ArticleLiterature Review

Diagnosis and management of cellulitis

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Abstract

#### Summary points Cellulitis is an acute, spreading, pyogenic inflammation of the lower dermis and associated subcutaneous tissue. It is a skin and soft tissue infection that results in high morbidity and severe financial costs to healthcare providers worldwide. Cellulitis is managed by several clinical specialists including primary care physicians, surgeons, general medics, and dermatologists. We assess the most recent evidence in the diagnosis and management of cellulitis. #### Sources and selection criteria We searched PubMed and the Cochrane library for recent and clinically relevant cohort studies and randomised controlled trials on cellulitis, using the search terms “cellulitis”, “erysipelas”, “diagnosis”, “investigation”, “recurrence”, “complications” and “management”. For position statements and guidelines we consulted the British Lymphology Society (BLS), National Health Service Clinical Knowledge Summaries (CKS), Clinical Resource Efficiency Support Team (CREST), and Infectious Disease Society of America (IDSA). In 2008-9 there were 82 113 hospital admissions in England and Wales lasting a mean length of 7.2 days1; an estimated £133m (€170m; $209m) was spent on bed stay alone.2 Cellulitis accounted for 1.6% of emergency hospital admissions during 2008-9.3 In Australia, hospital admissions for cellulitis have risen to 11.5 people …

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... Cellulitis refers to diffuse, superficial, spreading skin infections, involves the deeper dermis and subcutaneous fat (Steven et al., 2014). Cellulitis most commonly affects the lower extremities (Phoenix et al., 2012). The course is usually acute, but subacute, or chronic inflammation is also possible (Atzori et al., 2013). ...
... Diagnosis is based on clinical findings with investigations lending weight to confirm or refute diagnosis (Phoenix et al., 2012). Early recognition is mandatory to avoid potentially life-threatening complications due to a variable etiology from Gram-positive to Gram-negative bacteria and deep fungal infections. ...
... Laboratory findings usually support the infective origin, demonstrating a slight leukocytosis with neutrophilia (Atzori et al., 2013). An elevated level of C-reactive protein (CRP) is a better indicator of bacterial infection than an elevated white cell count but a normal level of CRP cannot rule out an infection (Phoenix et al., 2012). Exudates cultures by needle aspiration or swab are not routinely performed in logical, cost-effective management. ...
... Infections are typically caused by Streptococcus pyogenes or Staphylococcus aureus. 1 Of note, patients with diabetes mellitus are at greater risk of staphylococcal skin infections with increased morbidity and mortality. 2 The Infections Disease Society of American (IDSA) recommends antibiotic treatment for 5 days with the additional recommendation for longer duration if infection has not improved. ...
... 4 One component of HIH is providing and monitoring outpatient parenteral antimicrobial therapy (OPAT) for cellulitis. However, efficacy of cellulitis treatment in the HIH program has not been directly compared 1 Cincinnati VA Medical Center, OH, USA with inpatient treatment. OPAT has been used internationally with a variety of models and indications. ...
... Still, limited information regarding OPAT has been published in the United States and a Cochrane Review from 2010 calls for more studies to review IV antibiotics/OPAT and oral antibiotics for cellulitis treatment. 1 A recent meta-analysis describing OPAT for any ailment included 128 studies over approximately 22 years. However, 63% of those studies had less than n = 150 and only 35% were completed in North America. ...
There are few studies describing outpatient parenteral antimicrobial therapy (OPAT) for cellulitis treatment. The Hospital in Home (HIH) program is a multidisciplinary team at the Cincinnati VA Medical Center (CVAMC) that provides acute care in patients’ homes similar to inpatient hospital care for a variety of indications, including cellulitis. Efficacy of OPAT for cellulitis treatment in the HIH program has not been directly compared with inpatient treatment. The primary objective of this retrospective review is to compare the rates of efficacy of intravenous (IV) antibiotics for cellulitis treatment for patients followed by HIH and inpatient settings. Treatment failure was defined as a change in IV antibiotic medications prescribed. A retrospective chart review was completed at CVAMC for patients enrolled in HIH ( n = 111) and patients who received inpatient treatment at CVAMC ( n = 111) with IV antibiotics for a primary diagnosis of cellulitis from January 1, 2014, through June 30, 2018. Six patients in the HIH group experienced IV antibiotic treatment failure compared with 11 in the inpatient group. The HIH group showed non-inferiority in rates of treatment failure compared with the inpatient group ( p = .21). OPAT with the HIH program appears to be non-inferior to inpatient IV antibiotic treatment for cellulitis infections. Tolerance issues and rates of adverse events do not appear to be worse in patients treated with OPAT in the Veteran population.
... It is a common medical emergency in hospitals and the severity varies from mild to life threatening (Björnsdóttir et al., 2005). In 2010, over 600,000 hospitalizations, about 3.7% of total emergency admissions in the US, were reported due to cellulitis infection (Phoenix et al., 2012). These cellulitis incidences had resulted in a high morbidity rate and severe financial costs to the healthcare providers in US (Phoenix et al., 2012). ...
... In 2010, over 600,000 hospitalizations, about 3.7% of total emergency admissions in the US, were reported due to cellulitis infection (Phoenix et al., 2012). These cellulitis incidences had resulted in a high morbidity rate and severe financial costs to the healthcare providers in US (Phoenix et al., 2012). ...
... Cellulitis incidences had resulted in a high morbidity rate and severe financial costs to the healthcare providers worldwide (Phoenix et al., 2012). From a study conducted from 1998 to 2006 in US, cellulitis accounted for 10.1% among the infectious-disease related hospitalization with an overall age-adjusted rate of 156.2 admissions per 10,000 persons (Christensen et al., 2009). ...
Thesis
Cellulitis is a type of skin disease that can be found frequently from medical emergency in hospitals. The symptoms of disease begin from a small area of tenderness, followed by swelling, and redness that spreads to neighbouring parts of the skin. It can be treated by using a combination of antibiotics; however, the causing agent Staphylococcus aureus had been reported to develop resistance towards commonly used antibiotics. Furthermore, some patients are allergic towards certain antibiotics making the treatment even more difficult. Therefore, the search for an alternative, safe and cost-effective antimicrobial agent is crucial. In this study, Soxhlet extraction and maceration were utilized to produce crude extract from leaves, root and stem of Cassia alata Linn. The crude extracts were diluted and tested against S. aureus through agar-well diffusion assay, colorimetric broth microdilution and bacterial growth curve analysis. These crude extracts were further characterized through qualitative and quantitative phytochemical screenings to determine the presence of alkaloids, flavonoids, tannins and glycosides; the phenolic and flavonoid contents were quantified in the extracts. Meanwhile, the identities of phytoconstituents in the crude extracts were then identified using Gas Chromatography-Mass Spectrometry (GC-MS). From agar-well diffusion assay, root ethyl acetate Soxhlet extract showed the largest inhibition zone with an average diameter of 15.30 mm followed by leaves ethyl acetate Soxhlet extract [14.70 mm], root ethyl acetate maceration extract [13.70 mm], stem ethyl acetate Soxhlet extract [13.30 mm], leaves ethyl acetate maceration extract [13.30 mm], leaves ethanol maceration extract [13.30 mm] and stem ethyl acetate maceration extract [13.00 mm]. These crude extracts were tested in the colorimetric broth microdilution assay where the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of root ethyl acetate Soxhlet extract were identified as low as 31.25 and 62.50 µg, respectively. The MIC/MBC ratio of the C. alata Linn. extracts tested were found to be less than 4, which indicates the extracts can be utilised as the bactericidal agents. Meanwhile, the leaves hexane Soxhlet and leaves ethyl acetate maceration extract showed MIC/MBC ratio greater than 4, suggesting the potential of the extract to be utilised as the bacteriostatic agents. Apart from that, with the exemption of leaves water Soxhlet extract, most of the water extract did not show any significant inhibition effects against the S. aureus. Besides, the bacterial growth curve analysis revealed the growth pattern of the extract treated S. aureus. The application of C. alata Linn. crude extracts in this research manage to suppress the growth of S. aureus. It recorded a significant regression extension (p<0.06, p=0.00003) of lag phase for up to 6 hours after extract treatment with the increase of extract concentration. In the phytochemical screenings conducted, alkaloids were detected in all crude extracts tested while flavonoids, tannins and glycosides were only detected in eight crude extracts. Stem ethyl acetate Soxhlet and root ethyl acetate Soxhlet extract showed the highest amount of phenolic and flavonoid contents from total phenolic content (TPC) and total flavonoid content (TFC) quantitative analyses. Based on the GC-MS analysis, about 66 phytochemicals including phenolics, steroids, fatty acid, alcohol, ester and alkane hydrocarbon that possibly contributed to the antimicrobial properties were detected in the crude extracts. Hence, from this research study, the crude extracts of C. alata Linn., especially stem ethyl acetate Soxhlet, root ethyl acetate Soxhlet, stem ethyl acetate maceration and root ethyl acetate maceration extracts should be intensively studied by purification and identification of the fractions or molecules that had potential to be used as the antimicrobial agents to treat the cellulitis infection. Keywords: Cellulitis, S. aureus, C. alata Linn., antimicrobial assay, phytochemical screenings
... Cellulitis is a common infection of the skin and subcutaneous tissues that can lead to life-threatening complications [1,2]. It is an acute, pyogenic infection caused mainly by Streptococcus pyogenes or Staphylococcus aureus; characterised by an area of cutaneous erythema, warmth and oedema [3,4]. About 88% of cellulitis occurs in the lower limb [5]. ...
... The risk factors of cellulitis can be classified into general and local factors. General risk factors include obesity, diabetes mellitus, history of cellulitis, immunosuppression, lymphedema and peripheral vascular disease while local risk factors include neglected wounds, toe-web intertrigo and leg ulcers [3,[8][9][10]. A recent multicentre study carried out in eight sub-Saharan African countries including Cameroon identified obesity, lymphedema, voluntary cosmetic depigmentation, neglected traumatic wound and toe-web intertrigo as major risk factors of cellulitis in sub-Saharan Africa [9]. ...
... We defined alcohol misuse as a consumption of more than 11.2 g/l (14 units) of alcohol per week. History of HIV was sub-categorised into; severe immunodeficiency (CD4+ count <200 cells/mm 3 ) or not (CD4+ ≥200 cells/mm 3 ) based on the most recent measurement within a 3 month period [16], and the duration after diagnosis at which a person living with HIV is at risk of soft tissue infection (≥ 4 years) or not (< 4 years) [17]. Also, the disease burden was assessed by the length of hospital stay, need for necrosectomy and eventual amputation. ...
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Background: Cellulitis is a common infection of the skin and subcutaneous tissues. It is associated with significant morbidity from necrosectomies and amputations especially in sub-Saharan Africa. We aimed at identifying the risk factors and burden of lower limb cellulitis to inform preventive strategies in Cameroon. Methods: This was a hospital-based case-control study carried out in the Bamenda Regional Hospital (BRH) between September 2015 and August 2016. Cases were defined as consenting adults admitted to the surgical unit who presented with a localised area of lower limb erythema, warmth, oedema and pain, associated with fever (temperature ≥ 38 °C) and/or chills of sudden onset. Controls were adults hospitalised for diseases other than cellulitis, necrotising fasciitis, myositis, abscess or other variants of dermo-hypodermitis. Cases and controls were matched (1:2) for age and sex. Results: Of the 183 participants (61 cases of cellulitis and 122 controls) included in the study, the median age was 52 years [Interquartile range (IQR): 32.5-74.5]. After controlling for potential confounders, obesity [adjusted odds ratio (AOR) = 4.7, 95% CI (1.5-14.7); p = 0.009], history of skin disruption [AOR = 12.4 (3.9-39.1); p < 0.001], and presence of toe-web intertrigo [AOR = 51.4 (11.7-225.6); p < 0.001] were significantly associated with cellulitis. Median hospital stay was longer (14 days [IQR: 6-28]) in cases compared to the controls (3 days [IQR: 2-7]). Among the cases, Streptococci species were the most frequent (n = 50, 82%) isolated germ followed by staphylococci species (n = 9, 15%). Patients with cellulitis were more likely to undergo necrosectomy (OR: 21.2; 95% CI: 7.6-59.2). Toe-web intertrigo had the highest (48.9%) population attributable risk for cellulitis, followed by history of disruption of skin barrier (37.8%) and obesity (20.6%). Conclusion: This study showed a high disease burden among patients with cellulitis. While risk factors identified are similar to prior literature, this study provides a contextual evidence-base for clinicians in this region to be more aggressive in management of these risk factors to prevent disease progression and development of cellulitis.
