Prevalence of concurrent deep vein thrombosis in patients with lower limb cellulitis: a prospective cohort study.

Mar 2013

Maze MJ, Skea S, Pithie A, Metcalf S, Pearson JF, Chambers ST.

Source

Department of Infectious Diseases, Christchurch Hospital, Christchurch, 8002, New Zealand. Michael.Maze@cdhb.health.nz.

Abstract

BACKGROUND:

Lower limb cellulitis and deep vein thrombosis share clinical features and investigation of patients withcellulitis for concurrent DVT is common. The prevalence of DVT in this group is uncertain. This study aimed to determine the prevalence of deep vein thrombosis (DVT) in patients with lower limb cellulitis and to investigate the utility of applying the Wells algorithm to this patient group.

METHODS: Patients admitted with lower limb cellulitis prospectively underwent a likelihood assessment for DVT using the Wells criteria followed by investigation with D-dimer and ultrasonography of ipsilateral femoral veins as appropriate. Diagnoses of contralateral DVT or pulmonary embolism during admission were recorded.

RESULTS:

200 patients assessed for DVT. 20% of subjects were high risk by Wells criteria. D-dimer was elevated in 74% and 79% underwent insonation of the affected leg. Ipsilateral DVT was found in 1 patient (0.5%) and non-ipsilateral VTE in a further 2 (1%).

CONCLUSIONS:

Deep vein thrombosis rarely occurs concurrently with lower limb cellulitis. The Wells score substantially overestimates the likelihood of DVT due to an overlap of clinical signs. Investigation for DVT in patients with cellulitis is likely to yield few diagnoses and is not warranted in the absence of a hypercoaguable state.

TRIAL REGISTRATION:

ACTRN: 12610000792022 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=320662).

NIH

Genetic susceptibility to non-necrotizing erysipelas/cellulitis.

Genetic susceptibility to non-necrotizing erysipelas/cellulitis.

2013

Hannula-Jouppi K, Massinen S, Siljander T, Mäkelä S, Kivinen K, Leinonen R, Jiao H, Aitos P, Karppelin M, Vuopio J,Syrjänen J, Kere J.

Source

Department of Medical Genetics, University of Helsinki, and Folkhälsan Institute of Genetics, University of Helsinki, Helsinki, Finland.

Abstract

BACKGROUND:

Bacterial non-necrotizing erysipelas and cellulitis are often recurring, diffusely spreading infections of the skin and subcutaneous tissues caused most commonly by streptococci. Host genetic factors influence infection susceptibility but no extensive studies on the genetic determinants of human erysipelas exist.

METHODS:

We performed genome-wide linkage with the 10,000 variant Human Mapping Array (HMA10K) array on 52 Finnish families with multiple erysipelas cases followed by microsatellite fine mapping of suggestive linkage peaks. A scan with the HMA250K array was subsequently performed with a subset of cases and controls.

RESULTS:

Significant linkage was found at 9q34 (nonparametric multipoint linkage score (NPL(all)) 3.84, p = 0.026), which is syntenic to a quantitative trait locus for susceptibility to group A streptococci infections on chromosome 2 in mouse. Sequencing of candidate genes in the 9q34 region did not conclusively associate any to erysipelas/cellulitis susceptibility. Suggestive linkage (NPL(all)>3.0) was found at three loci: 3q22-24, 21q22, and 22q13. A subsequent denser genome scan with the HMA250K array supported the 3q22 locus, in which several SNPs in the promoter of AGTR1 (Angiotensin II receptor type I) suggestively associated with erysipelas/cellulitis susceptibility.

CONCLUSIONS:

Specific host genetic factors may cause erysipelas/cellulitis susceptibility in humans.

PLOS

Risk factors for abscess formation in patients with superficial cellulitis (erysipelas) of the leg.

Risk factors for abscess formation in patients with superficial cellulitis (erysipelas) of the leg.

Dec 2012

Picard D, Klein A, Grigioni S, Joly P.

Source

Department of Dermatology, Inserm U905, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University Hospital, University of Normandy, Rouen, France Nutrition unit and EA4311, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University Hospital, University of Normandy, Rouen, France.

