Journal of Infection (2014) 69, 26e34

www.elsevierhealth.com/journals/jinf

REVIEW

Antibiotic prophylaxis for preventing

recurrent cellulitis: A systematic review and
meta-analysis
Choon Chiat Oh a,*, Henry Chung Hung Ko b,c,g, Haur Yueh Lee a,
Nasia Safdar e,f, Dennis G. Maki f, Maciej Piotr Chlebicki d

a
Department of Dermatology, Singapore General Hospital, Singapore
b
SingHealth Corporate, Office of Research, Centre for Health Services Research, SingHealth, Singapore
c
Duke-NUS Graduate Medical School & SingHealth Academic Medicine Research Institute, Singapore
d
Department of Infectious Diseases, Singapore General Hospital, Singapore
e
William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
f
Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, USA

Accepted 18 February 2014

Available online 24 February 2014

KEYWORDS Summary Importance: A significant proportion of patients who have had a first episode of
Cellulitis; erysipelas or uncomplicated cellulitis will subsequently develop a recurrence. There is
Prophylaxis; disagreement about how effective antibiotic prophylaxis is for preventing recurrent cellulitis.
Prevention; Objective: To determine if antibiotic prophylaxis is effective in preventing recurrent cellulitis
Recurrence compared to no prophylaxis using a systematic review and meta-analysis.
Data sources: Studies in any language identified by searching Medline, EMBASE, Cochrane Li-
brary, CINAHL, TRIP database, clinical practice guidelines websites, and ongoing trials data-
bases up to 31st August 2012. Search terms included cellulitis, erysipelas, controlled clinical
trial, randomized, placebo, clinical trials, randomly, and trial.
Study selection: Only controlled trials comparing antibiotic prophylaxis to no antibiotic pro-
phylaxis in patients age 16 years and above, and after 1 or more episodes of cellulitis, were
included.
Data extraction and synthesis: Independent extraction of articles was done by 2 investiga-
tors using predefined data extraction templates, including study quality indicators. PROS-
PERO registration number: CRD42012002528. Meta-analyses were done using random-
effects models.

* Corresponding author.
E-mail addresses: oh.choon.chiat@sgh.com.sg (C.C. Oh), henry.ko@ctc.usyd.edu.au (H.C.H. Ko), lee.haur.yueh@sgh.com.sg (H.Y. Lee),
ns2@medicine.wisc.edu (N. Safdar), maki.dennis@yahoo.com (D.G. Maki), piotr.chlebicki@sgh.com.sg (M.P. Chlebicki).
g
Ko is now at the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia.

0163-4453/$36 ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jinf.2014.02.011
Antibiotic prophylaxis for recurrent cellulitis 27

Main outcomes and measures: The primary outcome was the number of patients with a
recurrence of cellulitis. Secondary outcomes were (1) the time to next episode of recur-
rence, (2) quality of life measures, and (3) adverse events (e.g. allergic reactions,
nausea).
Results: Five randomized controlled trials (n Z 535), with 260 patients in the intervention
arm and 275 in the comparator group met our inclusion criteria. 44 patients (8%) in the
antibiotic prophylaxis group and 97 patients (18%) in the comparator group had an episode
of cellulitis. Antibiotic prophylaxis significantly reduced the number of patients having
recurrent cellulitis, with a risk ratio (RR) of 0.46 (95% CI 0.26e0.79). None of the studies
reported severe adverse effects to antibiotics. There was methodological heterogeneity
amongst the studies in terms of types of antibiotic used, delivery modes, number of recur-
rences of cellulitis at study entry, and study quality.
Conclusion and relevance: Antibiotic prophylaxis can prevent recurrent cellulitis. Future
research should aim to identify the ideal type, dosage, and duration of antibiotics for pro-
phylaxis, as well as to identify the group of patients who will benefit most from antibiotic
prophylaxis.
ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Introduction Inclusion criteria