... Cellulitis and erysipelas are common bacterial infections [1,2]. Treatment usually results in cure, but the most effective antimicrobial regimen remains uncertain. ...
... Because of its excellent activity against Streptococcus pyogenes, and group C and group G streptococci, benzyl penicillin has been widely used in the treatment of cellulitis and erysipelas and has provided high cure rates in some case series [6]. However, recognition that Staphylococcus aureus is a relatively common cause of cellulitis and of erysipelas has led to recommendations that treatment should be with an anti-staphylococcal penicillin or a cephalosporin [1,7,8]. The rising incidence of disease due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) [9] has led to suggestions that in some regions treatment should be with an agent that is active against these strains [10]. ...
... The development of colitis due to C. difficile is a wellrecognised adverse effect of treatment with clindamycin [36,37]. Despite this, clindamycin is widely recommended for the treatment of patients with cellulitis or erysipelas, especially those in whom infection with MRSA is known or suspected [1,7,8]. One of 446 patients (0.2 %) treated with clindamycin for a skin or soft tissue infection [18,20,30] developed C. difficile-associated diarrhoea, which resolved with cessation of clindamycin therapy. ...
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Purpose: Beta-lactam antibiotics, such as penicillin, flucloxacillin or cephalexin, are widely considered first-line treatment for cellulitis and erysipelas, while macrolides and lincosamides, such as erythromycin, azithromycin or clindamycin, are widely considered second-line agents. We attempted to determine whether outcomes differed between patients treated either with a beta-lactam or with a macrolide or lincosamide. Methods: We conducted a meta-analysis of published trials in which patients with cellulitis or erysipelas were randomised to treatment either with a beta-lactam or with a macrolide or lincosamide. We searched PUBMED, EMBASE, MEDLINE and SCOPUS (up to March 2014) using the terms: cellulitis/erysipelas, penicillin/beta-lactam, macrolide/lincosamide, random*/controlled*/trial* as keywords. We included randomised trials that compared monotherapy with a beta-lactam with monotherapy with a macrolide or lincosamide for cellulitis or erysipelas. Results: We identified 15 studies, 9 in patients with cellulitis or erysipelas and 6 in patients with various skin and soft tissue infections including cellulitis and erysipelas. The efficacy of treatment of cellulitis or erysipelas was similar with a beta-lactam [27/221 (12 %) not cured] and a macrolide or lincosamide [21/241 (9 %) not cured, RR 1.24, 95 % CI 0.72-2.41, p = 0.44]. Treatment efficacy was also similar for skin or soft tissue infections including cellulitis and erysipelas (RR 1.28, 95 % CI 0.96-1.69, p = 0.09). Risk of adverse effects was similar for beta-lactams [148/1295 (11 %) not cured] and macrolides or lincosamides [228/1737 (13 %) not cured, RR 0.86, 95 % CI 0.64-1.16, p = 0.31]. Conclusion: Treatment with a macrolide or lincosamide for cellulitis or erysipelas has a similar efficacy and incidence of adverse effects as treatment with a beta-lactam.
... This condition increases the morbidity and mortality rates in DFI patients with induction of significant losses in the public health system. These detrimental complicated outcomes may be caused via the impact of important interactions occurred at levels of neuropathy, vasculopathy and reduced immunity in diabetic patients (Carratalà et al, 2003;Phoenix et al, 2012;Pitché et al, 2015). Definite and early diagnosis of these complications applies significant treatment results preventing severe induction of heavy abnormalities (Naidoo et al, 2015). ...
... higher GE in the MP and SP genes in the A. niger. These results agree with the fact that those fungi are opportunistic microorganisms that can initiate diseases after involvement of neuropathy, vasculopathy, and reduced immunity in diabetic patients (Carratalà et al, 2003;Phoenix et al, 2012;Pitché et al, 2015). This can be deeply confirmed as for example proteases such as MP, which was detected here, are important in wound healing; however, increases in the activity of such proteases may induce conditions of prolonged non-healing wounds, and that what is seen in DFI patients (Caley et al, 2015). ...
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The current study was aimed to identify the gene expression (GE) of virulence factors (VFs), aflatoxin (Af), metalloprotease (MP) and serine protease (SP), in Aspergillus (flavus and niger) associated with the diabetic foot in Nasiriyah City, Iraq. According to that, swab samples were collected from 167 diabetic foot patients attended the Diabetes and Endocrinology Center, Al-Nasiriyah City, Iraq. The samples were cultivated in a Lab for obtaining the pure isolates of the Aspergillus species. Then, 10 isolates from each fungus were exposed to nucleic acid-based techniques, polymerase chain reaction (PCR) to identify the presence of A. (flavus and Niger) in the purified isolates and real time-quantitative (RT-q) PCR to evaluate the GE of the VFs in A. (flavus and Niger) isolates using specific primers that targeted 18S rRNA gene (ITS1) region and specific regions of the VF genes respectively. The results of the PCR showed the positive identity of the A. (flavus and niger) in the samples. Moreover, the findings of the RT-qPCR revealed the GE of the Af, MP, and SP genes in A. (flavus and niger) with significant (p<0.05) higher GE in the SP gene in the A. flavus and significant (p<0.05) higher GE in the MP and SP genes in the A. niger. The current study indicates the current presence of the Af, MP and SP-encoding A. (flavus and niger) in the samples collected from the diabetic foot patients in Al-Nasiriyah city, Iraq.
... 1-5 It often presents as erythematous, warm, swollen skin, tender to palpation, frequently with systemic features such as fever and malaise. 3,5 The infection can be caused by a number of organisms, but in the majority of cases streptococci are involved. 1-5 Predisposing risk factors include lymphoedema, venous insufficiency, diabetes, portal of entry (such as toe web maceration) and immunosuppression. ...
... tinea pedis or venous eczema). [3][4][5] Unfortunately, recurrent disease occurs in up to almost 50% of cases, which can result in persistent swelling and impairment of the lymphatic system. 1-3,6-8 Although there is limited evidence, based on randomized controlled trials (RCTs) with small sample size, prophylactic antibiotic therapy is often prescribed for people with recurrent episodes of cellulitis. ...
Article
AimThomas et al. compared the effectiveness of prophylactic low-dose penicillin vs. placebo in patients with recurrent cellulitis for preventing the disease.Setting and designParticipants of this double-blind randomized controlled trial were recruited at 28 hospitals in the U.K. and Ireland between July 2006 and January 2010.Study exposurePatients with two or more episodes of cellulitis of the leg were randomized to receive low-dose oral penicillin (250 mg twice daily) or placebo over 12 months with a follow-up period of up to 3 years.OutcomesThe primary outcome was the time to a first recurrence. Secondary outcome measures were the proportion of participants with a repeat episode of cellulitis during the prophylaxis phase and during the follow-up phase, the number of repeat episodes of cellulitis, the proportion of participants with new oedema or ulceration during the prophylaxis phase and during the follow-up phase, the number of nights in hospital for cellulitis, the number of adverse drug reactions or adverse events of interest (death, nausea, diarrhoea, thrush, rash, severe skin reactions, sepsis and renal failure), cost–effectiveness and predictors of response.ResultsOf the 533 patients screened, 274 were eligible and included in the trial (136 were assigned to the penicillin group and 138 to the placebo group). The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the 12 months of treatment 30 (22%) of 136 patients in the penicillin group had a recurrence compared with 51 (37%) in the placebo group [hazard ratio 0·55, 95% confidence interval (CI) 0·35–0·86, P = 0·01; number needed to treat 7, 95% CI 4–9]. After the 12-month treatment period, during the follow-up there was no difference in the rate of first recurrence (27% in both groups). There were fewer repeat episodes in the penicillin group than in the placebo group during the treatment period (76 vs. 122, P = 0·03) and no difference during subsequent follow-up (43 vs. 42). There was no statistically significant difference between the groups in the number of participants with an adverse event (37 in the penicillin group vs. 48 in the placebo group, P = 0·50).Conclusions Thomas et al. concluded that low-dose penicillin was effective in preventing recurrent cellulitis in people with recurrent disease during prophylactic treatment, but that the effect reduced progressively after the discontinuation of penicillin.
... Cellulitis is among the most frequent infections leading to hospitalization [5]. In the USA, hospital visits for cellulitis and abscesses increased from 17.3 to 32.5 per 1000 person-years between 1997-2010, resulting in 600.000 hospitalizations in 2010 [6]. Similarly, the combined incidence of cellulitis and erysipelas of the leg (CEL) in the Netherlands increased from 1.7 to 22 per 1000 persons-years between 2001-2007, of which 5-10% were hospitalized. ...
... Standard demographic and other patient characteristics will be collected, including age, gender, non-trial medication use, comorbidity, ethnic background, recreational drug use, smoking, body weight, residential status, and risk factors for cellulitis [6] (i.e. venous insufficiency, lymphoedema, peripheral arterial disease, immunosuppression, diabetes, trauma, tattoos, ulcers, eczema, tinea pedis and burns). ...
Article
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Background Recommended therapy duration for patients hospitalized with cellulitis is 10–14 days. Unnecessary use of antibiotics is one of the key factors driving resistance. Recent studies have shown that antibiotic therapy for cellulitis in outpatients can safely be shortened, despite residual inflammation. This study will compare in hospitalized patients the safety and effectiveness of shortening antibiotic therapy for cellulitis from 12 to 6 days. Methods/design In a multicenter, randomized, double-blind, non-inferiority trial, adult patients admitted with cellulitis will be included. Cellulitis is defined as warmth, erythema, and induration of the skin and/or subcutaneous tissue, with or without pain (including erysipelas). All patients will initially be treated with intravenous flucloxacillin, and will be evaluated after 5–6 days. Those who have improved substantially (defined as being afebrile, and having a lower cellulitis severity score) will be randomized at day 6 between additional 6 days of oral flucloxacillin (n = 198) or placebo (n = 198). Treatment success is defined as resolution of cellulitis on day 14 (disappearance of warmth and tenderness, improvement of erythema and edema), without the need of additional antibiotics for cellulitis by day 28. Secondary endpoints are relapse rate (up to day 90), speed of recovery (using a cellulitis severity score until day 28, and VAS scores on pain and swelling until day 90), quality of life (using the SF-36 and EQ-5D questionnaires) and costs (associated with total antibiotic use and health-care resource utilization up to day 90). Discussion Inclusion is planned to start in Q2 2014. Trial registration ClinicalTrials.gov (NCT02032654) and the Netherlands Trial Register (NTR4360).
... This instrument was developed by the researcher after reviewing related literature (Koulaouzidis et al., 2007;Phoenix et al., 2012;Njim et al., 2017;Aiello et al., 2017;Cranendonk et al., 2017;Anwar et al., 2018;Tianyi et al., 2018;Cutfield et al., 2019;Ibrahim et al., 2019) to assess the critically ill hepatic patients' risk for the development of cellulites. It included four parts:  Part I: "Patients' Demographic profile": This part included patients' characteristics such as age and sex. ...
... 3 Chronic venous insufficiency, peripheral vascular disease, lymphoedema and comorbidities that result in immunosuppression (ie, diabetes) are all risk factors for development of wound-related cellulitis. 4 These are also risk factors for wounds and key contributors for wound chronicity. 5 As open wounds present an entry point for bacteria, clinicians specialising in wound care are on constant alert for any symptoms of this dangerous and challenging to diagnose clinical conundrum. ...
Article
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Early diagnosis of wound-related cellulitis is challenging as many classical signs and symptoms of infection (erythema, pain, tenderness, or fever) may be absent. In addition, other conditions (ie, chronic stasis dermatitis) may present with similar clinical findings. Point-of-care fluorescence imaging detects elevated bacterial burden in and around wounds with high sensitivity. This prospective observational study examined the impact of incorporating fluorescence imaging into standard care for diagnosis and management of wound-related cellulitis. Two hundred thirty-six patients visiting an outpatient wound care centre between January 2020 and April 2021 were included in this study. Patients underwent routine fluorescence scans for bacteria (range: 1-48 scans/patient). Wound-related cellulitis was diagnosed in 6.4% (15/236) of patients. In these patients, fluorescence scans showed an irregular pattern of red (bacterial) fluorescence extending beyond the wound bed and periwound that could not be removed through cleansing or debridement, indicating the invasive extension of bacteria (wound-related cellulitis). Point-of-care identification facilitated rapid initiation of treatments (source control and antibiotics, when warranted) that resolved the fluorescence. No patients had worsening of cellulitis requiring intravenous antibiotics and/or hospitalisation. These findings demonstrate the utility of point-of-care fluorescence imaging for efficient detection and proactive, targeted management of wound-related cellulitis.
