C4C

Adjunctive Clindamycin For Cellulitis: Clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis (C4C Trial)

Summary

Cellulitis is very common and some people can get it more than once. It can make people feel very ill and the streptococcus bacterium causing cellulitis produces a variety of poisons or 'toxins' which damage the skin. The normal treatment is with an antibiotic called flucloxacillin, which is effective. Another antibiotic called clindamycin is often used to treat a more serious infection, caused by the same bacterium, called necrotising fasciitis. This antibiotic is also sometimes added to, or used after, flucloxacillin if the cellulitis does not appear to be getting better. Clindamycin is added because some doctors think that it will reduce the amount of toxins released by the bacterium. If less toxin is released then there should be less skin damage. So we thought that if we added clindamycin to the normal flucloxacillin treatment of cellulitis it might reduce the amount of skin damage. If the amount of skin damage was less then the patient would have less pain and should have recovered more quickly. We wanted to give clindamycin to half our patients who had cellulitis together with flucloxacillin and just give flucloxacillin to the other half. We would then see which patients get better more quickly. Clindamycin can sometimes cause diarrhoea so we did not want to give it unless it really did make patients get better quickly. This study, called a clinical trial, should have told us whether adding clindamycin is effective and well tolerated.

The trial recruited over 400 patients with cellulitis and the majority were able to attend follow up. We found that the addition of clindamycin did not improve the patients' outcome in any way. We also found that patient receiving clindamycin for two days had double the chance of getting diarrhoea. The trial did allow us to collect very useful information on how quickly patients recover. We found that many patients were not back to their normal activities more than a month after getting cellulitis and that this slow recovery was normal. We hope that this information may stop both patients and doctors feeling that additional courses of antibiotic treatment are necessary.

We did a survey of patients' symptoms and their views on what made things better. This has allowed us to develop another study which will test things which might make the patient feel better and find out which ones, if any, do. 

Publications

Brindle R, Williams OM, Davies P, et al. Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis. BMJ Open 2017;7: e013260. doi:10.1136/ bmjopen-2016-013260