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Do topical antibiotics improve wound healing?
The use of topical triple-antibiotic ointments significantly decreases infection rates in minor contaminated wounds compared with a petrolatum control. Plain petrolatum ointment is equivalent to triple-antibiotic ointments for sterile wounds as a post-procedure wound dressing (strength of recommendation [SOR]: A, based on randomized controlled trials [RCTs]).
Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected minor wounds and, because of better tolerability, is the treatment of choice for the prevention and treatment of Staphylococcus aureus and Staphylococcus pyogenes infections. Emerging resistance, including methicillin-resistant S aureus (MRSA), makes it prudent to check for clinical response in 24 to 48 hours. Major contaminated wounds requiring parenteral antibiotics do not appear to additionally benefit from topical antibiotics (SOR: A, based on RCTs).
Topical antibiotics may also aid in the healing of chronic wounds (SOR: B, based on a systematic review of low-quality RCTs), as does the application of honey (SOR: B, based on a systematic review of cohort studies).
It would be helpful to have objective criteria to properly classify skin wounds
Michael Mendoza, MD, MPH
Pritzker School of Medicine, University of Chicago
These results are encouraging, but they do not fully account for variability in the diagnosis of skin wounds or in the practical use of topical agents. The evaluation of skin wounds is inherently subjective. In order to properly apply these findings to my practice, it would be helpful to have more objective diagnostic criteria to properly classify skin wounds.
Furthermore, how patients use topical agents varies considerably. Patients apply topical agents differently, due to individual preference or perhaps inconsistent recommendations from their physician. Used improperly, topical agents may not provide the same potential for clinical improvement.
Evidence summary
Topical antibiotics for prophylaxis
Numerous studies support the prophylactic application of topical antibiotics to wounds that are clean. Topical bacitracin zinc (Bacitracin), a triple ointment of neomycin sulfate, bacitracin zinc, and polymyxin B sulfate (Neosporin), and silver sulfadiazine (Silvadene) were compared with petrolatum as a control in a well-conducted RCT of 426 patients with uncomplicated wounds seen at a military community hospital. Wound infection rates were 17.6% (19/108) for petrolatum, 5.5% (6/109) for Bacitracin (number needed to treat [NNT]=8), 4.5% (5/110) for Neosporin (NNT=8), and 12.1% (12/99) for Silvadene (NNT=18).1 Most (60%) of the infections were “stitch abscesses” and were treated with local care only. There was no difference in rates of more serious infections between groups. One patient (0.9%) developed a hypersensitivity reaction to Neosporin.
A clinical trial compared the efficacy of a cetrimide, bacitracin zinc, and polymyxin B sulfate gel (a combination not available in the US) with placebo and povidone-iodine cream in preventing infections in 177 minor wounds (cuts, grazes, scrapes, and scratches) among children. The antibiotic gel was found to be superior to placebo and equivalent to povidone-iodine, in that it reduced clinical infections from 12.5% to 1.6% (absolute risk reduction [ARR]=0.109; 95% confidence interval [CI], 0.011–0.207; NNT=11).2
A double-blind study of 59 patients found Neosporin superior to placebo ointment in the prevention of streptococcal pyoderma for children with minor wounds. Infection occurred in 47% of placebo-treated children compared with 15% treated with the triple-antibiotic ointment (NNT=32; P=.01).3
A small randomized prospective trial of 99 patients, who self-reported compliance with wound care and dressing changes, compared Neosporin with mupirocin (Bactroban) in preventing infections in uncomplicated soft tissue wounds. The study found no statistical difference in infection rates, and the authors recommend the more cost-effective Neosporin, as well as a larger trial to confirm the results.4
Another randomized controlled trial of 933 outpatients—with a total of 1249 wounds from sterile dermatologic surgeries—compared white petrolatum with bacitracin zinc ointment prophylaxis. The study found no statistically significant differences in post-procedure infection rates, though only 13 patients developed an infection (2% in petrolatum group vs. 0.9% in bacitracin zinc group; 95% CI for the difference, –0.4 to 2.7).5
Topical antibiotics for treatment
Topical antimicrobials are appealing for the treatment of secondarily infected wounds for the sake of convenience and because they may reduce the risk of adverse effects.
An open randomized trial with 48 volunteers compared the effects of Neosporin with several antiseptics (3% hydrogen peroxide, 1% povidone-iodine, 0.25% acetic acid, 0.5% sodium hydrochloride) and a wound protectant (Johnson & Johnson First Aid Cream without antimicrobial agent) on blister wounds (6 blisters per volunteer) intentionally contaminated with S aureus. Only Neosporin eliminated the infection after 2 applications (at 16 and 24 hours). Both the antibiotic ointment and the wound protectant led to faster wound healing by about 4 days compared with the antiseptics or no treatment.6
Another study with 2 parallel, identical RCTs of a total of 706 patients found mupirocin cream (Bactroban) to be equivalent to oral cephalexin in the treatment of secondarily infected minor wounds, such as small lacerations, abrasions, or sutured wounds. Clinical success (95.1% for mupirocin and 95.3% for cephalexin), bacteriologic success (96.9% for mupirocin and 98.9% for cephalexin), as well as the intention-to-treat success rate of 83% at follow-up were equivalent in the 2 groups.7
A small but well-designed study of 62 patients with major contaminated wounds failed to show any additional benefit when topical piperacillin/tazobactam (not available in US as a topical agent) was added to parenteral piperacillin/tazobactam (Zosyn) alone. Two of 31 patients on just parenteral antibiotics and 3 of 31 patients on both topical and parenteral antibiotics developed wound infections (P>.05).8
Finally, topical antibiotics also appear to aid in the healing of chronic wounds. However, these findings are difficult to interpret in light of small sample size and other methodological problems. A systematic review of the treatment of chronic wounds, such as diabetic foot ulcers, found 30 trials, including 25 RCTs, mostly of low quality. Little evidence supports the routine use of systemic antibiotics for patients with chronic wounds; however, some topical antiseptic and antimicrobial agents may hasten the healing of these wounds. Topical preparations that may be helpful include dimethyl sulfoxide (Rimso-50), silver sulfadiazine (Silvadene), benzoyl peroxide (Benzac, Brevoxyl, Desquam, Triaz, ZoDerm), oxyquinoline (Trimo-san Vaginal Jelly), and gentamicin (Garamycin).9
Honey may also make an acceptable wound dressing for chronic wounds, as it has been repeatedly shown to suppress bacterial growth. Infection with Clostridium spores does not appear to be a concern when treating chronic wounds with honey.10,11
Recommendations from others
Guidelines for antibiotic prophylaxis of surgical wounds uniformly recommend prophylaxis for all clean-contaminated, contaminated, and dirty procedures. Prophylaxis is considered optional for most clean procedures, although it may be indicated for certain at-risk patients and for clean procedures that fulfill specific risk criteria.12
The Infectious Diseases Society of America recommends mupirocin as the best topical agent for the treatment and prevention of S aureus and S pyogenes infections, followed by bacitracin zinc and neomycin, although resistance is emerging.13 Expert and consensus opinion from the Canadian Chronic Wound Advisory Board and the International Wound Bed Preparation Advisory Board for wound care management of infected chronic wounds recommend that since bacterial infection can develop gradually, good-quality wound cultures should be used in conjunction with clinical assessment. Iodine and silver-based dressings, topical antibiotics, and systemic antibiotics can be helpful.14
1. Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 1995;2:4-10.
2. Langford JH, Artemi P, Benrimoj SI. Topical antimicrobial prophylaxis in minor wounds. Ann Pharmacotherapy 1997;31:559-563.
3. Maddox JS, Ware JC, Dillon HC, Jr. The natural history of streptococcal skin infection: prevention with topical antibiotics. J Am Acad Derm 1985;13:207-212.
4. Hood R, Shermock KM, Emerman C. A prospective, randomized pilot evaluation of topical triple antibiotic versus mupirocin for the prevention of uncomplicated soft tissue wound infections. Am J Emerg Med 2005;22:1-3.
5. Smack DP, Harrington AC, Dunn C, et al. Infection and allergic incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA 1996;276:972-977.
6. Leyden JJ, Bartelt NM. Comparison of topical antibiotic ointment, a wound protectant and antiseptic for the treatment of human blister wounds contaminated with Staphylococcus aureus. J Fam Pract 1987;24:601-604.
7. Kraus SJ, Eron LJ, Bottenfield GW, Drehobl MA, Bushnell WD, Cupo MA. Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected wounds. J Fam Pract 1998;47:429-433.
