1
|
Muller I, Teasdale E, Cowdell F, Smart P, Santer M, Francis N. Practice and community nurses' views and experiences of helping people manage risk factors for recurrent lower limb cellulitis: A qualitative interview study. SKIN HEALTH AND DISEASE 2024; 4:e395. [PMID: 39355750 PMCID: PMC11442058 DOI: 10.1002/ski2.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 10/03/2024]
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. Nurses who work in general practice (practice nurses) and see people at home (community or district nurses) could have an important role in managing risk factors for cellulitis, such as long-term leg swelling, wound care and skin care. Objective To explore practice and community nurses' views and experiences of helping people to manage risk factors for recurrent lower limb cellulitis. Methods Semi-structured, telephone interviews with 21 practice and community nurses in England from October 2020 to March 2021. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Results Nurses face multiple challenges when supporting people to manage risk factors for recurrent lower limb cellulitis. Key challenges include limited time and access to resources such as Doppler equipment, and the physical and psychosocial capabilities of patients to self-manage. Nurses identified potential strategies to overcome these challenges, such as placing greater emphasis on prevention and supporting self-management by providing resources for patients and support networks (paid and unpaid carers) to reinforce knowledge post-consultation and develop skills to self-care. Conclusions We identified a need to develop and evaluate resources, such as support materials, for nurses to use to help patients reduce their risk of recurrent cellulitis.
Collapse
Affiliation(s)
- Ingrid Muller
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Emma Teasdale
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Fiona Cowdell
- Faculty of Health, Education and Life SciencesBirmingham City UniversityBirminghamUK
| | - Peter Smart
- Patient RepresentativeCentre for Evidence Based DermatologyUniversity of NottinghamNottinghamUK
| | - Miriam Santer
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Nick Francis
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| |
Collapse
|
2
|
Nightingale RS, Etheridge N, Sweeny AL, Smyth G, Dace W, Pellatt RAF, Snelling PJ, Yadav K, Keijzers G. Cellulitis in the Emergency Department: A prospective cohort study with patient-centred follow-up. Emerg Med Australas 2024; 36:579-588. [PMID: 38481041 DOI: 10.1111/1742-6723.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to describe the demographics, clinical features (erythema, warmth, swelling and pain), patient-reported disease trajectory and medium-term follow-up for ED patients with cellulitis. METHODS Prospective observational cohort study of adults diagnosed with cellulitis in two EDs in Southeast Queensland, Australia. Patients with (peri)orbital cellulitis and abscess were excluded. Data were obtained from a baseline questionnaire, electronic medical records and follow-up questionnaires at 3, 7 and 14 days. Clinician adjudication of day 14 cellulitis cure was compared to patient assessment. Descriptive analyses were conducted. RESULTS Three-hundred patients (mean age 50 years, SD 19.9) with cellulitis were enrolled, predominantly affecting the lower limb (75%). Cellulitis features showed greatest improvement between enrolment and day 3. Clinical improvement continued gradually at days 7 and 14 with persistent skin erythema (41%) and swelling (37%) at day 14. Skin warmth was the feature most likely to be resolved at each time point. There was a discrepancy in clinician and patient assessment of cellulitis cure at day 14 (85.8% vs. 52.8% cured). CONCLUSIONS A clinical response of cellulitis features can be expected at day 3 with ongoing slower improvement over time. Over one third of patients had erythema or swelling at day 14. Patients are less likely than clinicians to deem their cellulitis cured at day 14. Future research should include parallel patient and clinician evaluation of cellulitis to help develop clearer definitions of treatment failure and cure.
Collapse
Affiliation(s)
- Rachael S Nightingale
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Nimai Etheridge
- Department of Emergency Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Amy L Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - Graham Smyth
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - William Dace
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Richard A F Pellatt
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
| | - Peter J Snelling
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Ontario, Canada
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
3
|
Gabe-Walters M, Thomas M, Jenkins L. Demonstrating the benefit of a cellulitis-specific patient reported outcome measure (CELLUPROM ©) as part of the National Cellulitis Improvement Programme in Wales. J Patient Rep Outcomes 2024; 8:69. [PMID: 38985230 PMCID: PMC11236826 DOI: 10.1186/s41687-024-00754-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024] Open
Abstract
PURPOSE Despite a known risk of cellulitis recurrence, the management of the wider impact and risk factors has been neglected. The innovative National Cellulitis Improvement Programme (NCIP) addresses this by providing evidence-based and individualised care to improve patient reported outcomes and reduce the risk of recurrence. The aim of this paper is to examine the longer-term impact of cellulitis and to identify a suitable and clinically relevant Patient Reported Outcome Measure (PROM). METHODS A review of existing cellulitis-specific PROMs was undertaken, alongside literature detailing the patient-focused impact of cellulitis, to identify a suitable PROM for clinical use. A group of expert therapists and patient representatives (n = 14) shared their individual and collective experiences over a series of events to discuss and debate the impact of cellulitis and review available PROMs. CELLUPROM© is introduced with anonymised PROM data and case study information reported to establish the impact of CELLUPROM© within usual NCIP care. RESULTS No cellulitis-specific PROMs were identified. Literature focused on the signs and symptoms of an acute episode of cellulitis, with outcome measures primarily used to evidence the impact of an intervention. An enduring physical, social and emotional impact of cellulitis was identified in this study, providing the basis for the new cellulitis-specific PROM (CELLUPROM©), which has been implemented with good effect in clinical care. CONCLUSION This study has highlighted the lasting impact of cellulitis. Using CELLUPROM© within the risk-reduction NCIP has helped develop Value-Based Healthcare and support programme evaluation.
