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Rubor, Dolor, Calor, Tumor

A belt and suspenders

Mark Crislip, MD, Infectious Diseases, 03:22PM Aug 14, 2013

Diffuse erythroderma with fevers and leukocytosis is usually Group A streptococcus. All the medical literature suggests if no abscess, no MRSA, and you do not need to cover MRSA. They need either cefaZOlin (my pronunciation) or ceFAZolin (or how the pharmacists mistakenly pronounce it); cephalexin as an outpatient.

"...guidelines do not recommend CA-MRSA coverage for cellulitis, except purulent cellulitis, which is uncommon. Despite this, antibiotics targeting CA-MRSA are prescribed commonly and increasingly for skin infections, perhaps due, in part, to lack of experimental evidence among cellulitis patients (I have a more cynical explaination)...Among patients diagnosed with cellulitis without abscess, the addition of trimethoprim-sulfamethoxazole to cephalexin did not improve outcomes overall or by subgroup."

No one does that of course. Got a call from the ER about a patient with chronic lymphedema who gets recurrent cellulite. Cultures are negative. Should be group A strep and the patient needs a long acting beta-lactam and perhaps suppressive penicillin. He was getting vancomycin and was taking diclox when there was an outbreak. I suggested a more literature based approach.

Although the 250 mg bid in the NEJM article for prophylaxis was a wee bit on the homeopathic side given the patient populations BMI. Although we often dose for CrCl, many docs to not take into consideration the volume of distribution of some patients, explaining in part why the obese have a higher failure rate with antibiotics. There is an understandable, but irrational, hesitancy to give large amounts of oral antibiotics. Most oral antibiotics are dosed for the 70 kg human, I weight I have not seen since high school.

I recently ran across a diffuse erythroderma on both vancomycin and cefazolin. It is good that rolling eyes is not fatal as I would coded and died.

There are times I use vancomycin and nafcillin empirically: epidural abscess and meningitis pending susceptibility, mostly on the basis of a studies that demonstrate that patients with MSSA bacteria who received vancomycin up-front have poorer outcomes than those who received a beta-lactam.

"The cases for the case-control study were defined as patients who received vancomycin treatment for MSSA-B; the controls, who were patients that received beta-lactam treatment for MSSA-B, were selected at a 1:2 (case:control) ratio according to the objective matching scoring system and the propensity score system. In the cohort study, SAB-related mortality in patients with vancomycin treatment (37%, 10/27) was significantly higher than that in those with beta-lactam treatment (18%, 47/267) (P = 0.02). In addition, multivariate analysis revealed that vancomycin treatment was associated with SAB-related mortality when independent predictors for SAB-related mortality and propensity score were considered (adjusted odds ratio of 3.3, 95% confidence interval of 1.2 to 9.5). In the case-control study using the objective matching scoring system and the propensity score system, SAB-related mortality in case patients was 37% (10/27) and in control patients 11% (6/54) (P < 0.01). Our data suggest that vancomycin is inferior to beta-lactam in the treatment of MSSA-B."

Given how lousy vancomycin is and how poorly it crosses the blood-brain barrier, I prefer to have both agents onboard for CNS infections. The brain is not a forgiving organ when damaged physically. Or emotionally and intellectually for that matter. Most sepsis/bacteremia patients are on a beta-lactam as part of protocols, although not an anti-staphylococcal antibiotic. But for uncomplicated cellulitis? No way.

It is one of the many signs of my growing senescence: I get irratated when antibiotics are not used optimally.


Clin Infect Dis. 2013 Jun;56(12):1754-62. doi: 10.1093/cid/cit122. Epub 2013 Mar 1. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial.

N Engl J Med. 2013 May 2;368(18):1695-703. doi: 10.1056/NEJMoa1206300. Penicillin to prevent recurrent leg cellulitis.

Clin Exp Dermatol. 2011 Jun;36(4):351-4. doi: 10.1111/j.1365-2230.2010.03978.x. Epub 2010 Dec 24. Local complications of erysipelas: a study of associated risk factors.

Antimicrob Agents Chemother. 2008 Jan;52(1):192-7. Epub 2007 Nov 5. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia.

About This Blog

For the Benefit of Mr Kite, there will be ID tonight. Infectious Diseases! Antibiotics! Viruses and Bacteria and Fungi! Oh my! Exclamation marks!!!!!! No trampolines, nor will any band be playing at 10 to 6. And Henry the Horse died of the Strangles. Sorry. That's the problem with infections.

The endless excitement that is the daily practice of Infectious Diseases in a Portland teaching hospital! The need for meta data!

Every day I make infectious disease rounds in the hospital and see at least one cool case or learn something new. 25 years and I still do not know everything. Why be selfish and keep all of that wonder and knowledge to myself? This blog will be a mostly qod account of days events, a cool ID case, a referenced pearl, and a minimum of 1 horrible, yet ultimately feeble, attempt at humor. I write these at night or in spare moments. There is always someone who will quibble about spelling, punctuation or grammer. My response is live with it. It's a blog, not Mandel.

Read and listen to more of me at my multimedia empire linked below.
Because The World Needs More Mark Crislip (tm).

Disclosure: Mark A. Crislip, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: Pusware LLC
Have a 5% or greater equity interest in: Pusware LLC (owner)

  • Mark Crislip

    Mark Crislip, MD, has been practicing in infectious diseases in Portland, Oregon, since 1990. He is nobody from nowhere, but he has an enormous ego that leads him to think someone might care about what he has to say about infectious diseases. And so he blogs and podcasts and writes on the most endlessly fascinating specialty in all of medicine.

    Mark A. Crislip, MD, has disclosed the following relevant financial relationships: Owner, Pusware LLC. He as not talked to a drug rep in over 25 years and does not even eat the pizza provided at conferences. But he is for sale for the right price. Please. Someone. Buy me.

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