Choon Chiat Oh

Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis

IMPORTANCE A significant proportion of patients who have had a first episode of erysipelas or uncomplicated cellulitis will subsequently develop a recurrence. There is disagreement about how effective antibiotic prophylaxis is for preventing recurrent cellulitis. OBJECTIVE To determine if antibiotic prophylaxis is effective in preventing recurrent cellulitis compared to no prophylaxis using a systematic review and meta-analysis. DATA SOURCES Studies in any language identified by searching Medline, EMBASE, Cochrane Library, CINAHL, TRIP database, clinical practice guidelines websites, and ongoing trials databases up to 31st August 2012. Search terms included cellulitis, erysipelas, controlled clinical trial, randomized, placebo, clinical trials, randomly, and trial. STUDY SELECTION Only controlled trials comparing antibiotic prophylaxis to no antibiotic prophylaxis in patients age 16 years and above, and after 1 or more episodes of cellulitis, were included. DATA EXTRACTION AND SYNTHESIS Independent extraction of articles was done by 2 investigators using predefined data extraction templates, including study quality indicators. PROSPERO registration number: CRD42012002528. Meta-analyses were done using random-effects models. MAIN OUTCOMES AND MEASURES The primary outcome was the number of patients with a recurrence of cellulitis. Secondary outcomes were (1) the time to next episode of recurrence, (2) quality of life measures, and (3) adverse events (e.g. allergic reactions, nausea). RESULTS Five randomized controlled trials (n = 535), with 260 patients in the intervention arm and 275 in the comparator group met our inclusion criteria. 44 patients (8%) in the antibiotic prophylaxis group and 97 patients (18%) in the comparator group had an episode of cellulitis. Antibiotic prophylaxis significantly reduced the number of patients having recurrent cellulitis, with a risk ratio (RR) of 0.46 (95% CI 0.26-0.79). None of the studies reported severe adverse effects to antibiotics. There was methodological heterogeneity amongst the studies in terms of types of antibiotic used, delivery modes, number of recurrences of cellulitis at study entry, and study quality. CONCLUSION AND RELEVANCE Antibiotic prophylaxis can prevent recurrent cellulitis. Future research should aim to identify the ideal type, dosage, and duration of antibiotics for prophylaxis, as well as to identify the group of patients who will benefit most from antibiotic prophylaxis.

Recurrent Cellulitis: Risk Factors, Etiology, Pathogenesis and Treatment

Erysipelas and uncomplicated cellulitis are common infections that tend to recur in a substantial proportion of affected patients following an initial episode, especially if the predisposing condition is chronic lymphedema. All patients who suffer an episode of cellulitis should be carefully evaluated to establish the risk of recurrence. Several predisposing conditions (such as lymphedema and skin conditions that serve as a portal of entry for bacteria) can be effectively treated in order to reduce the risk of relapse. The medical literature provides convincing evidence that antimicrobial prophylaxis can markedly reduce the frequency of relapse of erysipelas. Two recent studies performed by the ‘Prophylactic Antibiotics for the Treatment of Cellulitis at Home’ (PATCH) group have clearly confirmed the efficacy of antimicrobial prophylaxis. Penicillin remains the drug of choice. Treatment options in patients with penicillin allergy are limited by the rising prevalence of macrolide resistance among group A streptococci. Further research is required to clarify the optimal penicillin regimen as well as to develop new therapies for patients with allergy to penicillin.

An 81-Year-Old Man With Cutaneous Periumbilical Purpura

An 81-year-old man complained of abdominal pain and distension and had worsening pulmonary infi ltrates and a new rash. He had a background of cryptogenic organizing pneumonia for which he had been on prednisolone 20 mg po every morning for 4 months prior to admission to hospital. He had been admitted to the ICU 1 month prior for pseudomonas pneumonia, and the stay had been complicated by persistent Pseudomonas cultures, Escherichia coli bacteremia, cytomegalovirus antigenemia, and failure to wean from mechanical ventilation requiring tracheostomy. CT scan of the chest on day 17 of admission showed bilateral honeycomb appearance with widespread ground-glass changes, and BAL the same day was negative for bacterial, fungal, and Mycobacterium smears as well as viral studies. His prednisolone dose was increased to 30 mg every morning.