Cellulitis of the lower extremities is an acute, painful
and potentially serious infection of the skin and subcu-
taneous tissue associated with significant morbidity1,2
and healthcare costs.3e5 Erysipelas or uncomplicated
cellulitis refers to non-suppurative, acute and spreading
skin infection. Specifically, erysipelas tends to be more
superficial and has prominent lymphatic involvement;
while cellulitis extends deeper and involves subcutane-
ous tissues. We will use the terms erysipelas and cellulitis
interchangeably in this paper. Risk factors for developing
cellulitis of the leg include prior history of cellulitis,
lymphoedema, toe web maceration, obesity and
diabetes.6e9
Cellulitis is typically caused by b-haemolytic strepto-
cocci of group A, less often by group B, C, or G streptococci
or Staphylococcus aureus.10,11 Prior history of cellulitis is
strongly associated with acute cellulitis.7,12
An attack of acute cellulitis may lead to a vicious circle
of impaired lymphatic function leading to increased sus-
ceptibility to further recurrences of cellulitis.13
However, the causal association is not clear.14,15
In 2003, 428,274 patients were hospitalized in the US
with a principle diagnosis of cellulitis, with cellulitis being
responsible for 1.1% of all hospital discharges.16 Sixteen to
30% of patients who have had a first episode of erysipelas or
uncomplicated cellulitis will subsequently develop a
recurrence.17e19
There is disagreement about how effective antibiotic
prophylaxis is for preventing recurrent cellulitis. We un-
dertook a systematic review and meta-analysis to evaluate
the level and quality of available evidence regarding the
efficacy and reported adverse effects of antibiotic prophy-
laxis against recurrent cellulitis.
Methods
This systematic review protocol was registered with PROS-
PERO on 11th September 2012 with registration number
CRD42012002528.
The defined cellulitis population included patients aged 16
years and above, and after one or more episodes of
cellulitis. Participants with cellulitis secondary to filarial
lymphoedema were excluded. We use cellulitis and erysip-
elas interchangeably in this paper.
The intervention was any antibiotic prophylaxis used for
recurrent cellulitis. Any form of delivery, dose and duration
of antibiotics was considered. The control group was
patients without prophylactic antibiotics. Other forms of
standard care (e.g. local skin care) were allowed in the
control group.
The primary outcome was the number of patients with a
recurrence of cellulitis. This outcome was recorded as (1)
the number of patients with cellulitis, and (2) the number
of episodes per patient. Also noted where possible was the
total number of recurrences within a time period. Recur-
rence must have been diagnosed by a physician.
Secondary outcomes were (1) the time to next episode
of recurrence, (2) quality of life measures, and (3) adverse
events (e.g. allergic reactions, nausea). For these out-
comes, there was no limit to the follow-up period after
completion of antibiotics, but any events occurring during
the taking of the antibiotic treatment was particularly
noted.
Search strategy
Two authors (OCC, HCHK) searched and scanned the
electronic databases and other sources of studies. They
developed and checked the search strategies used for each
database with each other. The search strategies were
’translated’ for each database where needed.
A search was done in the following databases: Co-
chrane Library (Cochrane Central Register of Controlled
Trials (CENTRAL), CDSR, HTA, DARE, NHS EED), MEDLINE
via OVID SP, EMBASE, CINAHL via EBSCOhost, guidelines
websites (UK NICE, US National Guidelines Clearinghouse,
Scotland SIGN), TRIP database, and ongoing trials data-
bases (Clinicaltrials.gov; World Health Organization
28
ICTRP). We did not impose a language restriction to our
searches. The date of last search was 31st August 2012.
The authors also contacted experts in this field to enquire
if there were upcoming related trials, and they contacted
the Cochrane Skin Group editorial centre, as well as the
authors of the PATCH I and II trials. The search string
used in Medline via OVID SP is included in the Appendices
as an example.
This systematic review specifically sought out random-
ized controlled trials (RCTs), systematic reviews (SRs) and
evidence based clinical practice guidelines (EBCPGs). Two
authors independently reviewed the articles, and decided
on the inclusion of studies, having read the methods
section of each study and applied the stated P (Partici-
pant), I (Intervention), C (Control), and O (Outcome)
criteria. Differences were resolved by consensus, and in
cases where disagreements persisted, other co-authors
(MPC, LHY) were consulted to decide whether to include
or exclude articles.
For any studies that were possibly relevant but had
missing or unclear information or data, we contacted the
authors by email for further information. Articles in
languages other than English were translated into English.
A short narrative (descriptive) synthesis is presented
summarizing the PICO, risk of bias, and study quality for
each study, as well as across studies. Data was extracted