... Cellulitis is an acute, diffuse purulent inflammation of the dermis and subcutaneous tissues. 6 A previous study confirmed that cellulitis is one of the most common form of skin and soft tissue infection leading to more than 600,000 hospitalizations each year, 1 and more than 9 million patients always along with cutaneous abscess. 7 osteomyelitis and septic arthritis is an uncommon disease among adults. ...
Article
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Background: Musculoskeletal infection (MSKI) is a common reason to seek medical care in the emergency department (ED). We aimed to determine the clinical characteristics and etiology of patients with MSKI in our ED, the characteristics of MSKI with sepsis, and the predictors of death in sepsis patients. Methods: The study retrospectively analyzed patients with MSKI from April 1, 2017, to March 31, 2021. The patients were divided into non-sepsis and sepsis groups. Clinical data of these patients including their basic information, laboratory results, diagnostic results, and outcomes were collected. Statistical analysis was carried out using GraphPad Prism 5. Results: In all, 106 patients (70 male, 36 female) were enrolled in this study: 43 MSKI patients with sepsis and 63 MSKI patients without sepsis. Five patients with sepsis died. The patients' age and sex ratio were no significantly different between the sepsis and non-sepsis groups. In the sepsis group, the ratio of rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis was significantly different than that in the non-sepsis group (all p<0.05). Fifty-six patients (54.37%) had positive etiology results. Staphylococcus, streptococcus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli were the most common bacteria found in both groups, but sepsis patients had more Candida albicans infections than non-sepsis patients (p=0.0331, p<0.05). The five patients who died in the sepsis group had higher serum levels of creatinine and procalcitonin (PCT). Multivariate logistic regression analyses showed that PCT (p=0.026; odds ratio, 1.038) was significantly related to mortality. Conclusion: In MSKI patients, rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis are the risk factors for sepsis. Staphylococcus, streptococcus, K. pneumoniae, P. aeruginosa, and E. coli were the most common bacteria in MSKI patients, while MSKI patients with sepsis had more C. albicans infections. Elevated PCT was significantly related to death in sepsis patients.
... As reported in previous studies (Fjordbakk et al. 2008;Putnam et al. 2014), diagnosis of distal limb cellulitis was predominantly made based on clinical signs alone. Similarly, in humans, cellulitis is a common emergency presentation and diagnosis is often made via clinical signs (Hirschmann and Raugi 2012;Phoenix et al. 2012;Raff and Kroshinsky 2016;Patel et al. 2019), although a lack of robust, validated diagnostic criteria has also been identified in the human field (Patel et al. 2019). Furthermore, objective invasive diagnostic procedures, such needle aspiration and punch biopsies from intact skin, yield positive cultures in only a small proportion of cases (≤16%) (Chira and Miller 2010). ...
Article
Cellulitis is a commonly recognised condition in first opinion equine practice yet there is little published information regarding its diagnosis, treatment and management. To describe current approaches of veterinary surgeons working in the United Kingdom (UK) to the diagnosis, treatment and management of distal limb cellulitis in horses. Cross‐sectional survey. An online questionnaire was distributed via email and social media sites for a period of 12 weeks. Descriptive statistics were produced and chi‐square or Fisher’s exact tests were used to assess associations between categorical variables, with critical probability set at 0.05. Distal limb cellulitis is frequently encountered in the UK, with 83.5% (n = 224/268) of respondents having treated >5 cases in the preceding 12 months. Diagnosis was predominantly made based on clinical signs alone (89.2%; n = 239/268). The majority of respondents (95.5%; n = 256/268) treated cases with nonsteroidal anti‐inflammatory drugs (NSAIDs) and antimicrobials. Phenylbutazone (93.8%; n = 240/256) and trimethoprim sulphonamide (TMPS) (72.3%; n = 185/256) were most frequently prescribed and 61.7% (n = 148/240) of respondents prescribed these drugs in combination. Duration of treatment was most frequently five days for NSAIDs (33.5%; n = 64/191), TMPS (84.4%; n = 119/141) and doxycycline (62.5%; n = 25/40), the longest prescribed duration of any treatments being 10 days. Corticosteroids were administered by 41.0% of respondents (n = 110/268). Management recommendations included cold hosing/ice packing of the affected limb (79.4%; n = 212/267) with light exercise (turnout or hand walking) if the horse was comfortable enough to do so (97.4%; n = 260/267). Small sample size (n = 268) and low level of item omission for a small number of questions. Cellulitis is common in the UK and is usually treated with NSAIDs and antimicrobials for 5–10 days, plus cold hosing and light exercise. Further study on the topics of diagnosis and treatment, with particular emphasis on the aetiology and necessity of antimicrobials, is warranted.
... The cost of cellulitis treatment can vary depending on the severity of disease and the mechanism of treatment. In the United Kingdom, cellulitis is responsible for 82,113 hospital admissions, with the average length of stay around 7.2 days at the estimated cost of €133 million [52]. ...
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This is a sample Chapter (23) published in Telemedicine and Electronic Medicine Handbook, Vol. 1, 2016, ISBN: 13:978-1-4822-3658-3, edited by Halit Eren and John G Webster. Referencing should directly be made to chapter authors.
... The cost of cellulitis treatment can vary depending on the severity of disease and the mechanism of treatment. In the United Kingdom, cellulitis is responsible for 82,113 hospital admissions, with the average length of stay around 7.2 days at the estimated cost of €133 million [52]. ...
... Empiric antibiotic therapy is usually prescribed in patients with cellulitis, because identifi cation of the causative agent in this condition is uncommon, and the yield for recovery of the pathogen is low (3,4,7) . Although the use of empiric broad-spectrum antibiotic in cellulitis is a common practice at many centers (5) , the routine use of broad-spectrum antibiotic is not recommended by several practice guidelines for treatment of cellulitis. ...
Article
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Background: Cellulitis is a common infection at our center. Broad-spectrum antibiotic or antibiotic combination is often prescribed for most adult patients with cellulitis. A contributing factor to the high prevalence of broad-spectrum antibiotic or antibiotic combination for cellulitis is the lack of data speciic to the epidemiology and microbiology of cellulitis in Thai patients.
... At the present time there is no unambiguous consensus regarding empiric therapy of erysipelas and bacterial cellulitis. The UK guidelines [12,13] still recommend amoxicillin or flucloxacillin as the first-line treatment in most cases of bacterial dermatitis and subcutaneous tissue infection caused by b-hemolytic streptococci, S. aureus, or when the pathogen has not been identified. In the case of penicillin allergy, macrolide antibiotics or clindamycin are recommended as a suitable alternative. ...
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Introduction Erysipelas and bacterial cellulitis are two of the most common infectious skin diseases. They are usually caused by the β-hemolytic group of Streptococcus, and less frequently by other bacteria. The objective of the study was to assess the factors affecting the length of stay of patients admitted to hospital with erysipelas or bacterial cellulitis. Methods The study was based on the retrospective analysis of medical records of patients diagnosed with erysipelas or bacterial cellulitis. Selected clinical features of the disease, the results of additional tests, the treatment used, and the time of hospitalization were analyzed. Among an initial group of 78 pre-identified patients, 59 subjects aged from 32 to 89 years were included in the final analysis. The time spent in the hospital and the number of antibiotics necessary to cure the patient were chosen as the parameters of treatment efficacy. Results The average duration of stay in a hospital was 7.0 ± 2.9 days and was slightly longer for women than for men. Patients with chills on admission, with coexisting chronic venous insufficiency of the lower limbs, and with anemia were hospitalized for a significantly longer period than those without these conditions. A combination therapeutic regimen of amoxicillin + clavulanic acid was the most commonly used treatment option, and this therapy was linked with shortest duration of stay in the hospital; the length of hospital stay was significantly longer for those patients receiving cephalosporins or clindamycin as treatment. The combination therapy of amoxicillin + clavulanic acid as treatment option was also least often associated with the need to use other antibacterial agents. Conclusions Based on our evaluation of 59 subjects with either erysipelas or bacterial cellulitis, combination therapy with amoxicillin + clavulanic acid appears to be linked with the shortest stay in the hospital. We suggest that this combination therapy should be considered as a first-line treatment for patients hospitalized due to erysipelas or bacterial cellulitis, if other factors did not preclude the use of this therapy.
... 1 It is challenging in diagnosis and management. 2 A third of cellulitis patients could be misdiagnosed. 3 Ultrasonography or magnetic resonance imaging (MRI) are sometimes required to distinguish necrotizing fasciitis, abscess formation or venous thrombosis. ...
... As there was no clinical lymphoedema evident on presentation, other than a general lower leg swelling, lymphoscintigraphy was not performed although it has been shown that lymphatic abnormalities are commonly present in lower leg cellulitis without clinical signs of edema [1]. Conditions that reduce the circulation of blood in the veins or that reduce circulation of the lymphatic fluid (such as venous insufficiency, obesity, pregnancy, or surgeries) may also increase the risk of developing cellulitis, although different studies have given conflicting risk factors [2,3]. Possible risk factors in this patient were obesity, pre-diabetes, superficial venous insufficiency, dry skin, and a slight ooze from an ingrowing toenail. ...
... Partout dans le monde, et sous divers contextes climatiques, les maladies cutanées représentent une part importante dans le paysage épidémiologique infectieux. Par exemple, plus de 14 millions de consultations sont enregistrées chaque année aux États-Unis en raison des infections cutanées, avec plus de 600 000 hospitalisations (3,7 % des hospitalisations en urgence) (Phoenix et al., 2012). Le nombre d'hospitalisations pour de telles infections a augmenté de 29 % entre 2000 et 2004 (Edelsberg et al., 2009). ...
Article
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The fungal infections are a major public health problem in Sfax (Central-East of Tunisia) because it affects a vulnerable population. The study of the temporal distribution of consultations for mycosis over the period 2009-2013 allowed detecting both spring and falling peaks. The analyzes show a relationship between on the one hand, climate characteristics (temperature and relative humidity rate (heat-humidity)) which establish some discomfort and on the other hand, the increase in cases of fungal infections in the population studied.
... Neither blood analysis (WBC, CRP) nor cultures of blood or skin aspirates has been found to be clinically useful or cost-effective in determining abscess presence [2]. ...
Chapter
Impetigo is a common, contagious superficial skin infection seen most often in infants and children.
... Les répondants ont cerné 14 facteurs de risque de prévisibilité de l'échec du traitement par les antibiotiques par voie orale, notamment l'hypotension, la tachypnée et un INTRODUCTION Non-purulent skin and soft tissue infections (SSTIs), cellulitis or erysipelas, are common emergency department (ED) presentations. 1,2 Emergency physicians must decide on the type of antibiotic, the duration of therapy, the route to administer it (either oral or intravenous), and the time to reassessment. There are studies that make the case for the use of "simple" oral antibiotics for the treatment of "uncomplicated" SSTIs. ...
Article
Objectives: We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics. Methods: We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method. Results: The survey response rate was 36.9% (n=391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10. Conclusions: The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.
... Intravenous antibiotics should be changed to oral administration after 48 hours of apyrexia (<37.8°C) and regression of inflammation from skin markings. 115 ...
Article
Importance: Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650 000 admissions per year in the United States alone. Observations: In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S aureus, with expansion for methicillin-resistant S aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence. Conclusions and relevance: The diagnosis of cellulitis is based primarily on history and physical examination. Treatment of uncomplicated cellulitis should be directed against Streptococcus and methicillin-sensitive S aureus. Failure to improve with appropriate first-line antibiotics should prompt consideration for resistant organisms, secondary conditions that mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic liver disease, or chronic kidney disease.
... Selülit başlıca Streptococcus pyogenes ve bazen Staphylococcus aureus'a bağlı gelişen ve deri altı dokulardaki derin lenfatikleri tutan bakteriyel enfeksiyondur (1,2). Farklı vücut bölgelerinde görülebilen hastalığın en sık yerleşim yeri bacaktır (3,4). Diğer açılardan sağlıklı kişilerde de rastlanabilmekle birlikte lenfödem, tinea pedis, venöz yetmezlik, geçirilmiş bacak cerrahisi, radyoterapi öyküsü, nöropati, obezite, diabetes mellitus, sigara ve alkol kullanımı gibi kolaylaştırıcı faktörlerin varlığında daha sık oluşur (5). ...
