Background:Results from previous trials suggest that daptomycin may result in faster clinical improvement than penicillinase-resistant penicillins or vancomycin for patients with complicated skin and skin structure infections.Objective:The objective was to evaluate whether daptomycin treatment of cellulitis or erysipelas would result in faster resolution compared with vancomycin.Design:The study was a prospective, evaluator-blinded, multi-centre trial. Patients were randomised to receive daptomycin 4 mg/kg once daily or vancomycin according to standard of care for 7–14 days.Patients:Adults diagnosed with cellulitis or erysipelas requiring hospitalisation and intravenous antibiotic therapy were eligible for enrolment.Results:The clinical success rates were 94.0% for daptomycin and 90.2% for vancomycin (95% confidence interval for the difference, −6.7%, 14.3%). There were no statistically significant differences between treatment arms in the time to resolution or improvement in any of the predefined clinical end-points. Both daptomycin and vancomycin were well tolerated.Conclusions:There was no difference in the rate of resolution of cellulitis or erysipelas among patients treated with daptomycin or vancomycin. Daptomycin 4 mg/kg once daily appeared to be effective and safe for treating cellulitis or erysipelas.

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Providing patients and medical staff with better information about early symptoms of agranulocytosis could be a sensible way to prevent complications. Any suspicion of agranulocytosis should immediately lead to a differential blood count and to the withdrawal of all drugs possibly associated with agranulocytosis. Patients should be monitored and treated according to the severity of their symptoms.

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Positioning a patient for surgery requires great care and caution. Correct positioning provides the surgeon with good access to the site, minimizes blood loss and reduces the risk of damage to nerves, soft tissue, compartments and the cardio-pulmonary system. Each position has its specific risks. These have to be evalued against the benefits. Extreme positions of the joints should be avoided whenever possible. The ulnar nerve or the plexus brachialis are at highest risk in the positioning of extremities. Good anatomical comprehension makes it possible to take effective counter-measures. In the case of damage to the ulnar nerve in spite of optimal positioning, some authors found pre-existent non-symptomatic dysfunction in up to 30% of the cases. Patients suffering from peripheral vascular disease are usually at higher risk to suffer acute ischaemia, or, in the extreme, rhabdomyolysis with compartment syndrome, when positioned with elevated extremities (as in lithotomy position) or when a tourniquet is applied. Next to other factors, the duration of surgery seems to be of some importance. Operation sites above the heart carry a higher risk of venous air embolism unrelated to the positioning. In these cases adequate monitoring should be generously applied. Loss of visus is a rare but very severe complication most often seen in connection with the prone position. Still, postoperative blindness has occurred in all positions. It is absolutely imperative to avoid all pressure to the bulbus. The same law applies to surgery and positioning: indicated and correctly executed positioning, to which the patient has effectively consented, is legal, even if damage should occur. If the plaintiff demands compensation for damage, the distribution of onus of proof depends essentially on the accuracy of documentation. If documentation is faulty, the plaintiff may be granted relief or even shift of the onus of proof. This does not apply to a criminal lawsuit; in that case, culpable medical fallibility must be proven, since otherwise, the principle of "in dubio pro reo" applies. The interdisciplinary responsibilities concerning the positioning must be clearly defined and it is essential that the documentation of positioning as well as the documentation of positioning control is carried out as accurately as possible. Correct positioning can effectively aid surgery. Slovenly positioning should not be accepted, as there is a high probability of ill effects, possibly of permanent damage.