Assessment of Antibiotic Treatment of Cellulitis and Erysipelas: A Systematic Review and Meta-analysis.

IMPORTANCE: The optimum antibiotic treatment for cellulitis and erysipelas lacks consensus. The available trial data do not demonstrate the superiority of any agent, and data are limited on the most appropriate route of administration or duration of therapy. OBJECTIVE: To assess the efficacy and safety of antibiotic therapy for non-surgically acquired cellulitis. DATA SOURCES: The following databases were searched to June 28, 2016: Cochrane Central Register of Controlled Trials (2016, issue 5), Medline (from 1946), Embase (from 1974), and Latin American and Caribbean Health Sciences Information System (LILACS) (from 1982). In addition, 5 trials databases and the reference lists of included studies were searched. Further searches of PubMed and Google Scholar were undertaken from June 28, 2016, to December 31, 2018. STUDY SELECTION: Randomized clinical trials comparing different antibiotics, routes of administration, and treatment durations were included. DATA EXTRACTION AND SYNTHESIS: For data collection and analysis, the standard methodological procedures of the Cochrane Collaboration were used. For dichotomous outcomes, the risk ratio and its 95% CI were calculated. A summary of findings table was created for the primary end points, adopting the GRADE approach to assess the quality of the evidence. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of patients cured, improved, recovered, or symptom-free or symptom-reduced at the end of treatment, as reported by the trial. The secondary outcome was any adverse event. RESULTS: A total of 43 studies with a total of 5999 evaluable participants, whose age ranged from 1 month to 96 years, were included. Cellulitis was the primary diagnosis in only 15 studies (35%), and in other studies the median (interquartile range) proportion of patients with cellulitis was 29.7% (22.9%-50.3%). Overall, no evidence was found to support the superiority of any 1 antibiotic over another, and antibiotics with activity against methicillin-resistant Staphylococcus aureus did not add an advantage. Use of intravenous antibiotics over oral antibiotics and treatment duration of longer than 5 days were not supported by evidence. CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis, only low-quality evidence was found for the most appropriate agent, route of administration, and duration of treatment for patients with cellulitis; future trials need to use a standardized set of outcomes, including severity scoring, dosing, and duration of therapy.

The elbow flex-ex: a new sign to detect unilateral upper extremity non-organic paresis.

OBJECTIVE: To examine a new neurological sign that uses synergistic oppositional movements of the arms to evaluate for non-organic upper extremity weakness. METHODS: Patients with unilateral arm weakness were tested in a standing or sitting position with the elbows flexed at 30°. The examiner held both forearms near the wrists while asking the patient to flex or extend the normal arm at the elbow and simultaneously feeling for flexion or extension of the contralateral (paretic) arm. In patients with organic paresis, there was not a significant detectable force of contralateral opposition of the paretic limb. Patients with non-organic arm weakness had detectable strength of contralateral opposition in the paretic arm when the normal arm was tested. RESULTS: The test was first performed on 23 patients with no complaint of arm weakness. Then, 31 patients with unilateral arm weakness were tested (10 with non-organic weakness and 21 with organic weakness). The elbow flex-ex sign correctly identified the cause of weakness in all cases. CONCLUSIONS: The elbow flex-ex sign is useful in differentiating between functional and organic arm paresis.

Spinal infection caused by ESBL-producing Klebsiella pneumoniae treated with temocillin.

A case of cervical epidural abscess in a 63-year-old woman with a complex gastrointestinal surgical history is reported. The presenting symptom was neck pain, and blood analysis demonstrated raised erythrocyte sedimentation rate and C-reactive protein. MR imaging of the cervical spine revealed cervical discitis, osteomyelitis, and epidural collection. An ESBL-producing strain of Klebsiella pneumoniae, isolated from a previous episode of bacteraemia, was the causative organism. Surgical treatment was not possible and initial carbapenem therapy was aborted due to development of neutropaenia, and treatment continued with an extended course of temocillin. After 12 weeks of antibiotics the patient was pain-free with radiological improvement and resolution of blood markers of infection.

Abeta species removal after abeta42 immunization.

Neuropathologic examination of 3 patients with Alzheimer disease in the Elan Pharmaceuticals trial using antibodies specific for different Abeta species showed in one case, 4 months after the immunization, evidence of a stage of active plaque clearance with "moth-eaten" plaques and abundant Abeta phagocytosis by microglia. At 1 to 2 years after immunization, 2 cases showed extensive areas cleared of plaques (69% and 86% of the temporal cortex was plaque-free). Cortex cleared of plaques in all 3 cases had a characteristic constellation of features, including a very low plaque burden, sparse residual dense plaque cores, and phagocytosed Abeta within microglia. There was resolution of tau-containing dystrophic neurites, although other features of tau pathology (tangles and neuropil threads) remained and cerebral amyloid angiopathy persisted. Although most antibodies generated by Abeta42 immunization in humans bind the intact N-terminus, immunohistochemistry with specific antibodies showed clearance of all major species of Abeta (Abeta40, Abeta42, and N-terminus truncated Abeta). Abeta immunotherapy can clear all Abeta species from the cortex. However, if it is to be used for treatment of established Alzheimer disease, then the residual tau pathology and cerebral amyloid angiopathy require further study.