8. Simons JP, Johnson JT, Yu VL, et al. The role of topical antimicrobial prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction. Laryngoscope 2001;111:329-335.
9. O’Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg 2001;88:4-21.
10. Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2005;5:40-54.
11. Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatology 2001;2:13-19.
12. Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician 1998;57:2731-2740.
13. Stevens DL, Bisno AL, Chambers HF, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of soft-tissue infections. Clin Infect Dis 2005;41:1373-1406.
14. Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician 2005;51:1352-1359.
The use of topical triple-antibiotic ointments significantly decreases infection rates in minor contaminated wounds compared with a petrolatum control. Plain petrolatum ointment is equivalent to triple-antibiotic ointments for sterile wounds as a post-procedure wound dressing (strength of recommendation [SOR]: A, based on randomized controlled trials [RCTs]).
Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected minor wounds and, because of better tolerability, is the treatment of choice for the prevention and treatment of Staphylococcus aureus and Staphylococcus pyogenes infections. Emerging resistance, including methicillin-resistant S aureus (MRSA), makes it prudent to check for clinical response in 24 to 48 hours. Major contaminated wounds requiring parenteral antibiotics do not appear to additionally benefit from topical antibiotics (SOR: A, based on RCTs).
Topical antibiotics may also aid in the healing of chronic wounds (SOR: B, based on a systematic review of low-quality RCTs), as does the application of honey (SOR: B, based on a systematic review of cohort studies).
It would be helpful to have objective criteria to properly classify skin wounds
Michael Mendoza, MD, MPH
Pritzker School of Medicine, University of Chicago
These results are encouraging, but they do not fully account for variability in the diagnosis of skin wounds or in the practical use of topical agents. The evaluation of skin wounds is inherently subjective. In order to properly apply these findings to my practice, it would be helpful to have more objective diagnostic criteria to properly classify skin wounds.
Furthermore, how patients use topical agents varies considerably. Patients apply topical agents differently, due to individual preference or perhaps inconsistent recommendations from their physician. Used improperly, topical agents may not provide the same potential for clinical improvement.
Evidence summary
Topical antibiotics for prophylaxis
Numerous studies support the prophylactic application of topical antibiotics to wounds that are clean. Topical bacitracin zinc (Bacitracin), a triple ointment of neomycin sulfate, bacitracin zinc, and polymyxin B sulfate (Neosporin), and silver sulfadiazine (Silvadene) were compared with petrolatum as a control in a well-conducted RCT of 426 patients with uncomplicated wounds seen at a military community hospital. Wound infection rates were 17.6% (19/108) for petrolatum, 5.5% (6/109) for Bacitracin (number needed to treat [NNT]=8), 4.5% (5/110) for Neosporin (NNT=8), and 12.1% (12/99) for Silvadene (NNT=18).1 Most (60%) of the infections were “stitch abscesses” and were treated with local care only. There was no difference in rates of more serious infections between groups. One patient (0.9%) developed a hypersensitivity reaction to Neosporin.
A clinical trial compared the efficacy of a cetrimide, bacitracin zinc, and polymyxin B sulfate gel (a combination not available in the US) with placebo and povidone-iodine cream in preventing infections in 177 minor wounds (cuts, grazes, scrapes, and scratches) among children. The antibiotic gel was found to be superior to placebo and equivalent to povidone-iodine, in that it reduced clinical infections from 12.5% to 1.6% (absolute risk reduction [ARR]=0.109; 95% confidence interval [CI], 0.011–0.207; NNT=11).2
A double-blind study of 59 patients found Neosporin superior to placebo ointment in the prevention of streptococcal pyoderma for children with minor wounds. Infection occurred in 47% of placebo-treated children compared with 15% treated with the triple-antibiotic ointment (NNT=32; P=.01).3
A small randomized prospective trial of 99 patients, who self-reported compliance with wound care and dressing changes, compared Neosporin with mupirocin (Bactroban) in preventing infections in uncomplicated soft tissue wounds. The study found no statistical difference in infection rates, and the authors recommend the more cost-effective Neosporin, as well as a larger trial to confirm the results.4
Another randomized controlled trial of 933 outpatients—with a total of 1249 wounds from sterile dermatologic surgeries—compared white petrolatum with bacitracin zinc ointment prophylaxis. The study found no statistically significant differences in post-procedure infection rates, though only 13 patients developed an infection (2% in petrolatum group vs. 0.9% in bacitracin zinc group; 95% CI for the difference, –0.4 to 2.7).5
Topical antibiotics for treatment
Topical antimicrobials are appealing for the treatment of secondarily infected wounds for the sake of convenience and because they may reduce the risk of adverse effects.
An open randomized trial with 48 volunteers compared the effects of Neosporin with several antiseptics (3% hydrogen peroxide, 1% povidone-iodine, 0.25% acetic acid, 0.5% sodium hydrochloride) and a wound protectant (Johnson & Johnson First Aid Cream without antimicrobial agent) on blister wounds (6 blisters per volunteer) intentionally contaminated with S aureus. Only Neosporin eliminated the infection after 2 applications (at 16 and 24 hours). Both the antibiotic ointment and the wound protectant led to faster wound healing by about 4 days compared with the antiseptics or no treatment.6
Another study with 2 parallel, identical RCTs of a total of 706 patients found mupirocin cream (Bactroban) to be equivalent to oral cephalexin in the treatment of secondarily infected minor wounds, such as small lacerations, abrasions, or sutured wounds. Clinical success (95.1% for mupirocin and 95.3% for cephalexin), bacteriologic success (96.9% for mupirocin and 98.9% for cephalexin), as well as the intention-to-treat success rate of 83% at follow-up were equivalent in the 2 groups.7
A small but well-designed study of 62 patients with major contaminated wounds failed to show any additional benefit when topical piperacillin/tazobactam (not available in US as a topical agent) was added to parenteral piperacillin/tazobactam (Zosyn) alone. Two of 31 patients on just parenteral antibiotics and 3 of 31 patients on both topical and parenteral antibiotics developed wound infections (P>.05).8
Finally, topical antibiotics also appear to aid in the healing of chronic wounds. However, these findings are difficult to interpret in light of small sample size and other methodological problems. A systematic review of the treatment of chronic wounds, such as diabetic foot ulcers, found 30 trials, including 25 RCTs, mostly of low quality. Little evidence supports the routine use of systemic antibiotics for patients with chronic wounds; however, some topical antiseptic and antimicrobial agents may hasten the healing of these wounds. Topical preparations that may be helpful include dimethyl sulfoxide (Rimso-50), silver sulfadiazine (Silvadene), benzoyl peroxide (Benzac, Brevoxyl, Desquam, Triaz, ZoDerm), oxyquinoline (Trimo-san Vaginal Jelly), and gentamicin (Garamycin).9
Honey may also make an acceptable wound dressing for chronic wounds, as it has been repeatedly shown to suppress bacterial growth. Infection with Clostridium spores does not appear to be a concern when treating chronic wounds with honey.10,11
Recommendations from others
Guidelines for antibiotic prophylaxis of surgical wounds uniformly recommend prophylaxis for all clean-contaminated, contaminated, and dirty procedures. Prophylaxis is considered optional for most clean procedures, although it may be indicated for certain at-risk patients and for clean procedures that fulfill specific risk criteria.12
The Infectious Diseases Society of America recommends mupirocin as the best topical agent for the treatment and prevention of S aureus and S pyogenes infections, followed by bacitracin zinc and neomycin, although resistance is emerging.13 Expert and consensus opinion from the Canadian Chronic Wound Advisory Board and the International Wound Bed Preparation Advisory Board for wound care management of infected chronic wounds recommend that since bacterial infection can develop gradually, good-quality wound cultures should be used in conjunction with clinical assessment. Iodine and silver-based dressings, topical antibiotics, and systemic antibiotics can be helpful.14
The use of topical triple-antibiotic ointments significantly decreases infection rates in minor contaminated wounds compared with a petrolatum control. Plain petrolatum ointment is equivalent to triple-antibiotic ointments for sterile wounds as a post-procedure wound dressing (strength of recommendation [SOR]: A, based on randomized controlled trials [RCTs]).
Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected minor wounds and, because of better tolerability, is the treatment of choice for the prevention and treatment of Staphylococcus aureus and Staphylococcus pyogenes infections. Emerging resistance, including methicillin-resistant S aureus (MRSA), makes it prudent to check for clinical response in 24 to 48 hours. Major contaminated wounds requiring parenteral antibiotics do not appear to additionally benefit from topical antibiotics (SOR: A, based on RCTs).