Article
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Objective: To reveal the risk factors for lower-extremity cellulitis, to investigate the role of risk factors on the treatment, and to have knowledge about treatment efficiency and the optimal duration of therapy in patients on parenteral antibiotic therapy. Methods: Potential risk factors, therapies used during hospitalization, outcomes of therapies and follow-up data of 46 patients hospitalized in the Department of Dermatovenereology of İstanbul Medical Faculty of İstanbul University with lower-extremity cellulitis between years 2009 and 2014 were investigated retrospectively. Results: Tinea pedis (n=19), diabetes mellitus (n=12), by-pass surgery (n=6), and chronic lymphedema of the legs (n=5) were detected as main risk factors. Improvement with systemic therapy was seen in all patients except one patient who was lost to follow-up. Thirty nine of the patients (84.8%) were treated with parenteral ampicillin-sulbactam. The mean duration of parenteral antibiotic therapy was 17.7±12.4 (median: 14) days. In 11 patients (32.4%), recurrence was detected, during an average follow-up of 2 years. There was a significant correlation between tinea pedis and recurrence. Conclusion: Tinea pedis and chronic lymphedema were main risk factors for multiple attacks. Parenteral antibiotic treatment mostly used as the single drug regimen with ampicillin-sulbactam was highly effective. Relatively longer duration of treatment in our patients has been attributed to the facts that being a tertiary medical center, dealing mostly with therapy resistant and high risk patients of cellulitis or antibiotic resistance in our country.
... Data from the European Centre for Disease Prevention and Control (ECDC) estimated that 4% of all healthcare-acquired infections (HAIs) reported between 2011 and 2012 were SSTIs, with surgical-site infections being the second most frequently reported HAI (19.6%) [5]. During 2008 and 2009 there were 82,113 cellulitis hospital admissions in England and Wales with a mean hospital LOS of 7.2 days, and an estimated £133 million (€170 million; US$209 million) of costs were due to direct inpatient bed stay [6]. ...
Article
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Skin and soft-tissue infections (SSTIs) are a common indication for antibiotic use in Europe and are associated with considerable morbidity. Treatment of SSTIs, occasionally complicated by infection with meticillin-resistant Staphylococcus aureus, can be resource intensive and lead to high healthcare costs. For patients treated in an inpatient setting, once the acute infection has been controlled, a patient may be discharged on suitable oral antibiotic therapy or outpatient parenteral antibiotic therapy. The recently confirmed efficacy of single-dose (e.g. oritavancin) and two-dose (e.g. dalbavancin) infusion therapies as well as tedizolid phosphate, a short-duration therapy available both for intravenous (i.v.) and oral use, for treating SSTIs has highlighted the need for clinicians to re-evaluate their current treatment paradigms. In addition, recent clinical trial data reporting a novel endpoint of early clinical response, defined as change in lesion size at 48-72 h, may be of value in determining which patients are most suitable for early de-escalation of therapy, including switch from i.v. to oral antibiotics, and subsequent early hospital discharge. The aim of this paper is to review the potential impact of assessing clinical response on clinical decision-making in the management of SSTIs in Europe, with a focus on emerging therapies.
... In this case, at the second intravenous administration of tocilizumab, the patient developed serious anaphylaxis accompanied by edema in the lower limbs. Both immunosuppression and lower limbs edema are believed to be the important risk factors of cellulitis [11]. Before admission he had taken immunosuppressant continuously and methylprednisolone were administered by intravenous injection for the management of anaphylaxis. ...
Article
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Tocilizumab, a humanized monoclonal antibody against the interleukin-6 receptor, is therapeutically effective in patients diagnosed with rheumatoid arthritis (RA) compared with placebo. However patients treated with tocilizumab are at increased risk of several adverse effects including anaphylaxis and serious infections that may lead to hospitalization or death. Therefore, the risks and benefits of treatment with tocilizumab should be considered carefully and close monitoring of patients for development of signs and symptoms of side effects is required during and after treatment. Here, we report on a rare case of anaphylaxis and severe sepsis caused by cellulitis in a patient with RA after tocilizumab treatment.
... The number of ED visits for skin and soft tissue infections (SSTIs) has nearly tripled between 1993 and 2005 from 1.2 million to 3.4 million (1), with the largest relative increases seen in major medical center EDs (2). In the United States, there was a 29% increase in hospital admissions for SSTIs from 2000 to 2004 (3), and more than 600,000 hospitalizations for SSTIs were recorded in 2010, representing 3.7% of all hospital admissions (4). ...
Article
Cellulitis is a common cause for emergency department (ED) presentation and subsequent hospital admission. Underlying fracture, osteomyelitis, or foreign body is often considered in the clinical evaluation of these patients. Accordingly, plain radiographs (XRs) of the affected extremity are often ordered during the initial work-up. The utility of these imaging studies in the treatment of uncomplicated lower-extremity cellulitis, however, remains unclear. In an effort to treat this common problem more efficiently, we evaluated our imaging practices and results in a cohort of consecutive patients admitted to a large public city hospital for treatment of uncomplicated lower-extremity cellulitis. Retrospective cohort study of 288 consecutive ED admissions for treatment of uncomplicated cellulitis, of which 214 met the inclusion criteria for this study. Patient demographics, history, vitals, laboratory values, and test results were evaluated with univariate and multivariate statistical analyses. XRs of the affected lower extremity were obtained in 158 patients (73.8%). Positive XR findings were present in 19 patients (12.0%) and positively correlated with a history of acute trauma to the extremity (P < .001) or the presence of a chronic wound (P < .01). Multivariable logistic regression analysis revealed a history of trauma (P < .001) or the presence of a chronic wound (P < .05) to be independent predictors of positive XR findings with relative risks of 6.24 and 2.98, respectively. The establishment of evidence-based guidelines for the treatment of lower-extremity cellulitis has potential to significantly improve clinical efficiency and reduce cost by eliminating unnecessary testing. Based on our results, patients without a recent history of trauma to the affected extremity or the presence of a chronic wound do not appear to warrant XRs. When applied to our cohort, only 48 of 158 patients had a history of trauma or chronic wound. This means that 110 patients unnecessarily had plain films taken as part of their initial work-up. In a largely uninsured inner city patient population such as this cohort, that extra cost falls on the public hospital system. Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.
... [1][2][3][4][5][6] Erysipelas is currently an empiric clinical diagnosis based on the local presentation and systemic signs of infection because more specific microbiological tests have low sensitivity, with blood cultures becoming positive in fewer than 5% of all cases. [7][8][9] Hence, early differentiation between erysipelas and other causes of painful swelling of the lower limbsuch as deep vein thrombosis (DVT)remains a difficult task for the physician because of the overlap in clinical signs at presentation, including unilateral limb swelling, redness and pain. 10 The current gold standards in DVT diagnosis are duplex sonography, which has high sensitivity and specificity (both~95%), and duplex sonography in combination with D-dimer testing in low-to-moderate risk subjects, respectively. ...
Article
Early differentiation of erysipelas from deep vein thrombosis (DVT) based solely on clinical signs and symptoms is challenging. There is a lack of data regarding the usefulness of the inflammatory biomarkers procalcitonin (PCT), C-reactive protein (CRP) and white blood cell (WBC) count in the diagnosis of localized cutaneous infections. Herein, we investigated the diagnostic value of inflammatory markers in a prospective at-risk patient population. This is an observational quality control study including consecutive patients presenting with a final diagnosis of either erysipelas or DVT. The association of PCT (μg/L) and CRP (mg/L) levels and WBC counts (g/L) with the primary outcome was assessed using logistic regression models with area under the receiver-operator curve. Forty-eight patients (erysipelas, n = 31; DVT, n = 17) were included. Compared with patients with DVT, those with erysipelas had significantly higher PCT concentrations. No significant differences in CRP concentrations and WBC counts were found between the two groups. At a PCT threshold of 0.1 μg/L or more, specificity and positive predictive values (PPV) for erysipelas were 82.4% and 85.7%, respectively, and increased to 100% and 100% at a threshold of more than 0.25 μg/L. Levels of PCT also correlated with the severity of erysipelas, with a stepwise increase according to systemic inflammatory response syndrome criteria. We found a high discriminatory value of PCT for differentiation between erysipelas and DVT, in contrast to other commonly used inflammatory biomarkers. Whether the use of PCT levels for early differentiation of erysipelas from DVT reduces unnecessary antibiotic exposure needs to be assessed in an interventional trial. © 2015 Japanese Dermatological Association.
... In ambulatory care, uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics, and in EDs patients with cellulitis comprise 1-14% of visits [19,20]. In the USA hospital visits for abscesses and cellulitis increased from 17.3 to 32.5 per 1000 person-years from 1997 to 2010, and in 2010 there were 600,000 hospital admissions for these conditions [21]. Research in the United Kingdom found that skin and soft tissue infections (SSTIs) accounted for 10% of hospitalizations, with mean stays of approximately 5 days, and were the second most common reason for hospital-based IV antibiotic therapy lasting more than 48 hours [14]. ...
... Edema [3,13,15,16,25]. Biopsy of skin with cellulitis has shown dilated lymphatics and capillaries, marked dermal edema, and primarily neutrophilic infiltration, either diffusely within the dermis or concentrated around vessels [13]. ...
Article
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Methicillin-resistant Staphylococcus aureus (MRSA) has become the dominant strain of Staphylococcus aureus in many communities of the United States. As a result, many clinicians are now empirically covering for this pathogen in the treatment of various skin and soft-tissue infections. Should this practice apply to cellulitis? In order to answer this question, we defined cellulitis and reviewed the pathogenesis, microbiology, and current studies of inpatient and outpatient antimicrobial therapy. The current evidence suggests empirical MRSA coverage for community-acquired cellulitis may not be necessary in non-purulent (non-suppurative) forms of this infection. Most cases are non-purulent and not amenable to culture although antibody studies indicate streptococci are the most common etiologic agents. Current studies of antimicrobial therapy tend to agree with this finding. Empirical beta-lactam therapy directed primarily at streptococci appears sufficient for non-purulent cellulitis regardless of the prevalence of MRSA in the community.
Article
Red legs are a common symptom. Linda Nazarko looks at how nurses can differentiate between the different causes to ensure safe and effective treatment Nurses often encounter people with red legs. There are a number of reasons why an individual may develop red legs. The most common causes of red legs are cellulitis, venous eczema and lipodermatosclerosis. All have different causes and require different treatments. This article aims to enable readers to differentiate between these conditions which can appear similar, and to offer effective evidence-based care.
Article
Acute skin and soft tissue infections are among the most frequent infections in medicine. There is a broad spectrum including simple local infections as well as severe and life-threatening diseases. Along with Staphylococcus aureus, group A Streptococci are mainly responsible for these illnesses. The therapeutic approach ranges from antiseptic local treatments to administering systemic antibiotics or emergency surgery. Treating physicians often face challenges when presented with soft tissue infections due to a great discrepancy between the first impression of the disease compared to a possibly quick progression as well as the wide range of sometimes confusing historic terms and definitions being used in the English and German language, for instance pyoderma, erysipelas or phlegmon. A recently more popular collective term emphasized by clinical trials is "acute bacterial skin and skin structure infections" (ABSSSI).
Article
There is a shortage of dermatologists available to see hospitalized patients, especially for urgent evaluations such as in the emergency department setting. The use of teledermatology in the emergency setting was studied for patients presenting to the emergency department with symptoms of or a diagnosis of cellulitis. Thirty patients were enrolled and randomized to a teledermatology note being placed in their chart versus control patients undergoing standard care. Although randomized, in this small pilot study, the locations of involvement were unbalanced across treatment groups. The mean length of stay was slightly longer in the group randomized to teledermatology; however, this was largely related to the unbalanced number of patients presenting with bilateral and lower extremity complaints in the teledermatology group. This study provides important preliminary data for future studies, including ensuring appropriate balancing of locations of involvement, a larger sample size, and more rigid entry criteria.
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Cellulitis is generally referred to as the infection of the deeper layers of the skin. Early treatment with antibiotics is usually successful. This is a prospective, observational study to evaluate Clinical profile & Prescribing Patterns of cellulitis in foot ulcer. A detailed Patient Clinical Survey form was designed with 30 Questionnaires regarding the clinical status of the patient as well as the prevalent disorder. Data were collected from 120 Patients and enumerated statistical data on 8 parameters and the observations were recorded as graphical interpretations. It indicates that Males are more vulnerable than females as they work in agricultural fields without footwear. Though Diabetes is traced at an early age in adult males, their negligence had shown a high occurrence of Cellulitis in the age group of 60 to 70 years. When it comes to age and gender correlation, males are more affected in the above-mentioned age group than females. Co-morbidity like hypertension does not influence cellulitis. Diabetes is a unique reason. Non-Diabetic cellulitis stands in second place. Surprisingly males who are non-alcoholic and don't smoke are affected in high numbers. Males who were alcoholics and smokers stand in second place. Despite different clinical presentations and symptoms subjects with non-healing ulcers were high in occurrence. Subjects with swelling feet stood second. On random subjects who stayed for 5-10 days in the hospital are more in affected patients. Among the three prescribing patterns Broad-spectrum antibiotics, narrow spectrum, and both, most of the patients were prescribed narrow-spectrum antibiotics and obtained good results.