using a PICO template to ensure that all relevant study
details and results were captured.
Two authors (OCC, HCHK) independently assessed and
rated the methodological quality of each trial using the
Cochrane Collaboration tool for assessing risk of bias.20 The
quality of studies were judged by evaluating the following
six domains: (1) random sequence generation, (2) alloca-
tion concealment, (3) blinding of participants and
personnel, (4) incomplete outcome data, (5) selective
outcome reporting, and (6) other sources of bias. Each
domain was judged as either being (1) low risk of bias, (2)
high risk of bias, or (3) unclear risk (lack of information or
uncertainty over the potential for bias). Reasons were re-
corded as to why judgements were given.
Because only one type of intervention (i.e. antibiotics)
for a defined primary outcome (e.g. number of patients
who get recurrent cellulitis during treatment) was chosen,
a meta-analysis was done to calculate a weighted treat-
ment effect across trials. The results were expressed as a
risk ratio with 95% confidence intervals (CI) for dichotomous
outcomes.
The appropriateness of meta-analysis in the presence of
significant clinical or methodological/statistical heteroge-
neity for the other outcomes of interest was considered.
Meta-analyses was performed using the Cochrane Collabo-
ration Review Manager software (RevMan). Random effects
meta-analysis was used for outcome effect estimates from
groups of studies with high heterogeneity, to produce a
more conservative effect estimate. Statistical indications
of heterogeneity between the studies in effect measures
were assessed using both the Chi-squared test and the I-
squared statistic. We considered an I-squared value >50%
indicative of moderate heterogeneity and >75% indicative
of substantial heterogeneity. Methodological heterogeneity
amongst the collection of studies was also an indicator for
using a random effects meta-analysis, and was used where
C.C. Oh et al.
the studies had a high degree of methodological variability
between them.
We assessed the reporting of withdrawals, drop-outs,
protocol deviations, and whether participants were ana-
lysed in the group to which they were originally randomized
(ITT). We examined the methods, and a priori published
protocols (if present), of the selected studies to determine
if all relevant results reported matched the proposed out-
comes to be reported.
Subgroup analyses was used to explore heterogeneity in
effect estimates according to: study quality; study popula-
tions (1st occurrence of cellulitis vs 2nd or more recurrence
of cellulitis); intervention content (i.e. type of antibiotic
used, administration method), and the effect of small and
large studies on the effect estimate. Assessment of publi-
cation bias was not done as there were only five studies,
and it has been recommended that useful analysis of
publication bias requires at least 10 studies.
We conducted sensitivity analyses based on study quality
(i.e. higher quality vs lower quality studies).
Results
Our literature search yielded 1472 articles from all sources.
Fig. 1 shows the numbers of studies screened, resulting in
five studies that matched our criteria.21e26 Of these, two
studies were done by the UK’s ‘Prophylactic Antibiotics
for the Treatment of Cellulitis at Home’ (PATCH)
group.24e26
There were 535 participants from all five studies, with
260 participants taking antibiotics and 275 participants on
placebo or not taking any antibiotics. There were 209 males
and 326 females in the studies, with the lowest average age
from any group of participants being 45 years,21 and the
oldest average age being 67.5 years.23 Table 1 outlines
the key population, intervention, control and outcome
characteristics of the studies.
Antibiotics were given for six, 12, or 18 months in three
studies, and for an unclear duration in two studies.21,23 All
studies’ comparators were no antibiotic treatments. Only
the two PATCH studies used placebo tablets in their com-
parison arms.24e26 The other studies did not mention any
placebo treatment, or reported that no antibiotic was given
to the comparison group.
The quality of the individual studies, or risk of bias of the
studies’ methodology, is summarized in Fig. 2. It highlights
that the PATCH studies were of consistently good methodo-
logical quality, whilst the other studies had unclear or low
quality.
The primary outcome of the total number of recurrences
within a time period reported in Chakroun 1994 was that 0/
24 (0%) intervention group patients and 9/34 (26%) com-
parison group patients had recurrences after an average of
11.6 months follow-up.21 Kremer 1991 reported that 0/16
(0%) intervention group patients and 8/16 (50%) comparison
group patients had recurrences after an 18 month follow-
up.22 PATCH I reported that 30/136 (22%) patients in the
intervention group and 51/138 (37%) patients in the com-
parison group had recurrences after a 36 month follow-
up.24,26 PATCH II reported that 12/60 (20%) intervention
group patients and 21/63 (33%) comparison group patients
Antibiotic prophylaxis for recurrent cellulitis 29

