Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Eur J Clin Microbiol Infect Dis DOI 10.1007/s10096-012-1549-2 ARTICLE Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis M.-R. Perelló-Alzamora & J.-C. Santos-Duran & M. Sánchez-Barba & J. Cañueto & M. Marcos & P. Unamuno Received: 10 October 2011 / Accepted: 6 January 2012 # Springer-Verlag 2012 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 inM.-R. Perelló-Alzamora (*) : J.-C. Santos-Duran : P. Unamuno Department of Dermatology, University Hospital of Salamanca, Paseo San Vicente, 58-182, 37007, Salamanca, Spain e-mail: [email protected] M. Sánchez-Barba CAIBER Research Unit, University Hospital of Salamanca, Salamanca, Spain M. Marcos Department of Internal Medicine, University Hospital of Salamanca, Salamanca, Spain J. Cañueto Department of Dermatology, Hospital Nuestra Señora de Sonsoles, Ávila, Spain 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. Introduction Cellulitis is an inflammatory skin condition with an infectious origin which affects the deep dermis and the subcutaneous tissue [1]. Erysipelas affects the upper dermis, and it is usually accompanied by lymphatic involvement [1]. Patients with these diseases may usually receive outpatient treatment [2–4], but elderly patients or those with important comorbidities or moderate–severe infections may require admission [5, 6], and the length of hospitalization is usually determined by other factors rather than cellulitis. To date, there are scarce data regarding clinical aspects, microbiological spectrum (probably due to the difficulty in isolating a pathogen from the infected area), and pathogenesis of cellulitis [6]. Accordingly, there is no accepted consensus regarding admission criteria and empirical antibiotic therapy in moderate-severe cellulitis patients admitted to hospital [3, 6]. In view of this, the aim of this study was to analyze the epidemiological aspects of all cellulitis and erysipelas cases admitted to our department and to study the factors associated with the length of hospitalization. Eur J Clin Microbiol Infect Dis Patients and methods Patients This retrospective study was conducted in a 1,000-bed tertiary referral hospital in Salamanca, Spain. The hospital serves an urban and rural area with a population of 350,000 inhabitants. All patients admitted to the Department of Dermatology with a main diagnosis of cellulitis or erysipelas between January 2005 and May 2010 were included and episodes were identified through the database maintained by the Admission Department of the University Hospital of Salamanca. Cellulitis and erysipelas were defined by the presence of cutaneous tenderness, pain, and erythema, and both entities were considered to be non-complicated soft tissue infections. Although there are clinical features differentiating cellulitis from erysipelas, for the purposes of this study, the term “cellulitis” was used invariably to denote infection involving the skin and/or the subcutaneous tissue. Patients who were admitted with deep tissue infections (myositis or necrotizing fasciitis) were not included in this study. Other exclusion criteria were as follows: patients younger than 14 years of age, patients with a main diagnosis or a reason for hospitalization that was not cellulitis or erysipelas, and patients who were admitted to other departments. Patients with cellulitis and severe comorbidities, severe sepsis, or those with cellulitis but other main reason for admission were normally admitted to the General Internal Medicine Ward. The following data were retrospectively recorded for each episode: age, sex, location of infection, risk factors, origin of infection, length of hospitalization, reason for admission, prior episodes of cellulitis/erysipelas, general symptoms on admission and at discharge (fever, malaise), local symptoms on admission and at discharge (including classic manifestations such as erythema, edema, tenderness, and pain, and non-classic manifestations: blisters, purpuric or ecchymotic areas, pustule areas, and abscessed areas), microbiological results (results of blood cultures and swabs collected from infected areas, results of skin biopsies), the use of imaging studies, treatment before admission (antibiotic therapy and topical treatment), empirical and definitive antibiotic therapy, local and general complications, and 30day outcome. with Bonferroni correction was used. Two-tailed tests of significance were performed and p-values < 0.05 were regarded as being significant. Variables associated with the length of stay with p<0.20 in the univariate analysis were selected for inclusion in a logistic regression model, using a forward