Article
Objectives: Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. Methods: An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. Results: Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. Conclusions: Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
Article
Background: The Dundee classification is a simple severity assessment tool that could optimize treatment decisions and clinical outcomes in adult patients with cellulitis; however, it has not been validated in a large cohort. Objectives: To determine whether the Dundee classification reliably identified those patients with cellulitis who had a higher mortality, a longer length of hospital stay or an increased risk of readmission. Methods: We performed a retrospective study of all adults with a primary discharge diagnosis of cellulitis admitted to Auckland City Hospital from August 2013 to June 2015. We classified patients by severity using the Dundee scoring system. Results: The 30 day all-cause mortality in adult patients with a discharge diagnosis of cellulitis was 2% (29/1462) overall, and was 1% (10/806), 2% (6/271), 3% (10/353) and 9% (3/32) in Classes 1, 2, 3 and 4 of the Dundee classification, respectively (P = 0.01). Mortality was strongly associated with age >65 years (OR 9.37, 95% CI 3.00-41.23) and with heart failure (OR 6.16, 95% CI 2.73-14.23). There were significant associations between the Dundee classification and the incidence of bacteraemia, the length of hospital stay and the rate of readmission to hospital. Conclusions: The Dundee classification is a simple, reliable tool that can be easily applied in clinical settings to predict risk of mortality in order to determine which patients can be managed in the community with oral or intravenous therapy, and which require inpatient care.
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Objective To summarise available data on the risk factors, complications and the factors associated with complications of lower limb cellulitis in Africa. Methods We did electronic searches on PubMed, EMBASE, Scopus and African Journals Online from 1 January 1986 to 30 October 2017, extracted and summarised data on the risk factors, complications and, the factors associated with the complications of lower limb cellulitis from eligible literature. Results A total of seven studies were retained for final review after the search and screening processes. Local risk factors of cellulitis reported were: disruption of the skin barrier, neglected wounds, toe-web intertrigo, leg ulcers, use of depigmentation drugs and leg oedema. Obesity was the only reported general risk factor of cellulitis. Five studies reported on the complications of cellulitis which included: abscess formation, necrotising fasciitis, bullae, haemorrhagic lesions, necrosis, phlebitis and amputations. Nicotine addiction, chronic use of non-steroidal anti-inflammatory drugs, delay in the initiation of antibiotic treatment and elevated erythrocyte sedimentation rate were risk factors of complications of lower limb cellulitis identified from three studies. Conclusion This review highlights the important role of local risk factors in the pathogenesis of lower limb cellulitis in Africa. The association between voluntary skin depigmentation and lower limb cellulitis should alert public health authorities and the general population to the health risks associated with this practice. The identification and improved management of the risk factors of lower limb cellulitis and its complications could go a long way in decreasing the morbidity and health costs incurred by lower limb cellulitis in Africa.
Article
Background Contact dermatitis from topical antiseptic use has been reported mostly in adults but rare cases of chlorhexidine contact dermatitis have also been described in young children. Objective To evaluate contact allergic dermatitis to antiseptics in young children. Methods The children mostly referred for a misdiagnose (cellulitis) were patch tested with a selection of the European baseline series, an antiseptics series and the personal topical products used. Results 14 children (8 boys, 6 girls) received a diagnosis of contact dermatitis to antiseptics between May 2010 and December 2017. The mean age at diagnosis was 38 months (8 months to 8 years), 3 children only had a personal history of atopy. Chlorhexidine gluconate was positive in 7 cases, benzalkonium chloride in 8 cases, and in 4 cases both allergens were positive. Conclusion This small case series confirm that both chlorhexidine and benzalkonium chloride are implicated in contact dermatitis from antiseptic use in the pediatric population. We emphasize the initial misdiagnose of these patients, the very young age of the children, and the allergenic potential of common antiseptics in non‐atopic children. We hypothesize that the systematic use of antiseptics for umbilical cord care could be responsible for the sensitization in newborns. This article is protected by copyright. All rights reserved.
Article
Background: This study aimed to profile the clinical characteristics of patients presenting to Middlemore Hospital with cellulitis in order to identify factors that are associated with an increased length of stay (LOS). Methods: Retrospective clinical data were collected for all patients aged 18 and above who were admitted with cellulitis to Middlemore Hospital General Surgical Department between 1 January and 31 March 2014. Comorbidities, laboratory results and medical conditions were included in the investigation. Results: The study included 201 patients. Significant factors associated with increased LOS include type 2 diabetes mellitus (P < 0.012), obesity (P < 0.001), raised C-reactive protein (P < 0.0001), raised white cell count (P < 0.0001), raised temperature (P < 0.0001), septic shock (P < 0.003), multiorgan failure (P < 0.01), extended-spectrum beta-lactamases or methicillin-resistant Staphylococcus aureus colonization (P < 0.04) and intensive care unit admission (P < 0.0004). Conclusion: This single-centre, retrospective clinical study has identified several factors that are significantly associated with an increased LOS. These factors provide a basis for future studies that may facilitate identification and timely medical optimization of high-risk patients.
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Skin and soft tissue infections are among the most commonly encountered, and run the continuum from mild to life-threatening. In the last three decades, emerging resistance patterns in common pathogens have drastically increased morbidity and mortality of the affected patients, and caused a rapid increase in health care utilization. By stratifying patient risk factors and becoming familiar with epidemiology of these infections, we can focus treatment plans and improve patient outcomes.
Article
Introduction Skin and soft tissue infections (SSTIs) are commonly treated in ED observation units (EDOUs). The management failure rate in this setting is high, as evidenced by a large proportion of patients requiring inpatient admission. This systematic review sought to quantify the management failure rate and identify risk factors associated with management failure. Methods Searches of six databases and grey literature were conducted with no limits on publication year or language. Manuscripts describing patients admitted to an EDOU setting (≤24 hours planned admission to EDOU) with a primary diagnosis of cellulitis or other SSTIs were included. Variables associated with failure of management, defined as inpatient admission, stay >28 hours (4 hours in ED, 24 hours in EDOU) or death, were extracted. A narrative description of variables associated with failure of EDOU admission was conducted. Results There were 1119 unique articles identified through the literature search. Following assessment, 10 studies were included in the final systematic review, 9 of which reported the management failure rate (range 15%–38%). The presence of fever, a high total white blood cell count and known methicillin-resistant Staphylococcus aureus exposure were the most commonly reported variables associated with management failure. Conclusion A higher rate of EDOU management failure in SSTIs than the generally accepted rate of 15% was observed in most studies identified by this review. Risk factors identified were varied, but presence of a fever and elevated inflammatory markers were commonly associated with failure of EDOU admission by multiple studies. Recognition of risk factors and the increased application of clinical decision tools may help to improve disposition of patients at high risk for clinical deterioration or management failure.
Chapter
Impetigo is a common, contagious superficial skin infection seen most often in infants and children.
Book
Geriatric Emergencies is a practical guide to the common conditions affecting older patients who present in an emergency to hospital or primary care. Beginning with the essentials of history taking and clinical examination, the book covers a comprehensive range of emergencies, emphasizing the different management approaches which may be required in older patients. Common geriatric presentations such as falls, delirium and stroke, are explored in detail in addition to more diverse topics such as abdominal pain, major trauma and head injury. Ethical considerations such as advanced care planning, palliative care and capacity assessment are discussed with practical tips on communicating with patients and their relatives. Geriatric Emergencies provides concise up-to-date guidance to the emergency management of the older patient. It is a recommended resource for all health professionals working in the acute environment, in which a large proportion of patients are aged over 65.
Article
Background: Because Streptococcus pyogenes and Staphylococcus aureus are common causes of cellulitis and erysipelas, treatment with an antistaphylococcal β-lactam is widely recommended. However, during oral treatment, serum levels of these agents are less than the minimum inhibitory concentration of many methicillin-sensitive strains of S. aureus for a significant portion of the dosing interval, and consequently, treatment is often initially given intravenously and then orally. Clindamycin is active against most strains of S. pyogenes and S. aureus and, when given orally, achieves adequate serum levels throughout the dosing interval. Treatment of cellulitis with oral clindamycin might provide better outcomes than those achieved with an antistaphylococcal β-lactam given intravenously and then orally. Methods: Adult patients with cellulitis were enrolled in a randomized, double-blind trial that compared clindamycin 300 mg 4 times a day administered orally, with flucloxacillin 2 g every 6 hours administered intravenously, followed by flucloxacillin 500 mg 4 times a day administered orally. The patients were assessed daily while inpatients, at completion of treatment, and at 4 weeks after entry. Results: Forty eligible patients were randomized and completed treatment: 21 with oral clindamycin and 19 with intravenous followed by oral flucloxacillin. At the completion of treatment, 7 of 19 patients in the flucloxacillin group and 18 of 21 in the clindamycin group were considered cured and 11 of 19 in the flucloxacillin group and 3 of 21 in the clindamycin group were considered improved (P = 0.003). There were no significant differences between the 2 groups with regard to duration of treatment, duration of hospital stay, rate of relapse, or that of adverse events. Conclusions: Clindamycin administered orally was at least as effective as flucloxacillin administered intravenously and then orally.
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SUMMARY Streptococcus pyogenes, also known as group A Streptococcus (GAS), causes mild human infections such as pharyngitis and impetigo and serious infections such as necrotizing fasciitis and streptococcal toxic shock syndrome. Furthermore, repeated GAS infections may trigger autoimmune diseases, including acute poststreptococcal glomerulonephritis, acute rheumatic fever, and rheumatic heart disease. Combined, these diseases account for over half a million deaths per year globally. Genomic and molecular analyses have now characterized a large number of GAS virulence determinants, many of which exhibit overlap and redundancy in the processes of adhesion and colonization, innate immune resistance, and the capacity to facilitate tissue barrier degradation and spread within the human host. This improved understanding of the contribution of individual virulence determinants to the disease process has led to the formulation of models of GAS disease progression, which may lead to better treatment and intervention strategies. While GAS remains sensitive to all penicillins and cephalosporins, rising resistance to other antibiotics used in disease treatment is an increasing worldwide concern. Several GAS vaccine formulations that elicit protective immunity in animal models have shown promise in nonhuman primate and early-stage human trials. The development of a safe and efficacious commercial human vaccine for the prophylaxis of GAS disease remains a high priority.
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Acute bacterial skin and skin structure infections (SSSIs) are among the most common bacterial infections in children. The medical burden of SSSIs, particularly abscesses, has increased nationwide since the emergence of community-acquired methicillin-resistant Staphylococcus aureus. SSSIs represent a wide spectrum of disease severity. Prompt recognition, timely institution of appropriate therapy, and judicious antimicrobial use optimize patient outcomes. For abscesses, incision and drainage are paramount and might avoid the need for antibiotic treatment in uncomplicated cases. If indicated, empiric antimicrobial therapy should target Streptococcus pyogenes for nonpurulent SSSIs, such as uncomplicated cellulitis, and S aureus for purulent SSSIs such as abscesses.
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Empiric treatment of skin infections depends on the epidemiological characteristics, type of injury, the suspected etiologic agent and progression. Topical treatments are enough for surperficial infections. If there is deep infection, malaise or complications of other organs, systemic treatment should be initiated. In some cases, recurrent infections can be prevented with prophylactic doses of drugs.
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Quantify the prevalence, measure the severity, and describe treatment patterns in patients who present to medical clinics in Texas with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft-tissue infections (SSTI). Ten primary care clinics participated in this prospective, community-based study. Clinicians consented patients and collected clinical information, pictures, and wound swabs; data were processed centrally. MRSASelect™ was used for identification. Susceptibilities were determined via Etest®. Overall, 73 of 119 (61%) patients presenting with SSTIs meeting eligibility requirements had CA-MRSA. Among these, 49% were male, 79% were Hispanic, and 30% had diabetes. Half (56%) of the lesions were ≥ 5 cm in diameter. Most patients had abscesses (82%) and many reported pain scores of ≥ 7 of 10 (67%). Many presented with erythema (85%) or drainage (56%). Most received incision and drainage plus an antibiotic (64%). Antibiotic monotherapy was frequently prescribed: trimethoprim-sulfamethoxazole (TMP-SMX) (78%), clindamycin (4%), doxycycline (2%), and mupirocin (2%). The rest received TMP-SMX in combination with other antibiotics. TMP-SMX was frequently administered as one double-strength tablet twice daily. Isolates were 93% susceptible to clindamycin and 100% susceptible to TMP-SMX, doxycycline, vancomycin, and linezolid. We report a predominance of CA-MRSA SSTIs, favorable antibiotic susceptibilities, and frequent use of TMP-SMX in primary care clinics.
