Meta-analysis of randomised trials comparing a penicillin or cephalosporin with a macrolide or lincosamide in the treatment of cellulitis or erysipelas.

Purpose: Beta-lactam antibiotics, such as penicillin, flucloxacillin or cephalexin, are widely considered first-line treatment for cellulitis and erysipelas, while macrolides and lincosamides, such as erythromycin, azithromycin or clindamycin, are widely considered second-line agents. We attempted to determine whether outcomes differed between patients treated either with a beta-lactam or with a macrolide or lincosamide.

Methods: We conducted a meta-analysis of published trials in which patients with cellulitis or erysipelas were randomised to treatment either with a beta-lactam or with a macrolide or lincosamide. We searched PUBMED, EMBASE, MEDLINE and SCOPUS (up to March 2014) using the terms: cellulitis/erysipelas, penicillin/beta-lactam, macrolide/lincosamide, random*/controlled*/trial* as keywords. We included randomised trials that compared monotherapy with a beta-lactam with monotherapy with a macrolide or lincosamide for cellulitis or erysipelas.

Results: We identified 15 studies, 9 in patients with cellulitis or erysipelas and 6 in patients with various skin and soft tissue infections including cellulitis and erysipelas. The efficacy of treatment of cellulitis or erysipelas was similar with a beta-lactam [27/221 (12 %) not cured] and a macrolide or lincosamide [21/241 (9 %) not cured, RR 1.24, 95 % CI 0.72-2.41, p = 0.44]. Treatment efficacy was also similar for skin or soft tissue infections including cellulitis and erysipelas (RR 1.28, 95 % CI 0.96-1.69, p = 0.09). Risk of adverse effects was similar for beta-lactams [148/1295 (11 %) not cured] and macrolides or lincosamides [228/1737 (13 %) not cured, RR 0.86, 95 % CI 0.64-1.16, p = 0.31].

Conclusion: Treatment with a macrolide or lincosamide for cellulitis or erysipelas has a similar efficacy and incidence of adverse effects as treatment with a beta-lactam.