Background In a sham-controlled double-blind trial, we aim to establish the efficacy and safety of the local application of laser therapy in patients with diabetes, onychomycosis and risk factors for diabetes-related foot complications. Onychomycosis leads to thickened and distorted nails, which in turn lead to increased local pressure. The combination of onychomycosis and neuropathy or peripheral arterial disease (PAD) increases the risk of developing diabetes-related foot complications. Usual care for high-risk patients with diabetes and onychomycosis is completely symptomatic with frequent shaving and clipping of the nails. No effective curative local therapies exist, and systemic agents are often withheld due to concerns for side effects and interactions. Methods/Design The primary aim is to evaluate the efficacy of four sessions of Nd:YAG 1064 nM laser application on the one-year clinical and microbiological cure rate in a randomized, double-blind, sham-controlled design with blinded outcome assessment. Mandatory inclusion criteria are diagnosis of diabetes, risk factors for developing foot ulcers defined as a modified Simm’s classification score 1 or 2 and either neuropathy or PAD. A total of 64 patients are randomized to intervention or sham treatment performed by a podiatrist. Discussion This study will be the first double-blind study that investigates the effects of local laser therapy on onychomycosis, specifically performed in patients with diabetes with additional risk factors for foot complications. Trial registration Clinical trials.gov as NCT01996995, first received 22 November 2013.
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Affiliation(s)
- Leonie Nijenhuis-Rosien
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Innofeet Voetencentrum Nijenhuis Podiatry, Simon Stevinweg 13, 8013 NA, Zwolle, the Netherlands.
| | - Nanne Kleefstra
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands. .,Langerhans Medical Research Group, Postbus 21, 4254 ZG, Sleeuwijk, the Netherlands.
| | - Maurice J Wolfhagen
- Department of Medical Microbiology, Isala, Dr. van Heesweg 2, 8025 AB, Zwolle, the Netherlands.
| | - Klaas H Groenier
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of General Practice, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | - Henk J G Bilo
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands. .,Department of General Practice, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | - Gijs W D Landman
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, the Netherlands.
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18
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Todd M. Venous disease and chronic oedema: treatment and patient concordance. ACTA ACUST UNITED AC 2014; 23:466, 468-70. [PMID: 24820810 DOI: 10.12968/bjon.2014.23.9.466] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Compression therapy is the mainstay in the management of chronic venous disease, venous leg ulceration (VLU) and chronic oedema. The management of VLU alone is thought to cost a staggering £400 million per year and accounts for 13% of all district nursing visits. The predicted increase in elderly, obese and chronically ill patients will pose a further strain on already stretched resources. The impact of chronic venous and lymphovenous disease is also costly in terms of physical and psychological terms for patients. Adopting a preventive approach would reduce the financial, workload and symptomatic aspects of this condition.
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Affiliation(s)
- Marie Todd
- Lymphoedema Clinical Nurse Specialist at the Specialist Lymphoedema Service, Glasgow
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19
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Oh CC, Ko HCH, Lee HY, Safdar N, Maki DG, Chlebicki MP. Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis. J Infect 2014; 69:26-34. [DOI: 10.1016/j.jinf.2014.02.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/29/2014] [Accepted: 02/18/2014] [Indexed: 11/15/2022]
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Abstract
This project was developed to set up a nurse-led service based on the needs of patients diagnosed with 'red legs'. These patients are often wrongly admitted into hospital for treatment of cellulitis. Representatives from the specialties involved in caring for those individuals with red legs were invited to participate with patients to create a stakeholder group whose purpose was to develop integrated care pathways focused on referral criteria, diagnostics and treatment to inform a new nurse-led service. There was a commitment to utilising a number of facilitation techniques and practice-development methods in the progression of the project with the support of the Foundation of Nursing Studies. Much of the prescribed care can be carried out by the patients at home and only 25% patients have required a follow-up appointment within the new service. The service has now been fully commissioned and a secondment opportunity has been developed to lead the new service. Significant savings have been demonstrated and regular revision of the integrated care pathways with all groups, including the patients, will take place.