Collapse
Affiliation(s)
- Marie Gabe-Walters
- Lymphoedema Wales Clinical Network, Swansea Bay University Health Board, Swansea, Wales.
| | - Melanie Thomas
- Lymphoedema Wales Clinical Network, Swansea Bay University Health Board, Swansea, Wales
| | - Linda Jenkins
- National Cellulitis Improvement Programme Lead, Lymphoedema Wales Clinical Network, Swansea Bay University Health Board, Swansea, Wales
| |
Collapse
|
4
|
Taha M, Alzelaei MMM, Al-Qarni AMS, Al-Ammari MAM, Algamdi HST, Almaeidi AAI, Al-Faqih HAA. Assessment of Public Awareness of Cellulitis in Al-Qunfudhah Region, Saudi Arabia. Cureus 2024; 16:e63163. [PMID: 39070336 PMCID: PMC11272911 DOI: 10.7759/cureus.63163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND The term "cellulitis" is frequently used to describe a non-necrotizing inflammation of the skin and subcutaneous tissues that is typically caused by an acute infection and does not affect the muscles or fascia. Warmth, erythema, tenderness, swelling, and localized pain are the hallmarks of cellulitis. Life-threatening and debilitating outcomes from cellulitis include necrotizing fasciitis, necrotizing hypodermitis, abscess formation, septic shock, and, in extreme cases, death. The current study aimed to assess public awareness of cellulitis in the Al-Qunfudhah region, Saudi Arabia. METHODS A descriptive cross-sectional study was conducted targeting all residents in Al-Qunfudhah, Saudi Arabia, during the period from January to March 2024. Data were collected using a pre-structured online questionnaire. The study questionnaire included participants' demographic data, cellulitis data, and knowledge and attitude towards cellulitis. The final questionnaire was uploaded online using social media platforms by the researchers and their friends until no more new participants were included. RESULTS A total of 470 records were analyzed. Among the respondents, the majority were male (n=347, 73.8%), and the highest proportion fell within the age range of 18 to 25 years (n=174, 37.0%). The highest proportion of respondents correctly identified cellulitis as a medical condition affecting the skin and soft tissues underneath it, typically caused by infection or injury (n=278, 59.1%). Additionally, the majority acknowledged that cellulitis can cause pain, swelling, and redness in the affected area (n=240, 51.1%). As for factors associated with awareness of cellulitis, significant associations were found with age group (p=0.031), educational levels (p=0.003), and employment status (p=0.002). CONCLUSIONS This study revealed a high level of awareness of cellulitis among participants, especially highly educated and employed participants. Participants believed that healthcare providers play a crucial role in raising population awareness of cellulitis health problems.
Collapse
Affiliation(s)
- Medhat Taha
- Department of Anatomy, Umm Al-Qura University, Al-Qunfudhah, SAU
| | | | | | | | | | | | | |
Collapse
|
5
|
Confidence of recurrent cellulitis self-diagnosis among people with lymphoedema: a qualitative interview study. Br J Gen Pract 2020; 70:e130-e137. [PMID: 31848202 DOI: 10.3399/bjgp19x707909] [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: 06/11/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cellulitis can sometimes be challenging for healthcare professionals to diagnose, with no validated diagnostic criteria available. Supporting healthcare professionals to make a more accurate diagnosis of cellulitis in different groups, such as those with lymphoedema, is a cellulitis research priority. However, to the authors knowledge, no previous studies have looked at the involvement of non-healthcare professionals in the diagnostic process. AIM To explore the experience of people with lymphoedema and recurrent cellulitis in the diagnosis of lower-limb cellulitis. DESIGN AND SETTING Single, semi-structured, qualitative interviews carried out between 29 October and 19 December 2018. METHOD Adults with a suspected episode of cellulitis who had been diagnosed in the last 12 months or had a history of recurrent cellulitis were interviewed. RESULTS Three key themes emerged: the recurrent nature of cellulitis symptoms, participants' experience of getting a cellulitis diagnosis, and participants' suggestions of how cellulitis diagnosis might be improved. Generally, people with lymphoedema experienced similar clinical features during each of their own recurrent cellulitis episodes and were confident that they could make a self-diagnosis of cellulitis. This is also reflected in the participants' perceived trust from the healthcare professional in being able to make a self-diagnosis. A diagnostic checklist and educational resources were suggested as methods to improve diagnosis. CONCLUSION Selected people with lymphoedema who have recurrent cellulitis are confident in self-diagnosing their own recurrent cellulitis episodes. There may be a role for greater involvement of people with lymphoedema in their cellulitis diagnosis.
