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In response

Ann LN Chapman
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DOI: https://doi.org/10.7861/clinmedicine.13-3-322a
Clin Med June 2013
Ann LN Chapman
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Roles: Consultant in infectious diseases
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Editor – Dr Brindle makes the important point that oral antibiotics should always be used in preference to intravenous (IV) antibiotics where possible. However, the evidence base demonstrating the relative effectiveness of oral and IV antibacterials for significant soft tissue sepsis is limited.1 The paper he cites by Bernard et al2 used oral pristinamycin in comparison with intravenous penicillin in only a small subset of patients with soft tissue sepsis; that is, patients with erysipelas of moderate severity. The study demonstrated that in these patients pristinamycin was non-inferior to IV penicillin. Although drop-out rates were similar in the two groups, pristinamycin was associated with a significant increase in gastrointestinal upset.

Currently it is accepted that a proportion of patients with soft tissue sepsis will require IV antibiotics, but not admission. The CREST guidelines3 classify cellulitis by severity into four classes ranging from mild infection (class I) to severe life-threatening infection or sepsis syndrome (class IV). Class II patients have cellulitis with systemic symptoms of sepsis, or with comorbidities that may complicate or delay resolution of infection – for example, lymphoedema, peripheral vascular disease or chronic venous insufficiency. Intravenous antibiotics, through OPAT where available, are recommended for this group, which includes approximately 30% of patients presenting to hospital with cellulitis.4

However, there is a real danger of over-use of IV therapy in patients with mild infection4 and this may be more likely where an OPAT service exists. In our earlier paper this issue was discussed,5 but it was noted that virtually all patients were referred to OPAT by a physician (either GP or medical admissions unit doctor) and were then further assessed by a specialist OPAT doctor and nurse before being accepted in order to ensure as far as possible that IV therapy was appropriate. Our more recent (unpublished) data show that 8% of patients with cellulitis referred for OPAT are not accepted but are given optimised oral antibiotic therapy; virtually all have already received oral therapy from other healthcare providers, reinforcing the importance of ensuring oral therapy is adequate before considering parenteral antibiotics.

In managing soft tissue sepsis, as with many other infections, choice of IV vs oral antibiotic therapy is often determined to a large extent by clinical judgement, and it is important therefore that their use in OPAT and more generally is overseen through a robust antibiotic stewardship programme.6 There remain many uncertainties and therefore a need for further prospective comparative studies.

Footnotes

  • Please submit letters for the editor’s consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk

  • © 2013 Royal College of Physicians

References

  1. ↵
    1. Kilburn SA,
    2. Featherstone P,
    3. Higgins B,
    4. Brindle R
    . Interventions for cellulitis and erysipelas. Cochrane Database of Systematic Reviews 2010:(6);CD004299.
  2. ↵
    1. Bernard P,
    2. Chosidow O,
    3. Vaillant L
    . Oral pristinamycin versus standard penicillin regimen to treat erysipelas in adults: randomised non-inferiority open trial. BMJ 2002; 325:864-8.doi:10.1136/bmj.325.7369.864
    OpenUrlAbstract/FREE Full Text
  3. ↵
    CREST (Clinical Resource Efficiency Support Team). Guidelines on the management of cellulitis in adults. Belfast: Crest, 2005. www.acutemed.co.uk/docs/Cellulitis%20guidelines,%20CREST,%2005.pdf [Accessed 3 April 2013].
  4. ↵
    1. Marwick C,
    2. Broomhall J,
    3. McCowan C,
    4. et al
    . Severity assessment of skin and soft tissue infections: cohort study of management and outcomes for hospitalised patients. J Antimicrob Chemother 2011; 66:387-397.doi:10.1093/jac/dkq362
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Chapman ALN,
    2. Dixon S,
    3. Andrews D,
    4. et al
    . Clinical efficacy and cost effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J Antimicrob Chemother 2009; 64:1316-24.doi:10.1093/jac/dkp343
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Dryden M,
    2. Saeed K,
    3. Townsend R,
    4. et al
    . Antibiotic stewardship and early discharge from hospital: impact of a structured approach to antimicrobial management. J Antimicrob Chemother 2012; 67:2289-96.doi:10.1093/jac/dks193
    OpenUrlAbstract/FREE Full Text
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In response
Ann LN Chapman
Clinical Medicine Jun 2013, 13 (3) 322-323; DOI: 10.7861/clinmedicine.13-3-322a

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In response
Ann LN Chapman
Clinical Medicine Jun 2013, 13 (3) 322-323; DOI: 10.7861/clinmedicine.13-3-322a
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