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21
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Cranendonk DR, Opmeer BC, Prins JM, Wiersinga WJ. Comparing short to standard duration of antibiotic therapy for patients hospitalized with cellulitis (DANCE): study protocol for a randomized controlled trial. BMC Infect Dis 2014; 14:235. [PMID: 24885384 PMCID: PMC4016641 DOI: 10.1186/1471-2334-14-235] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/24/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Recommended therapy duration for patients hospitalized with cellulitis is 10-14 days. Unnecessary use of antibiotics is one of the key factors driving resistance. Recent studies have shown that antibiotic therapy for cellulitis in outpatients can safely be shortened, despite residual inflammation. This study will compare in hospitalized patients the safety and effectiveness of shortening antibiotic therapy for cellulitis from 12 to 6 days. METHODS/DESIGN In a multicenter, randomized, double-blind, non-inferiority trial, adult patients admitted with cellulitis will be included. Cellulitis is defined as warmth, erythema, and induration of the skin and/or subcutaneous tissue, with or without pain (including erysipelas). All patients will initially be treated with intravenous flucloxacillin, and will be evaluated after 5-6 days. Those who have improved substantially (defined as being afebrile, and having a lower cellulitis severity score) will be randomized at day 6 between additional 6 days of oral flucloxacillin (n = 198) or placebo (n = 198). Treatment success is defined as resolution of cellulitis on day 14 (disappearance of warmth and tenderness, improvement of erythema and edema), without the need of additional antibiotics for cellulitis by day 28. Secondary endpoints are relapse rate (up to day 90), speed of recovery (using a cellulitis severity score until day 28, and VAS scores on pain and swelling until day 90), quality of life (using the SF-36 and EQ-5D questionnaires) and costs (associated with total antibiotic use and health-care resource utilization up to day 90). DISCUSSION Inclusion is planned to start in Q2 2014. TRIAL REGISTRATION ClinicalTrials.gov (NCT02032654) and the Netherlands Trial Register (NTR4360).
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Affiliation(s)
- Duncan R Cranendonk
- Center for Experimental and Molecular Medicine (CEMM), Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Meibergdreef 9, room G2-130, 1105 AZ, Amsterdam, The Netherlands.
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22
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Mason JM, Thomas KS, Crook AM, Foster KA, Chalmers JR, Nunn AJ, Williams HC. Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials. PLoS One 2014; 9:e82694. [PMID: 24551029 PMCID: PMC3925077 DOI: 10.1371/journal.pone.0082694] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/04/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cellulitis (erysipelas) is a recurring and debilitating bacterial infection of the skin and underlying tissue. We assessed the cost-effectiveness of prophylactic antibiotic treatment to prevent the recurrence of cellulitis using low dose penicillin V in patients following a first episode (6 months prophylaxis) and more recurrent cellulitis (12 months prophylaxis, or 6 months in those declining 12 months). METHODS Within-trial cost-effectiveness analysis was conducted using the findings of two randomised placebo-controlled multicentre trials (PATCH I and PATCH II), in which patients recruited in the UK and Ireland were followed-up for up to 3 years. Incremental cost, reduction in recurrence, cost per recurrence prevented and cost/QALY were estimated. National unit and reference costs for England in 2010 were applied to resource use, exploring NHS and societal perspectives. A total of 397 patients from the two trials contributed to the analysis. RESULTS There was a 29% reduction in the number of recurrences occurring within the trial (IRR: 0.71 95%CI: 0.53 to 0.90, p = 0.02), corresponding to an absolute reduction of recurrence of 0.31 recurrences/patient (95%CI: 0.05 to 0.59, p = 0.02). Incremental costs of prophylaxis suggested a small cost saving but were not statistically significant, comparing the two groups. If a decision-maker is willing to pay up to £25,000/QALY then there is a 66% probability of antibiotic prophylaxis being cost-effective from an NHS perspective, rising to 76% probability from a secondary, societal perspective. CONCLUSION Following first episode or recurrent cellulitis of the leg, prophylactic low dose penicillin is a very low cost intervention which, on balance, is effective and cost-effective at preventing subsequent attacks. Antibiotic prophylaxis reduces cellulitis recurrence by nearly a third but is not associated with a significant increase in costs.