Collapse
|
6
|
Management of cellulitis: current practice and research questions. Br J Gen Pract 2019; 68:595-596. [PMID: 30498163 DOI: 10.3399/bjgp18x700181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/26/2018] [Indexed: 10/31/2022] Open
|
7
|
Brindle R, Williams OM, Barton E, Featherstone P. Assessment of Antibiotic Treatment of Cellulitis and Erysipelas: A Systematic Review and Meta-analysis. JAMA Dermatol 2019; 155:1033-1040. [PMID: 31188407 DOI: 10.1001/jamadermatol.2019.0884] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance The optimum antibiotic treatment for cellulitis and erysipelas lacks consensus. The available trial data do not demonstrate the superiority of any agent, and data are limited on the most appropriate route of administration or duration of therapy. Objective To assess the efficacy and safety of antibiotic therapy for non-surgically acquired cellulitis. Data Sources The following databases were searched to June 28, 2016: Cochrane Central Register of Controlled Trials (2016, issue 5), Medline (from 1946), Embase (from 1974), and Latin American and Caribbean Health Sciences Information System (LILACS) (from 1982). In addition, 5 trials databases and the reference lists of included studies were searched. Further searches of PubMed and Google Scholar were undertaken from June 28, 2016, to December 31, 2018. Study Selection Randomized clinical trials comparing different antibiotics, routes of administration, and treatment durations were included. Data Extraction and Synthesis For data collection and analysis, the standard methodological procedures of the Cochrane Collaboration were used. For dichotomous outcomes, the risk ratio and its 95% CI were calculated. A summary of findings table was created for the primary end points, adopting the GRADE approach to assess the quality of the evidence. Main Outcomes and Measures The primary outcome was the proportion of patients cured, improved, recovered, or symptom-free or symptom-reduced at the end of treatment, as reported by the trial. The secondary outcome was any adverse event. Results A total of 43 studies with a total of 5999 evaluable participants, whose age ranged from 1 month to 96 years, were included. Cellulitis was the primary diagnosis in only 15 studies (35%), and in other studies the median (interquartile range) proportion of patients with cellulitis was 29.7% (22.9%-50.3%). Overall, no evidence was found to support the superiority of any 1 antibiotic over another, and antibiotics with activity against methicillin-resistant Staphylococcus aureus did not add an advantage. Use of intravenous antibiotics over oral antibiotics and treatment duration of longer than 5 days were not supported by evidence. Conclusions and Relevance In this systematic review and meta-analysis, only low-quality evidence was found for the most appropriate agent, route of administration, and duration of treatment for patients with cellulitis; future trials need to use a standardized set of outcomes, including severity scoring, dosing, and duration of therapy.
Collapse
Affiliation(s)
- Richard Brindle
- Department of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - O Martin Williams
- Public Health England Microbiology Services Bristol, Bristol, United Kingdom.,University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Edward Barton
- North Cumbria University Hospitals NHS Trust, Carlisle, United Kingdom
| | - Peter Featherstone
- Acute Medicine Unit, Queen Alexandra Hospital, Portsmouth Hospitals, Portsmouth, United Kingdom
| |
Collapse
|
8
|
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: 1.7] [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.
Collapse
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
| |
Collapse
|
9
|
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: 0.5] [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.
