July 10, 2013

DynaMed EBM Journal Volume 8, Issue 28

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: July 10, 2013

Expiration Date: July 10, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304158J


Last week 327 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 168 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Addition of Co-trimoxazole to Cephalexin Does Not Increase Cure Rate of Uncomplicated Cellulitis
Reference: Clin Infect Dis 2013 Jun;56(12):1754, (level 1 [likely reliable] evidence)

The recommended treatment for non-purulent cellulitis (without abscess) is a beta-lactam antibiotic (e.g. cephalexin [Keflex]) (Clin Infect Dis 2011 Feb 1;52(3):e18). However, antibiotics that target methicillin-resistant S. aureus (MRSA) are often prescribed for patients with uncomplicated cellulitis. To assess the benefits of targeting MRSA, a new randomized trial compared the efficacy of combined treatment with co-trimoxazole and cephalexin vs. cephalexin alone in 153 patients with uncomplicated cellulitis.

Patients aged 3-74 years (median age 29 years) with symptoms of uncomplicated cellulitis for < 1 week were randomized to co-trimoxazole plus cephalexin vs. cephalexin alone (with placebo) for at least 7 days and followed for 30 days. Patients were instructed to continue antibiotic treatment for 3 days after resolution of treatment, up to a total of 14 days. Exclusion criteria included hospitalization, diabetes, renal insufficiency, immunosuppression, peripheral arterial disease, or purulent discharge > 1 mL. MRSA was endemic in the areas in which the patients lived, and 13% of patients in the trial had associated purulence.

At the end of follow-up, the cure rate was 85% with combination treatment and 82% with cephalexin alone (not significant). The infection progressed to abscess in 6.8% in each group (not significant). There were also no significant differences in the rates of diarrhea, nausea and vomiting, or other adverse events. Neither presence of purulence nor nasal colonization with MRSA appeared to influence outcomes.

A recent DynaMed EBM Focus (Volume 8, Issue 21) reported on a systematic review showing that in patients with uncomplicated skin abscesses, the use of antibiotics that target MRSA did not appear to increase cure rates over incision and drainage alone. These 2 reports suggest that although MRSA is a significant clinical concern, clinicians should be judicious in their use of MRSA targeted antibiotics.

For more information, see the Cellulitis topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

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