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Affiliation(s)
- James M. Mason
- Durham Clinical Trials Unit, Durham University, Queen’s Campus, Stockton-on-Tees, United Kingdom
| | - Kim S. Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Katharine A. Foster
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Joanne R. Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Andrew J. Nunn
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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23
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Grammatikos AP, Falagas ME. Linezolid for the treatment of skin and soft-tissue infections. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.5.539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lund A, Joo D, Lewis K, Arikan Y, Grunfeld A. Photodocumentation as an emergency department documentation tool in soft tissue infection: a randomized trial. CAN J EMERG MED 2013; 15:345-52. [PMID: 24176458 DOI: 10.2310/8000.2013.130726] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Current documentation methods for patients with skin and soft tissue infections receiving outpatient parenteral anti-infective therapy (OPAT) include written descriptions and drawings of the infection that may inadequately communicate clinical status. We undertook a study to determine whether photodocumentation (PD) improves the duration of outpatient treatment of skin and soft tissue infections. METHODS A single-blinded, prospective, randomized trial was conducted in the emergency departments of a community hospital and an academic tertiary centre. Participants included consecutive patients age ≥ 14 years presenting with noninvasive skin and soft tissue infections requiring OPAT. Patients in the intervention arm were treated with standard of care plus PD at each emergency physician assessment. Control subjects received care provided at the discretion of the treating physician and non-photographic documentation. The primary outcome was duration of therapy measured in half-days. The required sample size to detect a difference of one half-day was 253 patients per group (α = 0.05). Secondary outcomes included (1) completion and therapeutic failure rates, (2) patient satisfaction, and (3) physician and nurse satisfaction. RESULTS Enrolment was slower and follow-up rates lower than anticipated, and the trial was terminated when funds were exhausted. A total of 468 subjects with similar age and gender characteristics were enrolled, with 244 receiving the intervention and 224 in the control arm. The mean OPAT duration was similar in the two groups (3.6 days v. 3.5 days, p = 0.73). No differences in the rate for completion and therapeutic failure were observed (71% v. 68% and < 1% for both, respectively). Survey response rates varied significantly: patients, 65%; nurses, 17%; and physicians, 87%. Physicians endorsed more comfort with their assessment and OPAT judgment with PD (65% and 64%, respectively). Physicians cited too much time lost with technological challenges, which would affect implementation in a busy ED. CONCLUSIONS PD as an intervention is acceptable to patients and has reasonable endorsement by the majority of physicians. This trial had significant limitations that threatened the integrity of the study, so the results are inconclusive.
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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. Penicillin to prevent recurrent leg cellulitis. N Engl J Med 2013; 368:1695-703. [PMID: 23635049 DOI: 10.1056/nejmoa1206300] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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.).
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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Okajima S, Hirota A, Kimura E, Inagaki M, Tamai N, Iizaka S, Nakagami G, Mori T, Sugama J, Sanada H. Health-related quality of life and associated factors in patients with primary lymphedema. Jpn J Nurs Sci 2012; 10:202-11. [PMID: 24373443 DOI: 10.1111/j.1742-7924.2012.00220.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM Primary lymphedema requires continuous conservative treatment during the patient's life, which may affect their health-related quality of life (HRQOL). Physical and psychosocial characteristics related to lymphedema are associated with their HRQOL. This study aimed to assess HRQOL in those patients undergoing conservative treatment and to determine the factors associated with their HRQOL. METHODS This was a cross-sectional, observational study that included 83 patients with primary lymphedema at an outpatient clinic for lymphedema. HRQOL was assessed with the Medical Outcomes Study 36-Item Short Form Survey (SF-36) and EuroQol 5-Dimension (EQ-5D). Lymphedema status/complications and psychosocial status were evaluated by medical records, physical assessment, and self-administrative questionnaires. RESULTS The general health perception score in the SF-36 was lower than the age- and sex-stratified national norms (P = 0.001). In the EQ-5D, the proportions of patients with some/moderate or severe problems were 42.2% for pain/discomfort, 21.7% for usual activities, and 20.5% for anxiety/depression. By multiple regression analyses, a lower physical component summary score in the SF-36 was associated with a higher lymphedema stage (P = 0.021), cellulitis within 30 days (P = 0.003), exercise (P = 0.010), and more substance use coping (P = 0.012). A lower mental component summary score was associated with skin lesions over edematous limbs (P = 0.008), less humor coping (P = 0.005), and more self-blame coping (P = 0.014). CONCLUSION Patients with primary lymphedema have problems in health perception, discomfort, usual activities, and anxiety/depression. Preventing cellulitis and skin lesions and humor coping may be able to improve HRQOL.