Biopsychosocial factors associated with prurigo nodularis in endogenous eczema

Background: Prurigo nodularis is a dermatological manifestation secondary to chronic scratching or picking on focal areas of the skin. Its pathogenesis remains poorly understood, and limited data has indicated its association with psychological factors. Aim: To determine the biological, psychological and social factors associated with the occurrence of prurigo nodularis in patients with underlying endogenous eczema. Methods: A prospective case-control questionnaire –based study on patients with endogenous eczema, with and without prurigo nodules, was performed. The Impact of Skin Disease on Daily Life questionnaire was used to assess dimensions of physical functioning, including extent and severity of skin disease, itch, pain, fatigue and scratching, as well as dimensions of psychological and social functioning, including mood, illness cognition, disease-related impact, stigmatization and social support. Results: Thirty-six cases and 47 controls were recruited. Patients with endogenous eczema and prurigo nodules indicated a higher itch score on the visual analog scale over the previous 4 weeks compared to those without prurigo nodules (p=0.0292). There were no significant differences between the 2 groups in the scores reflecting the other parameters of physical, psychological and social functioning. Conclusion: In patients with endogenous eczema, those with prurigo nodules experience a greater itch intensity compared to those without prurigo nodules. There were no other physical, psychological and social factors that were found to be associated with the occurrence of prurigo nodules in endogenous eczema.

Deep dermal fungal infection in an Asian renal transplant recipient

A 38-year-old Malay man presented with asymptomatic nodules on the right hand for 2 weeks, with progressive development of new nodules proximally. His significant medical history included systemic lupus erythematosus with end stage renal failure, cadaveric renal transplant 1 year ago (on tacrolimus, mycophenolate mofetil, prednisolone, sulfamethoxazole/trimethoprim), and antiphospholipid syndrome with thromboembolic events (on warfarin). On examination, there were six non-tender erythematous nodules over the dorsum of the right hand, right wrist, and forearm, ranging from 1 to 2 cm (Fig. 1). In addition, there was the presence of distal onycholysis and subungual hyperkeratosis of fingernails, sparing toenails. Systemic examination was unremarkable.

Treatment of overlap cutaneous graft-versus-host disease with combination therapy of extracorporeal photopheresis and alemtuzumab.

Although graft-versus-host disease (GVHD) has been traditionally classified into acute and chronic forms based on an arbitrary cut-off of 100 days from date of onset, it is now recognized that the onset and presentation of disease may be modified by evolutions in transplant strategies and immunomodulatory treatments. The National Institutes of Health (NIH) consensus development project was conceived to standardize diagnostic criteria for clinical trials in chronic GVHD. Acute GVHD was divided into classic acute GVHD, in which symptoms appear within 100 days without any other features of chronic GVHD, and persistent, recurrent, or late-onset acute GVHD, in which symptoms appear after 100 days without features of chronic GVHD. Chronic GVHD includes classic chronic GVHD, which shows features supportive of chronic GVHD without those of acute GVHD regardless of time of presentation, and overlap syndrome, which includes features of both acute and chronic GVHD. Case report

Images in transplant dermatology

Transplant recipients can develop various skin conditions throughout their lives. Of concern are skin cancers, which are best treated with early detection. We report two cases seen in the transplant dermatology clinic in Singapore General Hospital.

Mycobacterium haemophilum in an elderly Chinese woman

An 80-year-old Chinese woman, with a background of diabetes mellitus and adrenal insufficiency caused by long term usage of traditional Chinese medication (currently on oral hydrocortisone 20 mg b.i.d. replacement therapy), presented with a painless, erythematous plaque over her left elbow, with surrounding painless, erythematous nodules. The patient was unsure of the exact duration of the skin lesions but considered they had been present for a few months. There was no history of trauma. Skin examination revealed an erythematous plaque measuring 8 cm in diameter (Fig. 1). It was surrounded by non-tender, erythematous nodules measuring up to 1 cm. A punch biopsy taken from the plaque was sent for histology and microbial cultures (bacterial, mycobacterial, and fungal cultures). Histopathology showed the superficial and mid-dermis to be completely obscured by a predominantly diffuse infiltrate of macrophages, in which only a few poorly formed granulomas were evident (Fig. 2). An admixture of less prominent inflammatory cells included lymphocytes, plasma cells, and some neutrophils. Occasional Langhans type multinucleated giant cells were also noted. No discrete isolated granulomas, necrosis, neutrophilic