stepwise selection algorithm with entry and removal criteria of p00.05 and 0.10, respectively. Results From January 2005 to May 2010, 1,356 patients were admitted to the Department of Dermatology of our institution and 70 patients presented with a main diagnosis of cellulitis or erysipelas. A total of 69 patients had one episode and one patient with chronic lymphedema had three episodes of erysipelas in her left arm. For the purposes of this study, we only considered one episode. Therefore, 70 episodes in 70 patients were included. The number of patients per year with these diagnoses ranged from a minimum of 7 patients (year 2008) to a maximum of 16 patients (year 2007), and the number of hospital stays due to cellulitis in the Department of Dermatology divided by the total number of hospital stays over the year is shown in Fig. 1. Clinical and epidemiological characteristics Among the 70 patients, 43 (61.4 %) patients were men and 27 (38.6%) were women. The characteristics of the 70 cases included in the study are detailed in Table 1. The most common site of infection was the lower limbs (67.1%). Risk factors for cellulitis were observed in 35 patients (50%), and the most common was the presence of chronic venous insufficiency or stasis dermatitis (21.4%). In our series, the frequency of cellulitis on the lower limbs was higher in men (odds ratio [OR] 1.913) and in patients over 65 years old (OR 1.44). Statistical analysis All data were collected from the patients’ clinical records and they were processed with SPSS (Statistical Package for Social Sciences) version 18.0. For categorical variables, Pearson’s χ2 or Fisher’s exact test was used; for continuous variables, Student’s t-test or one-way analysis of variance Fig. 1 Number of hospital stays due to cellulitis admitted to the Department of Dermatology per 10,000 patient-days in our hospital Eur J Clin Microbiol Infect Dis Table 1 Characteristics of the 70 episodes of cellulitis/erysipelas requiring hospital admission Variable n (%) Age (years) 63.8 (18.6) Gender Female 23 (38.3) Male 43 (61.4) Location Lower limbs 47 (67.1) Upper limbs 12 (17.1) Head and neck Risk factors for cellulitis 11 (15.7) Chronic venous insufficiency or stasis dermatitis 35 (50) Diabetes mellitus Mammary tumor and chronic lymphedema 8 (11.4) 4 (5.7) Immunosuppression Joint presence of diabetes mellitus and chronic venous insufficiency Previous surgery 3 (4.3) 2 (2.9) Alcoholism Source of infection Wounds or ulcers Web intertrigo Arthropod bites 2 (2.9) hospitalization were: face involvement (8), suspected complications such as necrotizing fasciitis or osteomyelitis (2), immunosuppression (2), and inability of the patient to carry out the outpatient treatment prescribed (14). Microbiological results With regard to the microbiological diagnosis, cutaneous swabs were taken from patients with open skin lesions in 19 cases (35.2%), and a pathogen was identified in 13 of them (Table 2). Blood culture was performed in 26 patients (37.1%), and only one patient had bacteremia secondary to Pseudomonas aeruginosa infection. Skin biopsy was performed in two patients with erysipeloid symptoms in the breast, with a personal record of mammary tumor and under the diagnostic suspicion of neoplastic infiltration. In both cases, the skin biopsies revealed perivascular dermatitis with no criteria for specific causation. Antibiotic therapy 1 (1.4) 38 (54.3) 8 (11.4) 4 (5.7) Categorical variables are presented as absolute (relative) frequencies and numerical variables as mean (standard deviation) With regard to systemic clinical symptoms that were observed on admission, malaise was found in 37% of patients (26 cases). Local signs and symptoms of inflammation, including soft tissue swelling, erythema, and pain, were present in all patients. With regard to unusual manifestations of cellulitis, blisters were observed in 7 cases (10%), purpuric or ecchymotic areas were seen in 18 cases (25.71%), pustule areas were observed in 5 cases (7.14%), abscessed areas were seen in 4 cases (5.71%), traumainduced hematoma was observed in 3 cases (4.28%), and there was one case of hematoma due to coagulation disorder or plateletpenia (1.43%). Before admission, 45 patients (64.3%) had previously consulted with their primary care physician and 24 (53.3%) were correctly diagnosed with cellulitis. The rest of the patients were diagnosed with microcrystalline arthritis (1), vasculitis (1), thrombophlebitis (10), septic arthritis (1), allergic reaction (1), and herpes simplex infection (1). In 6 cases, the primary care report does not include a diagnosis. The most common reason for admission was moderate– severe cellulitis in elderly