Thursday, October 19, 2006

Oedema as a risk factor for multiple episodes of cellulitis

Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up.

1: Br J Dermatol. 2006 Nov;155(5):947-50.

Cox NH.

Dermatology Department, Cumberland Infirmary, Carlisle CA2 7HY, U.K.


Cellulitis of the lower leg is a common problem with considerable morbidity. Risk factors are well identified but the relationship between consequences of cellulitis and further episodes is less well understood.


To review risk factors, treatment and complications in patients with lower leg cellulitis, to determine the frequency of long-term complications and of further episodes, and any relationship between them, and to consider the likely impact of preventive strategies based on these results.


Patients with ascending, presumed streptococcal, cellulitis of the lower leg were identified retrospectively from hospital coding. Hospital records, together with questionnaires to both general practitioners and patients, were used to record subsequent complications and identifiable risk factors for further episodes.


Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated (P <>


This study demonstrates that the true frequency of postcellulitic oedema, as well as that of further episodes, is probably underestimated. Furthermore, there is a strong association between these factors, each of which is both a risk factor for, and a consequence of, each other, and for which intervention (reduction of oedema or more prolonged antibiotic therapy) may reduce the risk of recurrent infection. By contrast, self-reporting of toeweb maceration is low, so attempts to reduce the risk of recurrent cellulitis by treatment of tinea pedis or bacterial intertrigo may fail.

British Journal of Dermatology

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Lower limb cellulitis: features associated with length of hospital stay.

J Infect. 2006 Jan;52(1):23-9.

Department of Infectious Diseases, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand.


This study aimed to identify features associated with length of hospital stay (LOHS), length of intravenous antibiotic therapy (LIVAT) and six-week outcomes for patients with lower limb cellulitis, and to test the Eron/Passos classification of cellulitis in the New Zealand system.


Eighty-five variables were collected prospectively from a cohort of 51 inpatients admitted to Christchurch hospital. The primary end-point for analysis was LOHS. LIVAT and six-week outcomes were secondary end-points.


On univariate analysis use of diuretics, living alone, cellulitis acuity, a creatinine concentration of >0.1 mmol/l, poor mobility, pulse >90 bpm, age >70 years, oedema extent, chronic oedema, ulceration, neutrophil count >10x10(9)/l, erythema area >1000 cm2 and haemoglobin concentration less than normal were significantly (P= or <0.05) or ="3">7 days was associated with use of diuretics, living alone, age >70 years, more oedema, erythema area >1000 cm2, haemoglobin less than normal, ulceration, creatinine >0.1 mmol/l and poor mobility. The presence of a discharge was associated with LIVAT. Multivariate analysis accounted for 48% of the variance in LOHS and 16% for LIVAT. Use of diuretics, neutrophil count >10x10(9)/l and oedema score were independently associated with LOHS, with oedema score associated with short stay and diuretic use with long stay. The Eron/Passos system was not helpful so a new scoring system was devised which successfully classified patients into length of stay groups.


The clinical features analysed accounted for half of the variance in LOHS. An important reason may be physician discretion. If so, our scoring system based on these results could be used in a clinical pathway to improve patient care. This tool would need to be evaluated prospectively.

Keywords: Lower limb cellulitis; Length of hospital stay

Journal of Infections

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Risk factors for acute cellulitis of the lower limb: a prospective case-control study.

Bjornsdottir S,
Gottfredsson M,
Thorisdottir AS,
Gunnarsson GB,
Rikardsdottir H,
Kristjansson M,
Hilmarsdottir I.

Department of Medicine, Division of Infectious Diseases, Landspitali University Hospital, Reykjavik, Iceland.


Acute bacterial cellulitis is a potentially serious infection that commonly recurs. The identification of preventable risk factors could reduce infection-related morbidity and cost and improve patient management. The aim of this study was to identify the risk factors associated with lower-limb cellulitis, including both analysis of risk factors associated with cellulitis in either limb and risk factors in a single limb associated with cellulitis in the same limb. We placed particular emphasis on dermatophytic infections of the foot and bacterial infection and colonization of the toe webs.


We conducted a prospective case-control study of 100 subjects with cellulitis and 200 control subjects, matched for age and sex, who were admitted to a university hospital during the period October 2000-February 2004. Data were obtained with a questionnaire and from examination of lower limbs and microbiological analyses of samples from the feet.


The median age of the participants was 66.5 years (interquartile range, 48.8-77.0). The following risk factors were strongly and independently associated with cellulitis: previous history of cellulitis (OR, 31.04; 95% CI, 4.15-232.20), the presence of Staphylococcus aureus and/or beta -hemolytic streptococci in the toe webs (OR, 28.97; 95% CI, 5.47-153.48), presence of leg erosions or ulcers (OR, 11.80; 95% CI, 2.47-56.33), and prior saphenectomy (OR, 8.49; 95% CI, 1.62-44.52). Tinea pedis interdigitalis was associated with cellulitis only when toe web bacteria were excluded from the analysis (OR, 3.86; 95% CI, 1.32-11.27).


Risk factors for acute bacterial cellulitis in hospitalized patients include predisposing factors and the presence of sites of pathogen entry on legs and toe webs. These findings indicate that improved awareness and management of toe web intertrigo, which may harbor bacterial pathogens, and other skin lesions might reduce the incidence of cellulitis.

University of Chicago Press

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Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study.

Roujeau JC,
Sigurgeirsson B,
Korting HC,
Kerl H,
Paul C.

Service de Dermatologie, Hopital Henri-Mondor, Creteil, France.


To assess the role of foot dermatomycosis (tinea pedis and onychomycosis) and other candidate risk factors in the development of acute bacterial cellulitis of the leg.


A case-control study, including 243 patients (cases) with acute bacterial cellulitis of the leg and 467 controls, 2 per case, individually matched for gender, age (+/-5 years), hospital and admission date (+/-2 months).


Overall, mycology-proven foot dermatomycosis was a significant risk factor for acute bacterial cellulitis (odds ratio, OR: 2.4; p < p =" 0.005)">


Tinea pedis and onychomycosis were found to be significant risk factors for acute bacterial cellulitis of the leg that are readily amenable to treatment with effective pharmacological therapy. Copyright (c) 2004 S. Karger AG, Basel.

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