Saturday, February 25, 2006

Short-course treatment for uncomplicated cellulitis

American Family Physcian

June 1, 2005

One of the most common diagnoses in primary care is cellulitis. Streptococcus sp. and Staphylococcus aureus are the most common etiologic organisms of cellulitis and usually respond to empiric antibiotics. A seven- to 10-day regimen is the recommended treatment. However, uncomplicated cellulitis has a strong inflammatory response with a low yield for bacteria in the affected area. Because shorter courses of antibiotics have been shown to treat other bacterial infections effectively, a shorter antibiotic regimen may be just as effective as a longer regimen in treating uncomplicated cellulitis. Hepburn and colleagues evaluated the effectiveness of a five-day versus a 10-day antibiotic course in treating uncomplicated cellulitis.

This randomized, double-blind, placebo-controlled study involved patients with presumed cellulitis who presented to an army medical center. Patients were excluded if they had preexisting conditions that would complicate the course of cellulitis, including bacteremia, severe sepsis, or deep soft tissue infection. All participants received five days of antibiotics, levofloxacin in most cases, orally or intravenously.

Researchers evaluated the severity of cellulitis at each office visit using a clinical scoring system, and the patients performed a self-assessment. On day 5, patients made a follow- up visit and were randomized to receive five more days of antibiotics or placebo. The patients made subsequent follow-up visits between days 10 and 14, and on day 28 patients were contacted by telephone. The primary outcome was resolution of infection at day 14 with no recurrence by day 28. Clinical failure in the short-course group was defined as worsening of signs and symptoms beyond five days of therapy, and antibiotic failure was defined as the need for further intervention (e.g., abscess drainage, restarting antibiotics) or recurrent infection.

A total of 87 patients participated in the study, with 44 patients assigned to short-course antibiotic therapy. Cellulitis was resolved by day 14 with no recurrence by day 28 in 98 percent of patients in both the long- and short-course groups. The medications caused no serious adverse events. However, three patients discontinued levof loxacin therapy during the study, two because of gastrointestinal intolerance and one because of a rash. The clinical scores were similar between the two groups and decreased over time. The participants' self-assessments also produced the same results in both groups.

The authors conclude that a five-day course of antibiotics can treat patients with uncomplicated cellulitis as effectively as a 10-day course. Improvement rates, measured objectively and subjectively, also were similar.

Hepburn MJ, et al. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med August 9/23, 2004;164:1669-74.


Monday, February 20, 2006

Cellulitis infection: Is it contagious?

Cellulitis is not contagious — which means you cannot catch cellulitis from someone who has it. However, the same bacteria that cause cellulitis can be spread by direct contact with an open sore of an infected person. If you acquire these bacteria, you may develop a minor skin infection — but you are also at some increased risk of developing cellulitis.

Cellulitis is a bacterial infection that occurs in the deeper layers (dermis and subcutaneous tissues) of the skin. Although the infection is apparent on the outer layer (epidermis) of skin, the infection spreads just beneath this outer layer in the dermis.

Signs and symptoms of cellulitis include redness, swelling, tenderness and warmth of the affected skin. The changes in your skin may be accompanied by a fever. Left untreated, the bacterial infection may rapidly turn into a life-threatening condition. For this reason, early diagnosis and treatment of cellulitis is important.

Mayo Clinic

Related Mayo Clinic Article

Saturday, February 18, 2006

Fatal Acute Cellulitis Due to Neisseria meningitidis

J Clin Microbiol. 2003 August; 41(8): 3996–3997.

doi: 10.1128/JCM.41.8.3996-3997.2003.

2003, American Society for Microbiology

Gian-Luigi Cartolano,1* Christophe Barbier,2 Leïla Arnoult,2 Didier Simon,3 Jean-Louis Ricome,2 and Jan Hayon2

Department of Microbiology,1 Intensive Care Unit,2 Department of Otorhinolaryngology, CHI Poissy-Saint-Germain-en-Laye, 78105 Saint-Germain-en-Laye, France3

*Corresponding author. Mailing address: Service de Microbiologie, CHI Poissy/St Germain en Laye, 20 rue Armagis, 78100 St Germain en Laye, France. Phone: Fax: E-mail:

Received April 11, 2003; Revised May 4, 2003; Accepted June 1, 2003.


We describe the first fatal evolution of cellulitis due to Neisseria meningitidis serogroup Y involving an 85-year-old woman. She presented with an extensive cellulitis of the left side of the face, neck, and thorax and septic shock. In spite of active antibiotic therapy, evolution was rapidly fatal.

