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

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

Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: A case-control study

Objective: To assess the role of foot dermatomycosis ( tinea pedis and onychomycosis) and other candidate risk factors in the development of acute bacterial cellulitis of the leg. Methods: A case-control study, including 243 patients ( cases) with acute bacterial cellulitis of the leg and 467 controls, 2 per case, individually matched for gender, age (+/-5 years), hospital and admission date (+/-2 months). Results: Overall, mycology-proven foot dermatomycosis was a significant risk factor for acute bacterial cellulitis (odds ratio, OR: 2.4; p < 0.001), as were tinea pedis interdigitalis (OR: 3.2; p < 0.001), tinea pedis plantaris (OR: 1.7; p = 0.005) and onychomycosis (OR: 2.2; p < 0.001) individually. Other risk factors included: disruption of the cutaneous barrier, history of bacterial cellulitis, chronic venous insufficiency and leg oedema. Conclusions: Tinea pedis and onychomycosis were found to be significant risk factors for acute bacterial cellulitis of the leg that are readily amenable to treatment with effective pharmacological therapy. Copyright (C) 2004 S. Karger AG, Basel

Morbidity following Surgical Management of Vulval Cancer.

The objective of this study was to know the complications following vulvectomy and inguinofemoral lymphadenectomy including the time taken to complete wound healing. 42 patients who were subjected to either radical or modified radical vulvectomy for primary and inguinofemoral lymphadenectomy (80 groins) for groin metastases were analysed retrospectively. The complications analysed were wound breakdown, wound cellulitis or infection, lymphocyst, limb edema and the time to wound healing. In a total of 80 inguinofemoral lymphadenectomies 55% had wound breakdown, 17.5% had wound infection/cellulitis, lymphocyst in 31%, limb edema in 36% and time taken for complete wound healing ranged from 10-134 (average 46 days). Overall post operative morbidity was 85%

Cellulitis Due to Salmonella infantis.

Bacteria of the genus Salmonella are highly adapted for the growth in both humans and animals and cause a wide spectrum of disease. The growth of Serotypes S. typhi and S. paratyphi is restricted to human hosts, in whom these organisms cause enteric (typhoid) fever. The remaining Serotypes (non typhoidal Salmonella or NTS) can colonize the gastrointestinal tracts of the broad range of animals, including mammals, reptiles, birds and insects. The usual clinical presentation of non-typhoidal salmonellae (NTS) infection is self limited gastroenteritis; however bacteremia and focal extra intestinal infection may occur. However salmonella localization to the skin presenting as cutaneous ulceration is regarded as a rare event. Rates of morbidity and mortality associated with NTS are highest among the elderly, infants, and immunocompromised individuals, including those with hemoglobinopathies, HIV infection, or infections that cause blockade of the reticuloendothelial system. We isolated S.infantis in 50 years old man with left leg cellulitis. The serotype was confirmed at Central Research Institute, Kasauli

Evaluating Prescriber Adherence to Guideline-Based Treatment Pathways of a Newly Initiated Antimicrobial Stewardship Program at a Rehabilitation Hospital

Background: Inappropriate use of antimicrobials in the healthcare setting is associated with consequences including antimicrobial resistance, Clostridium difficile infection (CDI), adverse drug reactions, and increased healthcare costs. To combat this, hospitals are creating antimicrobial stewardship programs (ASPs) which seek to optimize antimicrobial utilization. To date, no studies have been done to assess adherence to an ASP in a rehabilitation hospital setting. The objective of this study is to evaluate prescriber compliance to treatment pathways for common infections before and after ASP implementation. Methods: This was a retrospective cohort study of patients admitted to the Rehabilitation Hospital of Indiana (RHI) who received an antibiotic between October 1, 2015-December 31, 2015 (pre-ASP group) and January 1, 2016-September 30, 2016 (post-ASP group) for one of the following indications: pneumonia, urinary tract infection, CDI, bone and joint infection, skin or skin structure infection, febrile neutropenia, or central/peripherally inserted central catheter line bloodstream infection. Data extracted from the hospital’s electronic medical record system included patient demographic and clinical information, laboratory data, culture and susceptibility results, and antibiotic information. The primary outcome of this study was prescriber compliance to treatment pathways defined as correct drug based on the documented indication before and after the implementation of the antimicrobial stewardship program on January 1, 2016. Descriptive statistics were performed to analyze baseline characteristics and culture data, as well as antimicrobial class, indication, and overall compliance to the guideline-based treatment pathways. Results: Data was extracted from the hospital’s electronic medical record system for 381 patients (n=381) who received an antibiotic at RHI. There were 121 and 260 patients included in the pre- and post-ASP study groups, respectively. Urinary tract infections were the most common infection for which antibiotics were prescribed (n=293; 76.9%). The three most common antibiotics prescribed were ciprofloxacin (n=101; 26.5%), sulfamethoxazole/trimethoprim (n=81; 21.3%), and nitrofurantoin (n=49; 12.9%). Compliance was found to be 81% in the pre-ASP group and 78.5% in the post-ASP group (p=0.571). Overall compliance was found to be the highest (100% in both pre- and postASP groups) for osteomyelitis infections and CDI. Urinary tract infections had the next highest rate of compliance in both the pre- and post-ASP groups (86.5% and 81.7% respectively). Conclusions: No difference in rates of prescriber compliance to guideline-based treatment pathways was found in the pre- and post-ASP groups. Urinary tract infections were found to be the most common indication requiring antimicrobial usage at RHI and had the third highest rate of compliance out of the infections included in this study. Our study highlights a need for further investigation regarding the impact of the ASP on appropriate antimicrobial dose, duration of therapy, administration, and de-escalation based on culture data. Additionally, our study identified a need for formal prescriber education focusing on how to utilize the treatment pathways, especially for those infections with the lowest compliance rates

Incidence of surgical site infection following mastectomy with and without immediate reconstruction using private insurer claims data

OBJECTIVE: The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1–2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population. DESIGN: Retrospective cohort study. PATIENTS: Commercially-insured women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from 1/1/2004–12/31/2011. METHODS: Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidence of SSI after mastectomy +/− immediate reconstruction was compared by the chi-square test. RESULTS: From 2004–2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 (58%) procedures. The 180-day incidence of SSI following mastectomy with or without reconstruction was 8.1% (1,520/18,696). Forty-nine percent of SSIs were identified within 30 days post-mastectomy, 24.5% between 31–60 days, 10.5% between 61–90 days, and 15.7% between 91–180 days. The incidence of SSI was 5.0% (395/7,860) after mastectomy-only, 10.3% (848/8,217) after mastectomy plus implant, 10.7% (207/1,942) after mastectomy plus flap, and 10.3% (70/677) after mastectomy plus flap and implant (p<0.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with (11.4% vs. 9.4%, p=0.001) and without (6.1% vs. 4.7%, p=0.021) immediate reconstruction. CONCLUSIONS: SSI incidence was two-fold higher after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest stratification by procedure type will facilitate comparison of SSI rates after breast operations between facilities