Q1: High Yield PLAB 1 / UKMLA Exam Style Question
A 29-year-old pregnant woman at 26 weeks of gestation, who has a known allergy to penicillin, presents to the clinic with a 4-day history of a painful rash on her right forearm. She also complains of localized warmth and swelling. On examination, the area is erythematous, warm to the touch, with clear demarcated borders. There is no evidence of lymphangitis or systemic signs of infection such as fever or tachycardia. She has no past medical history of chronic diseases and no other medications. What is the SINGLE most appropriate initial treatment?
A. Clarithromycin
B. Flucloxacillin
C. Ciprofloxacin
D. Co-amoxiclav
E. Erythromycin
Answer: E. Erythromycin
Explanation
Diagnosis:
The patient is most likely suffering from cellulitis, a bacterial skin infection that is commonly caused by streptococci and staphylococci bacteria.
Clinical Presentation:
- Local symptoms: Painful, erythematous, warm skin with clear borders.
- Duration:4-day history.
- No systemic symptoms:** Important as it guides us towards oral rather than intravenous treatment.
Management Options:
A. Clarithromycin: Usually considered an alternative for patients who are allergic to penicillin; however, it is contraindicated in pregnancy.
B. Flucloxacillin: This is the first-line treatment for cellulitis, but our patient has a penicillin allergy.
C. Ciprofloxacin: This antibiotic is generally avoided in pregnancy due to potential concerns regarding fetal joint development and cartilage damage.
D. Co-amoxiclav: This is also a penicillin-based antibiotic and not appropriate for someone with a penicillin allergy.
E. Erythromycin: Safe in pregnancy and appropriate for a patient with a penicillin allergy. This becomes the antibiotic of choice in this specific scenario.
Why Erythromycin?
Erythromycin is considered safe during pregnancy and is an effective alternative for treating bacterial infections in patients who are allergic to penicillin. It covers the spectrum of bacteria commonly implicated in cellulitis and is available in an oral formulation, suitable for outpatient treatment as our patient has no systemic symptoms suggesting severe infection.
Summary:
In this case, the choice of antibiotic is influenced by three major factors:
- The likely diagnosis of cellulitis
- The patient's penicillin allergy
- The patient's pregnancy status
Given these factors, erythromycin becomes the most appropriate treatment option. Always ensure you are considering the patient's comorbidities and other risk factors when choosing a treatment pathway.
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Reference:
Cellulitis and erysipelas: antimicrobial prescribing - NICE: This is a guideline from the National Institute for Health and Care Excellence (NICE) that sets out an antimicrobial prescribing strategy for adults, young people, children and babies aged 72 hours and over with cellulitis and erysipelas. It includes recommendations on treatment, advice, reassessment, referral and seeking specialist advice, and choice of antibiotic. It also provides a 3-page visual summary of the recommendations, including tables to support prescribing decisions.
Cellulitis - acute | Health topics A to Z | CKS | NICE: This is a clinical knowledge summary from NICE that provides information on the diagnosis and management of acute cellulitis in primary care. It covers the assessment, investigations, referral criteria, antibiotic treatment, prevention of recurrence, and patient education.
Management of cellulitis: current practice and research questions: This is an article from the British Journal of General Practice that discusses the current practice and research questions regarding the management of cellulitis. It highlights the challenges in diagnosing cellulitis, the uncertainty about the optimal duration of antibiotic treatment, the role of prophylaxis in preventing recurrence, and the need for more evidence-based guidance.