Abstract

Background:  Superficial cellulitis of the leg (erysipelas) is a frequent skin infection. Abscess formation is the most frequent local complication. Determinants of abscess formation in patients with leg cellulitis have not been clearly established yet. 

The aim of this study was to assess risk factors for abscess formation in patients with leg cellulitis.

Patients and methods:  The clinical, biological and bacteriological records of all patients referred to the Dermatology Department of a University Hospital for superficial cellulitis of the leg during a 3-year period were retrospectively reviewed. Using univariate and multivariate analysis, main patients' characteristics at baseline were compared between the group of patients who developed abscess and the group who did not. 

Results:  One-hundred-and-sixty-four patients (93 females, 71 males) of mean age 65±18 years were included. Abscess occurred in 13 cases (8%). The following general factors were positively associated with abscess formation: male gender, smoking, alcohol abuse, delayed introduction of antibiotic treatment. Based on multivariate analysis, only chronic alcohol abuse (OR=4.3, 95%CI:1.08-20.57) and delayed antibiotic treatment initiation (OR=1.4, 95%CI:1.02-2.04) remained independently associated with abscess formation. 

Conclusion:  Alcohol abuse and delayed initiation of antibiotic treatment are risk factors for abscess formation in patients with cellulitis of the leg. Patients with these predictors must be monitored carefully for abscess formation.

Wiley

Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the U.K. Dermatology Clinical Trials Network’s PATCH II trial

2012

U.K Dermatology Clinical Trials Network's PATCH Trial Team

Background

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.

Objectives

To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes.

Methods

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.

Results

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.

Conclusions

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.

Complete article:  NIH

Cellulitis: diagnosis and management.

Mar 2011

Bailey E, Kroshinsky D.

Source

Columbia University College of Physicians and Surgeons, New York, NY, USA.

Abstract

Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma. It is a common diagnosis in both inpatient and outpatient dermatology, as well as in the primary care setting. Cellulitis classically presents with erythema, swelling, warmth, and tenderness over the affected area. There are many other dermatologic diseases, which can present with similar findings, highlighting the need to consider a broad differential diagnosis. Some of the most common mimics of cellulitis include venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis. History, local characteristics of the affected area, systemic signs, laboratory tests, and, in some cases, skin biopsy can be helpful in confirming the correct diagnosis. Most patients can be treated as an outpatient with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern.

Wiley Online Library

Incidence of deep vein thrombosis in erysipelas or cellulitis of the lower extremities.

Aug 2012

Mortazavi M, Samiee MM, Spencer FA.

Source

Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.

Abstract

The incidence of deep vein thrombosis (DVT) in patients with erysipelas and cellulitis of the lower extremities is unknown. As such, the indication and efficacy of prophylactic anticoagulation for prevention of DVT in these patients is unclear. 

The main goal of this review is to provide an estimate of the incidence of DVT in erysipelas and cellulitis based on existing literature. A comprehensive search of the electronic sources: MEDLINE, EMBASE, CINAHL, LILAC and Cochrane without any language limitation was performed from 1950 to April 2011 for articles focused on the occurrence of DVT in cellulitis or erysipelas of the lower extremities. The selected studies were divided into two groups according to presence or absence of systematic investigation for DVT. Those studies in which the patients received prophylactic or therapeutic anticoagulants before a diagnosis of DVT were excluded. The reported incidence rate of DVT in patients with erysipelas or cellulitis of the lower extremities is highly variable, ranging from 0 to 15%.

In this review, the overall incidence rates of DVT in studies with and without systematic investigation for thromboembolism were 2.72% (95% CI: 1.71-3.75%) and 0.68% (95% CI: 0.27-1.07%), respectively. Given the low reported overall incidence of DVT, neither routine prophylactic anticoagulation nor systematic paraclinical investigation for DVT is indicated in low risk patients with erysipelas or cellulitis of the lower extremities. DVT should still be considered in patients with high pretest probability or other thromboembolic risk factors.

PubMed

Incidence of deep vein thrombosis in erysipelas or cellulitis of the lower extremities.

Aug 2012

Mortazavi M, Samiee MM, Spencer FA.

Source

Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.

