Comparison of initial antibiotic choice and treatment of cellulitis in the pre- and post–community-acquired methicillin-resistant Staphylococcus aureus eras

Wells, Ryan D.; Mason, Phillip E.; Roarty, Joseph; Dooley, Melissa

doi:10.1016/j.ajem.2008.03.026

Cited by 11 publications

(13 citation statements)

References 12 publications

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“…Because of the recent increase in community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections [3, 4], practice guidelines increasingly recommend treating uncomplicated cellulitis [5] with MRSA-effective regimens, leading to greater use of non-beta-lactam, broad spectrum antibiotics [6]. …”

Section: Introductionmentioning

confidence: 99%

PCR offers no advantage over culture for microbiologic diagnosis in cellulitis

Johnson

Kiyatkin

et al. 2012

Infection

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Purpose Most cases of cellulitis are traditionally attributed to β-hemolytic streptococci and Staphylococcus species, although in most cases, no organism is identified. Development of PCR using the conserved bacterial 16s-rRNA DNA permits identification of bacteria independent of conventional culture approaches and prior use of antibiotics. Methods We used PCR-based techniques to identify cellulitis etiology using aspirate samples from affected skin. Saline was infiltrated and aspirated at the site of greatest erythema or at the cellulitic border. Samples were tested for 16s-rRNA DNA and organism-specific probes used to identify bacteria commonly seen in skin infections. Results Aspirates from 32 patients were studied and16s-rRNA DNA was detected in 9/32 of the cases (28.1%). Bacterial species were identified by PCR methods in 6/9 (66.6%). S. aureus was identified in 4/6 samples, and 2/6 were methicillin-resistant S. aureus (MRSA). Of patients with positive aspirate bacterial cultures (3/9, 33.3%), S. aureus was present on culture in 2/3 (66.6%) positive samples, and coagulase-negative Staphylococcus (CoNS) was present on culture in 2/3 (66.6%) positive samples. Only in one of the three positive bacterial cultures did the PCR method detect the same organism as was detected by culture. Among patients with positive provider-collected clinical cultures, MRSA was the predominant organism (11/18, 61.1%) and when present, it was found as the sole organism. Where S. aureus or Streptococcus species were detected by molecular methods, clinical cultures yielded a positive result as well. Conclusions PCR-based techniques do not appear to be more sensitive than aspirate cultures for detection of pathogens in cellulitis.

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Section: Introductionmentioning

confidence: 99%

PCR offers no advantage over culture for microbiologic diagnosis in cellulitis

Johnson

Kiyatkin

et al. 2012

Infection

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“…Despite the CA-MRSA epidemic, treatment targeted toward β-hemolytic streptococci (i.e., β-lactams) continues to be effective for cellulitis 13,24–26 and may result in fewer adverse events than antibiotics with MRSA activity. 25 We found that MRSA-active agents – most commonly trimethoprim-sulfamethoxazole – were prescribed in approximately 60% of uncomplicated cellulitis cases.…”

Section: Discussionmentioning

confidence: 99%

Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting

Hurley

Knepper

Price

et al. 2013

The American Journal of Medicine

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Background Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. Methods This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines. Results 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%. Conclusions Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic.

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“…Therapeutic failure rates in prior studies for cephalexin treatment of cellulitis have ranged from 15·1% to 40% . Considering the available data and the efforts made to exclude patients with critical risk factors for polymicrobial or purulent cellulitis, a therapeutic failure rate of 20% in non‐obese patients was assumed.…”

Section: Methodsmentioning

confidence: 99%

“…Infectious Disease Society of America (IDSA) guidelines recommend beta‐lactam monotherapy in non‐allergic individuals for the treatment of non‐purulent cellulitis, with cephalexin dosed 500 mg four times daily in those with normal renal function . Studies evaluating the efficacy of this cephalexin regimen have failed to include a substantial morbidly obese population, resulting in a paucity of literature available to address the therapeutic efficacy of extrapolating this dosing scheme to morbidly obese patients . Further, laboratory and clinical data from cefazolin, a related cephalosporin, indicate that increased doses are required in morbidly obese patients to achieve comparable success rates as compared to non‐obese patients .…”

Section: What Is Known and Objectivementioning

confidence: 99%