BACKGROUND: New skin and soft tissue infections (SSTI) guidelines were published in 2019 in France, changing the recommended duration for antibiotic treatment. The objective of the present study was to assess the impact of the publication of the 2019 French guidelines on SSTIs on the duration of antibiotic prescription for erysipelas.
METHODS: In a before-after study (a year before and a year after April 1st, 2019), we included all adult patients diagnosed with erysipelas in Reims University Hospital medical wards and the emergency department. We retrospectively retrieved antibiotic prescription duration in the patients\' medical files.
RESULTS: Among 50 patients in the \"before\" and 39 in the \"after\" group, the mean duration of antibiotic prescription was significantly shorter in the \"after\" group (9.4 ± 2.8 vs. 12.4 ± 3.8 days, p = 0.0001).
CONCLUSIONS: A 25% decrease in the duration of antibiotic prescription for erysipelas was observed following the implementation of these guidelines, providing useful information for an antibiotic stewardship policy.

The guidelines on calculated parenteral initial treatment of bacterial infections in adults from 2018 were the first German language S2k guidelines for these infections. This article summarizes the experiences with respect to their practicality in the clinical routine and the resulting supplementations and comments. In view of the many different terms for soft tissue infections, the guidelines had to first establish some definitions and diagnostic criteria. Among others, the guidelines introduced the provisional term limited phlegmons (phlegmons are usually termed cellulitis in Angloamerican literature) for the frequent initially superficial soft tissue infections with Staphylococcus aureus, which do not always extend to the fascia, in order to differentiate them from erysipelas caused by Streptoccocus, which in contrast to phlegmons always respond to penicillin. The general symptoms present in erysipela are a practical differential criterion. Somewhat more complex are the definitions and recommendations for the severe forms of phlegmon, which involve the fascia and are accompanied by necrosis, so that here the practicality of the guidelines needs to prove its worth over time. The guidelines also give recommendations how to proceed in case of alleged or confirmed hypersensitivity to beta-lactam antibiotics. Currently, relevant guidelines recommend, and it is correspondingly here elaborated, that in acute cases a beta-lactam antibiotic with side chains other than those in the suspected drug may present an alternative without prior testing. Therefore, cefazolin, that does not share any side chains with other beta-lactam antibiotics, could be administered under appropriate precautionary measures. The term cellulitis is avoided in the guidelines. Since it is used frequently, and also for non-infectious dermatoses, the various meanings are discussed and distinguished from each other.
UNASSIGNED: Die Leitlinie „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen“ von 2018 ist die erste deutschsprachige S2k-Leitlinie für diese Infektionen gewesen. In diesem Beitrag werden Erfahrungen zu ihrer Praktikabilität im klinischen Alltag und daraus rührende Ergänzungen und Kommentare zusammengefasst. Angesichts vieler verschiedener Begriffe zu Weichgewebeinfektionen musste die Leitlinie sich zunächst auf einige Definitionen und diagnostische Kriterien festlegen. Unter anderem hat sie für die häufigen, noch nicht die Faszie einschließenden Weichgewebeinfektionen mit Staphylococcus aureus den provisorischen Begriff „begrenzte Phlegmone“ eingeführt, um sie von den eher Streptokokken-bedingten Erysipelen zu unterscheiden, die im Gegensatz zu Phlegmonen immer auf Penizillin ansprechen. Die bei Erysipelen vorliegenden Allgemeinsymptome sind ein praktikables Unterscheidungskriterium. Etwas komplexer sind die Definitionen und Empfehlungen bei den Formen der schweren oder komplizierten Phlegmone, die bis zur Faszie reichen und mit Nekrosen einhergehen, sodass sich die Praktikabilität der Leitlinie hier noch bewähren muss. Die Leitlinie gibt auch jeweils Alternativen für den Fall einer vermeintlichen Allergie auf Betalaktamantibiotika. Inzwischen wird in einschlägigen Leitlinien empfohlen und entsprechend hier ausgeführt, dass im Akutfall auch ohne vorherige Testung ein Betalaktamantibiotikum mit anderen Seitenketten als bei dem in Verdacht stehenden Präparat in der Regel möglich ist und dass deswegen Cefazolin, das mit den anderen Betalaktamantibiotika keine Seitenkette teilt, unter entsprechenden Vorsichtsmaßnahmen eingesetzt werden kann. In den Leitlinien wird der Begriff „Zellulitis“ umgangen. Da er aber häufig und auch für nicht erregerbedingte Dermatosen gebraucht wird, werden seine unterschiedlichen Bedeutungen hier gegeneinander abgegrenzt.