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Affiliation(s)
- Shizuko Okajima
- Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences and Nursing Department of Life Support Technology (Molten), Graduate School of Medicine, University of Tokyo Hirota Internal Medicine Clinic, Tokyo Aomori University of Health and Welfare, Aomori Department of Clinical Nursing, Division of Nursing Science, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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Thomas K, Crook A, Foster K, Mason J, Chalmers J, Bourke J, Ferguson A, Level N, Nunn A, Williams H. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial. Br J Dermatol 2011; 166:169-78. [PMID: 21910701 PMCID: PMC3494300 DOI: 10.1111/j.1365-2133.2011.10586.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cellulitis (erysipelas) of the leg is a common, painful infection of the skin and underlying tissue. Repeat episodes are frequent, cause significant morbidity and result in high health service costs. OBJECTIVES To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes. METHODS Double-blind, randomized controlled trial including patients recently treated for an episode of leg cellulitis. Recruitment took place in 20 hospitals. Randomization was by computer-generated code, and treatments allocated by post from a central pharmacy. Participants were enrolled for a maximum of 3 years and received their randomized treatment for the first 6 months of this period. RESULTS Participants (n=123) were randomized (31% of target due to slow recruitment). The majority (79%) had suffered one episode of cellulitis on entry into the study. The primary outcome of time to recurrence of cellulitis included all randomized participants and was blinded to treatment allocation. The hazard ratio (HR) showed that treatment with penicillin reduced the risk of recurrence by 47% [HR 0·53, 95% confidence interval (CI) 0·26-1·07, P=0·08]. In the penicillin V group 12/60 (20%) had a repeat episode compared with 21/63 (33%) in the placebo group. This equates to a number needed to treat (NNT) of eight participants in order to prevent one repeat episode of cellulitis [95% CI NNT(harm) 48 to ∞ to NNT(benefit) 3]. We found no difference between the two groups in the number of participants with oedema, ulceration or related adverse events. CONCLUSIONS Although this trial was limited by slow recruitment, and the result failed to achieve statistical significance, it provides the best evidence available to date for the prevention of recurrence of this debilitating condition.
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Affiliation(s)
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- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Lenton Lane, Nottingham NG7 2N, UK
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Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Res 2011; 4:26. [PMID: 22136082 PMCID: PMC3248359 DOI: 10.1186/1757-1146-4-26] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/04/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Effective treatment of tinea pedis and onychomycosis is crucial for patients with diabetes as these infections may lead to foot ulcers and secondary bacterial infections resulting in eventual lower limb amputation. Although numerous studies have assessed the effectiveness of antifungal drug and treatment regimens, most exclude patients with diabetes and examine otherwise healthy individuals. While these studies are useful, results cannot necessarily be extrapolated to patients with diabetes. The purpose of this study was to therefore identify the best evidence-based treatment interventions for tinea pedis or onychomycosis in people with diabetes. METHODS The question for this systemic review was: 'what evidence is there for the safety and/or efficacy of all treatment interventions for adults with tinea pedis and/or onychomycosis in people with diabetes'? A systematic literature search of four electronic databases (Scopus, EbscoHost, Ovid, Web of Science) was undertaken (6/1/11). The primary outcome measure for safety was self-reported adverse events likely to be drug-related, while the primary outcome measures assessed for 'efficacy' were mycological, clinical and complete cure. RESULTS The systematic review identified six studies that examined the safety and/or efficacy of treatment interventions for onychomycosis in people with diabetes. No studies were identified that examined treatment for tinea pedis. Of the studies identified, two were randomised controlled trials (RCTs) and four were case series. Based on the best available evidence identified, it can be suggested that oral terbinafine is as safe and effective as oral itraconazole therapy for the treatment of onychomycosis in people with diabetes. However, efficacy results were found to be poor. CONCLUSIONS This review indicates that there is good evidence (Level II) to suggest oral terbinafine is as safe and effective as itraconazole therapy for the treatment of onychomycosis in people with diabetes. Further research is needed to establish the evidence for other treatment modalities and treatment for tinea pedis for people with diabetes. Future efforts are needed to improve the efficacy of treatment intervention.
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Affiliation(s)
- Lisa Matricciani
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Kerwin Talbot
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Sara Jones
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
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Noh JY, Cheong HJ, Song JY, Hong SJ, Myung JS, Choi WS, Jo YM, Heo JY, Kim WJ. Skin and soft tissue infections: Experience over a five-year period and clinical usefulness of ultrasonography-guided gun biopsy-based culture. ACTA ACUST UNITED AC 2011; 43:870-6. [DOI: 10.3109/00365548.2011.600324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
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.