Topical antibiotics may also aid in the healing of chronic wounds (SOR: B, based on a systematic review of low-quality RCTs), as does the application of honey (SOR: B, based on a systematic review of cohort studies).
It would be helpful to have objective criteria to properly classify skin wounds
Michael Mendoza, MD, MPH
Pritzker School of Medicine, University of Chicago
These results are encouraging, but they do not fully account for variability in the diagnosis of skin wounds or in the practical use of topical agents. The evaluation of skin wounds is inherently subjective. In order to properly apply these findings to my practice, it would be helpful to have more objective diagnostic criteria to properly classify skin wounds.
Furthermore, how patients use topical agents varies considerably. Patients apply topical agents differently, due to individual preference or perhaps inconsistent recommendations from their physician. Used improperly, topical agents may not provide the same potential for clinical improvement.
Evidence summary
Topical antibiotics for prophylaxis
Numerous studies support the prophylactic application of topical antibiotics to wounds that are clean. Topical bacitracin zinc (Bacitracin), a triple ointment of neomycin sulfate, bacitracin zinc, and polymyxin B sulfate (Neosporin), and silver sulfadiazine (Silvadene) were compared with petrolatum as a control in a well-conducted RCT of 426 patients with uncomplicated wounds seen at a military community hospital. Wound infection rates were 17.6% (19/108) for petrolatum, 5.5% (6/109) for Bacitracin (number needed to treat [NNT]=8), 4.5% (5/110) for Neosporin (NNT=8), and 12.1% (12/99) for Silvadene (NNT=18).1 Most (60%) of the infections were “stitch abscesses” and were treated with local care only. There was no difference in rates of more serious infections between groups. One patient (0.9%) developed a hypersensitivity reaction to Neosporin.
A clinical trial compared the efficacy of a cetrimide, bacitracin zinc, and polymyxin B sulfate gel (a combination not available in the US) with placebo and povidone-iodine cream in preventing infections in 177 minor wounds (cuts, grazes, scrapes, and scratches) among children. The antibiotic gel was found to be superior to placebo and equivalent to povidone-iodine, in that it reduced clinical infections from 12.5% to 1.6% (absolute risk reduction [ARR]=0.109; 95% confidence interval [CI], 0.011–0.207; NNT=11).2
A double-blind study of 59 patients found Neosporin superior to placebo ointment in the prevention of streptococcal pyoderma for children with minor wounds. Infection occurred in 47% of placebo-treated children compared with 15% treated with the triple-antibiotic ointment (NNT=32; P=.01).3
A small randomized prospective trial of 99 patients, who self-reported compliance with wound care and dressing changes, compared Neosporin with mupirocin (Bactroban) in preventing infections in uncomplicated soft tissue wounds. The study found no statistical difference in infection rates, and the authors recommend the more cost-effective Neosporin, as well as a larger trial to confirm the results.4
Another randomized controlled trial of 933 outpatients—with a total of 1249 wounds from sterile dermatologic surgeries—compared white petrolatum with bacitracin zinc ointment prophylaxis. The study found no statistically significant differences in post-procedure infection rates, though only 13 patients developed an infection (2% in petrolatum group vs. 0.9% in bacitracin zinc group; 95% CI for the difference, –0.4 to 2.7).5
Topical antibiotics for treatment
Topical antimicrobials are appealing for the treatment of secondarily infected wounds for the sake of convenience and because they may reduce the risk of adverse effects.
An open randomized trial with 48 volunteers compared the effects of Neosporin with several antiseptics (3% hydrogen peroxide, 1% povidone-iodine, 0.25% acetic acid, 0.5% sodium hydrochloride) and a wound protectant (Johnson & Johnson First Aid Cream without antimicrobial agent) on blister wounds (6 blisters per volunteer) intentionally contaminated with S aureus. Only Neosporin eliminated the infection after 2 applications (at 16 and 24 hours). Both the antibiotic ointment and the wound protectant led to faster wound healing by about 4 days compared with the antiseptics or no treatment.6
Another study with 2 parallel, identical RCTs of a total of 706 patients found mupirocin cream (Bactroban) to be equivalent to oral cephalexin in the treatment of secondarily infected minor wounds, such as small lacerations, abrasions, or sutured wounds. Clinical success (95.1% for mupirocin and 95.3% for cephalexin), bacteriologic success (96.9% for mupirocin and 98.9% for cephalexin), as well as the intention-to-treat success rate of 83% at follow-up were equivalent in the 2 groups.7
A small but well-designed study of 62 patients with major contaminated wounds failed to show any additional benefit when topical piperacillin/tazobactam (not available in US as a topical agent) was added to parenteral piperacillin/tazobactam (Zosyn) alone. Two of 31 patients on just parenteral antibiotics and 3 of 31 patients on both topical and parenteral antibiotics developed wound infections (P>.05).8
Finally, topical antibiotics also appear to aid in the healing of chronic wounds. However, these findings are difficult to interpret in light of small sample size and other methodological problems. A systematic review of the treatment of chronic wounds, such as diabetic foot ulcers, found 30 trials, including 25 RCTs, mostly of low quality. Little evidence supports the routine use of systemic antibiotics for patients with chronic wounds; however, some topical antiseptic and antimicrobial agents may hasten the healing of these wounds. Topical preparations that may be helpful include dimethyl sulfoxide (Rimso-50), silver sulfadiazine (Silvadene), benzoyl peroxide (Benzac, Brevoxyl, Desquam, Triaz, ZoDerm), oxyquinoline (Trimo-san Vaginal Jelly), and gentamicin (Garamycin).9
Honey may also make an acceptable wound dressing for chronic wounds, as it has been repeatedly shown to suppress bacterial growth. Infection with Clostridium spores does not appear to be a concern when treating chronic wounds with honey.10,11
Recommendations from others
Guidelines for antibiotic prophylaxis of surgical wounds uniformly recommend prophylaxis for all clean-contaminated, contaminated, and dirty procedures. Prophylaxis is considered optional for most clean procedures, although it may be indicated for certain at-risk patients and for clean procedures that fulfill specific risk criteria.12
The Infectious Diseases Society of America recommends mupirocin as the best topical agent for the treatment and prevention of S aureus and S pyogenes infections, followed by bacitracin zinc and neomycin, although resistance is emerging.13 Expert and consensus opinion from the Canadian Chronic Wound Advisory Board and the International Wound Bed Preparation Advisory Board for wound care management of infected chronic wounds recommend that since bacterial infection can develop gradually, good-quality wound cultures should be used in conjunction with clinical assessment. Iodine and silver-based dressings, topical antibiotics, and systemic antibiotics can be helpful.14
1. Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 1995;2:4-10.
2. Langford JH, Artemi P, Benrimoj SI. Topical antimicrobial prophylaxis in minor wounds. Ann Pharmacotherapy 1997;31:559-563.
3. Maddox JS, Ware JC, Dillon HC, Jr. The natural history of streptococcal skin infection: prevention with topical antibiotics. J Am Acad Derm 1985;13:207-212.
4. Hood R, Shermock KM, Emerman C. A prospective, randomized pilot evaluation of topical triple antibiotic versus mupirocin for the prevention of uncomplicated soft tissue wound infections. Am J Emerg Med 2005;22:1-3.
5. Smack DP, Harrington AC, Dunn C, et al. Infection and allergic incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA 1996;276:972-977.
6. Leyden JJ, Bartelt NM. Comparison of topical antibiotic ointment, a wound protectant and antiseptic for the treatment of human blister wounds contaminated with Staphylococcus aureus. J Fam Pract 1987;24:601-604.
7. Kraus SJ, Eron LJ, Bottenfield GW, Drehobl MA, Bushnell WD, Cupo MA. Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected wounds. J Fam Pract 1998;47:429-433.
8. Simons JP, Johnson JT, Yu VL, et al. The role of topical antimicrobial prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction. Laryngoscope 2001;111:329-335.
9. O’Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg 2001;88:4-21.
10. Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2005;5:40-54.
11. Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatology 2001;2:13-19.
12. Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician 1998;57:2731-2740.
13. Stevens DL, Bisno AL, Chambers HF, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of soft-tissue infections. Clin Infect Dis 2005;41:1373-1406.
14. Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician 2005;51:1352-1359.
1. Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 1995;2:4-10.