Figure 1 PRISMA flowchart of the study selection process.

 30
Table 1 Characteristics of included studies.
Study Population Intervention Control Outcome Follow-up time
Kremer 1991. 22

2 previous Erythromycin. 250 mg, No medication. N Z 20. Number of patients with 18 months.
Israel. episodes of soft tissue tablets, b.i.d., recurrences; number of
infection 18 months. Patients recurrences; adverse events.
(cellulitis or erysipelas). allergic to erythromycin
given penicillin V-K,
250 mg b.i.d. N Z 20.
Chakroun 1994.21 Infectious cellulitis. Penicillin G. 1.2 million Unclear. N Z 34. Note: Patients with 11.6 months
France. Most had prior units (w720 mg), 29.4% had prior antibiotics. recurrences. average follow-up.
antibiotics. intramuscular injection,
every 15 days,
unclear duration.
N Z 24. Note: 77.8%
had prior antibiotics.
Sjoblom 1993.23
2 episodes of Phenoxymethylpenicillin. No treatment. N Z 20. Number of Follow-up time
Sweden. erysipelas during the last 3 years. 1 g for BW <90 kg. patients with possibly varied.
1 g þ 2 g for BW 90e120 kg. recurrences;
2 g for BW >120 kg. adverse events.
Tablets, b.i.d., unclear
duration. Patients allergic
to penicillin were given
erythromycin: 0.25 g b.i.d.
for BW <90 kg. 0.25 þ 0.5 g
b.i.d. for BW 90e120 kg.
0.5 g b.i.d. for
BW >120 kg. N Z 20.
PATCH 1 2012.26
2 episodes of cellulitis. Penicillin VK. 250 mg, Placebo tablets, b.i.d., Number of patients with 36 months.
UK. Within 3 years tablets, b.i.d., 12 months. N Z 138. recurrences; number of
of index occurrence. 12 months. N Z 136. recurrences; adverse
events; time to
next episode.
PATCH II 2012.25
1 episode of cellulitis. Index Penicillin VK. 250 mg, Placebo tablets, b.i.d., Number of patients with 36 months.
UK. episode diagnosed within tablets, b.i.d., 6 months. N Z 63. recurrences; number of
last 12 weeks. 6 months. N Z 60. recurrences; adverse