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Affiliation(s)
- Sally A Kilburn
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, Hampshire, UK, PO1 2FR
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Risk stratification and outcome of cellulitis admitted to hospital. J Infect 2010; 60:431-9. [DOI: 10.1016/j.jinf.2010.03.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/17/2010] [Accepted: 03/19/2010] [Indexed: 01/22/2023]
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Baseline factors predicting the duration of intravenous antibiotic therapy for cellulitis in an outpatient setting. Eur J Clin Microbiol Infect Dis 2010; 29:347-9. [DOI: 10.1007/s10096-009-0855-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 12/05/2009] [Indexed: 11/26/2022]
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Kang Y, Crogan NL. An evidence-based review of infectious diseases. Geriatr Nurs 2009; 30:272-86. [PMID: 19673155 DOI: 10.1016/j.gerinurse.2009.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review. Epidemiol Infect 2009; 138:313-7. [PMID: 19646308 DOI: 10.1017/s0950268809990483] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We utilized Medline to perform a systematic review of the literature to quantify the aetiology of cellulitis with intact skin. Of 808 patients with cellulitis, 127-129 (15.7-16.0%) patients had positive needle aspiration and/or punch biopsy cultures from intact skin. Of the patients with positive cultures, 65 (50.4-51.2%) had cultures positive for Staphylococcus aureus, 35 (27.1-27.6%) for group A streptococcus, and 35-37 (27.1-29.1%) for other pathogens. The most common aetiology of cellulitis with intact skin, when it can be determined, is S. aureus, outnumbering group A streptococcus by a ratio of nearly 2:1. Given the increasing incidence of community-associated methicillin-resistant S. aureus infections, our findings may have critical therapeutic implications.
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Abstract
AIMS To review the current evidence for the presence of fungal foot infection (tinea pedis and toenail onychomycosis) as a risk factor for the development of cellulitis within the lower limb, particularly for those individuals with diabetes. METHODS A structured review of medline, embase and cinahl databases was undertaken to identify publications investigating fungal foot infection as a risk factor for the development of cellulitis. RESULTS Sixteen studies were identified. Eight studies adopted a case-control methodology, with the remainder being cross-sectional surveys. The majority of studies established the presence of tinea infection by clinical rather than established microbiological methods. Although the majority of papers suggested a link, only two case-control studies employed microbiological diagnosis to demonstrate that fungal foot infection was a risk for the development of lower limb cellulitis, particularly when infection was located between the toes. There were insufficient data to suggest that fungal foot infection posed an increased risk to patients with diabetes. CONCLUSION There is some evidence to suggest that fungal infection of the foot is a factor in the development of lower limb cellulitis, but further robust research is needed to confirm these findings and quantify the risk that fungi pose, particularly to the diabetic foot. Meanwhile, improved surveillance and treatment of tinea infections on the foot by healthcare professionals should be encouraged to reduce potential complications.
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Affiliation(s)
- I R Bristow
- School of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK.
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Tyrer A, Thornalley C. Cycloidal vibration for the treatment of cellulitis in a community setting. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2008; 17:S34-S37. [PMID: 19043325 DOI: 10.12968/bjon.2008.17.sup9.31664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Cellulitis of the lower limb is a common infection seen in primary care resulting in a significant number of hospital admissions per year. The NHS is proposing and developing services to treat patients more effectively in the community to prevent hospital admission. Cycloidal vibration (CV) therapy is a medical device that when combined with standard antibiotic therapy for cellulitis results in an effective treatment. This retrospective analysis is a review of patients with cellulitis seen in a community medical centre before and after the introduction of CV therapy. This therapy in conjunction with antibiotics resulted in the successful recovery of patients with cellulitis that previously required hospital admission for treatment. As a consequence a significant reduction in the cost of treating these patients has been determined.
