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

Three Degrees Help Drive Antibiotic Decision in Cellulitis

Three Degrees Help Drive Antibiotics in Cellulitis

By: M. ALEXANDER OTTO, Family Practice News Digital Network

SAN FRANCISCO – A greater than 3° C difference in skin temperature between affected and unaffected limbs in cellulitis – measured using inexpensive, handheld, infrared laser thermometers – was found to signal the need for hospital admission for intravenous antibiotics.

Skin temperature changes in cellulitis had never been quantified, said Dr. Michael Montalto. "We’ve never had a concept in absolute terms of the differences we feel as clinicians every day. [Our study gives] an idea of the kind of scale that might cause you to think the patient needs to have an admission for IV therapy. At least in our study, if the temperature difference [between the affected and unaffected limb] was above 3 °C, those people were getting IV therapy," he said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Of 63 cellulitis patients who were admitted to the hospital for intravenous antibiotic therapy, lesions were on average 3.4 °C warmer (95% confidence interval, 3.0-3.9) than the corresponding location on the unaffected limb. The difference dropped to an average 2.1° C warmer (95% CI, 1.7-2.6) at discharge after a mean stay of 5 days, the investigators found.

Patients in the study, who were 50 years old on average, had mostly lower-limb cellulitis; just over half were men. Nurses took the limb temperatures to keep researchers blinded to the results until the study’s end. Skin temperatures did not correlate with blood pressure, core temperature, or other variables.

Dr. Montalto and his colleagues found that the warmest point on limbs affected by cellulitis dropped from an average of 34.4 °C on the day of admission for intravenous antibiotics to 32° C when patients were well enough to be discharged on oral antibiotics, a statistically significant difference (95% CI, 1.9-3.0).

Furthermore, the results also suggested a role for laser thermometers – which can cost less than $50 at electronic stores and until now have been used mostly for industrial purposes – to measure severity and treatment response in cellulitis, said Dr. Montalto, a hospitalist at Epworth Hospital and Royal Melbourne Hospital. The devices emit two beams that are focused into one dot on the skin, at which point the temperature is read from a screen. The process is quick and painless.

The thermometers are "another tool to use for tricky patients when you are wondering whether or not they are getting better," he said. Current measures – white cell counts, erythema, fever, and skin color, among others – are not specific enough, he said.

The next step in the project is to see if skin temperature helps identify the causative organism in cellulitis, which remains unknown in many cases. Methicillin-resistant Staphylococcus aureus (MRSA) cellulitis, for instance, may project a higher temperature than other types of cellulitis.

"We often have people presenting from nursing homes who don’t have a wound. They just have a big, fat, painful, red leg with nothing to swab. You’ve got no way of determining what the organism is except trial and error. If we could show that the temperature profile helps with that," and, thus, appropriate antibiotic selection, it would be a significant advance, Dr. Montalto said at the meeting, which was sponsored by the American Society for Microbiology.

True to the point, 12 patients (19%) had positive swabs in the study, mostly for staphylococci, but a few MRSA and gram-negative bacteria also showed up.

Dr. Montalto said that he had no relevant financial disclosures.

Family Practice News

Severe lower limb cellulitis

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

May 2011

Levell NJ, Wingfield CG, Garioch JJ.

Source

Dermatology Department, Norfolk and Norwich University Hospital, Norwich, UK. nick.levell@nnuh.nhs.uk

Abstract

BACKGROUND:

Cellulitis is responsible for over 400,000 bed days per year in the English National Health Service (NHS) at the cost of £96 million.

OBJECTIVES:

An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists.

METHODS:

Review of patient details and work diaries from the first 40 months of implementation of the new model of care.

RESULTS:

Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty-eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment.

CONCLUSIONS:

This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.

Wiley Online

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

Molecular typing of beta-hemolytic streptococci from two patients with lower limb cellulitis: identical isolates in toe web and blood specimens.

Molecular typing of beta-hemolytic streptococci from two patients with lower limb cellulitis: identical isolates in toe web and blood specimens.

J Clin Microbiol. 2007 Jul 3;

Ingibjörg Hilmarsdóttir* and Freyja Valsdóttir
Department of Microbiology, Landspítali University Hospital, Reykjavík, Iceland
* To whom correspondence should be addressed. Email: ingibjh@landspitali.is

Hilmarsdóttir I, Valsdóttir F.
Department of Microbiology, Landspítali University Hospital, Reykjavík, Iceland.

Intertriginous toe webs harbouring cellulitis-causing bacteria constitute a risk factor for lower limb cellulitis. Molecular typing of Streptococcus pyogenes and S. dysgalactiae subspecies equisimilis isolates from blood and toe webs of two cellulitis patients revealed identical strains for each species. This finding supports the role of toe webs as a potential site of entry for cellulitis pathogens.

Journal of Clinical Microbiology

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

Clin Infect Dis. 2005 Nov

Björnsdóttir S, Gottfredsson M, Thórisdóttir AS, Gunnarsson GB, Ríkardsdóttir H, Kristjánsson M, Hilmarsdóttir I.
Department of Medicine, Division of Infectious Diseases, Landspítali University Hospital, Reykjavik, Iceland.

BACKGROUND: 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.

METHODS: 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.

RESULTS: 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).

CONCLUSIONS: 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 Journals * Full Text Article

Lower limb cellulitis: features associated with length of hospital stay

Lower limb cellulitis: features associated with length of hospital stay

J Infect. 2006 Jan
Morpeth SC,
Chambers ST,
Gallagher K,
Frampton C,
Pithie AD.
Department of Infectious Diseases, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand.

AIMS: 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.

METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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.

Science Direct