pluripathologic patients or in patients with several comorbidities (27 patients, 38.6%), followed by a lack of improvement despite oral antibiotic therapy for 48 h (17 patients, 24.3%). Other reasons for Concerning treatment prior to admission, eight patients were given amoxicillin–clavulanate 875/125 mg/8 h, and five patients were given cloxacillin 500 mg/6 h. Topical treatment would have to be prescribed in 23 cases (79%), but they were only administered in 4 cases (13%). The prescribed topical treatments were acyclovir and mupirocin, one case each. Drainage of a sero-hematic fluid/abscess was performed in two patients. With regard to empirical therapy after admission, 50 patients (71.4%) received systemic antibiotic therapy plus topical treatment; in 12 cases (17.1%), only systemic antibiotic therapy was used; in 5 cases (7.1%), systemic antibiotic therapy was prescribed together with topical treatment and drainage of a purulent or serohematic collection; and in 3 cases (4.3%), systemic antibiotic therapy and topical treatment were combined with ulcer debridement. The empirical antibiotic treatment on admission is detailed in Table 3. Amoxicillin–clavulanate was not administered in two cases Table 2 Microorganisms isolated in the 70 episodes of cellulitis Microorganism n MSSA (methicillin-sensitive Staphylococcus aureus) Pseudomonas aeruginosa Morganella morganii Serratia marcescens MRSA (methicillin-resistant S. aureus) Polymicrobial infection MSSA and Streptococcus pyogenes P. aeruginosa and S. pyogenes MSSA and Proteus vulgaris 5 1 2 1 1 3 1 1 1 Eur J Clin Microbiol Infect Dis due to allergy to penicillin and its derivatives, and macrolide (erythromycin) plus clindamycin was administered instead. Antibiotic doses were adjusted to the creatinine clearance in three patients. Empirical antibiotic was changed in 16 cases because of poor clinical and/or analytical evolution (7 cases, 43%), due to resistance to the initial antibiotic (6, 37.5%), and due to adverse side effects or intolerance (3 cases, 18.8%). Antibiotics used in these cases were: ceftriaxone (1), ciprofloxacin plus clindamycin (2), erythromycin (2), clarithromycin (1), cloxacillin (2), imipenem (2), linezolid (1), vancomycin (1), meropenem plus vancomycin (2), and piperacillin–tazobactam (2). This second antibiotic choice had to be replaced in two patients, due to poor clinical evolution, and the third option was cefotaxime plus cloxacillin and imipenem in one case each. A fourth antibiotic alternative was not necessary. The topical treatments are also detailed in Table 3 and other topical treatments for concomitant processes were applied in 16 cases: treatment of interdigital tinea pedis with topical antifungal (ketoconazole or terbinafine) in eight cases, treatment of candidal intertrigo on the inguinal or inframammary folds with topical antifungal (nystatin or clotrimazole) in seven cases, treatment of myiasis with topical metronidazole and occlusion of the lesion in one case. Outcome and complications With regard to local complications, they appeared in 14 patients. The most common was the presence of vesicles, blisters, denudation or erosion (9 cases), followed by dissecting hematoma (2 cases), abscess that required draining Table 3 Empirical treatment on admission in our series (2 cases), and diabetic foot with involvement of deep tissue that required debridement (1 case). With regard to general complications, they appeared in 18 patients (25.7%), and the most common was the decompensation of comorbid conditions (16 cases), followed by sepsis (2 cases). The mean length of hospitalization was 6.99 days ± 4.27 days, with a minimum stay of 1 day and a maximum stay of 23 days (range: 21 days). Variables associated with hospital stay longer than 7 days are shown in Table 4. After multivariable analysis, the development of in-hospital complications and the need for changing the empiric antibiotic therapy were independently and significantly associated with longer length of stay (OR: 4.27, 95% confidence interval [CI]: 1.27–14.49; p 00.019 for in-hospital complications and OR: 3.66, 95% CI: 1.06–12.66; p00.019 for substitution of the initial antibiotic). The evolution was very good (with rapid and complete healing without after-effects) in 34 cases (48.6%); it was good (with slower healing, but complete and without aftereffects) in 31 cases (44.3%); it was poor (with an acceptable improvement but with residual after-effects) in 3 cases (4.3%), and it was bad (death) in 2 cases (2.9%). Overall, 68 patients (97.1%) had total or partial recovery, and two patients died due to uncontrolled sepsis (2.9%). With regard to clinical symptoms, at discharge, 