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Affiliation(s)
- Alison Tyrer
- Clinical Nurse Specialist, Tissue Viability Countywide Professional Advisor, Lincolnshire, UK
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Soo J, Bicanic T, Heenan S, Mortimer P. Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis. Br J Dermatol 2008; 158:1350-3. [DOI: 10.1111/j.1365-2133.2007.08423.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Halpern J, Holder R, Langford N. Ethnicity and other risk factors for acute lower limb cellulitis: a U.K.-based prospective case–control study. Br J Dermatol 2008; 158:1288-92. [DOI: 10.1111/j.1365-2133.2008.08489.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Infectious diseases remain a significant cause of morbidity and mortality in the growing number of adults over the age of 65 years in the United States. Declining immunity coupled with aging anatomy and physiology set the stage for increased vulnerability to infections and the development of atypical presentations in the elderly. Pneumonia, urinary tract infection, and skin and soft tissue infections are illnesses commonly encountered in the care of this unique population. This article explores the etiology, diagnosis, and constantly evolving treatment of these conditions in the context of the elderly patient.
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Affiliation(s)
- Stephen Y Liang
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th floor, Suite 200, Baltimore, MD 21201, USA.
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Johnson S, Leak K, Singh S, Tan P, Pillay W, Cuschieri RJ, Mostyn E. Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times? J Wound Care 2007; 16:166-9. [PMID: 17444382 DOI: 10.12968/jowc.2007.16.4.27026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This single-centre non-blind randomised controlled trial aimed to compare clinical outcomes in terms of recovery time of standard treatment of lower limb cellulitis versus standard treatment combined with cycloidal vibration (Vibro-Pulse) therapy. METHOD Thirty-six patients (18 per group) with lower limb cellulitis were randomised to receive either standard treatment (intravenous or oral antibiotic therapy) and bed rest or standard treatment combined with cycloidal vibration treatment three times per day, 30 minutes per treatment. The outcome measure was the daily amount of reduction in erythema/cellulitis and oedema reduction against time for up to seven days of treatment and the resources required. RESULTS There was a clinically significant difference between the two groups, with 66% of the study group fully recovering within the seven days compared with 11% of the control group. CONCLUSION Cycloidal vibration combined with standard therapy can significantly reduce cellulitis treatment time. This can reduce both hospital bed days and the resources required.
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Affiliation(s)
- S Johnson
- Department of Vascular Surgery, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster Royal Infirmary, UK.
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Carter K, Kilburn S, Featherstone P. Cellulitis and treatment: a qualitative study of experiences. ACTA ACUST UNITED AC 2007; 16:S22-4, S26-8. [PMID: 17505397 DOI: 10.12968/bjon.2007.16.sup1.27089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although cellulitis is usually a relatively mild condition, it is potentially life threatening, often necessitating emergency treatment in either the acute or community care settings. The treatment of cellulitis with antibiotics is well established, with effectiveness generally measured against purely biochemical and clinical outcomes (Cox, 2002). Although important, these outcomes are centred purely on the disease process from the medical perspective and little is known about patients' experiences of cellulitis. This qualitative study explores patients' view on the management of community-acquired cellulitis in the secondary healthcare setting. Data were collected through semi-structured groups and individual telephone interviews. Participants were selected through purposive sampling and the Framework Analysis Technique was used to analyse the data. Three superordinate themes emerged: initial presentation/motivation for seeking help; confidence and satisfaction; anxiety and dissatisfaction. Severe pain was almost universally a cause of distress and flu-like symptoms delayed recognition. Health information and communication was generally poor. Participants largely welcomed a move from inpatient to day-patient or outpatient care provided there was adequate information and support. To meet the diverse needs of cellulitis patients, services must be more flexible and tailored to the needs of the individual. Patients are often not told what they can do to prevent recurrence.
