Oral pristinamycin versus standard penicillin regimen to treat erysipelas in adults: randomised, non-inferiority, open trial

Abstract

Objective To assess the efficacy and safety of oral pristinamycin versus intravenous then oral penicillin to treat erysipelas in patients in hospital. Design Multicentre, parallel group, open labelled, randomised non-inferiority trial. Setting 22 French hospitals. Participants 289 adults admitted to hospital with erysipelas. Results At follow up (day 25-45) the cure rate (primary efficacy end point) for the per protocol populations was 81% (83/102) for pristinamycin and 67% (68/102) for penicillin. The planned interim analysis (global one sided type I error 5%) showed that the one sided 97.06% confidence interval of the observed difference (pristinamycin − penicillin) between cure rates (3.3% to ∞) exceeded the − 10% non-inferiority threshold. For the intention to treat populations the cure rate at follow up was 65% (90/138) for pristinamycin and 53% (79/150) for penicillin, with the one sided 97.06% confidence interval of the observed difference between cure rates (1.7% to ∞) exceeding the − 10% non-inferiority threshold. That the lower limit of the confidence interval exceeded the -10% threshold and was also > 0 supports the hypothesis that pristinamycin is significantly superior at the 5% level. More adverse events related to treatment, as assessed by the investigators, were reported in the pristinamycin group than in the penicillin group. Most adverse events involved the gastrointestinal tract (nausea, vomiting, and diarrhoea) but were minor and usually did not require discontinuation of treatment. Conclusion Pristinamycin could be an alternative to the standard intravenous then oral penicillin regimen used to treat erysipelas in adults in hospital, with the advantages of oral first line therapy.

Risk Factors for Erysipelas of the Leg in Tunisia: A Multicenter Case-Control Study

“…Although it may be a potentially severe disease, erysipelas can usually be controlled with oral/parenteral antibiotics [3]. Potential local risk factors described in the medical literature were edema, lymphedema, cutaneous barrier rupture, superficial or deep venous insufficiency, history of leg surgery, radiation therapy (inferior limb or pelvis) and leg neuropathy.…”

Recurrent Erysipelas: 47 Cases

“…Erysipelas is an acute bacterial dermal-hypodermal infection (cellulitis) that usually affects the legs and is commonly caused by streptococci [1]. Recurrence is considered its most frequent complication (6.7–29%) [2,3,4,5].…”

Streptococcal Cellulitis/Erysipelas of the Lower Leg

“…Both drugs have a high level of antistreptococcal activity. The cure rates (per protocol and intention to treat) were 81% and 65% for pristinamycin in comparison with 67% and 53% for penicillin, both statistically significant differences (per-protocol absolute risk difference, 14%; 97.06% CI, 3.3% to ∞; intention-totreat absolute risk difference, 12%; 97.06% CI, 1.7% to ∞) [28]. Adverse effects included a higher frequency of (usually nonlimiting) gastrointestinal symptoms with pristinamycin.…”

“…The writing group was unable to define the best treatment for cellulitis. However, the reviewers concluded that the limited evidence of three trials [28][29][30] suggested macrolide and streptogramin antibiotics are slightly better than penicillins for reducing symptoms at the end of antibiotic treatment for cellulitis.…”