Abstract

The incidence of deep vein thrombosis (DVT) in patients with erysipelas and cellulitis of the lower extremities is unknown. As such, the indication and efficacy of prophylactic anticoagulation for prevention of DVT in these patients is unclear. The main goal of this review is to provide an estimate of the incidence of DVT in erysipelas and cellulitis based on existing literature. A comprehensive search of the electronic sources: MEDLINE, EMBASE, CINAHL, LILAC and Cochrane without any language limitation was performed from 1950 to April 2011 for articles focused on the occurrence of DVT in cellulitis or erysipelas of the lower extremities. The selected studies were divided into two groups according to presence or absence of systematic investigation for DVT. Those studies in which the patients received prophylactic or therapeutic anticoagulants before a diagnosis of DVT were excluded. The reported incidence rate of DVT in patients with erysipelas or cellulitis of the lower extremities is highly variable, ranging from 0 to 15%. In this review, the overall incidence rates of DVT in studies with and without systematic investigation for thromboembolism were 2.72% (95% CI: 1.71-3.75%) and 0.68% (95% CI: 0.27-1.07%), respectively. Given the low reported overall incidence of DVT, neither routine prophylactic anticoagulation nor systematic paraclinical investigation for DVT is indicated in low risk patients with erysipelas or cellulitis of the lower extremities. DVT should still be considered in patients with high pretest probability or other thromboembolic risk factors.

PubMed

A systematic review of bacteremias in cellulitis and erysipelas.

Feb 2012

Gunderson CG, Martinello RA.

Source

Department of Internal Medicine and VA Connecticut Health Care System, Yale School of Medicine, 950 Campbell Avenue, West Haven CT 06516, USA; Veterans Health Administration, Public Health, 950 Campbell Avenue, West Haven CT 06516, USA.

Abstract

OBJECTIVES:

Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.

METHODS:

OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.

RESULTS:

For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. Forcellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.

CONCLUSIONS:

Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis and erysipelas in terms of the relative proportion of infections due to S. aureus.

Elsevier-sciVerse

Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis.

Feb 2012

Perelló-Alzamora MR, Santos-Duran JC, Sánchez-Barba M, Cañueto J, Marcos M, Unamuno P.

Source

Department of Dermatology, University Hospital of Salamanca, Paseo San Vicente, 58-182, 37007, Salamanca, Spain, mariarosaperello@yahoo.es.

Abstract

The purpose of this investigation was to analyze the clinical and epidemiological aspects of all cases of erysipelas and infectious cellulitis admitted to a tertiary hospital during a period of five years. All patients admitted with the main diagnosis of erysipelas or cellulitis to the Department of Dermatology of the author's institution from January 2005 to May 2010 were included. Seventy patients were identified and their medical records were retrospectively reviewed so as to record the epidemiological and clinical data. Univariate and multivariable analyses were performed to analyze variables that predicted longer length of stay. The frequency of cellulitis in the lower limbs was higher in men and patients older than 65 years.

Moderate/severe cellulitis in patients with basal comorbidity followed by a poor response to oral antibiotic therapy for 48 h were the most common reasons for admission. At arrival, four patients had abscessed areas. Fourteen patients developed local complications and 18 cases developed general in-hospital complications. Most patients improved or were healed with intravenous amoxicillin-clavulanate 1 g-200 mg/8 h. Intravenous amoxicillin-clavulanate 1 g-200 mg/8 h may be a good choice for empiric treatment in our setting. The development of in-hospital complications and the need for changing empiric antibiotic therapy were significant and independent variables associated with longer length of stay.

Springerlink

Fungal foot infection, cellulitis and diabetes: a review.

Fungal foot infection, cellulitis and diabetes: a review.
Diabet Med. 2009 May

Bristow IR, Spruce MC.
School of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK. ib@soton.ac.uk

AIMS: To review the current evidence for the presence of fungal foot infection (tinea pedis and toenail onychomycosis) as a risk factor for the development of cellulitis within the lower limb, particularly for those individuals with diabetes.

METHODS: A structured review of medline, embase and cinahl databases was undertaken to identify publications investigating fungal foot infection as a risk factor for the development of cellulitis.

