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having received a 6-week course of intravenous ertapenem &#40;1<span class="elsevierStyleHsp" style=""></span>g daily&#41; followed by 12-week consolidation phase&#58; a 6-week course of rifampicin 10<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg once daily&#47;moxifloxacin 400<span class="elsevierStyleHsp" style=""></span>mg once daily&#47;metronidazole 500<span class="elsevierStyleHsp" style=""></span>mg 3id and a final 6-week of rifampicin and moxifloxacin alone&#46; At 6 months&#44; 16&#47;30 patients had received continuous &#8220;consolidation treatments&#8221; with other antibiotics after ertapenem&#59; the other 14&#47;30 were either lost to follow-up or received intermittent &#8220;consolidation treatments&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The authors state that clinical remission was obtained for 100&#37; of Hurley stage I lesions&#44; 96&#37; of Hurley stage II lesions and 27&#37; of Hurley stage III lesions&#44; concluding that a 6-week course of ertapenem can significantly ameliorate severe HS and that consolidation treatments are essential for further improvement and preventing relapses&#46; The complexity of the study design and the obvious need of further AB to prevent&#47;treat flares after the ertapenem induction phase may raise doubts about the long-term effectiveness of this therapeutic choice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ertapenem and other carbapenemes have a broad-spectrum antibacterial activity&#44; being active against many aerobic and anaerobic gram-positive and gram-negative organisms with a major impact on the gut flora&#46; Resistance in Gram-negative bacteria is increasing at an alarming rate and &#946;-lactamases-mediated carbapenem resistance has now become a serious clinical issue and a public health threat worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In the late 20th century&#44; many resistant Gram-negative infections were treated with carbapenems as single therapeutic agents but that overuse of carbapenems resulted in a 69&#37; increase in imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Today we are seeing a global dissemination of new multiple broad-spectrum beta-lactamases and multidrug-resistant <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The use of topical and systemic antibiotics in HS patients is associated with antimicrobial resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> In our perspective&#44; the therapeutic strategy when treating HS must be decided on an individual basis and rely on short-term treatments to control flares and long-term treatments to control persisting inflammation&#46; Ertapenem is a &#946;-lactamic carbapenem with no anti-inflammatory properties&#59; in fact&#44; it induces bacterial lysis and promotes inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Therefore&#44; its effect in improving HS can occur&#44; but mainly through antibacterial mechanisms and should be reserved to control suppurative flares only&#44; i&#46;e&#46;&#44; superinfection of HS lesions&#46; Given the risk of randomly using a broad-spectrum AB like ertapenem&#44; determining which seriously affected HS patients would benefit from it is essential&#46; As ertapenem&#39;s mode of action is only antibacterial&#44; microbiologic studies with antibiogram analysis should guide the prescribing clinician when considering using this drug&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In fact&#44; if a suppurative flare is resistant to tetracyclines or rifampicin&#47;clindamycin combination&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> two actions should be taken into account before considering any broader spectrum antibiotic&#58; to take optimal cultures and to reassess the non-responding skin areas as HS structures such as scarring fistulas are unresponsive to medical therapy and require a surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> Recent studies adding color Doppler ultrasound to improve the accuracy of clinical examination have confirmed that it can significantly modify HS management because of clinical underestimation of severity&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> prompting an earlier combination of medical and surgical treatments&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We believe that antibiotics play a very important role in treating superinfection and should be generally prescribed to control flares&#44; in the short-term management of HS&#46; Long-term management should include a personalized combination of medical and surgical strategies&#44; preferably using ultrasound to accurately characterize HS lesions&#47;extension and monitor response to therapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interes</span><p id="par0035" class="elsevierStylePara elsevierViewall">P&#46; Mendes-Bastos has worked as an investigator in clinical studies supported by Abbvie and has been paid as a speaker in events supported by Abbvie&#46; A&#46; Martorell and S&#46; Magina declare no conflicts of interest&#46;</p></span></span>"
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Opinion Article
Ertapenem for the treatment of Hidradenitis suppurativa: how much do we need it?
Ertapenem para el tratamiento de hidradenitis supurativa: ¿en qué medida lo necesitamos?
P. Mendes-Bastosa,
Autor para correspondencia
Pmendesbastos@gmail.com

Corresponding author.