2. Langford JH, Artemi P, Benrimoj SI. Topical antimicrobial prophylaxis in minor wounds. Ann Pharmacotherapy 1997;31:559-563.
3. Maddox JS, Ware JC, Dillon HC, Jr. The natural history of streptococcal skin infection: prevention with topical antibiotics. J Am Acad Derm 1985;13:207-212.
4. Hood R, Shermock KM, Emerman C. A prospective, randomized pilot evaluation of topical triple antibiotic versus mupirocin for the prevention of uncomplicated soft tissue wound infections. Am J Emerg Med 2005;22:1-3.
5. Smack DP, Harrington AC, Dunn C, et al. Infection and allergic incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA 1996;276:972-977.
6. Leyden JJ, Bartelt NM. Comparison of topical antibiotic ointment, a wound protectant and antiseptic for the treatment of human blister wounds contaminated with Staphylococcus aureus. J Fam Pract 1987;24:601-604.
7. Kraus SJ, Eron LJ, Bottenfield GW, Drehobl MA, Bushnell WD, Cupo MA. Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected wounds. J Fam Pract 1998;47:429-433.
8. Simons JP, Johnson JT, Yu VL, et al. The role of topical antimicrobial prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction. Laryngoscope 2001;111:329-335.
9. O’Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg 2001;88:4-21.
10. Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2005;5:40-54.
11. Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatology 2001;2:13-19.
12. Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician 1998;57:2731-2740.
13. Stevens DL, Bisno AL, Chambers HF, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of soft-tissue infections. Clin Infect Dis 2005;41:1373-1406.
14. Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician 2005;51:1352-1359.
Evidence-based answers from the Family Physicians Inquiries Network
What is the best way to diagnose a suspected rotator cuff tear?
The evaluation of a suspected rotator cuff tear should start with a history and a clinical exam of the shoulder (strength of recommendation [SOR]: B, based on a systematic review of cohort studies).1 Three clinical test results in particular—supraspinatus weakness, weakness of external rotation, and impingement—or 2 positive tests for a patient older than 60 years were highly predictive of rotator cuff tear (SOR: B, based on individual prospective study).2
Either magnetic resonance imaging (MRI) or ultrasound can confirm a possible full-thickness tear (SOR: B, based on a systematic review of cohort studies).1 If a patient has an implantable device prohibiting MRI imaging, conventional arthrography is an alternative (SOR: A, individual randomized controlled trial).3 Suspected partial-thickness tears are best verified with an ultrasound (SOR: B, based on a systematic review of cohort studies).1
The best test is based on experience, availability, cost, and contraindications
A thorough history and detailed exam (with the patient disrobed) contributes to an accurate diagnosis. The mechanism of injury, such as falling on an outstretched arm or repetitive/excessive use of the shoulder like pitching a baseball, can begin to suggest a rotator cuff tear. Rotator cuff pain is typically located in the lateral deltoid and is aggravated by activities like combing one’s hair or reaching for a wallet in the back pocket. Patients often have trouble sleeping, since they are unable to find a comfortable position.
Other important factors to consider are cost, availability of a test in a timely manner, and the skill of the operators in carrying out and interpreting a given study. What constitutes the most accurate, cost-effective, expedient, or least invasive approach to the diagnosis of either full- or partial-thickness rotator cuff tears is controversial. For now the question as to what is “best” should be answered on the basis of clinical experience, availability, the expected sensitivity and specificity of a test at your institution, and the cost and contraindications for your patient.
Evidence summary
Rotator cuff tears can cause shoulder pain, decreased strength, and decreased range of motion. Clinical findings associated with a rotator cuff injury can vary. Full-thickness and partial-thickness tears may present differently, and it is important to test clinically for both of these conditions.
A meta-analysis of 10 cohort studies found the overall sensitivity and specificity of a clinical exam to rule out a full-thickness rotator cuff tear to be 0.9 (95% confidence interval [CI], 0.87–0.93) and 0.54 (95% CI, 0.47–0.61).1 However, no single physical exam finding provided comparable accuracy. Another prospective study of 400 patients comparing 23 different clinical exams found that 3 simple clinical tests—supraspinatus weakness, weakness in external rotation, and the presence of impingement—were highly predictive of rotator cuff tear. When all 3 tests were positive, or when 2 tests were positive for a patient aged >60 years, there was a 98% chance of the patient having a rotator cuff tear.2
Ultrasound can be used to evaluate both suspected full- and partial-thickness rotator cuff tears. In a systematic review of 38 cohort studies, the overall sensitivity and specificity of ultrasound for full-thickness rotator cuff tears was 0.87 (95% CI, 0.84–0.89) and 0.96 (95% CI, 0.94–0.97).1 For partial-thickness tears, ultrasound sensitivity was 0.67 (95% CI, 0.61–0.73).1 The incidence of rotator cuff tears increases with age and with athletic activity.5
Positive and negative predictive values of a test depend on the prevalence of the condition in the study population. In the case of rotator cuff tears, such differences in prevalence of rotator cuff tears in the 38 cohort studies left it unclear whether a negative ultrasound could reliably rule out a tear.
A meta-analysis of 29 cohort studies of MRI for the diagnosis of full-thickness tears found a pooled sensitivity of 0.89 (95% CI, 0.86–0.92) and a pooled specificity of 0.93 (95% CI, 0.91–0.95), respectively.1 For partial-thickness tears, the pooled MRI sensitivity was lower at 0.44 (95% CI, 0.36–0.51), but with a high specificity of 0.90 (95% CI, 0.87–0.92).1 This implies that MRI is the most valuable test to rule out a partial-thickness tear. However, we found no studies that directly compared the test characteristics of ultrasound and MRI.
Conventional arthrography can be used as an invasive alternative to MRI imaging for full-thickness tears, particularly when an implanted device precludes the use of MRI. One prospective trial (in which patients were randomized to the order in which MRI or arthrography were performed) of 38 patients showed arthrography to have a sensitivity of 0.50 and a specificity of 0.96 when used to diagnose full-thickness tears.3,6
Magnetic resonance arthrography (MRA), based on 6 cohort studies, may be accurate in the diagnosis of a full-thickness tear, with a sensitivity of 0.95 (95% CI, 0.82–0.98) and specificity of 0.93 (95% CI, 0.84–0.97).1 In these studies, diagnosis of partial-thickness tears with MRA was inconsistent.1 The invasiveness of MRA limits its utility as compared with MRI and ultrasound. The TABLE summarizes these findings.
TABLE
Summary of test characteristics of diagnostic studies for rotator cuff injuries
| DIAGNOSTIC STUDY | FULL-THICKNESS ROTATOR CUFF TEAR | PARTIAL-THICKNESS ROTATOR CUFF TEAR | ||||||
|---|---|---|---|---|---|---|---|---|
| SN | SP | LR+ | LR– | SN | SP | LR+ | LR– | |
| Clinical exam1 | 0.9 | 0.54 | 1.96 | 0.19 | Inconclusive due to small sample size | |||
| Ultrasound1 | 0.87 | 0.96 | 21.75 | 0.14 | 0.67 | 0.94 | 11.17 | 0.35 |
| MRI1 | 0.89 | 0.93 | 12.71 | 0.12 | 0.44 | 0.9 | 4.4 | 0.73 |
| Arthrography2 | 0.50 | 0.96 | 12.5 | 0.52 | Not evaluated | |||
| MR arthrography1 | 0.95 | 0.96 | 23.75 | 0.05 | Inconsistent test performance | |||
| Sn, sensitivity; Sp, specificity; LR+, positive likelihood ratio; LR–, negative likelihood ratio; MRI, magnetic resonance imaging. | ||||||||
Recommendations from others
The American Academy of Orthopaedic Surgeons has a clinical guideline on shoulder pain,4 and the Brigham and Women’s Hospital has a guide to the prevention, diagnosis and treatment of upper extremity musculoskeletal disorders.5 These guidelines emphasize the importance and utility of physical examination of the shoulder. A patient with a full-thickness tear will likely demonstrate compromised strength in shoulder active mid-arc abduction and resisted external rotation with elbow flexed at patient’s side. However, a partial tear might not compromise strength. Atrophy of the infraspinatus or supra-spinatus muscles is sometimes seen with a full-thickness tear that is several weeks old.5
Following a clinical assessment, the guidelines give no preference to any of the diagnostic tests mentioned above, with the exception of arthrography in the presence of implantable devices. Plain X-rays are typically unrevealing, but could be used to rule out other reasons for pain, such as calcific tendonitis.
1. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003;7:iii,1-166.
2. Murrell G, Walton J. Diagnosis of rotator cuff tears. Lancet 2001;357:769-770.
3. Blanchard TK, Bearcroft PW, Constant CR, Griffin DR, Dixon AK. Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears. Eur Radiol 1999;9:638-642.
4. American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain: support document. Rosemont, III: American Academy of Orthopaedic Surgeons; 2001.
5. Brigham and Women’s Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, Mass: Brigham and Women’s Hospital; 2003.
6. Oh CH, Schweitzer ME, Spettell CM. Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography. Skeletal Radiol 1999;28:670-678.
The evaluation of a suspected rotator cuff tear should start with a history and a clinical exam of the shoulder (strength of recommendation [SOR]: B, based on a systematic review of cohort studies).1 Three clinical test results in particular—supraspinatus weakness, weakness of external rotation, and impingement—or 2 positive tests for a patient older than 60 years were highly predictive of rotator cuff tear (SOR: B, based on individual prospective study).2
Either magnetic resonance imaging (MRI) or ultrasound can confirm a possible full-thickness tear (SOR: B, based on a systematic review of cohort studies).1 If a patient has an implantable device prohibiting MRI imaging, conventional arthrography is an alternative (SOR: A, individual randomized controlled trial).3 Suspected partial-thickness tears are best verified with an ultrasound (SOR: B, based on a systematic review of cohort studies).1
The best test is based on experience, availability, cost, and contraindications
A thorough history and detailed exam (with the patient disrobed) contributes to an accurate diagnosis. The mechanism of injury, such as falling on an outstretched arm or repetitive/excessive use of the shoulder like pitching a baseball, can begin to suggest a rotator cuff tear. Rotator cuff pain is typically located in the lateral deltoid and is aggravated by activities like combing one’s hair or reaching for a wallet in the back pocket. Patients often have trouble sleeping, since they are unable to find a comfortable position.
Other important factors to consider are cost, availability of a test in a timely manner, and the skill of the operators in carrying out and interpreting a given study. What constitutes the most accurate, cost-effective, expedient, or least invasive approach to the diagnosis of either full- or partial-thickness rotator cuff tears is controversial. For now the question as to what is “best” should be answered on the basis of clinical experience, availability, the expected sensitivity and specificity of a test at your institution, and the cost and contraindications for your patient.
Evidence summary
Rotator cuff tears can cause shoulder pain, decreased strength, and decreased range of motion. Clinical findings associated with a rotator cuff injury can vary. Full-thickness and partial-thickness tears may present differently, and it is important to test clinically for both of these conditions.
A meta-analysis of 10 cohort studies found the overall sensitivity and specificity of a clinical exam to rule out a full-thickness rotator cuff tear to be 0.9 (95% confidence interval [CI], 0.87–0.93) and 0.54 (95% CI, 0.47–0.61).1 However, no single physical exam finding provided comparable accuracy. Another prospective study of 400 patients comparing 23 different clinical exams found that 3 simple clinical tests—supraspinatus weakness, weakness in external rotation, and the presence of impingement—were highly predictive of rotator cuff tear. When all 3 tests were positive, or when 2 tests were positive for a patient aged >60 years, there was a 98% chance of the patient having a rotator cuff tear.2
Ultrasound can be used to evaluate both suspected full- and partial-thickness rotator cuff tears. In a systematic review of 38 cohort studies, the overall sensitivity and specificity of ultrasound for full-thickness rotator cuff tears was 0.87 (95% CI, 0.84–0.89) and 0.96 (95% CI, 0.94–0.97).1 For partial-thickness tears, ultrasound sensitivity was 0.67 (95% CI, 0.61–0.73).1 The incidence of rotator cuff tears increases with age and with athletic activity.5
Positive and negative predictive values of a test depend on the prevalence of the condition in the study population. In the case of rotator cuff tears, such differences in prevalence of rotator cuff tears in the 38 cohort studies left it unclear whether a negative ultrasound could reliably rule out a tear.
A meta-analysis of 29 cohort studies of MRI for the diagnosis of full-thickness tears found a pooled sensitivity of 0.89 (95% CI, 0.86–0.92) and a pooled specificity of 0.93 (95% CI, 0.91–0.95), respectively.1 For partial-thickness tears, the pooled MRI sensitivity was lower at 0.44 (95% CI, 0.36–0.51), but with a high specificity of 0.90 (95% CI, 0.87–0.92).1 This implies that MRI is the most valuable test to rule out a partial-thickness tear. However, we found no studies that directly compared the test characteristics of ultrasound and MRI.
Conventional arthrography can be used as an invasive alternative to MRI imaging for full-thickness tears, particularly when an implanted device precludes the use of MRI. One prospective trial (in which patients were randomized to the order in which MRI or arthrography were performed) of 38 patients showed arthrography to have a sensitivity of 0.50 and a specificity of 0.96 when used to diagnose full-thickness tears.3,6
Magnetic resonance arthrography (MRA), based on 6 cohort studies, may be accurate in the diagnosis of a full-thickness tear, with a sensitivity of 0.95 (95% CI, 0.82–0.98) and specificity of 0.93 (95% CI, 0.84–0.97).1 In these studies, diagnosis of partial-thickness tears with MRA was inconsistent.1 The invasiveness of MRA limits its utility as compared with MRI and ultrasound. The TABLE summarizes these findings.
TABLE
Summary of test characteristics of diagnostic studies for rotator cuff injuries
| DIAGNOSTIC STUDY | FULL-THICKNESS ROTATOR CUFF TEAR | PARTIAL-THICKNESS ROTATOR CUFF TEAR | ||||||
|---|---|---|---|---|---|---|---|---|
| SN | SP | LR+ | LR– | SN | SP | LR+ | LR– | |
| Clinical exam1 | 0.9 | 0.54 | 1.96 | 0.19 | Inconclusive due to small sample size | |||
| Ultrasound1 | 0.87 | 0.96 | 21.75 | 0.14 | 0.67 | 0.94 | 11.17 | 0.35 |
| MRI1 | 0.89 | 0.93 | 12.71 | 0.12 | 0.44 | 0.9 | 4.4 | 0.73 |
| Arthrography2 | 0.50 | 0.96 | 12.5 | 0.52 | Not evaluated | |||
| MR arthrography1 | 0.95 | 0.96 | 23.75 | 0.05 | Inconsistent test performance | |||
| Sn, sensitivity; Sp, specificity; LR+, positive likelihood ratio; LR–, negative likelihood ratio; MRI, magnetic resonance imaging. | ||||||||
Recommendations from others
The American Academy of Orthopaedic Surgeons has a clinical guideline on shoulder pain,4 and the Brigham and Women’s Hospital has a guide to the prevention, diagnosis and treatment of upper extremity musculoskeletal disorders.5 These guidelines emphasize the importance and utility of physical examination of the shoulder. A patient with a full-thickness tear will likely demonstrate compromised strength in shoulder active mid-arc abduction and resisted external rotation with elbow flexed at patient’s side. However, a partial tear might not compromise strength. Atrophy of the infraspinatus or supra-spinatus muscles is sometimes seen with a full-thickness tear that is several weeks old.5
Following a clinical assessment, the guidelines give no preference to any of the diagnostic tests mentioned above, with the exception of arthrography in the presence of implantable devices. Plain X-rays are typically unrevealing, but could be used to rule out other reasons for pain, such as calcific tendonitis.
The evaluation of a suspected rotator cuff tear should start with a history and a clinical exam of the shoulder (strength of recommendation [SOR]: B, based on a systematic review of cohort studies).1 Three clinical test results in particular—supraspinatus weakness, weakness of external rotation, and impingement—or 2 positive tests for a patient older than 60 years were highly predictive of rotator cuff tear (SOR: B, based on individual prospective study).2
Either magnetic resonance imaging (MRI) or ultrasound can confirm a possible full-thickness tear (SOR: B, based on a systematic review of cohort studies).1 If a patient has an implantable device prohibiting MRI imaging, conventional arthrography is an alternative (SOR: A, individual randomized controlled trial).3 Suspected partial-thickness tears are best verified with an ultrasound (SOR: B, based on a systematic review of cohort studies).1
The best test is based on experience, availability, cost, and contraindications
A thorough history and detailed exam (with the patient disrobed) contributes to an accurate diagnosis. The mechanism of injury, such as falling on an outstretched arm or repetitive/excessive use of the shoulder like pitching a baseball, can begin to suggest a rotator cuff tear. Rotator cuff pain is typically located in the lateral deltoid and is aggravated by activities like combing one’s hair or reaching for a wallet in the back pocket. Patients often have trouble sleeping, since they are unable to find a comfortable position.