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Misdiagnosis of non-infectious conditions such as cellulitis is a common error and can result in unnecessary hospitalization and antibiotic use. We sought to prospectively determine the misdiagnosis rate of cellulitis among hospitalized patients and to determine if a visually-based computerized diagnostic decision support system (VCDDSS, also named VisualDx) could generate an improved differential diagnosis (DDx) for misdiagnosed patients. In two separate institutions, attending dermatologists or infectious disease specialists evaluated all consecutive patients hospitalized for "cellulitis" by the emergency department. Among 145 subjects enrolled, misdiagnosis occurred in 41 (28%) patients. The diagnosis most commonly mistaken as cellulitis was stasis dermatitis (37%). At one center, in cases that were misdiagnosed by the emergency department, the VCDDSS included the correct diagnosis in the DDx more frequently than the admitting team (18/28 cases (64%) compared to 4/28 cases (14%), p=0.0003). These results demonstrate the capability of this VCDDSS to assist primary care physicians with generating a more accurate DDx when confronted with patients presenting with possible skin infections. Misdiagnoses may result in a significant source of healthcare costs and misdiagnosis-related patient harm. Inclusion of decision support tools early in the diagnostic workflow may reduce misdiagnosis and result in more efficient healthcare management.
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Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.
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Cellulitis and erysipelas are now usually considered manifestations of the same condition, a skin infection associated with severe pain and systemic symptoms. A range of antibiotic treatments are suggested in guidelines. To assess the efficacy and safety of interventions for non-surgically-acquired cellulitis. In May 2010 we searched for randomised controlled trials in the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and the ongoing trials databases. We selected randomised controlled trials comparing two or more different interventions for cellulitis. Two authors independently assessed trial quality and extracted data. We included 25 studies with a total of 2488 participants. Our primary outcome 'symptoms rated by participant or medical practitioner or proportion symptom-free' was commonly reported. No two trials examined the same drugs, therefore we grouped similar types of drugs together.Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98).Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99, 95% CI 0.68 to 1.43).Six trials which included 538 people that compared different generations of cephalosporin, showed no difference in treatment effect (RR 1.00, 95% CI 0.94 to1.06).We found only small single studies for duration of antibiotic treatment, intramuscular versus intravenous route, the addition of corticosteroid to antibiotic treatment compared with antibiotic alone, and vibration therapy, so there was insufficient evidence to form conclusions. Only two studies investigated treatments for severe cellulitis and these selected different antibiotics for their comparisons, so we cannot make firm conclusions. We cannot define the best treatment for cellulitis and most recommendations are made on single trials. There is a need for trials to evaluate the efficacy of oral antibiotics against intravenous antibiotics in the community setting as there are service implications for cost and comfort.
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Outpatient parenteral antibiotic therapy (OPAT) is an effective treatment strategy for a wide variety of infections as long as clinical risk is minimized by conforming to practice guidelines. However, its cost-effectiveness has not been established in the setting of the UK National Health Service. We examined the clinical efficacy and cost-effectiveness of an OPAT service based in a large UK teaching hospital, predominantly using the outpatient 'infusion centre' and patient/carer administration models of service delivery. Data on clinical activity and outcomes were collected prospectively on 334 episodes of treatment administered by the Sheffield OPAT service between January 2006 and January 2008. Cost-effectiveness was calculated by comparing real costs of OPAT with estimated inpatient costs for these patient episodes incorporating two additional sensitivity analyses. Of the OPAT episodes, 87% resulted in cure or improvement on completion of intravenous therapy. The readmission rate was 6.3%, and patient satisfaction was high. OPAT cost 41% of equivalent inpatient costs for an Infectious Diseases Unit, 47% of equivalent inpatient costs using national average costs and 61% of inpatient costs using minimum inpatient costs for each diagnosis. Using this service model, OPAT is safe and clinically effective, with low rates of complications/readmissions and high levels of patient satisfaction. OPAT is cost-effective when compared with equivalent inpatient care in the UK healthcare setting.
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We utilized Medline to perform a systematic review of the literature to quantify the aetiology of cellulitis with intact skin. Of 808 patients with cellulitis, 127-129 (15.7-16.0%) patients had positive needle aspiration and/or punch biopsy cultures from intact skin. Of the patients with positive cultures, 65 (50.4-51.2%) had cultures positive for Staphylococcus aureus, 35 (27.1-27.6%) for group A streptococcus, and 35-37 (27.1-29.1%) for other pathogens. The most common aetiology of cellulitis with intact skin, when it can be determined, is S. aureus, outnumbering group A streptococcus by a ratio of nearly 2:1. Given the increasing incidence of community-associated methicillin-resistant S. aureus infections, our findings may have critical therapeutic implications.
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To assess risk factors for erysipelas of the leg (cellulitis). Case-control study. 7 hospital centres in France. 167 patients admitted to hospital for erysipelas of the leg and 294 controls. In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable risk for toe-web intertrigo was 61%. This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg.
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To assess the cost-effectiveness of blood cultures for patients with cellulitis, a retrospective review was conducted of clinical and microbiological data for all 757 patients admitted to a medical center because of community-acquired cellulitis during a 41-month period. Blood cultures were performed for 553 patients (73%); there were a total of 710 blood samples (i.e., a mean of 1.3 cultures were performed per patient). In only 11 cases (2.0%) was a significant patient-specific microbial strain isolated, mainly β-hemolytic streptococci (8 patients [73%]). An organism that was considered a contaminant was isolated from an additional 20 culture bottles (3.6%). The cost of laboratory workup of the 710 culture sets was $36,050. Isolation of streptococci led to a change from empirical treatment with cefazolin to penicillin therapy for 8 patients. All patients recovered. In conclusion, the yield of blood cultures is very low, has a marginal impact on clinical management, and does not appear to be cost-effective for most patients with cellulitis.
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Soft-tissue infections are common, generally of mild to modest severity, and are easily treated with a variety of agents. An etiologic diagnosis of simple cellulitis is frequently difficult and generally unnecessary for patients with mild signs and symptoms of illness. Clinical assessment of the severity of infection is crucial, and several classification schemes and algorithms have been proposed to guide the clinician [1]. However, most clinical assessments have been developed from either retrospective studies or from an author's own "clinical experience," illustrating the need for prospective studies with defined measurements of severity coupled to management issues and outcomes. Until then, it is the recommendation of this committee that patients with soft-tissue infection accompanied by signs and symptoms of systemic toxicity (e.g., fever or hypothermia, tachycardia [heart rate, >100 beats/min], and hypotension [systolic blood pressure, <90 mm Hg or 20 mm Hg below baseline]) have blood drawn to determine the following laboratory parameters: results of blood culture and drug susceptibility tests, complete blood cell count with differential, and creatinine, bicarbonate, creatine phosphokinase, and C-reactive protein levels. In patients with hypotension and/or an elevated creatinine level, low serum bicarbonate level, elevated creatine phosphokinase level (2-3 times the upper limit of normal), marked left shift, or a C-reactive protein level >13 mg/L, hospitalization should be considered and a definitive etiologic diagnosis pursued aggressively by means of procedures such as Gram stain and culture of needle aspiration or punch biopsy specimens, as well as requests for a surgical consultation for inspection, exploration, and/or drainage. Other clues to potentially severe deep soft-tissue infection include the following: (1) pain disproportionate to the physical findings, (2) violaceous bullae, (3) cutaneous hemorrhage, (4) skin sloughing, (5) skin anesthesia, (6) rapid progression, and (7) gas in the tissue. Unfortunately, these signs and symptoms often appear later in the course of necrotizing infections. In these cases, emergent surgical evaluation is of paramount importance for both diagnostic and therapeutic reasons. Emerging antibiotic resistance among Staphylococcus aureus (methicillin resistance) and Streptococcus pyogenes (erythromycin resistance) are problematic, because both of these organisms are common causes of a variety of skin and soft-tissue infections and because empirical choices of antimicrobials must include agents with activity against resistant strains. Minor skin and soft-tissue infections may be empirically treated with semisynthetic penicillin, first-generation or second-generation oral cephalosporins, macrolides, or clindamycin (A-I); however, 50% of methicillin-resistant S. aureus (MRSA) strains have inducible or constitutive clindamycin resistance [2] (table 1). Most community-acquired MRSA strains remain susceptible to trimethoprim-sulfamethoxazole and tetracycline, though treatment failure rates of 21% have been reported in some series with doxycycline or minocycline [3]. Therefore, if patients are sent home receiving these regimens, it is prudent to reevaluate them in 24-48 h to verify a clinical response. Progression despite receipt of antibiotics could be due to infection with resistant microbes or because a deeper, more serious infection exists than was previously realized. Patients who present to the hospital with severe infection or whose infection is progressing despite empirical antibiotic therapy should be treated more aggressively, and the treatment strategy should be based upon results of appropriate Gram stain, culture, and drug susceptibility analysis. In the case of S. aureus, the clinician should assume that the organism is resistant, because of the high prevalence of community-associated MRSA strains, and agents effective against MRSA (i.e., vancomycin, linezolid, or daptomycin) should be used (A-I). Stepdown to treatment with other agents, such as tetracycline or trimethoprim-sulfamethoxazole, for MRSA infection may be possible, based on results of susceptibility tests and after an initial clinical response. In the United States, not all laboratories perform susceptibility testing on S. pyogenes. However, the Centers for Disease Control and Prevention has provided national surveillance data that suggest a gradual trend of increasing macrolide resistance of S. pyogenes from 4%-5% in 1996-1998 to 8%-9% in 1999-2001 [4]. Of interest, 99.5% of strains remain susceptible to clindamycin, and 100% are susceptible to penicillin. Impetigo, erysipelas, and cellulitis. Impetigo may be caused by infection with S. aureus and/or S. pyogenes. The decision of how to treat impetigo depends on the number of lesions, their location (face, eyelid, or mouth), and the need to limit spread of infection to others. The best topical agent is mupirocin (A-I), although resistance has been described [5]; other agents, such as bacitracin and neomycin, are considerably less effective treatments. Patients who have numerous lesions or who are not responding to topical agents should receive oral antimicrobials effective against both S. aureus and S. pyogenes (A-I) (table 2). Although rare in developed countries (<1 case/1,000,000 population per year), glomerulonephritis following streptococcal infection may be a complication of impetigo caused by certain strains of S. pyogenes, but no data demonstrate that treatment of impetigo prevents this sequela. Classically, erysipelas, is a fiery red, tender, painful plaque with well-demarcated edges and is commonly caused by streptococcal species, usually S. pyogenes. Cellulitis may be caused by numerous organisms that are indigenous to the skin or to particular environmental niches. Cellulitis associated with furuncles, carbuncles, or abscesses is usually caused by S. aureus. In contrast, cellulitis that is diffuse or unassociated with a defined portal is most commonly caused by streptococcal species. Important clinical clues to other causes include physical activities, trauma, water contact, and animal, insect, or human bites. In these circumstances appropriate culture material should be obtained, as they should be in patients who do not respond to initial empirical therapy directed against S. aureus and S. pyogenes and in immunocompromised hosts. Unfortunately, aspiration of skin is not helpful in 75%-80% of cases of cellulitis, and results of blood cultures are rarely positive (<5% of cases). Penicillin, given either parenterally or orally depending on clinical severity, is the treatment of choice for erysipelas (A-I). For cellulitis, a penicillinase- resistant semisynthetic penicillin or a first-generation cephalosporin should be selected (A-I), unless streptococci or staphylococci resistant to these agents are common in the community. For penicillin-allergic patients, choices include clindamycin or vancomycin. Lack of clinical response could be due to unusual organisms, resistant strains of staphylococcus or streptococcus, or deeper processes, such as necrotizing fasciitis or myonecrosis. In patients who become increasingly ill or experience increasing toxicity, necrotizing fasciitis, myonecrosis, or toxic shock syndrome should be considered, an aggressive evaluation initiated, and antibiotic treatment modified, on the basis of Gram stain results, culture results, and antimicrobial susceptibilities of organisms obtained from surgical specimens. Necrotizing infections. Necrotizing fasciitis may be monomicrobial and caused by S. pyogenes, Vibrio vulnificus, or Aeromonas hydrophila. Recently, necrotizing fasciitis was described in a patient with MRSA infection [7]. Polymicrobial necrotizing fasciitis may occur following surgery or in patients with peripheral vascular disease, diabetes mellitus, decubitus ulcers, and spontaneous mucosal tears of the gastrointestinal or gastrourinary tract (i.e., Fournier gangrene). As with clostridial myonecrosis, gas in the deep tissues is frequently found in these mixed infections. Gas gangrene is a rapidly progressive infection caused by Clostridium perfringens, Clostridium septicum, Clostridium histolyticum, or Clostridium novyi. Severe penetrating trauma or crush injuries associated with interruption of the blood supply are the usual predisposing factors. C, perfringens and C. novyi infections have recently been described among heroin abusers following intracutaneous injection of black tar heroin. C. septicum, a more aerotolerant Clostridium species, may cause spontaneous gas gangrene in patients with colonic lesions (such as those due to diverticular disease), adenocarcinoma, or neutropenia. Necrotizing fasciitis and gas gangrene may cause necrosis of skin, subcutaneous tissue, and muscle. Cutaneous findings of purple bullae, sloughing of skin, marked edema, and systemic toxicity mandate prompt surgical intervention. For severe group A streptococcal and clostridial necrotizing infections, parenteral clindamycin and penicillin treatment is recommended (A-II). A variety of antimicrobials directed against aerobic gram-positive and gram-negative bacteria, as well as against anaerobes, may be used in mixed necrotizing infections (B-II). Infections following animal or human bites. Animal bites account for 1% of all emergency department visits, and dog bites are responsible for 80% of such cases. Although Pasteurella species are the most common isolates, cat and dog bites contain an average of 5 different aerobic and anaerobic bacteria per wound, often including S. aureus, Bacteroides tectum, and Fusobacterium, Capnocytophaga, and Porphyromonas species. The decision to administer oral or parenteral antibiotics depends on the depth and severity of the wound and on the time since the bite occurred. © 2005 by the Infectious Diseases Society of America. All rights reserved.