Case Report

An 85-year-old woman was admitted to the Intensive Care Unit of Saint-Germain-en-Laye Hospital with cellulitis of the face and neck and septic shock. She had been bedridden since 1998 following a traumatic vertebral compression (fourth lumbar vertebra) and right cerebral ischemia. She was undergoing corticosteroid therapy (0.5 mg of oral prednisone/kg of body weight/day for 2 years) for polymyalgia rheumatica. She had chronic heart and renal failure. Asthenia associated with pain on the left side of her neck began 8 days before admission. At the time of admission, her temperature was 38.3°C, her pulse rate was 120 (tachyarrhythmia), and her blood pressure was 80/50 mm Hg. She was conscious and alert. There were no symptoms of meningitis. The left side of the neck, the left shoulder, and the upper anterior part of the chest showed a painful erythema and edema and were swollen and warm. Clinical examination showed no angina and the recent partial loss of a left premolar. Otorhinolaryngologic evaluation showed a normal larynx, hypopharynx, and oropharynx and no phlegmon. A tumefaction of the submandibular space was observed; thus, submandibular sialadenitis was suspected. Laboratory findings included a white blood cell count of 2.71 × 109/liter with 46% neutrophils, a hemoglobin level of 7.1 g/dl, a hematocrit of 24.2%, a platelet count of 279 × 109/liter, a C-reactive protein level of 279 mg/liter (n < n =" 0.5">

Cellulitis due to N. meningitidis is a very rare manifestation of meningococcal disease. The international literature concerning this subject is very scarce (13). Cellulitis is an acutely spreading infection of the skin involving the deep dermis and subcutaneous fat, usually due to a group A beta-hemolytic Streptococcus sp. or Staphylococcus aureus. However, cellulitis must be considered a possible clinical manifestation of meningococcal disease. The present case is to our knowledge the first fatal cellulitis due to N. meningitidis (13, 18). However, rates of fatal evolution of meningococcal disease are still very high and have stayed relatively stable over the past 20 years: 9 to 12%, with a rate of up to 40% among patients with meningococcemia (16). The most typical manifestations of meningococcal disease are meningitis (50% of patients), meningococcemia, (5 to 20%), and pneumonia (5 to 15%) (14-16). Nontypical manifestations, including conjunctivitis, otitis media, epiglottitis, arthritis, urethritis, pericarditis, and cellulitis, have been described (1, 2, 9, 13, 16, 17). In the United States, the number of cases involving serogroup Y has increased during the last 10 years, and from 1996 to 1998 one-third of the cases were due to serogroup Y (15). In France, the data obtained from the National Reference Center ( are very different: in 2001, serogroup B accounted for 52.3% of meningococcemia cases, serogroup C accounted for 38%, serogroup W135 accounted for 7%, and serogroup Y accounted for 2%. Even if skin lesions are very common in meningococcal disease, cellulitis is so rare that it has not been mentioned in recent reviews (3, 16). Only two cases of cellulitis of the face or neck involving adults have been published (6, 18). Our present case involved the oldest patient (85 years). The first case was a 76-year-old woman with cellulitis of the face and neck associated with sialadenitis (6). Predisposing factors (diabetes mellitus and corticosteroid therapy) and bacteremia were present. Evolution was favorable after a 10-day course of antibiotic therapy (cefuroxime). The second case was a cervical cellulitis associated with meningococcal supraglottitis (18). The patient, a 44-year-old woman, had no predisposing factors, but bacteremia was present (N. meningitidis serogroup Y). She recovered fully after 16 days of antibiotic therapy (ceftriaxone and clindamycin on day 1 and then ampicillin-sulbactam). Five other case reports of adults with cellulitis due to N. meningitidis involved limbs. Ploy-Song-Sang et al. described a 64-year-old woman with cellulitis of the ankle, without bacteremia (12). Predisposing factors (chronic heart failure, plasma cell dyscrasia, diabetes mellitus, and stasis dermatitis due to venous insufficiency) were present. The absence of bacteremia and the presence of skin lacerations raised the possibility of a primary cutaneous infection of the leg. The patient was discharged after 3 weeks of antibiotic therapy (tetracycline for 2 days, chloramphenicol for 5 days, and erythromycin for 19 days). Another nonbacteremic cellulitis involved a 50-year-old man with necrotizing fasciitis of an arm and a leg (8). A recent nonsteroidal anti-inflammatory therapy was supposed to be the predisposing factor. N. meningitidis serogroup C was isolated from subcutaneous and bulla aspirates. However, involvement of two distant sites suggested hematogenous dissemination. A favorable outcome was obtained after surgery and antibiotic therapy (penicillin G and netilmicin IV). Lin et al. described a 45-year-old woman with meningococcal endocarditis presenting as calf cellulitis (7). The patient had predisposing factors (mixed connective tissue disease, hypocomplementemia, and valvular heart disease). N. meningitidis serogroup Y was isolated from blood cultures. A favorable outcome was obtained after a 6-week course of antibiotic therapy (ampicillin and gentamicin, relayed with ceftriaxone). Porras et al. described an 83-year-old woman with cellulitis of the hand and arm (13). Predisposing factors were absent, apart from the age of the patient and pulmonary and systemic hypertension. N. meningitidis serogroup C was isolated from blood cultures. After 2 weeks of ceftriaxone therapy, the patient was asymptomatic. A cellulitis of the foot due to Neisseria mucosa involving a 33-year-old woman was also described (19). Predisposing factors were present (corticosteroid therapy and lupus erythematosus). Bacteremia was absent, but a skin lesion of the foot was noted. Healing was obtained with lincomycin. Six other case reports involved children presenting with periorbital cellulitis (4, 5, 10, 11, 13, 20). Obvious predisposing factors were absent. Bacteremia was present in three cases, and conjunctivitis was present in three cases. Cellulitis was associated with pericarditis in one case and with meningitis in one other case (5, 20). All children were healed.