Shortening the duration of antibiotic therapy (DAT) for common infectious diseases may be an effective strategy to tackle antimicrobial resistance. Shorter DAT has been proven safe and effective for community-acquired pneumonia (CAP), cellulitis, and cholangitis.
In a retrospective multicentre quality-control study, medical records of 770 patients hospitalized with CAP, cellulitis, and cholangitis at three tertiary care hospitals in Switzerland during 2017-2018 were randomly selected. Appropriateness of antibiotic treatment duration was assessed according to international and local guidelines.
Records of 271, 260, and 239 patients with CAP, cellulitis, and cholangitis were included, respectively. Median DAT was seven days (interquartile range [IQR] 6-9), ten days (IQR 8-13), and nine days (IQR 6-13) in CAP, cellulitis, and cholangitis, respectively. DAT longer than recommended by local and international guidelines was observed in 32% and 37% of CAP patients, 23% and 70% of cellulitis patients, and 33% and 37% of cholangitis patients, respectively. Positive blood cultures (odds ratio [OR] = 2.42 (95% confidence interval [CI] 1.33-4.34]), infectious diseases consultation (OR = 1.79 [95% CI 1.05-2.78]), impaired renal function (OR = 0.99 [95% CI 0.98-1.00] per 1 ml/min / 1.73 m2 increase in estimated glomerular filtration rate) and a higher degree of inflammation on admission (OR = 1.0 [95% CI 1.001-1.005] per 10 mg/L increase in C-reactive protein) were independently associated with a DAT longer than recommended in international guidelines.
DAT exceeded recommendations in a significant proportion of patients with mostly community-acquired infections.

OBJECTIVE: Despite evidence-based guidelines, antibiotics prescribed for uncomplicated skin and soft tissue infections can involve inappropriate microbial coverage. Our aim was to evaluate the appropriateness of antibiotic prescribing practices for mild nonpurulent cellulitis in a pediatric tertiary academic medical center over a 1-year period.
METHODS: Eligible patients treated in the emergency department or urgent care settings for mild nonpurulent cellulitis from January 2017 to December 2017 were identified by an International Classification of Diseases, Tenth Revision, code for cellulitis. The primary outcome was appropriateness of prescribed antibiotics as delineated by adherence with the Infectious Diseases Society of America guidelines. Secondary outcomes include reutilization rate as defined by revisit to the emergency department/urgent cares within 14 days of the initial encounter.
RESULTS: A total of 967 encounters were evaluated with 60.0% overall having guideline-adherent care. Common reasons for nonadherence included inappropriate coverage of MRSA with clindamycin (n = 217, 56.1%) and single-agent coverage with sulfamethoxazole-trimethoprim (n = 129, 33.3%). There were 29 revisits within 14 days of initial patient encounters or a reutilization rate of 3.0%, which was not significantly associated with the Infectious Diseases Society of America adherence.
CONCLUSIONS: Our data show antibiotic prescription for nonpurulent cellulitis as a potential area of standardization and optimization of care at our center.

Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.

UNASSIGNED: Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hospitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team (CREST) guideline in management of cellulitis in emergency department.
UNASSIGNED: Studies that had evaluated cellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database, from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate Guideline Network (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AUROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriateness of antimicrobial treatment in management of cellulitis in emergency department was evaluated.
UNASSIGNED: Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation of the rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95% confidence interval (CI): 0.06 - 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicrobial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department, OR=0.21 (95% CI: 0.009‎ - ‎ 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 - 0.89) showed accuracy of the CREST classification in prediction of being hospitalized more or less than 24 hours.
UNASSIGNED: CREST classification shows good accuracy in determining the duration of hospitalization or observation in ED but it could lead to inevitable over/under treatment with empirical antimicrobial agents.

UNASSIGNED: To determine the effectiveness of implementing a locally developed clinical practice guideline (CPG) for antibiotic treatment in adults with community-acquired cellulitis at Siriraj Hospital in Bangkok, Thailand.
UNASSIGNED: The CPG for antibiotic treatment of community-acquired cellulitis was developed based on local data during June to December 2016. The CPG was introduced by multifaceted interventions, including posters, brochures, circular letters, social media, conference, classroom training, and interactive education during January to September 2018.
UNASSIGNED: Among 360 patients with community-acquired cellulitis, 84.4% were ambulatory and 15.6% were hospitalized. The median age of patients was 62 years, and 59.4% were female. Antibiotic prescription according to CPG (CPG-compliant group) was observed in 251 patients (69.7%), and CPG noncompliance was found in 109 patients (30.3%) (CPG-noncompliant group). The demographics and characteristics of patients were comparable between groups. Patients in the CPG-compliant group had a significantly lower rate of intravenous antibiotics (18.7% vs 33.9%, P = .007), lower prescription rate of broad-spectrum antibiotics (14.7% vs 78.9%, P < .001) and antibiotic combination (6.4% vs 13.8%, P = .022), shorter median duration of antibiotic treatment (7 vs 10 days, P < .001), lower median cost of antibiotic treatment (US $3 vs $7, P < .001), and lower median hospitalization cost (US $601 vs $1587, P = .008) than those in the CPG-noncompliant group. Treatment outcomes were not significantly different between groups.
UNASSIGNED: Adherence to CPG seems to reduce inappropriate prescription of broad-spectrum antibiotic or antibiotic combination and treatment costs in adults with community-acquired cellulitis without differences in favorable outcomes or adverse events.

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OBJECTIVE: Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy.
METHODS: A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)).
RESULTS: Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy.
CONCLUSIONS: There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.

These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for \"calculated initial parenteral treatment of bacterial infections\" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for \"complicated soft tissue infections\", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.