No Single Optimal Antibiotic Therapy for Cellulitis Identified

No evidence exists to support the superiority of any one antibiotic for the treatment of cellulitis — although short treatment courses of antibiotics appear to be as effective as longer treatment courses.

No single antibiotic therapy is superior to another in the treatment of cellulitis, suggest results from a systematic review and meta-analysis published in JAMA Dermatology. However, few reviewed studies comprised high-quality evidence, underscoring the need for further research into antibiotic treatment for this condition.  

Investigators conducted a systematic review of the Cochrane Central Register of Controlled Trials, Medline, Embase, and Latin American and Caribbean Health Sciences Information System to identify randomized clinical trials examining the efficacy and safety of different antibiotic therapies for nonsurgically acquired cellulitis. The primary outcome measure was the proportion of patients who improved, recovered, or who were cured, were symptom free, or whose symptoms were reduced by the end of their antibiotic course. Risk ratios (RRs) for patient improvement and other dichotomous variables were calculated. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to evaluate evidence quality across studies.

A total of 43 studies with a total of 5999 evaluable participants were included in the meta-analysis. Patient age ranged from 1 month to 96 years. Cellulitis was the primary diagnosis in just 15 studies (35%); in the remaining studies, the proportion of patients with cellulitis ranged from 8.9% to 90.9%, with a median (interquartile range) frequency of 29.7% (22.9%-50.3%). The majority of studies compared different antibiotics or antibiotic durations, and no studies compared antibiotics with placebo. Overall, no study suggested the superiority of one antibiotic over another. According to 2 studies (n=557) that compared antibiotics with activities against methicillin-resistant Staphylococcus aureus (MRSA) with non-MRSA-active antibiotics, MRSA-active antibiotics were not associated with an increased proportion of recovered patients (RR, 0.99; 95% CI, 0.92-1.06). Low-quality evidence was found suggesting that intravenous administration was inferior to oral administration (RR, 0.83; 95% CI, 0.75-0.93; P <.001), And there was no evidence for improved outcomes following treatment duration exceeding 5 days compared with treatment of shorter durations (RR, 0.99; 95% CI, 0.94-1.04).

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Study limitations include a lack of objective outcome measures and a lack of blinding, which could increase the risk of bias.

Researchers were unable to identify a single ideal antibiotic therapy for cellulitis treatment from the studies in this review. According to GRADE criteria, the evidence quality observed across studies was low, emphasizing the necessity of further research with standardized outcomes, including cellulitis severity scoring, antibiotic dosing, and therapy duration, the investigators wrote.  

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Brindle R, Williams OM, Barton E, Featherstone P. Assessment of antibiotic treatment of cellulitis and erysipelas: a systematic review and meta-analysis [published online June 12, 2019]. JAMA Dermatol. doi:10.1001/jamadermatol.2019.0884