使用廣效抗生素治療 組織炎 (cellulitis) 仍無效，考慮外敷藥的過敏

 

這篇說的是，當cellulitis 使用各種應該有效的抗生素，還治療無效，外觀仍然紅腫，且逐漸擴大，就要考慮是否對外敷的抗生素有過敏現象；有時病人會私自塗上歪膚抗生素! 如果使用的是應該有效的廣效抗生素，懷疑有外敷藥物過敏現象時，可以塗類固醇，會一兩天內就消除紅腫。  Bacitracin及 Neomycin 是最常引起過敏。Polymixin B 及Mupirocin是最少發生過敏現象的外敷用康生素。

 

When Cellulitis Doesn't Resolve: A
Mysterious Case

Paul G. Auwaerter, MD

Posted: 09/27/2011

Hello. Paul Auwaerter here, speaking for Medscape Infectious
Diseases from the Johns Hopkins University School of Medicine. I just got off a
clinical service, so I thought I would tell you about a case that was fairly
interesting. This case was a patient with a facial cellulitis. As infectious
disease physicians or primary care clinicians, cellulitis is one of the most
common entities that we diagnose, but, oddly, almost always without any
microbiological data. The case that I thought I would tell you about is a woman
who had been scratched by a cat right near her eye and was admitted because of
a concern for facial and periorbital cellulitis affecting the left side of her
face. She was admitted and placed on antibiotics. We were asked to consult 3
days into her course when the left side of her face was not improving. In fact,
it was turning more red. The patient had increasing complaints of unrelenting
pain. Her eye was swollen shut and very red.

We recommended changing to broader-spectrum antibiotics,
including vancomycin (to cover MRSA) as well as cefepime, on the off chance
that she had a resistant gram-negative process. CT imaging confirmed that she
did not have orbital cellulitis, and there did not seem to be any abscess. The
left side of her face was just fiery red. We started these antibiotics. For the
next 2-3 days, the patient was absolutely miserable, and then oddly this
cellulitis crossed over her face and began affecting her other cheek, which
also became fiery red. She was incredibly uncomfortable, and then her [right]
eye became involved and turned red. We did not know what to think. She was
scratched by a cat. We thought Pasteurella or any of the streptococcal
or staphylococcal species should be well covered by our current antibiotic
program. Cellulitis often doesn't respond promptly and may take more than the
customary 24-48 hours, but honestly we were flummoxed. We began thinking about
those odd causes of cellulitis that aren't infectious but mimic it, such as
eosinophilic cellulitis, leukemic infiltration, or just slow clearance of
erythrotoxins.

The patient had also seen an ophthalmologist to confirm that
there was no keratitis or other ocular involvement. They agreed that other than
a conjunctivitis, nothing was going on. The clue did not come from
x-ray/radiology but merely from history and observation. Although it was not on
her computer-generated list, the patient was religiously placing Cortisporin®
on her cheeks and around her eyes in the hopes that this additional topical
antibiotic would help resolve the infection. We often use these topical
antibiotics after surgical wound care, or for impetigo, for example, in hopes
that it will speed recovery.

Here are some interesting facts about Cortisporin. As many
of you know, it has components of neomycin, polymyxin B, and bacitracin in it,
but what may not be as commonly understood is that neomycin and bacitracin are highly allergenic. In fact, a
number of series have found that people can be allergic on patch testing 6%-11%
of the time.^[1,2] This patient was placing the Cortisporin on her
whole face in hopes of helping the infection. This was causing a severe
allergic dermatitis, so we stopped broad-spectrum antibiotics. We spied the
tube of Cortisporin on her bedside table and asked her not to place it on her
face any longer. We applied some topical corticosteroids, and within 48 hours
she was markedly improved.

So the lessons learned are that although some topical
antibiotics are used very routinely, if used for the long term, these
antibiotics can cause an allergic dermatitis. The worst offenders are
bacitracin and neomycin. The
antibiotics that don't cause allergic profiles for the most part are polymyxin
B and mupirocin. Those are probably safer if you feel the need to use
them for the long term. Thanks for listening to this case. I hope it provides
some help and instruction, especially if you see lots of patients with
cutaneous infections, employ these drugs in wound clinics, etc. Thank you.

[ CLOSE WINDOW ]

References

1. Yoo JY, Al Naami M, Markowitz
   O, Hadi SM. Allergic contact dermatitis: patch testing results at Mount
   Sinai Medical Center. Skinmed. 2010;8:257-260. Abstract


2. Sheth VM, Weitzul S.
   Postoperative topical antimicrobial use. Dermatitis.
   2008;19:181-189. Abstract

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Diseases © 2011 WebMD, LLC