RESULTS: Sixteen studies were identified. Eight studies adopted a case-control methodology, with the remainder being cross-sectional surveys. The majority of studies established the presence of tinea infection by clinical rather than established microbiological methods. Although the majority of papers suggested a link, only two case-control studies employed microbiological diagnosis to demonstrate that fungal foot infection was a risk for the development of lower limb cellulitis, particularly when infection was located between the toes. There were insufficient data to suggest that fungal foot infection posed an increased risk to patients with diabetes.

CONCLUSION: There is some evidence to suggest that fungal infection of the foot is a factor in the development of lower limb cellulitis, but further robust research is needed to confirm these findings and quantify the risk that fungi pose, particularly to the diabetic foot. Meanwhile, improved surveillance and treatment of tinea infections on the foot by healthcare professionals should be encouraged to reduce potential complications.

Wiley InterScience

Defining Cellulitis

Defining Cellulitis

Skinmed. 2007 Nov-Dec

Lawrence Charles Parish, MD; Joseph A. Witkowski, MD

Exactly what does cellulitis mean? How many consultation requests state that the patient has cellulitis, when, in fact, it was stasis dermatitis from which the patient suffered? Leider and Rosenblum, 1 considered the 20th-century lexicographers for dermatology, wrote:

Cellulitis literally means inflammation (-itis) of the little cells (cellul-). What is really meant, of course, is diffuse inflammation of parenchyma without necrosis or sharp localization of pus.

The definition given by the Microsoft Word dictionary is less precise but more limiting as describing cellulitis as “infection and inflammation of the tissues beneath the skin.”We have traditionally considered cellulitis to be inflammation in the dermis with both redness and induration present. No purulent opening can be seen; when there is a portal for pus, a furuncle or boil would be the diagnosis.

Cellulitis and Erysipelas

The terms cellulitis and erysipelas connote a diffusely spreading bacterial infection, excluding such walled-off lesions as the abscess, furuncle, and carbuncle (ie, not a boil). The pathology of erysipelas ( Figure 1 ) should be limited to the upper portions of the dermis, while cellulitis ( Figure 2 , Figure 3 ) seeks the lower portions of the dermis and the subcutaneous tissue. Because the clinical pictures often blend, many Northern European physicians use the term erysipelas to include both erysipelas and cellulitis. Unfortunately, both terms get bantered about in the United States, creating a continuing state of confusion. There seems to be a movement to discard the concept of erysipelas entirely. 2–5

Both conditions represent the results of pyogenic infections due to such bacterium as β-hemolytic streptococcus, group A, B, C, or G. Sometimes Staphyloccocus aureus is implicated in cellulitis, while Haemophilus influenzae type b can cause childhood cellulitis. Rarer causes of cellulitis include Aeromonas hydrophila, 6 Vibrio alginolyticus, 7 and Pasteurella multocida. 8 Erysipelas, once called phlegmona diffusa, and cellulitis can develop due to Pseudomonas aeruginosa, Streptococcus pneumoniae, Serratia marcescens, 9 and Campylobacter jejuni, particularly in immunocompromised patients.

Clinical manifestations can include tenderness and malaise with the addition of chills and/or fever. There can be induration and pitting edema as a result of the rapid spread of the infection. Lymphangitis may also appear in the vicinity of the erythema. Chronic attacks of cellulitis may lead to elephantiasis. 10

Dissecting cellulitis, also known by the more cumbersome term perifollicutis capitis abscedens et suffodiens ( Figure 4 ), only partially meets the criteria for cellulitis. While there is induration, erythema, and edema, there are also accompanying pustular openings and subsequent crusting.

Nonbacterial Cellulitis

If the definition of cellulitis denotes bacterial origin, then several diseases are as misnamed as is pyogenic granuloma, which has no overt bacterial origin. These include recurrent preseptal cellulitis, which appears to be a factitial entity not due to bacteria, and breast cellulitis, also called isolated erythema of the breast, that does not have a bacterial cause. 11 Cervical carcinoma may metastasize to the skin, producing red induration, at which point it is termed cellulitis-like cutaneous metastasis. To add to the confusion, eosinophilic cellulitis, also called Wells syndrome, has a cellulitic component without bacteria being involved 12 ; sometimes a viral etiology is even suggested.