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Affiliation(s)
- Kim Carter
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth
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Thomas KS, Cox NH, Savelyich BSP, Shipley D, Meredith S, Nunn A, Reynolds N, Williams HC. Feasibility study to inform the design of a UK multi-centre randomised controlled trial of prophylactic antibiotics for the prevention of recurrent cellulitis of the leg. Trials 2007; 8:3. [PMID: 17257411 PMCID: PMC1797057 DOI: 10.1186/1745-6215-8-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 01/26/2007] [Indexed: 12/03/2022] Open
Abstract
Background This paper describes the results of a feasibility study for a randomised controlled trial (RCT). Methods Twenty-nine members of the UK Dermatology Clinical Trials Network (UK DCTN) expressed an interest in recruiting for this study. Of these, 17 obtained full ethics and Research & Development (R&D) approval, and 15 successfully recruited patients into the study. A total of 70 participants with a diagnosis of cellulitis of the leg were enrolled over a 5-month period. These participants were largely recruited from medical admissions wards, although some were identified from dermatology, orthopaedic, geriatric and general surgery wards. Data were collected on patient demographics, clinical features and willingness to take part in a future RCT. Results Despite being a relatively common condition, cellulitis patients were difficult to locate through our network of UK DCTN clinicians. This was largely because patients were rarely seen by dermatologists, and admissions were not co-ordinated centrally. In addition, the impact of the proposed exclusion criteria was high; only 26 (37%) of those enrolled in the study fulfilled all of the inclusion criteria for the subsequent RCT, and were willing to be randomised to treatment. Of the 70 participants identified during the study as having cellulitis of the leg (as confirmed by a dermatologist), only 59 (84%) had all 3 of the defining features of: i) erythema, ii) oedema, and iii) warmth with acute pain/tenderness upon examination. Twenty-two (32%) patients experienced a previous episode of cellulitis within the last 3 years. The median time to recurrence (estimated as the time since the most recent previous attack) was 205 days (95% CI 102 to 308). Service users were generally supportive of the trial, although several expressed concerns about taking antibiotics for lengthy periods, and felt that multiple morbidity/old age would limit entry into a 3-year study. Conclusion This pilot study has been crucial in highlighting some key issues for the conduct of a future RCT. As a result of these findings, changes have been made to i) the planned recruitment strategy, ii) the proposed inclusion criteria and ii) the definition of cellulitis for use in the future trial.
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Neil H Cox
- Department of Dermatology, Cumberland Infirmary, Carlisle, UK
| | - Boki SP Savelyich
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Debbie Shipley
- Department of Dermatology, Bristol Royal Infirmary, Bristol, UK
| | | | | | - Nick Reynolds
- Department of Dermatology, University of Newcastle, Newcastle, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Cox NH. Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up. Br J Dermatol 2006; 155:947-50. [PMID: 17034523 DOI: 10.1111/j.1365-2133.2006.07419.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cellulitis of the lower leg is a common problem with considerable morbidity. Risk factors are well identified but the relationship between consequences of cellulitis and further episodes is less well understood. OBJECTIVES To review risk factors, treatment and complications in patients with lower leg cellulitis, to determine the frequency of long-term complications and of further episodes, and any relationship between them, and to consider the likely impact of preventive strategies based on these results. METHODS Patients with ascending, presumed streptococcal, cellulitis of the lower leg were identified retrospectively from hospital coding. Hospital records, together with questionnaires to both general practitioners and patients, were used to record subsequent complications and identifiable risk factors for further episodes. RESULTS Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated (P < 0.0002). Based on 143 completed questionnaires, oedema was apparently due to or persistently asymmetrical after the cellulitic episode in 52 (37%), and 19 (13%) had ulceration attributed to, rather than causing, cellulitis. Of those with three or more episodes, half did not lead to hospital admission. Toeweb maceration was reported in only 15% of questionnaires. Use of antibiotic treatment for more than 28 days was associated with a reduced risk of leg ulceration or of prolonged oedema compared with shorter courses, but neither difference was statistically significant. CONCLUSIONS This study demonstrates that the true frequency of postcellulitic oedema, as well as that of further episodes, is probably underestimated. Furthermore, there is a strong association between these factors, each of which is both a risk factor for, and a consequence of, each other, and for which intervention (reduction of oedema or more prolonged antibiotic therapy) may reduce the risk of recurrent infection. By contrast, self-reporting of toeweb maceration is low, so attempts to reduce the risk of recurrent cellulitis by treatment of tinea pedis or bacterial intertrigo may fail.
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Affiliation(s)
- N H Cox
- Dermatology Department, Cumberland Infirmary, Carlisle CA2 7HY, UK.
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Abstract
Persistent lower limb oedema is an underestimated problem in the elderly population. Oedematous tissue predisposes the individual to the development of bacterial infections. Accurate assessment of the underlying aetiology and application of compression hosiery could prevent cellulitis and reduce the risk of recurrent episodes. Awareness of the complications of leg oedema needs to be raised in the general population. Healthcare professions require education to enable the provision of safe, effective treatment to reduce morbidity relating to chronic oedema and cellulitis. The 'National Service Framework for Older People' and the 'British Lymphology Society's Framework for Education' could facilitate the development of national service provision to meet the needs of the population with chronic oedema.
