Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment

Elizabeth L A Cross; Harriet Jordan; Rebecca Godfrey; Igho J Onakpoya; Annalie Shears; Katy Fidler; Timothy E A Peto; A Sarah Walker; Martin J Llewelyn

doi:10.1016/j.jinf.2020.07.030

Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment

J Infect. 2020 Oct;81(4):521-531. doi: 10.1016/j.jinf.2020.07.030. Epub 2020 Jul 31.

Authors

Elizabeth L A Cross¹, Harriet Jordan², Rebecca Godfrey², Igho J Onakpoya³, Annalie Shears², Katy Fidler¹, Timothy E A Peto⁴, A Sarah Walker⁴, Martin J Llewelyn⁵

Affiliations

¹ Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
² Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
³ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁴ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK.
⁵ Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK. Electronic address: m.j.llewelyn@bsms.ac.uk.

PMID: 32745638
DOI: 10.1016/j.jinf.2020.07.030

Abstract

Objectives: Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children.

Methods: We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response.

Prospero: CRD42018100602.

Results: We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I²=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I² = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse.

Conclusions: The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.

Keywords: Administration, Intravenous; Administration, Oral; Anti-bacterial agents; Cellulitis; Duration of therapy; Erysipelas; Soft tissue infections.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Adult
Anti-Bacterial Agents* / adverse effects
Cellulitis* / drug therapy
Child
Humans

Substances

Anti-Bacterial Agents

Grants and funding

Department of Health/United Kingdom