With only a few cases of meningococcal cellulitis reported in the literature, it is difficult to draw general conclusions. However, it seems that periorbital cellulitis is the usual presenting picture in children. In adults, host predisposing factors are usually present. Possible mechanisms of cellulitis development are hematogenous dissemination, direct inoculation of oral secretions into a preexisting skin lesion, and contiguous spread from another soft tissue infection site.

In summary, this first fatal acute cellulitis due to N. meningitidis underlines the great difficulty in distinguishing the clinical manifestations of meningococcal disease from those of more common but less-serious illnesses. In patients with cellulitis due to N. meningitidis recovery can be expected if the infection is properly diagnosed and treated (


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Cartolano, G. L., Z. Le Lostec, M. Cheron, A. Boisivon, Y. Welker, and P. Mornet. 2001. Primary Neisseria meningitidis arthritis of the knee without meningitis: contribution of synovial fluid culture in blood-culture vial. Rev. Med. Interne 22:75-78. [
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Gartaganis, S. P., M. J. Eliopoulou, C. D. Georgakopoulos, J. X. Koliopoulos, and E. K. Mela. 2001. Bilateral panophthalmitis as the initial presentation of meningococcal meningitis in an infant. J. AAPOS 5:260-261. [
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Ploy-Song-Sang, Y., R. A. Winkle, and J. P. Phair. 1972. Neisseria meningitidis cellulitis. South. Med. J. 65:1243-1244. [

Porras, M. C., V. C. Martinez, I. M. Ruiz, P. M. Encinas, M. T. Fernandez, J. Garcia, and L. C. Martin Martin. 2001. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand. J. Infect. Dis. 33:56-59. [

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Rosenstein, N. E., B. A. Perkins, D. S. Stephens, L. Lefkowitz, M. L. Cartter, R. Danila, P. Cieslak, K. A. Shutt, T. Popovic, A. Schuchat, L. H. Harrison, and A. L. Reingold. 1999. The changing epidemiology of meningococcal disease in the United States, 1992-1996. J. Infect. Dis. 180:1894-1901. [
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American Society for Microbiology

Saturday, February 11, 2006

Prolonged cellulitis due to plant thorn.

Journal of Turkish Pediatrics

Cengiz AB, Kanra G, Celik T, Comert B, Devrim I, Ozen M, Kara A.

Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.

We report the case of a five-year-old healthy boy who was admitted with abscess and soft tissue infection between the left wrist and the distal end of the forearm. Postero-anterior X-ray examination of the forearm showed a transverse line on the radius; however, further comparative radiographic examinations of the forearm were not compatible with fracture. Enterobacter cloacae was identified in the pus culture and initial intravenous empiric treatment with sulbactam-ampicillin was continued. Although the microorganism was susceptible to the empiric antimicrobial agent, at the eighth day of the treatment, inflammatory drainage was still present so further evaluations were performed. Ultrasonography of the forearm and wrist revealed only collection; magnetic resonance imaging showed a foreign body on the anterior distal section of the left forearm.