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Affiliation(s)
- Julie Stalbow
- Binscombe Medical Centre, Binscombe, Godalming, Surrey
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Abstract
Elderly individuals have an increased susceptibility to skin infections due to age-related anatomical, physiological and environmental factors. The types of organisms that cause primary skin and soft tissue infections are diverse, and include bacterial, viral and fungal pathogens as well as parasites. In the elderly, these infections and infestations may present with atypical signs and symptoms or may complicate underlying chronic skin disorders. Clinical features, investigations and management of the following important and common skin infections are described in more detail: cellulitis, erysipelas, necrotizing fasciitis, impetigo, folliculitis, furunculosis and carbunculosis, erythrasma, herpes zoster and postherpetic neuralgia, herpes simplex, warts, molluscum contagiosum, dermatophytosis of the skin, hair and nails, candidiasis, and scabies. Treatment should be based on the results of the appropriate diagnostic tests. Correct diagnosis and therapy of skin infections lead to satisfactory outcome in the majority of elderly patients.
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Affiliation(s)
- Simone Laube
- Department of Dermatology, University Hospital of North Staffordshire, Central Out-Patients, Hartshill Road, Stoke-on-Trent ST4 7PA, UK.
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47
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Gupta R, Rauf SJ, Singh S, Smith J, Agraharkar ML. Sepsis in a renal transplant recipient due to Citrobacter braakii. South Med J 2003; 96:796-8. [PMID: 14515921 DOI: 10.1097/01.smj.0000051068.52066.e2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cellulitis is usually caused by organisms such as beta-hemolytic streptococci and Staphylococcus aureus. Citrobacter are gram-negative bacilli that can cause opportunistic infections in immunocompromised hosts. They are rarely implicated in skin or soft tissue infections. The genus Citrobacter has been respeciated according to genetic relatedness. Citrobacter braakii refers to the genomospecies 6 of the Citrobacter freundii complex. There are no detailed studies of infections caused by the newly formed specific genetic species. We report a case of C. braakii infection in a renal transplant patient receiving immunosuppressive therapy. The patient's lower extremity cellulitis did not respond to conventional antibiotic therapy. Blood cultures grew C. braakii. Sensitivity studies and treatment with appropriate antibiotics resulted in prompt recovery. Immunosuppressive therapy in renal transplant recipients predisposes to infection by unusual pathogens, and this should be suspected when lack of a clinical response to conventional antibiotics is observed. We believe this is the first reported case of C. braakii cellulitis and bacteremia in a renal transplant recipient.
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Affiliation(s)
- Rajiv Gupta
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0562, USA
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48
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Abstract
Skin and soft tissue infections are quite common in elderly people. A number of special conditions and circumstances need to be considered in the diagnosis and therapy. It is important to try to establish the causative organism, exclude other cutaneous disorders and identify precipitating factors. Treatment modalities include antiseptics, topical and systemic antibacterials, dressings and biotherapy. Skin infections presenting with erythema, blisters, pustules, and ulcerations or in body folds are described in detail. Cellulitis and infected ulcers are the most commonly encountered cutaneous infections in the elderly. Accurate and quick diagnosis and treatment are imperative to prevent significant morbidity and mortality. Appropriate antibacterials, antiseptics and dressings are necessary depending on the severity of the clinical presentation and resistance patterns. Laboratory tests, such as skin swabs, to establish the exact pathogen take time and the results might represent colonisation rather than infection of the skin. Cellulitis should be clinically distinguished from erysipelas and necrotising fasciitis. The latter is a life-threatening condition, which in the majority of cases requires surgical debridement of the infected tissue. Blisters and honey-coloured crusts are typical features of impetigo. It is very contagious and close contacts should be examined. Folliculitis is a commonly seen skin infection, which often responds to the use of antiseptics and topical antibacterials. More severe pustular skin eruptions, such as furunculosis and carbunculosis, usually require treatment with systemic antibacterials. Intertrigo and erythrasma have a predilection for the body folds, especially the axillae and groin, and topical therapy is usually sufficient. Secondary skin infections are often the result of persistent pruritus associated with increasing dryness of the aging skin. Emollients and antihistamines are useful measures. Primary cutaneous disorders and systemic diseases should be excluded with the aid of appropriate investigations, such as blood tests and skin biopsy. Staphylococcus aureus and beta-haemolytic streptococci are the most common causative organisms of cutaneous infections.
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Affiliation(s)
- Simone Laube
- Department of Dermatology, University Hospital of Wales, Cardiff, Wales, UK.
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