C.C. Oh et al.
events; time to next episode.
Antibiotic prophylaxis for recurrent cellulitis
Figure 2 Appraisal of the quality of study methodology of in-
dividual studies. “þ” indicates low risk of bias; “?” indicates
unclear risk of bias; “-” indicates high risk of bias.
had recurrences after a 36 month follow-up.25 Sjoblom 1993
reported that 2/20 (10%) intervention group patients and 8/
20 (40%) comparison group patients had recurrences after
up to a maximum of approximately 3 years of follow-up.23
The primary outcome of the number of episodes per
patient reported in Kremer 1991 was that 7/16 (44%)
patients had 1 recurrence of cellulitis, and that 1/16 (6%)
patients had 2 relapses of cellulitis in the comparison group
(there were no recurrences of cellulitis in the intervention
group).22 PATCH II reported that there were 3 patients with
2 recurrences, 2 patients with 3 recurrences, 2 patients
with 4 recurrences, and 1 patient with 7 recurrences. It
was unclear which treatment groups had which numbers.25
The secondary outcome of time to next episode of
occurrence, reported as the median time to next episode
in PATCH I, was longer, at 626 days, for the intervention
group than for the 532 days for the comparison group.24,26
Figure 3 Forest plot of total number of recurrences of cellulitis between prophylactic antibiotics vs no antibiotics.
31
As for adverse events, the most commonly reported prob-
lems were nausea and diarrhoea, but these figures were
similar between treatment and comparison groups within
each study. A small number of deaths were also reported
in PATCH I, PATCH II, and Sjoblom 1993, however these
were not related to the study treatments. Kremer 1991 re-
ported that 3/16 (19%) intervention group patients experi-
enced nausea and abdominal pain.22
For the primary outcome of the total number of re-
currences of cellulitis, a random effects meta-analysis of
all five studies showed that prophylactic antibiotics were
beneficial for preventing recurrence of cellulitis with an RR
of 0.46, 95% CI 0.26e0.79 (Fig. 3).
Fig. 4 shows the risk of bias across studies for the various
bias components, showing a mix of low, high and unclear
risk of bias in methodology in the body of evidence.
Subgroup analyses for previous episodes of cellulitis
showed there was no statistically significant advantage to
using prophylactic antibiotics for patients with two or
more prior episodes of cellulitis (RR 0.35, 0.12e1.02)
compared to delivering no antibiotics. For antibiotic
administration routes, there was a statistically significant
benefit for oral administration of antibiotics for prevent-
ing recurrence of cellulitis (RR 0.52, 95% CI 0.33e0.82) vs
no antibiotics. Only one study examined intramuscular
administration,24 but the difference in recurrence was not
statistically significant between treatment groups (RR
0.07, 95% CI 0.00e1.21), however we should caution that
this analysis only used one small study so interpretation
of this result should be done conservatively. For the
type of antibiotics used, penicillin shows a statistically
significant benefit for preventing recurrent cellulitis (RR
0.54, 95% CI 0.36e0.80). Erythromycin also showed
statistically significant benefit for prophylaxis (RR 0.06,
95% CI 0.00e0.94), however this analysis only used one
small study so this result should be interpreted with
caution.22
Sensitivity analysis results from analysis of only high
quality studies (two studies)24e26 and lower or unclear qual-
ity studies (three studies)21e23 both agreed that antibiotic
prophylaxis was effective for reducing recurrent cellulitis
(RR 0.60, 95% CI 0.43e0.83, and RR 0.16, 95% CI
0.05e0.50, respectively).
Discussion
Antibiotic prophylaxis reduced the risk of recurrent cellu-
litis compared to no antibiotic prophylaxis, with an RR of
0.46 (95% CI 0.26e0.79) in patients with a history of
cellulitis. This review also suggests that in patients with
32
Figure 4 Risk of bias across studies for the various bias components.
two or more baseline episodes of cellulitis, antibiotic
prophylaxis seemed to half the recurrence of cellulitis as
compared to no antibiotic prophylaxis; while not statisti-
cally significant (RR 0.35, 95% CI 0.12e1.02) this finding
hints to a possibly clinically important effect pending more
trials conducted with larger sample size and power to
detect a difference. Studies that used oral administration
of antibiotics showed RR 0.52 (95% CI 0.33e0.82), but it is
unclear if intramuscular injection is effective (RR 0.07, 95%
CI 0.00e1.21). Penicillin was effective at reducing the
recurrence of cellulitis (RR 0.54, 95% CI 0.36e0.80), as
was erythromycin (RR 0.06, 95% CI 0.00e0.94).
Strengths of this systematic review were that it
included studies in languages other than English, searched
for unpublished data, and solicited views from experts in
this field. Clinical practice guidelines and health technol-
ogy assessments on the topic were also searched to
determine if there was already published high level
evidence and recommendations on the topic. Sensitivity
analysis results from analysis of only high quality studies
(two studies)24e26 and lower or unclear quality studies
(three studies)21e23 both agreed that antibiotic prophy-
laxis was effective for reducing recurrent cellulitis (RR
0.60, 95% CI 0.43e0.83, and RR 0.16, 95% CI 0.05e0.50,
respectively). The UK NICE (National Institute for Health
and Care Excellence) clinical knowledge summary on
cellulitis (last revised in September 2012) also stated
that if the cellulitis is recurrent (more than two episodes
at the same site within 1 year), one should consider
routine referral to a dermatologist for advice about start-