The patient underwent operation and a 22 mm wooden foreign body was removed. Detailed history after removing a tree branch particle revealed that the boy had recently fallen from a tree causing an abrasion over the left wrist. The postoperative course was uneventful and clinical response was excellent in two days. In view of this case report, we would like to emphasize the importance of medical history and imaging studies in cases of cellulitis that do not respond to appropriate antimicrobial therapy.

Another point to be kept in mind is that Enterobacter cloacae, which is very rarely reported as a causative agent for cellulitis, could be the etiological agent in cases after plant thorn injuries.


Soft tissue infections are generally associated with previous trauma or infection in the superficial area[1]. Because of the association with previous trauma, most cellulitis occurs on the extremities. A wide variety of organisms may cause cellulitis, but the most common organisms implicated are coagulase positive staphylococci, group A beta hemolytic streptococci, and Haemophilus influenzae in areas where H. influenzae vaccine is not routinely administered. Cases of cellulitis due to Enterobacter cloacae (E. cloacae) have been reported quite rarely[2,3].

Diagnosis of soft tissue infections generally is clinical; laboratory examination including radiography is usually for determination of extension or detection of complications.

We report a case of cellulitis-abscess in which E. cloacae was isolated and unresponsive to appropriate antimicrobial therapy. A foreign body was later shown by magnetic resonance imaging.

Case Presentation

A five-year-old boy was admitted to hospital with localized swelling and erythema between the distal end of the left forearm and the wrist. The parents had observed swelling and erythema, followed by yellow purulent fluid drainage within the last two days with increased body temperature.

When the patient was admitted, he was in good condition. His temperature was 36.5º C, pulse and respiratory rate were 90 beats and 26 breaths per minute, respectively, and blood pressure 100/70 mmHg. A 2x2 cm area of the volar surface of his left wrist was swollen and tender and erythema was present. The movement of his left wrist was restricted. Initial laboratory findings revealed hemoglobin: 12.5 g/dl, leukocytes: 11,500/mm3 with 64% polymorphonuclear leukocytes on blood film, platelet count: 600,000/mm3, erythrocyte sedimentation rate: 24 mm/h, and C-reactive-protein: 0.6 mg/dl (normal, 0-0.8). Urinalysis was within normal limits. Radiographs of the hand and forearm showed neither fracture nor periosteal reaction (Fig. 1). The abscess on the wrist was drained in the outpatient clinic. Gram smear of abscess specimen demonstrated Gram-positive cocci.

Fig. 1: Conventional postero-anterior and lateral X-ray of the patient’s forearm.

The patient was hospitalized with the diagnosis of soft tissue infection. He was initially treated with sulbactam-ampicillin (100 mg/kg daily) intravenously. On the second day of his hospitalization, culture of the pus revealed E. cloacae sensitive to ampicillin and sulbactamampicillin, and only resistant to cephalothin and cefazolin. No bacterial growth was detected on blood culture. On the seventh day of therapy the patient was still febrile and there were still drainage and collection. Because of unresponsive clinical course over a one-week period, ultrasound examination was performed and showed fluid accumulation; magnetic resonance imaging was performed to rule out abscess formation and possible osteomyelitis. A foreign body (21-22 mm in length) was demonstrated on the anterior distal part of the left forearm just below the subcutaneous tissue at the level of the anterior distal part of the radius (Fig. 2).

Fig. 2: A foreign body (between the black arrows) is seen on the anterior distal section of the radius on the T2 scans of magnetic resonance imaging.

Based on these findings, his medical history was detailed and his family reported that he had fallen from a tree two weeks prior to admission, suffering only a small abrasion over his left wrist at the time. Because of foreign body and the detection of abscess on the wrist, on the ninth day of hospitalization, the patient underwent an abscess drainage in the operation room under general anesthesia. A tree branch particle (22 mm in length) was taken out of the abscess (Fig. 3). The pus culture taken during the operation revealed no bacteria. His treatment was completed in two weeks using the same antibiotic. The postoperative course, including one-month follow-up examination, was uneventful.

Fig. 3: Segment of tree branch (22 mm) removed from the forearm of the patient.


Since many children spend a significant portion of their leisure time outdoors, they are highly susceptible to hazards relating to plant-associated accidents. Septic arthritis, periostitis, osteomyelitis, and deep soft tissue infections may develop after plant thorn and wood sliver injuries[4-7]. Thorns of especially the palm, yucca, hawthorn, bougainvillea, sentry plant, blackthorn, cactus, and rose may lead to arthritis, especially among children[5].