97% of patients did not have fever or malaise. Local erythema still persisted in 75% of the patients, and 21% of them reported pain at discharge. Topical treatment, analgesics, and oral antibiotic therapy were prescribed in 36 cases at discharge (51.4%); oral antibiotic therapy and analgesics in 16 cases (22.9%); topical treatment and analgesics in 5 cases (7.1%); and analgesics alone in 11 cases (15.7%). Empirical antibiotic therapy n (%) Amoxicillin–clavulanate IV 1 g/200 mg q8h Amoxicillin–clavulanate IV 1 g/200 mg q8h and IV clindamycin 1.2 g q8h Amoxicillin–clavulanate IV 500 mg/50 mg q8h and IV clindamycin 1.2 g q8h 60 (89.5) 16/60 (26.7) 2/60 (3.3) Amoxicillin–clavulanate IV 500 g/50 mg q8h and ciprofloxacin VO 500 mg q12h Ceftriaxone IV 1 g q24h and cloxacillin IV 1 g q8h Azithromycin VO 500 mg/24 h and clindamycin IV 1.2 g q8h Cefoxitin IV 1 g q8h Vancomycin IV 1 g q12h and metronidazole IV 500 mg q8h Topical treatments Zinc sulfate fomentations 1/1,000 and mupirocin Zinc sulfate fomentation and bacitracin and neomycin sulfate and polymyxin B sulfate Zinc sulfate fomentation 1/1,000 and silver sulfadiazine Zinc sulfate fomentation 1/1,000 Mupirocin Silver sulfadiazine Bacitracin and neomycin sulfate and polymyxin B sulfate 1/60 (1.6) 1 (1.5) 1 (1.5) 1 (1.5) 1 (1.5) n (%) 22 (41.4) 2 (3.8) 1 (1.9) 3 (5.7) 16 (30.2) 6 (11.3) 3 (5.7) Eur J Clin Microbiol Infect Dis Table 4 Factors associated with prolonged hospital stay in the 70 patients admitted to hospital with cellulitis Variables Number of patients with stay longer than 7 days/number of patients (%) Univariate p-value Multivariate OR (95% CI), p-value Age >60 years 23/44 (52.3) 0.08 NS Male sex 15/43 0.046 NS Unusual manifestations on admission (blisters, pustule areas, abscessed areas, hematoma) Risk factors for cellulitis Local complications during admission 12/25 (48.0) 0.641 NS 20/35 (57.1) 9/14 (64.3) 0.03 0.092 NS NS Medical complications during admission 13/18 (72.2) 0.006 4.27 (1.27–14.49), p00.019 Prior cellulitis episodes Isolated pathogen 3/12 (2.5) 9/13 0.140 0.392 NS NS Empirical antibiotherapy on admission 14/39 0.209 NS Substitution of the initial antibiotic 5/17 0.012 3.66 (1.06–12.66), p00.019 NS non-significant Discussion Cellulitis and erysipelas are common among the general population, although few series have been published on the last 10 years and their exact prevalence is still unknown [5, 6]. In our series of cases, as previously described [6], more cases are described in patients older than 60 years, with the most common location being the lower limbs. We also report a similar prevalence of risk factors for cellulitis, such as chronic venous insufficiency and diabetes mellitus, as published in the literature [6]. With regard to the origin of the infection, it has been registered more cases of cellulitis in patients with ulcers than in patients with web intertrigo. As expected, all patients presented with the classical local symptoms of cellulitis (a painful erythematous plaque with not well-defined edges). We also included patients with abscess, since its presence on admission might be related to a higher risk of complications and, therefore, to a potential increase in the hospitalization stay. We acknowledge, however, that the presence of abscessed areas on the cellulitis plaque is a rare non-classical manifestation of cellulites and that it may be difficult to differentiate abscess on admission from cellulitis. Being that cellulitis prognosis is highly variable and microbiological diagnosis difficult to carry out, clinical findings gain a special importance. For this reason, we believe that the presence of this clinical sign at the time of diagnosis should be taken into account in classifying the risks and the approaches taken in the Emergency Room in order to decide on hospitalization versus outpatient treatment. The mean duration of hospitalization was 6.99 days ± 4.27, in accordance with previously published data [2, 5]. The mean duration of hospitalization for cellulitis in a tertiary hospital ranges between 5 and 10 days [2]. With regard to microbiological diagnosis, we confirm in our study that the lack of a microbiological diagnosis is common in patients with cellulitis [2, 5–7]. As for specific microorganisms, the leading pathogen was methicillin-sensitive S. aureus (MSSA), which is in accordance with the data published by Carratalà et al. [5], although other authors have found that the most common pathogen is S. pyogenes, followed by MSSA [2, 3]. Besides, we have not found that methicillin-resistant S. aureus (MRSA) is a pathogen of concern in our setting [1, 3], although more studies are needed in order to confirm