Other important factors to consider are cost, availability of a test in a timely manner, and the skill of the operators in carrying out and interpreting a given study. What constitutes the most accurate, cost-effective, expedient, or least invasive approach to the diagnosis of either full- or partial-thickness rotator cuff tears is controversial. For now the question as to what is “best” should be answered on the basis of clinical experience, availability, the expected sensitivity and specificity of a test at your institution, and the cost and contraindications for your patient.
Evidence summary
Rotator cuff tears can cause shoulder pain, decreased strength, and decreased range of motion. Clinical findings associated with a rotator cuff injury can vary. Full-thickness and partial-thickness tears may present differently, and it is important to test clinically for both of these conditions.
A meta-analysis of 10 cohort studies found the overall sensitivity and specificity of a clinical exam to rule out a full-thickness rotator cuff tear to be 0.9 (95% confidence interval [CI], 0.87–0.93) and 0.54 (95% CI, 0.47–0.61).1 However, no single physical exam finding provided comparable accuracy. Another prospective study of 400 patients comparing 23 different clinical exams found that 3 simple clinical tests—supraspinatus weakness, weakness in external rotation, and the presence of impingement—were highly predictive of rotator cuff tear. When all 3 tests were positive, or when 2 tests were positive for a patient aged >60 years, there was a 98% chance of the patient having a rotator cuff tear.2
Ultrasound can be used to evaluate both suspected full- and partial-thickness rotator cuff tears. In a systematic review of 38 cohort studies, the overall sensitivity and specificity of ultrasound for full-thickness rotator cuff tears was 0.87 (95% CI, 0.84–0.89) and 0.96 (95% CI, 0.94–0.97).1 For partial-thickness tears, ultrasound sensitivity was 0.67 (95% CI, 0.61–0.73).1 The incidence of rotator cuff tears increases with age and with athletic activity.5
Positive and negative predictive values of a test depend on the prevalence of the condition in the study population. In the case of rotator cuff tears, such differences in prevalence of rotator cuff tears in the 38 cohort studies left it unclear whether a negative ultrasound could reliably rule out a tear.
A meta-analysis of 29 cohort studies of MRI for the diagnosis of full-thickness tears found a pooled sensitivity of 0.89 (95% CI, 0.86–0.92) and a pooled specificity of 0.93 (95% CI, 0.91–0.95), respectively.1 For partial-thickness tears, the pooled MRI sensitivity was lower at 0.44 (95% CI, 0.36–0.51), but with a high specificity of 0.90 (95% CI, 0.87–0.92).1 This implies that MRI is the most valuable test to rule out a partial-thickness tear. However, we found no studies that directly compared the test characteristics of ultrasound and MRI.
Conventional arthrography can be used as an invasive alternative to MRI imaging for full-thickness tears, particularly when an implanted device precludes the use of MRI. One prospective trial (in which patients were randomized to the order in which MRI or arthrography were performed) of 38 patients showed arthrography to have a sensitivity of 0.50 and a specificity of 0.96 when used to diagnose full-thickness tears.3,6
Magnetic resonance arthrography (MRA), based on 6 cohort studies, may be accurate in the diagnosis of a full-thickness tear, with a sensitivity of 0.95 (95% CI, 0.82–0.98) and specificity of 0.93 (95% CI, 0.84–0.97).1 In these studies, diagnosis of partial-thickness tears with MRA was inconsistent.1 The invasiveness of MRA limits its utility as compared with MRI and ultrasound. The TABLE summarizes these findings.
TABLE
Summary of test characteristics of diagnostic studies for rotator cuff injuries
| DIAGNOSTIC STUDY | FULL-THICKNESS ROTATOR CUFF TEAR | PARTIAL-THICKNESS ROTATOR CUFF TEAR | ||||||
|---|---|---|---|---|---|---|---|---|
| SN | SP | LR+ | LR– | SN | SP | LR+ | LR– | |
| Clinical exam1 | 0.9 | 0.54 | 1.96 | 0.19 | Inconclusive due to small sample size | |||
| Ultrasound1 | 0.87 | 0.96 | 21.75 | 0.14 | 0.67 | 0.94 | 11.17 | 0.35 |
| MRI1 | 0.89 | 0.93 | 12.71 | 0.12 | 0.44 | 0.9 | 4.4 | 0.73 |
| Arthrography2 | 0.50 | 0.96 | 12.5 | 0.52 | Not evaluated | |||
| MR arthrography1 | 0.95 | 0.96 | 23.75 | 0.05 | Inconsistent test performance | |||
| Sn, sensitivity; Sp, specificity; LR+, positive likelihood ratio; LR–, negative likelihood ratio; MRI, magnetic resonance imaging. | ||||||||
Recommendations from others
The American Academy of Orthopaedic Surgeons has a clinical guideline on shoulder pain,4 and the Brigham and Women’s Hospital has a guide to the prevention, diagnosis and treatment of upper extremity musculoskeletal disorders.5 These guidelines emphasize the importance and utility of physical examination of the shoulder. A patient with a full-thickness tear will likely demonstrate compromised strength in shoulder active mid-arc abduction and resisted external rotation with elbow flexed at patient’s side. However, a partial tear might not compromise strength. Atrophy of the infraspinatus or supra-spinatus muscles is sometimes seen with a full-thickness tear that is several weeks old.5
Following a clinical assessment, the guidelines give no preference to any of the diagnostic tests mentioned above, with the exception of arthrography in the presence of implantable devices. Plain X-rays are typically unrevealing, but could be used to rule out other reasons for pain, such as calcific tendonitis.
1. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003;7:iii,1-166.
2. Murrell G, Walton J. Diagnosis of rotator cuff tears. Lancet 2001;357:769-770.
3. Blanchard TK, Bearcroft PW, Constant CR, Griffin DR, Dixon AK. Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears. Eur Radiol 1999;9:638-642.
4. American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain: support document. Rosemont, III: American Academy of Orthopaedic Surgeons; 2001.
5. Brigham and Women’s Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, Mass: Brigham and Women’s Hospital; 2003.
6. Oh CH, Schweitzer ME, Spettell CM. Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography. Skeletal Radiol 1999;28:670-678.
1. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003;7:iii,1-166.
2. Murrell G, Walton J. Diagnosis of rotator cuff tears. Lancet 2001;357:769-770.
3. Blanchard TK, Bearcroft PW, Constant CR, Griffin DR, Dixon AK. Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears. Eur Radiol 1999;9:638-642.
4. American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain: support document. Rosemont, III: American Academy of Orthopaedic Surgeons; 2001.
5. Brigham and Women’s Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, Mass: Brigham and Women’s Hospital; 2003.
6. Oh CH, Schweitzer ME, Spettell CM. Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography. Skeletal Radiol 1999;28:670-678.
Evidence-based answers from the Family Physicians Inquiries Network
How effective is desmopressin for primary nocturnal enuresis?
Desmopressin reduces the number of nights of primary noctural enuresis by at least 1 per week, and increases the likelihood of “cure” (defined as 14 consecutive dry nights) while treatment is continued (number needed to treat [NNT]=5–6) (strength of recommendation [SOR]: A, based on meta-analysis). Evidence suggests that the benefits of desmopressin are temporary, with a high relapse rate once treatment is discontinued (SOR: B). However, long-term therapy with occasional weaning attempts is a safe option (SOR: B). Evidence is inadequate to judge the relative efficacy of the nasal vs oral forms of desmopressin (SOR: C).