ing prophylactic antibiotics.27
A limitation of the methods is the small number of
relatively heterogeneous studies (only five studies) and
small aggregate population able to be used in this analysis
(n Z 535). Caution should be used when interpreting the
subgroup analyses regarding the patient types to be treated
(two or more prior episodes of cellulitis at baseline), the
type of antibiotic used (penicillin or erythromycin), and
administration routes (oral or intramuscular injection), as
the number of studies and patients for each analyses may
be small.
As a further note on administration routes, it should be
noted that it is difficult to compare oral vs intramuscular
administration of antibiotics, as absorption (and therefore
bioavailability) is different for the different routes.
C.C. Oh et al.
The variability and quality of data between studies did
not allow us to make a recommendation on the optimal
antibiotic or duration of treatment.
The studies were conducted in mainly Caucasian pa-
tients in France, UK/Ireland, Sweden, and Israel, so
generalizability to other ethnicities and geographic settings
may be limited.
A previous systematic review on antibiotics prophylaxis
for recurrent cellulitis in BMJ Clinical Evidence published in
2008 only found two studies, which have also been included
in our systematic review.28 This review found that antibi-
otic prophylaxis was likely to be beneficial. Our systematic
review is has identified more studies, used a transparent
and rigorous systematic review methodology, and has sum-
marized the current state of research on antibiotic prophy-
laxis for recurrent cellulitis up to August 2012.
In a study by Forcade et al. the impact of CA-MRSA in the
United States was discussed.29 The patients described in
this study had symptoms suggestive of Staphylococcus
Aureus infection, and would not be expected to benefit
from penicillin prophylaxis. This highlights the importance
of selecting the appropriate group of patients who may
benefit from penicillin prophylaxis. While current guide-
lines state that it is reasonable to give antibiotic prophy-
laxis for prevention of recurrent cellulitis, our data
suggests that the benefit of giving prophylactic antibiotics
is considerable in a patient population with recurrent cellu-
litis and should be strongly considered.
Some papers in the literature indicate that despite
antibiotic prophylaxis, cellulitis still recurs.23,30,31 Postu-
lated reasons for failure of preventive therapy may be
that the recurrence of erysipelas include noncompliance;
incorrect antibiotic; other causative micro-organisms; or
insufficient antibiotic concentrations. In half of the cases,
no valid explanation could be obtained.31 The exact diag-
nosis of cellulitis (caused by streptococcus) may not always
be possible11,32 and one must also consider other differen-
tial diagnoses for red and swollen limbs.33e35
One study using monthly intramuscular injections of
benzathine penicillin G to prevent recurrences of cellulitis
found that monthly benzathine penicillin G prophylaxis
benefitted only patients without predisposing factors for
cellulitis.36 We recognize some limitations of applying long-
term prophylaxis in clinical practice. Long-term compliance
will be an obstacle. If oral prophylaxis is being prescribed,
Antibiotic prophylaxis for recurrent cellulitis
patient information is a crucial issue, and the importance of
prophylactic treatment to prevent further damage of the
vessels and serious infections should be stressed to try to
increase compliance by the patients.
Other aspects of cellulitis prevention should not be
neglected. These include treatment of toe web intertrigo,
reducing lower limbs oedema and managing underlying
venous insufficiency.37
Resistance of group A Streptococcus pyogenes to macro-
lides has dramatically increased and in many areas of the
world, this class of antibiotics cannot be relied upon to pro-
vide effective protection. Although clindamycin remains
more effective against group A streptococci, it has a very
broad spectrum of activity and potential for causing an
antibiotic-associated diarrhoea or colitis, which may
severely limit its use for long term prophylaxis.38 In light
of the reasons above, patients with allergy to penicillin
have very limited choices.
According to the PATCH II study, this intervention
represents an intervention which costs £18 per 6-month
course. Assuming an NNT of 8, this equates to a treatment
cost of £144 per episode of cellulitis prevented.25 In
another study, the cost of treating a single erysipelas
episode was 8.3 times higher than the cost of one year of
prophylaxis.23
In conclusion, our analyses support the use of antibiotics
for prophylaxis against recurrent cellulitis or erysipelas.
Antibiotics used for this indication were generally well
tolerated, without increased risk of major adverse events.
However, more RCTs need to be done to better answer the
following questions: (1) when oral antibiotic prophylaxis
should be started (after 1st or 2nd episode of cellulitis), (2)
which patient population may benefit the most from
antibiotic prophylaxis (e.g. which age groups, excluding
which comorbidities), (3) what is the optimal duration and
dosage of antibiotics, (4) what is the best choice of
antibiotics for those allergic to penicillin.
Funding
Nasia Safdar is supported by a MERIT award from the
Department of Veterans Affairs. The views in this paper
do not necessarily represent the views of the authors’
employers, nor the Department of Veterans Affairs.
Acknowledgements
The authors would like to thank Dr Melina Willlson for her
translation work in Ref. 21.
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