Skip to main content

Is Prevention Possible? Antibiotic Prophylaxis for Recurrent Lower Extremity Cellulitis



Case
As a geriatrician it is not uncommon to have patients present in clinic with signs of infection like cellulitis, an infection of the skin. My patient, who I will call Mr. Sa, is a 79 year old man with a history of hypertension, high cholesterol, and COPD who struggled with recurrent cellulitis of his right lower leg. Despite two prior clinic visits and completed courses of antibiotics, the infection would heal but return several months later.

Clinical Question
In patients with recurrent lower extremity cellulitis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate of lower extremity cellulitis?

Best Available Evidence
A search of the literature found a systemic review and meta-analysis of antibiotic prophylaxis for preventing recurrent cellulitis1. The systemic review used the Cochrane Collaboration tool for assessing the risk of bias and the meta-analysis was used to calculate a weighted treatment effect across trials. Five studies met the inclusion criteria resulting in a total of 535 participants with 260 participants taking antibiotics and 275 participants on placebo or not taking any antibiotics. The average age of participants in the five studies ranged from 45 to 67.5 years. A majority of the participants (397) were from the PATCH 1 and 2 studies located in the United Kingdom with a follow up time of 36 months. Statistical methods calculated included risk ratio, Chi2, and I2 tests.

Results
Analysis revealed that prophylactic antibiotics were beneficial for preventing recurrent cellulitis (RR 0.46, 95% CI 0.26-0.79) with a number needed to treat (NNT) of 5 patients. This means that 5 patients would need to receive the prophylactic antibiotics in order to benefit 1 patient (in preventing recurrent cellulitis).

Appraisal
It should be noted that two of the studies (PATCH 1 and 2) were found to be high quality whereas three of the studies were of low or unclear quality with respect to randomization, allocation concealment, blinding, incomplete outcome data, and selective reporting. Overall limitations include a small number of studies performed in the United Kingdom, a heterogeneous study population among subjects, optimal duration of treatment was non-specified, and finally specific antibiotic medication choice (erythromycin or penicillin) varied across the studies. The most commonly reported adverse events with prescribing prophylactic antibiotics were nausea, abdominal pain, and diarrhea. These limitations hinder the generalizability of the study results, especially with varying antibiotic resistances profiles dependent on location.

The review supports the positive impact of antibiotics for prophylaxis against recurrent cellulitis in the United Kingdom. However, there needs to be more randomized controlled trials set in the United States to determine the applicability, specific antibiotic choice, and optimal duration of treatment.

Back to our Patient
For Mr. Sa, prophylactic antibiotics were not prescribed for cellulitis prevention given his allergy to Penicillin antibiotics. However, for future patients who struggle with recurrent cellulitis, the low NNT and low risk of side effects makes prescribing prophylactic antibiotic a treatment to consider.

Reference:
1. Oh, C.C., Ko, H.C.H, et al. (2014). Antibiotic prophylaxis for preventing recurrent cellulitis: A systemic review and meta-analysis. Journal of Infection, 69, 26-34.

By: Megan E. Rau, MD, MPH
@meganerau
Megan is currently a first year fellow in Geriatrics and Palliative Care at Mount Sinai Hospital in New York City.

This post is part of the #GeriCases series, in which we discuss a clinical case in geriatrics and palliative medicine and the attempt to provide patient-centered care with the use of best available evidence.

Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases

Comments

By reading this I hope this situation is easily curable. Now the over all world temperature is increasing and people are suffering with the problem like this.

Popular posts from this blog

Lost in Translation: Google’s Translation of Palliative Care to ‘Do-Nothing Care’

by: Cynthia X. Pan, MD, FACP, AGSF (@Cxpan5X)

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life.  Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation.  It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

Elderhood: Podcast with Louise Aronson

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th.

We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody).

This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey as a geriatrician facing burnout, aging and death of family of Louise's members, insightful stories of patients, and more.

We focus therefore on the 3 main things we think our listeners and readers will be interested in.

First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"?

Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking?  We focus on Louise's…

Psychedelics: Podcast with Ira Byock

In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life.

Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously."

In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness.   Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

While you're reading, I'll just go over and lick this toad.

-@AlexSmithMD





You can also find us on Youtube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher
Transcript
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, I spy someone in our …