Evidence summary
Desmopressin is an analogue of the natural pituitary hormone vasopressin acetate. It produces an antidiuretic effect, resulting in increased reabsorption of water from the kidney, a reduced volume of more concentrated urine entering the bladder, and a reduced 24-hour urine production.1,2 Desmopressin is available in a nasal spray (10 μg/spray) and an oral tablet (0.2 mg), and is most often prescribed as 1 to 2 sprays per nostril or 1 to 3 tablets at bedtime, regardless of age or weight.1
A Cochrane review1 of 16 randomized controlled trials found nasal desmopressin to be better than placebo in reducing the number of wet nights per week (mean 1.34 fewer wet nights/week; 95% confidence interval, 1.11–1.57). Desmopressin at doses of 20 μg, 40 μg, and 60 μg similarly increased the likelihood of a cure (14 consecutive dry nights during treatment) in 3 trials reporting this outcome (relative risk for failure to achieve 14 dry nights with 20 μg=0.84; NNT for cure=5.6).3 No difference was found in cure rates after treatment was stopped. Data were insufficient to judge the effectiveness of the oral versus nasal route of desmopressin.1
One randomized controlled trial found a linear dose response for oral desmopressin in reducing wet nights. After 2 weeks of treatment, the number of wet nights was decreased by 27%, 30%, and 40% at doses of 0.2 mg, 0.4 mg, and 0.6 mg, respectively, compared with 10% with placebo.1
Snajderova and colleagues studied desmopressin as a long-term treatment for 55 children with primary nocturnal enuresis. Intranasal desmopressin was titrated upward until bedwetting stopped (7–21 μg; 89.1% responders); children in whom no response occurred to a maximum of 28 μg were excluded. Every 3 months, a weaning attempt was made; if relapse occurred, the previous successful dose was reinstated. At the end of each of the 3 years, the number of responders remained higher (72.7%, 70.9%, 61.6%) than the spontaneous cure rate of 15%.4
The Swedish Enuresis Trial (SWEET) demonstrated a similar outcome in an open-label study of 399 children.5
The main side effects of desmopressin are nasal discomfort, nose bleeds, headache, abdominal pain, rash, and (rare but serious) water intoxication. Restrict fluid to 240 mL (8 oz) on nights desmopressin is given.1
Recommendations from others
A University of California at San Diego Medical Group Guideline recommends using desmopressin for primary nocturnal enuresis in children aged >5 years when it occurs frequently and causes distress, as well as under specific circumstances, such as when a child shares a room or goes to camp, or a sleepover.
Therapy begins at 10 μg (1 nasal puff) each night, increasing weekly to a maximum of 40 μg. Younger children should be reassured, encouraged to limit fluids and void before bedtime, partake in the responsibility to change bedding, and be praised for dry nights.6
The American Academy of Pediatrics also emphasizes support and encouragement of the child, and reassurance that the problem will get better in time. For children aged 7 years, alarm systems or bladder-stretching exercises might help.7
David M. Bercaw, MD
Christiana Care Health System, Wilmington, Del
Primary nocturnal enuresis can be challenging for the primary care physician, frustrating for the patient’s parents, and embarrassing for the child. The physician’s role is to help the child and parents realize that almost all children eventually maintain nocturnal continence whether or not pharmacotherapy is used.
Nonpharmacologic interventions, such as behavioral modification (eg, use of a nocturnal conditioning alarm with a moisture sensor) may be more acceptable to families, at least as a first attempt at therapy. In my experience, however, many children sleep through these alarms.
The decision to use medication should be made by a well-informed and motivated child and their parents. They should understand the limitations and expectations of pharmacotherapy. The authors of this clinical inquiry have provided the physician with an excellent summary of the evidence for the efficacy of desmopressin.
Children with enuresis associated with sleep arousal disorder should theoretically respond to older forms of pharmacotherapy, such as imipramine. However, due to potential toxicity, many clinicians are reluctant to use tricyclic antidepressants in their patients. The efficacy and low toxicity of desmopressin makes it an attractive choice for pharmacotherapy in enuretic children.
1. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 2002;(3):CD002112.-
2. Hvistendahl GM, Rawashdeh YF, Kamperis K, Hansen MN, Rittig S, Djurhuus JC. The relationship between desmopressin treatment and voiding pattern in children. BJU Int 2002;89:917-922.
3. Schulman SL, Stokes A, Salzman PM. The efficacy and safety of oral desmopressin in children with primary nocturnal enuresis. J Urol 2001;166:2427-2431.
4. Snajderova M, Lehotska V, Kernova T, Kocnarova N, Archmanova E, Janda P, Lanska V. Desmopressin in a long-term treatment of children with primary nocturnal enuresis—a symptomatic therapy? Eur J Pediatr 2001;160:197-198.
5. Tullus K, Bergstrom R, Fosdal I, Winnergard I, Hjälmås K. Efficacy and safety during long-term treatment of primary monosyptomatic nocturnal enuresis with desmopressin. Swedish Enuresis Trial Group. Acta Paediatr 1999;88:1274-1278.
6. University of California at San Diego Medical Group. UCSD Outpatient Clinical Practice Guidelines. Enuresis (pediatric). San Diego, Calif: UCSD Healthcare; 1998. Available at: http://health.ucsd.edu/clinicalresources/clinres1.html. Accessed on June 12, 2003.
7. Medem Medical Library. Bed-wetting. Chicago, Ill: American Academy of Pediatrics, 2002. Available at: www.medem.com. Accessed on June 12, 2003.
Desmopressin reduces the number of nights of primary noctural enuresis by at least 1 per week, and increases the likelihood of “cure” (defined as 14 consecutive dry nights) while treatment is continued (number needed to treat [NNT]=5–6) (strength of recommendation [SOR]: A, based on meta-analysis). Evidence suggests that the benefits of desmopressin are temporary, with a high relapse rate once treatment is discontinued (SOR: B). However, long-term therapy with occasional weaning attempts is a safe option (SOR: B). Evidence is inadequate to judge the relative efficacy of the nasal vs oral forms of desmopressin (SOR: C).
Evidence summary
Desmopressin is an analogue of the natural pituitary hormone vasopressin acetate. It produces an antidiuretic effect, resulting in increased reabsorption of water from the kidney, a reduced volume of more concentrated urine entering the bladder, and a reduced 24-hour urine production.1,2 Desmopressin is available in a nasal spray (10 μg/spray) and an oral tablet (0.2 mg), and is most often prescribed as 1 to 2 sprays per nostril or 1 to 3 tablets at bedtime, regardless of age or weight.1
A Cochrane review1 of 16 randomized controlled trials found nasal desmopressin to be better than placebo in reducing the number of wet nights per week (mean 1.34 fewer wet nights/week; 95% confidence interval, 1.11–1.57). Desmopressin at doses of 20 μg, 40 μg, and 60 μg similarly increased the likelihood of a cure (14 consecutive dry nights during treatment) in 3 trials reporting this outcome (relative risk for failure to achieve 14 dry nights with 20 μg=0.84; NNT for cure=5.6).3 No difference was found in cure rates after treatment was stopped. Data were insufficient to judge the effectiveness of the oral versus nasal route of desmopressin.1
One randomized controlled trial found a linear dose response for oral desmopressin in reducing wet nights. After 2 weeks of treatment, the number of wet nights was decreased by 27%, 30%, and 40% at doses of 0.2 mg, 0.4 mg, and 0.6 mg, respectively, compared with 10% with placebo.1
Snajderova and colleagues studied desmopressin as a long-term treatment for 55 children with primary nocturnal enuresis. Intranasal desmopressin was titrated upward until bedwetting stopped (7–21 μg; 89.1% responders); children in whom no response occurred to a maximum of 28 μg were excluded. Every 3 months, a weaning attempt was made; if relapse occurred, the previous successful dose was reinstated. At the end of each of the 3 years, the number of responders remained higher (72.7%, 70.9%, 61.6%) than the spontaneous cure rate of 15%.4
The Swedish Enuresis Trial (SWEET) demonstrated a similar outcome in an open-label study of 399 children.5
The main side effects of desmopressin are nasal discomfort, nose bleeds, headache, abdominal pain, rash, and (rare but serious) water intoxication. Restrict fluid to 240 mL (8 oz) on nights desmopressin is given.1
Recommendations from others
A University of California at San Diego Medical Group Guideline recommends using desmopressin for primary nocturnal enuresis in children aged >5 years when it occurs frequently and causes distress, as well as under specific circumstances, such as when a child shares a room or goes to camp, or a sleepover.
Therapy begins at 10 μg (1 nasal puff) each night, increasing weekly to a maximum of 40 μg. Younger children should be reassured, encouraged to limit fluids and void before bedtime, partake in the responsibility to change bedding, and be praised for dry nights.6
The American Academy of Pediatrics also emphasizes support and encouragement of the child, and reassurance that the problem will get better in time. For children aged 7 years, alarm systems or bladder-stretching exercises might help.7
David M. Bercaw, MD
Christiana Care Health System, Wilmington, Del
Primary nocturnal enuresis can be challenging for the primary care physician, frustrating for the patient’s parents, and embarrassing for the child. The physician’s role is to help the child and parents realize that almost all children eventually maintain nocturnal continence whether or not pharmacotherapy is used.