this aspect . In our hospital, the prevalence of MRSA in S. aureus bacteremia was 27.3% last year and there are no other data available about the prevalence of MRSA in our region of Spain (Castilla-Leon). Some data has been published in other regions showing that the cumulative incidence of MRSA in long-term care facilities appears to be approximately 20% per year [8]. In our series, the most common reason for hospitalization was moderate or severe cellulitis in patients with basal comorbidities, followed by a poor response to oral antibiotic therapy after 48 h. With regard to empirical antibiotic therapy, most patients showed improvement or healing with intravenous amoxicillin–clavulanate 1 g–200 mg/8 h, with no serious adverse effects. In some cases, this drug could not be administered due to allergy to penicillin, and in other cases, it had to be replaced due to a lack of response or to the appearance of adverse effects. In these circumstances, quinolones or clindamycin were prescribed with satisfactory results. Currently, there is no consensus regarding empirical antibiotic therapy in erysipelas and cellulitis. Recent studies [2] recommend an empirical antibiotic therapy of cloxacillin or first-generation cephalosporins as the first therapeutic choice, and levofloxacin, moxifloxacin, or clindamycin as therapeutic alternatives, except for the case of MRSA suspicion or beta-lactam allergy. In these cases, linezolid is the Eur J Clin Microbiol Infect Dis first therapeutic choice, and vancomycin–teicoplanin, clindamycin, or cotrimoxazole are listed as alternatives [1]. With regard to the complications, most of the patients that were admitted to our department did not present severe complications, and only in two cases was the outcome fatal, with uncontrolled sepsis followed by death. Although cellulitis is a disorder that has traditionally been considered a benign entity, its global mortality rate after 30 days is 5% [5], and mortality after one year is estimated at 20% [9]. In our series, the global mortality rate was 2.85%. We must admit, however, that a potential limitation of our work regarding this point is that patients admitted to our Department of Dermatology usually have fewer comorbidities than patients admitted to the General Internal Medicine Ward. As a result, the rate of complications as well as the mortality rate may be lower in our work when compared with other series. Local complications appeared in 14 patients, the most common being the presence of vesicles, blisters, denudation, or erosion in the plaque of cellulitis. Skin abscesses have been traditionally considered as the most common local complication [2] . The development of general complications on admission and the need for changing the antibiotic therapy are the only variables significantly associated with longer hospital stay. We think that the small sample size of the study could limit the results in the multivariable analysis. We believe that more studies on empirical antibiotic therapy and prophylaxis for cellulitis recurrence are needed in order to confirm the findings observed in our case series. Conflict of interests interests. We declare that we do not have any conflict of References 1. Stevens DL (2009) Treatments for skin and soft-tissue and surgical site infections due to MDR Gram-positive bacteria. J Infect 59 (Suppl 1):S32–S39 2. Figtree M, Konecny P, Jennings Z, Goh C, Krilis SA, Miyakis S (2010) Risk stratification and outcome of cellulitis admitted to hospital. J Infect 60(6):431–439 3. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al (2005) Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 41 (10):1373–1406 4. Weigelt J, Itani K, Stevens D, Lau W, Dryden M, Knirsch C (2005) Linezolid versus vancomycin in treatment of complicated skin and soft tissue infections. Antimicrob Agents Chemother 49(6):2260–2266 5. Carratalà J, Rosón B, Fernández-Sabé N, Shaw E, del Rio O, Rivera A et al (2003) Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. Eur J Clin Microbiol Infect Dis 22(3):151–157 6. Lazzarini L, Conti E, Tositti G, de Lalla F (2005) Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect 51(5):383–389 7. Lebre C, Girard-Pipau F, Roujeau JC, Revuz J, Saiag P, Chosidow O (1996) Value of fine-needle aspiration in infectious cellulitis. Arch Dermatol 132(7):842–843 8. Manzur A, Gudiol F (2009) Methicillin-resistant Staphylococcus aureus in long-term-care facilities. Clin Microbiol Infect 15(Suppl 7):26–30 9. Tan R, Newberry DJ, Arts GJ, Onwuamaegbu ME (2007) The design, characteristics and predictors of mortality in the North of England Cellulitis Treatment Assessment (NECTA). Int J Clin Pract 61(11):1889–1893