Unnecessary Confusion

A clinical presentation of erythema and induration may be found in both stasis dermatitis, for example, and cellulitis. Because these signs are present, this does not make the cutaneous findings of venous insufficiency an infectious disease. Similarly, oozing and crusting superimposed on dusky, erythematous skin suggest bacterial superinfection, but they do not create the picture of cellulitis ( Figure 5 ).

Conclusions

Cellulitis is a specific sign with recognized etiologies. The word should not have its meaning diluted by extensions of its definition, nor should cellulitis be used inappropriately.

Clinical manifestations can include tenderness and malaise with the addition of chills and/or fever. There can be induration and pitting edema as a result of the rapid spread of the infection. Lymphangitis may also appear in the vicinity of the erythema. Chronic attacks of cellulitis may lead to elephantiasis. 10

Dissecting cellulitis, also known by the more cumbersome term perifollicutis capitis abscedens et suffodiens ( Figure 4 ), only partially meets the criteria for cellulitis. While there is induration, erythema, and edema, there are also accompanying pustular openings and subsequent crusting.

Nonbacterial Cellulitis

If the definition of cellulitis denotes bacterial origin, then several diseases are as misnamed as is pyogenic granuloma, which has no overt bacterial origin. These include recurrent preseptal cellulitis, which appears to be a factitial entity not due to bacteria, and breast cellulitis, also called isolated erythema of the breast, that does not have a bacterial cause. 11 Cervical carcinoma may metastasize to the skin, producing red induration, at which point it is termed cellulitis-like cutaneous metastasis. To add to the confusion, eosinophilic cellulitis, also called Wells syndrome, has a cellulitic component without bacteria being involved 12 ; sometimes a viral etiology is even suggested.

Unnecessary Confusion

A clinical presentation of erythema and induration may be found in both stasis dermatitis, for example, and cellulitis. Because these signs are present, this does not make the cutaneous findings of venous insufficiency an infectious disease. Similarly, oozing and crusting superimposed on dusky, erythematous skin suggest bacterial superinfection, but they do not create the picture of cellulitis ( Figure 5 ).

Conclusions

Cellulitis is a specific sign with recognized etiologies. The word should not have its meaning diluted by extensions of its definition, nor should cellulitis be used inappropriately.

References

1 Leider M, Rosenblum M. A Dictionary of Dermatological Words, Terms and Phrases. New York, NY: McGraw-Hill; 1968.
2 Grosshans EM. The red face: erysipelas. Clin Dermatol. 1993;11:307–313.
3 Lazzarini L, Conti E, Tositti G, et al. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. 2005;51:383–389.
4 Parish LC, Jungkind DL. Systemic antimicrobial therapy for skin and skin structure infections: comparison of fleroxacin and ceftazidime. Am J Med. 1993;94:166S–173S.
5 Witkowski JA, Parish LC. Bacterial skin infections: management of common streptococcal and stapylococcal lesions. Postgrad Med. 1982;72:166–168, 171–173, 176–178 passim.
6 Mathur MN, Patrick WG, Unsworth IP, et al. Cellulitis owing to Aeromonas hydrophilia: treatment with hyperbaric oxygen. Aust N Z J Surg. 1995;65:367–369.
7 Lee SY, Chuang YC, Young CD. Extensive cellulitis with septic shock caused by Vibrio vulnificus infection-a case report with review of literature. Kansenshogaku Zasshi. 1991;65:1484–1487.
8 Bradaric N, Milas I, Luksic B, et al. Erysipelas-like cellulitis with Pasteurella multocida bacteremia after a cat bite. Croat Med J. 2000;41:446–449.
9 Bornstein PF, Ditto AM, Noskin GA. Serratia marcescens cellulitis in a patient on hemodialysis. Am J Nephrol. 1992;12:374–376.
10 Bonnetblanc JM, Bedane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4:157–163.
11 Miller SR, Mondry T, Reed JS, et al. Delayed cellulitis associated with conservative therapy for breast cancer. J Surg Oncol. 1998;67:242–245.
12 Chung CL, Cusack CA. Wells syndrome: an enigmatic and therapeutically challenging disease. J Drugs Dermatol. 2006;5:908–911.

SKINmed: Dermatology for the Clinician. 6;6:261-263 (November/December 2007)

LeJacq