Collapse
|
10
|
Smith E, Patel M, Thomas KS. Which outcomes are reported in cellulitis trials? Results of a review of outcomes included in cellulitis trials and a patient priority setting survey. Br J Dermatol 2018; 178:1028-1034. [PMID: 29222939 DOI: 10.1111/bjd.16235] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is an emerging need to develop consistent outcomes in clinical trials to allow effective comparison of treatment effects. No systematic review has previously looked at the reporting of outcome measures used in randomized controlled trials (RCTs) on the treatment and prevention of cellulitis (erysipelas). OBJECTIVES The primary aim of this review was to describe the breadth of outcomes reported from RCTs on cellulitis treatment and prevention. The secondary aim was to identify outcome themes from patients' and healthcare professionals' feedback from a cellulitis Priority Setting Partnership (PSP). METHODS We conducted a review of all outcome measures used in RCTs from two recent Cochrane reviews. Free-text responses from a cellulitis priority setting survey were used to understand the perspectives of patients and healthcare professionals. RESULTS Outcomes from 42 RCTs on treatment of cellulitis and six RCTs on prevention of cellulitis were reviewed. Only 28 trials stated their primary outcome. For trials assessing treatment of cellulitis, clinical response to treatment was categorized in 25 different ways. Five of these trials used an outcome that was in accordance with FDA guidance and only four trials incorporated either quality of life or patient satisfaction. For trials assessing prevention of cellulitis, recurrence was the key outcome measure. From the cellulitis PSP, prevention of recurrence, clinical features and long-term disease impact were the most important outcome themes for patients. CONCLUSIONS We have shown that in cellulitis treatment and prevention research, there is significant heterogeneity in clinical outcomes, inadequate focus on patient-reported outcomes, and a disparity between what is currently measured and what patients and healthcare professionals feel is important. We recommend that future cellulitis treatment trials consider the use of longer-term outcomes to capture recurrence and long-term morbidity, as well as short-term resolution of acute infection.
Collapse
Affiliation(s)
- E Smith
- Centre of Evidence Based Dermatology, The University of Nottingham, Nottingham, U.K
| | - M Patel
- Division of Primary Care, The University of Nottingham, Nottingham, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, The University of Nottingham, Nottingham, U.K
| |
Collapse
|
11
|
Brindle R, Williams OM, Davies P, Harris T, Jarman H, Hay AD, Featherstone P. Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis. BMJ Open 2017; 7:e013260. [PMID: 28314743 PMCID: PMC5372109 DOI: 10.1136/bmjopen-2016-013260] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis. DESIGN Parallel, double-blinded, randomised controlled trial. SETTING Emergency department attendances and general practice referrals within 20 hospitals in England. INTERVENTIONS Flucloxacillin, at a minimum of 500 mg 4 times per day for 5 days, with clindamycin 300 mg 4 times per day for 2 days given orally versus flucloxacillin given alone. MAIN OUTCOME MEASURES The primary outcome was improvement at day 5. This was defined as being afebrile with either a reduction in affected skin surface temperature or a reduction in the circumference of the affected area. Secondary outcomes included resolution of systemic features, resolution of inflammatory markers, recovery of renal function, reduction in the affected area, decrease in pain, return to work or normal activities and the absence of increased side effects. RESULTS 410 patients were included in the trial. No significant difference was seen in improvement at day 5 for flucloxacillin with clindamycin (136/156, 87%) versus flucloxacillin alone (140/172, 81%)-OR 1.55 (95% CI 0.81 to 3.01), p=0.174. There was a significant difference in the number of patients with diarrhoea at day 5 in the flucloxacillin with clindamycin allocation (34/160, 22%) versus flucloxacillin alone (16/176, 9%)-OR 2.7 (95% CI 1.41 to 5.07), p=0.002. There was no clinically significant difference in any secondary outcome measures. There was no significant difference in the number of patients stating that they had returned to normal activities at the day 30 interview in the flucloxacillin with clindamycin allocation (99/121, 82%) versus flucloxacillin alone (104/129, 81%)-adjusted OR 0.90 (95% CI 0.44 to 1.84). CONCLUSIONS The addition of a short course of clindamycin to flucloxacillin early on in limb cellulitis does not improve outcome. The addition of clindamycin doubles the likelihood of diarrhoea within the first few days. TRIAL REGISTRATION NUMBER NCT01876628, Results.
Collapse
Affiliation(s)
- Richard Brindle
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - O Martin Williams
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - Paul Davies
- General Practice Support Unit, Bristol Royal Infirmary, Bristol, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Heather Jarman
- Department of Emergency Medicine, St George's University Hospitals, London, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | |
Collapse
|
12
|
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: 2.0] [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.
Collapse
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
| |
Collapse
|
13
|
Colegrave M, Rippon M, Richardson C. The effect of Ringer's solution within a dressing to elicit pain relief. J Wound Care 2016; 25:184, 186-8, 190. [DOI: 10.12968/jowc.2016.25.4.184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - M.G. Rippon
- School of Human and Health Sciences, Institute of Skin Integrity and Infection Prevention. University of Huddersfield
| | - C. Richardson
- The School of Nursing, Midwifery and Social Work, University of Manchester
| |
Collapse
|
14
|
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: 3.7] [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]
|
15
|
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: 4.0] [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.
Collapse
Affiliation(s)
-
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Lenton Lane, Nottingham NG7 2N, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Levell N, Wingfield C, Garioch J. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 2011; 164:1326-8. [DOI: 10.1111/j.1365-2133.2011.10275.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
17
|
|
18
|
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.
Collapse
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
| | | | | | | |
Collapse
|
19
|
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]
|