Original Title: Guides d'usage optimal pour la cellulite infectieuse

Authors' objectives: Antibiotic resistance has been a major concern in Québec for several years, as evidenced by the series of targets set and measures undertaken to combat the nosocomial infections included in the action plan of the Ministère de la Santé et des Services sociaux (MSSS). It was in this context that the Institut national d’excellence en santé et services sociaux (INESSS) updated the antibiotic therapy optimal usage guides (OUGs), in addition to which it has drafted a new optimal usage guide on cellulitis. Recent studies suggest that a diagnosis of cellulitis may be incorrect in 10 to 30% of cases, most involving similar pathologies that do not require antibiotic therapy. Furthermore, the marked increase in the incidence of skin infections caused by beta-lactam-resistant Staphylococcus aureus in the United States raises important issues regarding the identification and treatment of these cases in the Québec context. Lastly, since the recurrence rate of cellulitis can exceed 30%, it is very important to identify the best available strategies for reducing this risk. The objective of this report is to present all the data gathered on this topic as part of this project and to propose recommendations developed to promote the judicious use of antibiotics in cellulitis, both in children and adults.

Authors' results and conclusions: RESULTS: Cellulitis is a bacterial skin infection that spreads progressively, usually from a break in the skin barrier. It requires oral or intravenous systemic antibiotic therapy, depending on the severity of the infection and the patient’s overall health. Cellulitis diagnosis is mainly based on the acute appearance of a continuous, edematous, warm and tender erythematous area. Since these features are also observed in a number of noninfectious inflammatory conditions, such as stasis dermatitis, contact dermatitis and septic arthritis, it is essential to rule out these conditions in order to establish a differential diagnosis. Most cellulitis cases are caused by β-hemolytic streptococci or Staphylococcus aureus. However, in certain specific circumstances, notably animal and human bites or cellulitis of sinus or dental origin, the clinician should suspect the presence of other pathogenic agents. A thorough review of the patient’s history is therefore key to diagnosing cellulitis in order to guide the antibiotic therapy accordingly. Even if there is no clear, validated criterion for assessing cellulitis severity, the clinician should quickly recognize certain warning signs that suggest a deeper or more severe infection, such as necrotizing fasciitis, in order to allow adequate inpatient management. For its part, orbital cellulitis constitutes a medical emergency that can quickly have serious consequences for the patient. Clinicians should thus be able to recognize the signs that warrant suspicion of orbital involvement in cases of infections close to the eye. In the absence of specific circumstances that could suggest the presence of pathogenic agents other than streptococci or S. aureus, the antibiotic therapy of choice for cellulitis includes the penicillinase-resistant penicillins and the first-generation cephalosporins, with clindamycin as an alternative treatment option in patients with penicillin allergy. The amoxicillin/clavulanate combination is, however, the main treatment option to be considered for cellulitis associated with an animal or human bite or of dental or sinus origin, while the tetracyclines, trimethoprim/sulfamethoxazole (TMP/SMX) and vancomycin (by intravenous administration only) are the main preferred treatment options when there is strong suspicion of community-acquired methicillin-resistant S. aureus (C-MRSA). Lastly, for complete healing of cellulitis, and to reduce the recurrence risk, it is also essential to treat the infection source, whether it is a possible entry point or a major comorbidity, when initially managing the patient. CONCLUSION: To improve patient management in the presence of cellulitis signs and symptoms, the clinician should take care to use a diagnostic approach that will: enable him/her to first confirm the cellulitis diagnosis by ruling out the possibility of a similar pathology; secondly, to identify clues in the patient’s history that would warrant suspicion of pathogenic agents other than streptococci and S. aureus; and thirdly, to recognize the main warning signs for which a hospital visit is generally required. To guide the clinician, the OUG proposes a clear diagnostic approach involving a reminder of the main clinical elements to consider in order to facilitate the choice of antibiotic therapy and therefore permit optimal patient management.

Authors' methods: This OUG is based on the best available scientific data available aggregated by authors of clinical practice guidelines (CPG) and policies, and on recent systematic reviews (SRs) on cellulitis. These data were enriched with organizational and legislative information specific to Québec, as well as the prevalence and resistance data for various bacterial strains, and the experiential knowledge provided by Québec experts and clinicians who collaborated on the project. MEDLINE, EBM Review and Embase databases were systematically searched for CPGs, policies, consensus conferences and SRs. The literature search was restricted to CPGs published between 2011 and 2016 in French or English. In addition, a grey literature search was conducted by a librarian, who consulted the websites of the Guidelines International Network (G-I-N) and the National Guideline Clearinghouse (NGC). The official product monographs for Health Canada-approved antibiotics were consulted as well.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/guides-dusage-optimal-pour-la-cellulite-infectieuse.html

Year Published: 2017

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/guides-dusage-optimal-pour-la-cellulite-infectieuse.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en santé et en services sociaux (INESSS)