Kratz et al.[
5] reviewed reports published between 1953 and 2002 about arthritis and synovitis developed by plant thorn injury and reported that Pantoea agglomerans (formerly named Enterobacter agglomerans) was the most common isolated organism. However, they did not report any arthritis or synovitis case due to E. cloacae.

Enterobacter cloacae is a member of the genus Enterobacter[3]. This Gram-negative bacterium can be found in human and animal feces and in plants. Like other Enterobacter species, E. cloacae is an opportunistic pathogen. E. cloacae accounts for most hospital-acquired infections with this genus[3]. Neutropenic patients with malignancies, and patients with burns, wounds, respiratory and urinary tract infections, invasive procedures, and indwelling catheters are the groups at highest risk for E. cloacae bacteremia and sepsis[3,8].

The literature also contains no report of periostitis or osteomyelitis cases due to E. cloacae. Soft tissue infections due to E. cloacae have been reported quite rarely. Among the literature published in English which we have reviewed, only McCown[7] reported that E. cloacae was isolated from the culture of the wound in a seven-year-old child who had fallen near the edge of a pond.

In conventional radiographic examinations, nonopaque foreign bodies are generally not readily recognized in the soft tissues. In the literature, it is reported that such plant materials could not be detected using X-ray examination[5,6]. Radiographs have been reported to reveal a wooden foreign body in only 15% of patients[9]. Kratz et al.[5] reported that foreign bodies could not be identified in X-ray examination of arthritis and synovitis developing after tree thorn injuries. They recommended the use of ultrasound or magnetic resonance imaging examination in order to identify and locate the suspected foreign bodies, even if they could not be detected by conventional X-ray radiography[5].

Since it is necessary to remove the foreign body and drain the abscess for the cure, identification of the foreign body is of vital importance. As can be seen, laboratory examination has limited success for identification of foreign bodies. In our case, in whom soft tissue infection and abscess developed following a fall from a tree, there was no embedded plant material history. Nevertheless, it must be strongly considered in cases that do not respond to treatment.

Additionally, the pus culture in our case revealed E. cloacae, which does not exist in the skin flora of a child, and therefore implicates a plant pathogen as the causative agent. In view of the nature of the trauma in our case, it is not surprising that a plant pathogen was isolated.

Therefore, especially in children who are not old enough to provide a good history, if wounds have potentially been contaminated by bacteria from plant or soil, prospective examination should be accompanied by the imaging technique in unresponsive cases. We also emphasize that despite advances in imaging techniques, the detection of retained wooden foreign bodies remains a difficult and challenging task. The basic component of the medical evaluation, patient history, is essential in even the modern technical era.


Journal of Turkish Pediatrics

Saturday, February 04, 2006

Senegalese experience of orbital cellulitis


Dec 28, 2005

Wane AM, Ba EA, Ndoye-Roth PA, Kameni A, Demedeiros ME, Dieng M, Ndiaye MR, Ndiaye PA, Ben Nasr S, Wade A.

Clinique Ophtalmologique, EPS Hopital Aristide le Dantec, Senegal.


To show the etiological, clinical, and epidemiological aspects of orbital cellulitis at the ophthalmological clinic of A. le Dantec hospital.

PATIENTS: and method:

This is a retrospective study conducted from January 1994 to October 2003. Sixty-eight patient records were used. We noted patients' civil status, past medical history, clinical and paraclinical examinations, treatment received before and at admission to the clinic, and progression.


The incidence of orbital cellulitis was 8.9 cases per year. The average age of patients was 18 years and the sex ratio 2.78 in favor of males. Patients were hospitalized for a mean of 11 days. The fever was often stopped at admission. All patients had violent retrobulbar pain, associated with inflammatory exophthalmos in 77.8% of cases, and ophthalmoplegia in 67.2%. Two cases of diplopia were noted; 57.5% had sinusitis. Streptococcus was the bacterium found most frequently. In hospital, all patients received three antibiotics (ampicillin, aminoglycoside, metronidazole) and prednisone. In 51.5% of the cases, surgical treatment was necessary. Progression was favorable in 55.88% of the cases. Three patients died and 18 cases of blindness were noted.


Orbital cellulitis is a young people's disorder with serious complications. This medical emergency requires a combination of effective antibiotics and a corticosteroid. Treating the source of infections is essential to avoid recurrence. In our practice, these three drugs in association in first intention was beneficial without an antibiogram.

PMID: 16395202

[PubMed - in process]