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Studies have shown that community-acquired methicillin-resistant Staphylococcus aureus (MRSA) causes S. aureus skin and soft-tissue infection in selected populations. To determine the proportion of infections caused by community-acquired MRSA, the clinical characteristics associated with community-acquired MRSA, and the molecular epidemiology of community-acquired MRSA among persons with community-onset S. aureus skin and soft-tissue infection. Active, prospective laboratory surveillance to identify S. aureus recovered from skin and soft-tissue sources. 1000-bed urban hospital and its affiliated outpatient clinics in Atlanta, Georgia. 384 persons with microbiologically confirmed community-onset S. aureus skin and soft-tissue infection. Proportion of infections caused by and clinical factors associated with community-acquired MRSA among persons with community-onset S. aureus skin and soft-tissue infection. Pulsed-field gel electrophoresis and antimicrobial susceptibility patterns were used to epidemiologically classify community-onset S. aureus infections. Community-acquired MRSA was defined by MRSA isolates that either demonstrated a USA 300 or USA 400 pulsed-field type or had a susceptibility pattern showing resistance only to beta-lactams and erythromycin (for isolates not available for pulsed-field gel electrophoresis). Community-onset skin and soft-tissue infection due to S. aureus was identified in 389 episodes, with MRSA accounting for 72% (279 of 389 episodes). Among all S. aureus isolates, 63% (244 of 389 isolates) were community-acquired MRSA. Among MRSA isolates, 87% (244 of 279 isolates) were community-acquired MRSA. When analysis was restricted only to MRSA isolates that were available for pulsed-field gel electrophoresis, 91% (159 of 175 isolates) had a pulsed-field type consistent with community-acquired MRSA; of these, 99% (157 of 159 isolates) were the MRSA USA 300 clone. Factors independently associated with community-acquired MRSA infection were black race (prevalence ratio, 1.53 [95% CI, 1.16 to 2.02]), female sex (prevalence ratio, 1.16 [CI, 1.02 to 1.32]), and hospitalization within the previous 12 months (prevalence ratio, 0.80 [CI, 0.66 to 0.97]). Inadequate initial antibiotic therapy was statistically significantly more common among those with community-acquired MRSA (65%) than among those with methicillin-susceptible S. aureus skin and soft-tissue infection (1%). Some MRSA isolates were not available for molecular typing. The community-acquired MRSA USA 300 clone was the predominant cause of community-onset S. aureus skin and soft-tissue infection. Empirical use of agents active against community-acquired MRSA is warranted for patients presenting with serious skin and soft-tissue infections.
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Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized in infections among persons in the community without established risk factors for MRSA. We enrolled adult patients with acute, purulent skin and soft-tissue infections presenting to 11 university-affiliated emergency departments during the month of August 2004. Cultures were obtained, and clinical information was collected. Available S. aureus isolates were characterized by antimicrobial-susceptibility testing, pulsed-field gel electrophoresis, and detection of toxin genes. On MRSA isolates, we performed typing of the staphylococcal cassette chromosome mec (SCCmec), the genetic element that carries the mecA gene encoding methicillin resistance. S. aureus was isolated from 320 of 422 patients with skin and soft-tissue infections (76 percent). The prevalence of MRSA was 59 percent overall and ranged from 15 to 74 percent. Pulsed-field type USA300 isolates accounted for 97 percent of MRSA isolates; 74 percent of these were a single strain (USA300-0114). SCCmec type IV and the Panton-Valentine leukocidin toxin gene were detected in 98 percent of MRSA isolates. Other toxin genes were detected rarely. Among the MRSA isolates, 95 percent were susceptible to clindamycin, 6 percent to erythromycin, 60 percent to fluoroquinolones, 100 percent to rifampin and trimethoprim-sulfamethoxazole, and 92 percent to tetracycline. Antibiotic therapy was not concordant with the results of susceptibility testing in 100 of 175 patients with MRSA infection who received antibiotics (57 percent). Among methicillin-susceptible S. aureus isolates, 31 percent were USA300 and 42 percent contained pvl genes. MRSA is the most common identifiable cause of skin and soft-tissue infections among patients presenting to emergency departments in 11 U.S. cities. When antimicrobial therapy is indicated for the treatment of skin and soft-tissue infections, clinicians should consider obtaining cultures and modifying empirical therapy to provide MRSA coverage.
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Few data exist on the clinical utility of the expanded-spectrum tetracyclines doxycycline and minocycline for the treatment of community-associated methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTI). We performed a retrospective cohort study of 276 patients who presented with 282 episodes of MRSA SSTI to the emergency room or outpatient clinic at two tertiary medical centers between October 2002 and February 2007. The median percentage of patients infected with MRSA strains that were susceptible to tetracycline was 95%. Time zero was defined as the time of the first incision and drainage procedure or, if none was performed, the time of the first positive wound culture. The median patient age was 48 years. Abscesses constituted the majority of clinical presentations (75%), followed by furuncles or carbuncles (13%) and cellulitis originating from a purulent focus of infection (12%). A total of 225 patients (80%) underwent incision and drainage. Doxycycline or minocycline was administered in 90 episodes (32%); the other 192 SSTI were treated with beta-lactams. Treatment failure, defined as the need for a second incision and drainage procedure and/or admission to the hospital within at least 2 days after time zero, was diagnosed in 28 episodes (10%) at a median of 3 days after time zero. On logistic regression analysis, receipt of a beta-lactam agent was the only clinical characteristic associated with treatment failure (adjusted odds ratio, 3.94; 95% confidence interval, 1.28 to 12.15; P = 0.02). The expanded-spectrum tetracyclines appear to be a reasonable oral treatment option for patients with community onset MRSA SSTI in areas where MRSA strains are susceptible to the tetracyclines.
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Deep vein thrombosis (DVT) and cellulitis are common conditions whose symptoms lead patients to seek medical attention in the emergency department (ED). Distinguishing between these two conditions quickly and accurately is important. To determine the yield of duplex scanning among ED patients whose clinical presentation is compatible with DVT or cellulitis. In addition, to determine whether baseline clinical variables are predictive of the final diagnosis among ED patients with an initial clinical impression of 'DVT versus cellulitis' who underwent duplex scanning. In this historical cohort study, patients with a final diagnosis of DVT (positive duplex) were compared on several baseline variables with patients with a final diagnosis of cellulitis (negative duplex and antibiotics prescribed) . One hundred-nine of 542 ED patients referred for a duplex scan were initially diagnosed as 'DVT versus cellulitis', 17% of whom had DVT confirmed by a positive duplex scan. Comparing patients with DVT versus those with cellulitis, 0% versus 15.3% had rigors (P=0.06); 0% versus 8.3% had distinct margins of erythema (P<0.01); 5.3% versus 22.2% were currently on antibiotics (P=0.09); and 50% versus 21.3% had an elevated white blood cell count (P=0.04). There are differences in a number of baseline characteristics of 'DVT versus cellulitis' patients who went on to have either positive or negative duplex scans, some of which were statistically significant despite the limited sample size. These findings should be confirmed prospectively in a larger study sample since they may have the potential to aid in the clinical differentiation between DVT and cellulitis.
Article
Objective To define the immediate and long-term volumetric reduction following complete decongestive physiotherapy (CDP) for lymphedema.Design Prospective study of consecutively treated patients.Setting Freestanding outpatient referral centers.Patients Two hundred ninety-nine patients referred for evaluation of lymphedema of the upper (2% primary, 98% secondary) or lower (61.3% primary, 38.7% secondary) extremities were treated with CDP for an average duration of 15.7 days. Lymphedema reduction was measured following completion of treatment and at 6- and 12-month follow-up visits.Intervention Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen. The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care. Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises.Main Outcome Measures Average limb volumes in milliliters were calculated prior to treatment, at the end of phase 1, and at 6- to 12-month intervals during phase 2 to assess percent volume reduction.Results Lymphedema reduction averaged 59.1% after upper-extremity CDP and 67.7% after lower-extremity treatment. With an average follow-up of 9 months, this improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper extremities and lower extremities. Noncompliant patients lost a part (33%) of their initial reduction. The incidence of infections decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP.Conclusions Complete decongestive physiotherapy is a highly effective treatment for both primary and secondary lymphedema. The initial reductions in volume achieved are maintained in the majority of the treated patients. These patients typically report a significant recovery from their previous cosmetic and functional impairments, and also from the psychosocial limitations they experienced from a physical stigma they felt was often trivialized by the medical and payor communities.
Article
Objectives: To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis. Methods: This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded. Results: Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%. Conclusions: Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.
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Cellulitis (erysipelas) of the leg is a common, painful infection of the skin and underlying tissue. Repeat episodes are frequent, cause significant morbidity and result in high health service costs. To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes. Double-blind, randomized controlled trial including patients recently treated for an episode of leg cellulitis. Recruitment took place in 20 hospitals. Randomization was by computer-generated code, and treatments allocated by post from a central pharmacy. Participants were enrolled for a maximum of 3 years and received their randomized treatment for the first 6 months of this period. Participants (n=123) were randomized (31% of target due to slow recruitment). The majority (79%) had suffered one episode of cellulitis on entry into the study. The primary outcome of time to recurrence of cellulitis included all randomized participants and was blinded to treatment allocation. The hazard ratio (HR) showed that treatment with penicillin reduced the risk of recurrence by 47% [HR 0·53, 95% confidence interval (CI) 0·26-1·07, P=0·08]. In the penicillin V group 12/60 (20%) had a repeat episode compared with 21/63 (33%) in the placebo group. This equates to a number needed to treat (NNT) of eight participants in order to prevent one repeat episode of cellulitis [95% CI NNT(harm) 48 to ∞ to NNT(benefit) 3]. We found no difference between the two groups in the number of participants with oedema, ulceration or related adverse events. Although this trial was limited by slow recruitment, and the result failed to achieve statistical significance, it provides the best evidence available to date for the prevention of recurrence of this debilitating condition.