, A. Martorellb, S. Maginac,d
a Centro de Dermatología, Hospital CUF Descobertas, Lisboa, Portugal
b Departamento de Dermatología, Hospital de Manises, Valencia, España
c Departamento de Dermatología y Venereología, Centro Hospitalario de São João, Oporto, Portugal
d Departamento de Farmacología y Terapéutica, Facultad de Medicina, Universidad de Oporto, Oporto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hidradenitis suppurativa &#40;HS&#41; is a chronic&#44; recurrent and debilitating skin disease of the hair follicle that can be accompanied by systemic inflammation&#46; Many systemic drugs prescribed in HS lack robust evidence supporting its use and personalized therapy must guide the therapeutic decision process&#46; The aim of this letter is discussing the clinical relevance of ertapenem in the control of this chronic disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The evidence supporting its use is based on a single retrospective study in which Join-Lambert <span class="elsevierStyleItalic">et al</span> demonstrated the efficacy of a 6-week course of intravenous ertapenem followed by consolidation therapy with a triple AB regimen &#40;rifampicin&#47;moxifloxacin&#47;metronidazole&#41; in severe HS patients &#40;LOE IV&#44; SOR C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Thirty consecutive patients with severe HS were retrospectively included&#44; having received a 6-week course of intravenous ertapenem &#40;1<span class="elsevierStyleHsp" style=""></span>g daily&#41; followed by 12-week consolidation phase&#58; a 6-week course of rifampicin 10<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg once daily&#47;moxifloxacin 400<span class="elsevierStyleHsp" style=""></span>mg once daily&#47;metronidazole 500<span class="elsevierStyleHsp" style=""></span>mg 3id and a final 6-week of rifampicin and moxifloxacin alone&#46; At 6 months&#44; 16&#47;30 patients had received continuous &#8220;consolidation treatments&#8221; with other antibiotics after ertapenem&#59; the other 14&#47;30 were either lost to follow-up or received intermittent &#8220;consolidation treatments&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The authors state that clinical remission was obtained for 100&#37; of Hurley stage I lesions&#44; 96&#37; of Hurley stage II lesions and 27&#37; of Hurley stage III lesions&#44; concluding that a 6-week course of ertapenem can significantly ameliorate severe HS and that consolidation treatments are essential for further improvement and preventing relapses&#46; The complexity of the study design and the obvious need of further AB to prevent&#47;treat flares after the ertapenem induction phase may raise doubts about the long-term effectiveness of this therapeutic choice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ertapenem and other carbapenemes have a broad-spectrum antibacterial activity&#44; being active against many aerobic and anaerobic gram-positive and gram-negative organisms with a major impact on the gut flora&#46; Resistance in Gram-negative bacteria is increasing at an alarming rate and &#946;-lactamases-mediated carbapenem resistance has now become a serious clinical issue and a public health threat worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In the late 20th century&#44; many resistant Gram-negative infections were treated with carbapenems as single therapeutic agents but that overuse of carbapenems resulted in a 69&#37; increase in imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Today we are seeing a global dissemination of new multiple broad-spectrum beta-lactamases and multidrug-resistant <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The use of topical and systemic antibiotics in HS patients is associated with antimicrobial resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> In our perspective&#44; the therapeutic strategy when treating HS must be decided on an individual basis and rely on short-term treatments to control flares and long-term treatments to control persisting inflammation&#46; Ertapenem is a &#946;-lactamic carbapenem with no anti-inflammatory properties&#59; in fact&#44; it induces bacterial lysis and promotes inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Therefore&#44; its effect in improving HS can occur&#44; but mainly through antibacterial mechanisms and should be reserved to control suppurative flares only&#44; i&#46;e&#46;&#44; superinfection of HS lesions&#46; Given the risk of randomly using a broad-spectrum AB like ertapenem&#44; determining which seriously affected HS patients would benefit from it is essential&#46; As ertapenem&#39;s mode of action is only antibacterial&#44; microbiologic studies with antibiogram analysis should guide the prescribing clinician when considering using this drug&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In fact&#44; if a suppurative flare is resistant to tetracyclines or rifampicin&#47;clindamycin combination&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> two actions should be taken into account before considering any broader spectrum antibiotic&#58; to take optimal cultures and to reassess the non-responding skin areas as HS structures such as scarring fistulas are unresponsive to medical therapy and require a surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> Recent studies adding color Doppler ultrasound to improve the accuracy of clinical examination have confirmed that it can significantly modify HS management because of clinical underestimation of severity&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> prompting an earlier combination of medical and surgical treatments&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We believe that antibiotics play a very important role in treating superinfection and should be generally prescribed to control flares&#44; in the short-term management of HS&#46; Long-term management should include a personalized combination of medical and surgical strategies&#44; preferably using ultrasound to accurately characterize HS lesions&#47;extension and monitor response to therapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interes</span><p id="par0035" class="elsevierStylePara elsevierViewall">P&#46; Mendes-Bastos has worked as an investigator in clinical studies supported by Abbvie and has been paid as a speaker in events supported by Abbvie&#46; A&#46; Martorell and S&#46; Magina declare no conflicts of interest&#46;</p></span></span>"
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