Nonpharmacologic interventions, such as behavioral modification (eg, use of a nocturnal conditioning alarm with a moisture sensor) may be more acceptable to families, at least as a first attempt at therapy. In my experience, however, many children sleep through these alarms.
The decision to use medication should be made by a well-informed and motivated child and their parents. They should understand the limitations and expectations of pharmacotherapy. The authors of this clinical inquiry have provided the physician with an excellent summary of the evidence for the efficacy of desmopressin.
Children with enuresis associated with sleep arousal disorder should theoretically respond to older forms of pharmacotherapy, such as imipramine. However, due to potential toxicity, many clinicians are reluctant to use tricyclic antidepressants in their patients. The efficacy and low toxicity of desmopressin makes it an attractive choice for pharmacotherapy in enuretic children.
Desmopressin reduces the number of nights of primary noctural enuresis by at least 1 per week, and increases the likelihood of “cure” (defined as 14 consecutive dry nights) while treatment is continued (number needed to treat [NNT]=5–6) (strength of recommendation [SOR]: A, based on meta-analysis). Evidence suggests that the benefits of desmopressin are temporary, with a high relapse rate once treatment is discontinued (SOR: B). However, long-term therapy with occasional weaning attempts is a safe option (SOR: B). Evidence is inadequate to judge the relative efficacy of the nasal vs oral forms of desmopressin (SOR: C).
Evidence summary
Desmopressin is an analogue of the natural pituitary hormone vasopressin acetate. It produces an antidiuretic effect, resulting in increased reabsorption of water from the kidney, a reduced volume of more concentrated urine entering the bladder, and a reduced 24-hour urine production.1,2 Desmopressin is available in a nasal spray (10 μg/spray) and an oral tablet (0.2 mg), and is most often prescribed as 1 to 2 sprays per nostril or 1 to 3 tablets at bedtime, regardless of age or weight.1
A Cochrane review1 of 16 randomized controlled trials found nasal desmopressin to be better than placebo in reducing the number of wet nights per week (mean 1.34 fewer wet nights/week; 95% confidence interval, 1.11–1.57). Desmopressin at doses of 20 μg, 40 μg, and 60 μg similarly increased the likelihood of a cure (14 consecutive dry nights during treatment) in 3 trials reporting this outcome (relative risk for failure to achieve 14 dry nights with 20 μg=0.84; NNT for cure=5.6).3 No difference was found in cure rates after treatment was stopped. Data were insufficient to judge the effectiveness of the oral versus nasal route of desmopressin.1
One randomized controlled trial found a linear dose response for oral desmopressin in reducing wet nights. After 2 weeks of treatment, the number of wet nights was decreased by 27%, 30%, and 40% at doses of 0.2 mg, 0.4 mg, and 0.6 mg, respectively, compared with 10% with placebo.1
Snajderova and colleagues studied desmopressin as a long-term treatment for 55 children with primary nocturnal enuresis. Intranasal desmopressin was titrated upward until bedwetting stopped (7–21 μg; 89.1% responders); children in whom no response occurred to a maximum of 28 μg were excluded. Every 3 months, a weaning attempt was made; if relapse occurred, the previous successful dose was reinstated. At the end of each of the 3 years, the number of responders remained higher (72.7%, 70.9%, 61.6%) than the spontaneous cure rate of 15%.4
The Swedish Enuresis Trial (SWEET) demonstrated a similar outcome in an open-label study of 399 children.5
The main side effects of desmopressin are nasal discomfort, nose bleeds, headache, abdominal pain, rash, and (rare but serious) water intoxication. Restrict fluid to 240 mL (8 oz) on nights desmopressin is given.1
Recommendations from others
A University of California at San Diego Medical Group Guideline recommends using desmopressin for primary nocturnal enuresis in children aged >5 years when it occurs frequently and causes distress, as well as under specific circumstances, such as when a child shares a room or goes to camp, or a sleepover.
Therapy begins at 10 μg (1 nasal puff) each night, increasing weekly to a maximum of 40 μg. Younger children should be reassured, encouraged to limit fluids and void before bedtime, partake in the responsibility to change bedding, and be praised for dry nights.6
The American Academy of Pediatrics also emphasizes support and encouragement of the child, and reassurance that the problem will get better in time. For children aged 7 years, alarm systems or bladder-stretching exercises might help.7
David M. Bercaw, MD
Christiana Care Health System, Wilmington, Del
Primary nocturnal enuresis can be challenging for the primary care physician, frustrating for the patient’s parents, and embarrassing for the child. The physician’s role is to help the child and parents realize that almost all children eventually maintain nocturnal continence whether or not pharmacotherapy is used.
Nonpharmacologic interventions, such as behavioral modification (eg, use of a nocturnal conditioning alarm with a moisture sensor) may be more acceptable to families, at least as a first attempt at therapy. In my experience, however, many children sleep through these alarms.
The decision to use medication should be made by a well-informed and motivated child and their parents. They should understand the limitations and expectations of pharmacotherapy. The authors of this clinical inquiry have provided the physician with an excellent summary of the evidence for the efficacy of desmopressin.
Children with enuresis associated with sleep arousal disorder should theoretically respond to older forms of pharmacotherapy, such as imipramine. However, due to potential toxicity, many clinicians are reluctant to use tricyclic antidepressants in their patients. The efficacy and low toxicity of desmopressin makes it an attractive choice for pharmacotherapy in enuretic children.
1. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 2002;(3):CD002112.-
2. Hvistendahl GM, Rawashdeh YF, Kamperis K, Hansen MN, Rittig S, Djurhuus JC. The relationship between desmopressin treatment and voiding pattern in children. BJU Int 2002;89:917-922.
3. Schulman SL, Stokes A, Salzman PM. The efficacy and safety of oral desmopressin in children with primary nocturnal enuresis. J Urol 2001;166:2427-2431.
4. Snajderova M, Lehotska V, Kernova T, Kocnarova N, Archmanova E, Janda P, Lanska V. Desmopressin in a long-term treatment of children with primary nocturnal enuresis—a symptomatic therapy? Eur J Pediatr 2001;160:197-198.
5. Tullus K, Bergstrom R, Fosdal I, Winnergard I, Hjälmås K. Efficacy and safety during long-term treatment of primary monosyptomatic nocturnal enuresis with desmopressin. Swedish Enuresis Trial Group. Acta Paediatr 1999;88:1274-1278.
6. University of California at San Diego Medical Group. UCSD Outpatient Clinical Practice Guidelines. Enuresis (pediatric). San Diego, Calif: UCSD Healthcare; 1998. Available at: http://health.ucsd.edu/clinicalresources/clinres1.html. Accessed on June 12, 2003.
7. Medem Medical Library. Bed-wetting. Chicago, Ill: American Academy of Pediatrics, 2002. Available at: www.medem.com. Accessed on June 12, 2003.
1. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 2002;(3):CD002112.-
2. Hvistendahl GM, Rawashdeh YF, Kamperis K, Hansen MN, Rittig S, Djurhuus JC. The relationship between desmopressin treatment and voiding pattern in children. BJU Int 2002;89:917-922.
3. Schulman SL, Stokes A, Salzman PM. The efficacy and safety of oral desmopressin in children with primary nocturnal enuresis. J Urol 2001;166:2427-2431.
4. Snajderova M, Lehotska V, Kernova T, Kocnarova N, Archmanova E, Janda P, Lanska V. Desmopressin in a long-term treatment of children with primary nocturnal enuresis—a symptomatic therapy? Eur J Pediatr 2001;160:197-198.
5. Tullus K, Bergstrom R, Fosdal I, Winnergard I, Hjälmås K. Efficacy and safety during long-term treatment of primary monosyptomatic nocturnal enuresis with desmopressin. Swedish Enuresis Trial Group. Acta Paediatr 1999;88:1274-1278.
6. University of California at San Diego Medical Group. UCSD Outpatient Clinical Practice Guidelines. Enuresis (pediatric). San Diego, Calif: UCSD Healthcare; 1998. Available at: http://health.ucsd.edu/clinicalresources/clinres1.html. Accessed on June 12, 2003.
7. Medem Medical Library. Bed-wetting. Chicago, Ill: American Academy of Pediatrics, 2002. Available at: www.medem.com. Accessed on June 12, 2003.
Evidence-based answers from the Family Physicians Inquiries Network