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Skin and soft tissue infections (SSTIs) are caused by bacterial invasion of the skin and underlying soft tissues and can present with a wide spectrum of signs, symptoms and illness severity. They are a common indication for antimicrobial therapy. However, there are few data on treatment outcomes or the validity of clinical severity scores. Two hundred and five adult patients admitted to Ninewells Hospital, Scotland in 2005, and treated with antibiotics for SSTI, were identified. They were stratified into four classes of severity (class IV = most severe) based on sepsis, co-morbidity and their standardized early warning score (SEWS). Empirical antimicrobial therapy by severity class was compared with the recommendations of a UK guideline. Thirty-five different empirical antimicrobial regimens were prescribed. Overall, 43% of patients were over-treated, this being particularly common in the lowest severity class I (65% patients). Thirty-day mortality was 9% (18/205) and 17 patients (8%) died during their index admission. Mortality (30 day) and inadequate therapy increased with severity class: I, no sepsis or co-morbidity (45% patients, 1% mortality, 14% therapy inadequate); II, significant co-morbidity but no sepsis (32% patients, 11% mortality, 39% therapy inadequate); III, sepsis but SEWS <4 (17% of patients, 17% mortality, 39% therapy inadequate); and IV, sepsis plus SEWS ≥ 4 (6% of patients, 33% mortality, 92% therapy inadequate). SSTI in hospital is associated with significant mortality. Choice of empirical therapy is not evidence based, with significant under-treatment of severely ill patients.
Article
Over the past decade, community-associated meticillin-resistant Staphylococcus aureus (MRSA) has emerged in patients without health-care contact, especially in the USA. Although data are limited, the prevalence of community-associated MRSA in Europe seems to be low but is increasing. The organism has been reported in most European countries, including The Netherlands and Nordic countries, which have low rates of health-care-associated MRSA. In Greece, rates of community-associated MRSA in some centres approach those of the USA. By contrast with North America, where the USA300 clone (ST8-IV) predominates, community-associated MRSA in Europe is characterised by clonal heterogeneity. The most common European strain is the European clone (ST80-IV), although reports of USA300 are increasing. Several community-associated MRSA clones have arisen in Europe, most notably the ST398-V pig-associated MRSA clone in The Netherlands and Denmark. An understanding of the epidemiology of community-associated MRSA is essential to guide new control initiatives to prevent these organisms from becoming endemic in Europe.
Article
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred. We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing. Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P < .001 for trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.
Article
After an average follow-up time of three years, recurrent erysipelas was observed in 29% of 143 patients admitted primarily with erysipelas. Nineteen patients (13%) had two or more recurrences during this period. The predisposing factor with the highest recurrence rate was venous insufficiency. Regular prophylaxis with phenoxymethylpenicillin (or erythromycin in penicillin allergics) after the second recurrence may be cost-effective. This antibiotic prophylaxis is only recommended in patients with predisposing factors who have suffered severe attacks.
Article
Fifty patients with cellulitis were evaluated prospectively using cultures of aspirates from the advancing edge of cellulitis, skin biopsy specimens, and blood. Potential microbial pathogens were isolated in 13 patients. Biopsy specimen cultures were positive in ten patients, while aspirate and blood cultures were positive in five and two, respectively. Aspirate, biopsy, or blood cultures were more often positive in patients with apparent primary lesions than in patients without such lesions. Apparent primary sites of infection were identified and cultured in 24 patients. beta-Hemolytic streptococci were isolated from 17 primary lesions, and coagulase-positive staphylococci were present in 13. Both organisms were isolated from ten primary lesions. Among patients with positive aspirate, biopsy, and/or blood cultures, the same pathogens were also isolated from primary sites in ten of ten patients. Clinical features, including temperature, white blood cell count, and erythrocyte sedimentation rate, were not predictive of positive aspirate, biopsy, or blood cultures. These cultures provided no microbiologic information that was not obtainable from culture of primary lesions.
Article
To describe magnetic resonance (MR) imaging findings in acute infectious cellulitis and assess its value for the diagnosis of severe necrotizing forms. Spin-echo (SE) T1- and T2-weighted imaging was performed in 36 patients with acute infectious cellulitis. T1-weighted SE images obtained after injection of a paramagnetic contrast agent were also obtained when an abscess was suspected on precontrast images. Sixteen patients underwent surgical débridement, along with fascial and muscle biopsy. Distinct MR imaging features were found in patients with necrotizing soft-tissue infections, that is, hyperintense signal on T2-weighted images at the deep fasciae, poorly defined areas of hyperintense signal on T2-weighted images within muscles, and peripheral enhancement on contrast material-enhanced T1-weighted images. In nonnecrotizing cellulitis, signal intensity abnormalities were seen only in the subcutaneous fat. The precise extent of acute cellulitis and the presence of necrotizing soft-tissue infections can be determined with MR imaging, particularly on T2-weighted images.
Article
To define the immediate and long-term volumetric reduction following complete decongestive physiotherapy (CDP) for lymphedema. Prospective study of consecutively treated patients. Freestanding outpatient referral centers. Two hundred ninety-nine patients referred for evaluation of lymphedema of the upper (2% primary, 98% secondary) or lower (61.3% primary, 38.7% secondary) extremities were treated with CDP for an average duration of 15.7 days. Lymphedema reduction was measured following completion of treatment and at 6- and 12-month follow-up visits. Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen. The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care. Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises. Average limb volumes in milliliters were calculated prior to treatment, at the end of phase 1, and at 6- to 12-month intervals during phase 2 to assess percent volume reduction. Lymphedema reduction averaged 59.1% after upper-extremity CDP and 67.7% after lower-extremity treatment. With an average follow-up of 9 months, this improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper extremities and lower extremities. Noncompliant patients lost a part (33%) of their initial reduction. The incidence of infections decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP. Complete decongestive physiotherapy is a highly effective treatment for both primary and secondary lymphedema. The initial reductions in volume achieved are maintained in the majority of the treated patients. These patients typically report a significant recovery from their previous cosmetic and functional impairments, and also from the psychosocial limitations they experienced from a physical stigma they felt was often trivialized by the medical and payor communities.
Article
The aim of this multicentre prospective study was to analyse microbial pathogens cultured from an infected wound. The study was performed in the emergency rooms of 10 public hospitals. All adult patients with a clinical diagnosis of cellulitis after a wound in the upper or lower extremities were included. Cultures were obtained with swabs from infected lesions. Micro-organisms cultured were identified by the usual methods and susceptibility testing was performed. The study population consisted of 214 patients, 153 men and 61 women, with a mean (SD) age of 40 (10) years. Wound cultures remained sterile in 28 cases and infected with micro-organisms in 186 cases. Of the 186 positive cultures, three were not identified. Of the 183 remaining cultures, one micro-organism was present in 132 patients (62%) and several micro-organisms in 51 patients (24%). A total of 248 micro-organisms were isolated in 183 patients. Staphylococcus and streptococcus were the most frequently isolated micro-organisms (56% and 21% respectively) followed by Gram negative bacilli (18%). Determination of the susceptibility to the antibiotics commonly used to treat wound infections showed resistance in some cases. These results support the need always to take culture specimens from infected wounds for microbiological evaluation and antibiotic susceptibility determination, so that adapted chemotherapy can be prescribed.
Article
Ascending cellulitis of the leg is a common emergency. An audit was conducted in two district general hospitals to determine how it is managed and the long-term morbidity, and to formulate a treatment strategy. Case notes were reviewed for 92 patients admitted to hospital under adult specialties. Mean duration of inpatient therapy was 10 days. A likely portal of entry was identified in 51/92 cases, of which the commonest were minor injuries and tinea pedis. Pathogens were rarely identified, group G streptococci being the single most frequent organism. Benzylpenicillin was administered in only 43 cases. Long-term morbidity, identified in 8 of 70 patients with over six months' follow-up, included persistent oedema (6) and leg ulceration (2); an additional 19 patients had either suffered previous episodes or experienced a further episode subsequently. Ascending cellulitis of the leg has substantial short-term and long-term morbidity. Important but often neglected therapeutic suggestions are the inclusion of benzylpenicillin in all cases without a contraindication, assessment and treatment of tinea pedis, use of support hosiery, and serological testing for streptococci to confirm the diagnosis in retrospect. The high frequency of recurrent episodes suggests that longer courses of penicillin, or penicillin prophylaxis, might be useful.
Article
This investigation evaluates the feasibility of using C-reactive protein (CRP) levels as an indicator of bacterial infection of adult patients in the Emergency Department (ED), by comparing them with clinical signs and routine laboratory tests. One hundred and fifty adult atraumatic patients admitted through the ED of Linkou Chang Gung Memorial Hospital were consecutively enrolled. Seventy-nine patients had documented infection, and 58 had no infection. Body temperature (BT), white blood cell (WBC) count, CRP levels, and the presence of systemic inflammatory response syndrome (SIRS) were compared between the infected and uninfected groups. SIRS was the most sensitive indicator of bacterial infection (sensitivity 84.8%), but it had a 37.9% false-positive rate. BT and WBC count were more specific (at 89.7% and 84.5%) but less sensitive (at 48.1% and 43.0%, respectively). Using Youden's Index, the best cut-off value for CRP was 60 mg/l (sensitivity 67.1%, specificity 94.8%, positive predictive value 94.6%, and negative predictive value 67.9%). The area under the receiver operating characteristics (ROC) curve was highest for CRP (at 0.88), followed by BT (at 0.77) and WBC (at 0.67) (all p < 0.05). CRP is a better indicator of bacterial infection than either BT or WBC count for adult atraumatic ED patients. A low serum CRP level cannot safely be used to exclude the presence of infection.
Article
Acute lower limb cellulitis is a common yet potentially serious condition. Previous studies have identified risk factors in the non-U.K. population. Ethnicity has been postulated as a possible risk factor but has not previously been investigated. To identify risk factors for acute lower limb cellulitis in the U.K. population. One hundred and fifty consecutive patients with cellulitis requiring hospital admission and 300 controls were recruited to this prospective case-control study. Controls were matched for age and sex. Strongly predictive risk factors for acute lower limb cellulitis in the U.K. include being of white ethnicity and preceding episodes of injury to the affected leg. No systemic illnesses were identified as increasing an individual's risk of presenting with cellulitis. This study has identified that patients of white ethnicity are at higher risk of developing acute lower limb cellulitis compared with other ethnic groups. The importance of local risk factors has also been shown in the U.K. population.
Infections of skin and soft tissues: outcome of a classification scheme
  • L J Eron
Eron L. J. Infections of skin and soft tissues: outcome of a classification scheme. Clin Infect Dis 2000;31:287.
Hospital episode statistics Primary diagnosis NHS Information Centre, 2010. www.hesonline.nhs.uk. 2 NHS. Institute for innovation and improvement. Quality and service improvement tools
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Department of Health. Hospital episode statistics. Primary diagnosis 2008-2009. NHS Information Centre, 2010. www.hesonline.nhs.uk. 2 NHS. Institute for innovation and improvement. Quality and service improvement tools. 2008. www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_ improvement_tools/length_of_stay.html. 3
Trends in emergency admissions in England 2004-9
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  • M Bardsley
  • J Dixon
Blunt I, Bardsley M, Dixon J. Trends in emergency admissions in England 2004-9. The Nuffield Trust, 2010. www.nuffieldtrust.org.uk/sites/files/nuffield/Trends_in_emergency_ admissions_REPORT.pdf.
Healthcare Cost and Utilization Project (HCUP) Overview of the Nationwide Inpatient Sample (NIS) National Hospital Ambulatory Medical Care Survey
  • Healthcare Agency
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Agency for Healthcare Research and Quality. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). Overview of the Nationwide Inpatient Sample (NIS). June 2012. www.hcup-us.ahrq.gov/nisoverview.jsp. 6 National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. www.cdc.gov/nchs/fastats/ervisits.htm.
Department of Health. Hospital episode statistics. Primary diagnosis
Department of Health. Hospital episode statistics. Primary diagnosis 2008-2009. NHS Information Centre, 2010. www.hesonline.nhs.uk.
Overview of the Nationwide Inpatient Sample (NIS)
  • Healthcare Agency
  • Quality Research
  • Databases
Agency for Healthcare Research and Quality. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). Overview of the Nationwide Inpatient Sample (NIS). June 2012. www.hcup-us.ahrq.gov/nisoverview.jsp.
Emergency Department Summary
National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. www.cdc.gov/nchs/fastats/ervisits.htm.
Guidelines on the management of cellulitis in adults
Clinical Resource Efficiency Support Team (2005) Guidelines on the management of cellulitis in adults. Crest, Belfast. http://www.acutemed.co.uk/docs/Cellulitis%20guidelines, %20CREST,%2005.pdf.
Cost-effectiveness of blood cultures for adult patients with cellulitis
  • B Perl
  • N P Gottehrer
  • D Ravesh
  • Y Schlesinger
  • B Rudensky
  • A M Yinnon
Perl B, Gottehrer NP, Ravesh D, Schlesinger Y, Rudensky B, Yinnon AM. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis 1999;29:1483-8.