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

BACKGROUND

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.

OBJECTIVES

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.

METHODS

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.

RESULTS

Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated (P < 0.0002). Based on 143 completed questionnaires, oedema was apparently due to or persistently asymmetrical after the cellulitic episode in 52 (37%), and 19 (13%) had ulceration attributed to, rather than causing, cellulitis. Of those with three or more episodes, half did not lead to hospital admission. Toeweb maceration was reported in only 15% of questionnaires. Use of antibiotic treatment for more than 28 days was associated with a reduced risk of leg ulceration or of prolonged oedema compared with shorter courses, but neither difference was statistically significant.

CONCLUSIONS

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.

Erysipelas of the left upper limb occurring after elbow dislocation

BACKGROUND

Erysipelas is an acute infection occurring chiefly in the lower limbs, rarely in the upper limbs.

OBSERVATION

A 45-year-old patient suffering from Charcot-Marie-Tooth disease with neuropathy of the limbs, presented with fever and a 24-hour history of a well-circumscribed inflammatory and infiltrated plaque of the left arm. Erysipelas was diagnosed and intravenous penicillin was administered leading to regression of the inflammatory signs, however edema persisted in the inner part of the left elbow. An x-ray showed left elbow dislocation. The patient revealed trauma of the left upper limb 5 weeks before.

DISCUSSION

The occurrence of erysipelas is usually associated with lymphatic edema or venous incontinence. Lymphatic lesions due to radiotherapy or surgery may afflict draining vessels leading to venous and lymphatic stasis and then infection occurs. We find no reported cases of erysipelas following elbow dislocation but we postulate its pathogenesis to be similar.

[Treatment of erysipelas in Germany and Austria--results of a survey in German and Austrian dermatological clinics]

BACKGROUND

Erysipelas is a severe soft tissue infection usually caused by streptococci. The infection is restricted to the dermis and subcutaneous tissues. Treatment with antibiotics is essential. Many different therapeutic regimens are recommended, based mainly on empirical data and only partly proven by clinical studies.

MATERIAL AND METHODS

Our aim was to evaluate the treatment of erysipelas in Germany and Austria by means of a questionnaire and to derive treatment recommendations from this data.

RESULTS AND CONCLUSION

The majority of clinics treat patients with erysipelas as inpatients with intravenous antibiotics. The usual first line treatment is group G penicillin (80%). Other choices include amino-penicillins (11%), cephalosporins (16.5%) and anti-staphylococcal penicillins (6.9%) are used. As second line antibiotics macrolides (63.5%), clindamycin (52.5%), penicillins (18.5%), cephalosporins (40%) and fluoroquinolones (20.5%) are mentioned. Carbapenems, tetracyclines, nitroimidazoles, glycopeptides, aminoglycosides, cotrimoxazole, fusidic acid and fosfomycin are used rarely. The median treatment duration is 10 days. Adjuvant measures are anticoagulation, non-steroidal anti-inflammatory agents, dressings, immobilization and treatment of local predisposing factors such as interdigital tinea.

Bullous Erysipelas: Clinical Presentation, Staphylococcal Involvement and Methicillin Resistance

BACKGROUND

Erysipelas is a bacterial infection of the dermis and hypodermis, mostly of streptococcal origin. Bullous erysipelas represents a severe form of the disease.

OBJECTIVE

To evaluate the clinical and microbiological characteristics and treatment of bullous erysipelas.

METHODS

Patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, University Hospital of Heraklion, Crete, Greece, between the years 1996 and 2001 were retrospectively studied.

RESULTS

Fourteen patients (11 women, 3 men) with bullous erysipelas were evaluated. The lesions were located on the legs and face in 9 and 4 patients, respectively. The median duration of disease before hospital admission was 4 days. Eight patients had fever at presentation. Local trauma and various lesions were common causes for pathogen entry. The initial empirical antibiotic treatment included intravenous beta-lactams and was modified according to the sensitivities of the isolated strains. Staphylococcus aureus was isolated from 7 (50%), while S. warneri, Streptococcus pyogenes and Escherichia coli grew from the lesions of 3 other patients. Six out of 7 S. aureus strains were methicillin resistant (MRSA) but susceptible to several other non-beta-lactam antibiotics such as quinolones, vancomycin, rifampicin and trimethoprim/sulfamethoxazole.

CONCLUSION

Our findings suggest that S. aureus is frequently involved in and probably contributes in synergy with beta-hemolytic streptococci to the complicated course of bullous erysipelas. The frequency of MRSA isolation suggests that beta-lactam antibiotics may not be sufficient for the treatment of bullous erysipelas anymore, at least in areas with a high incidence of MRSA strains. The role of other classes of antibiotics providing adequate coverage for MRSA has to be evaluated in prospective clinical trials.

Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital

Patients hospitalized in the authors' institution for erysipelas or cellulitis between January 1995 and December 2002 were included in this retrospective review. Two hundred cases of soft tissue infections were hospitalized during the study period. The mean age of the patients was 58 years. The most commonly involved site was the leg (66%), followed by the arm (24%) and face (6%). Most patients (71%) had a recognized risk factor for soft tissue infection. Fever was present in 71% of cases, with a mean duration of 3 days. Blood cultures were positive in 3 out of 141 (2%) cases, whereas cutaneous swabs were positive in 73 out of 92 (79%) cases. On admission, white blood cells counts (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels were elevated above normal levels in 100 out of 191 (50%) cases, 151 out of 176 (85%) cases, and 150 out of 154 (97%) cases, respectively. Patients with a hospital stay of more than 10 days had significantly higher CRP and ESR values than patients hospitalized for 10 days or less (P<0.01). A single antibiotic was used as treatment in 115 cases, whereas in the remaining 85 cases a combination of two antibiotics was administered. The most commonly used antibiotics were amoxicillin-clavulanic acid as single agent and penicillin with clindamycin as combination therapy. The mean duration of hospitalization was 7 days for patients treated with a single antibiotic and 11 days for patients treated with an antibiotic combination. A recurrence of infection occurred in 34 (17%) patients. Soft tissue infections are common and have a high degree of morbidity and require prolonged hospitalization and antibiotic treatment. Microbiological diagnosis is difficult and treatment is based on empiric evidence. ESR and CPR levels on admission may predict the severity of the disease and duration of hospitalization.

Erysipelas of the upper extremity following locoregional therapy for breast cancer

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.

[Management of erysipelas in French hospitals: a post-consensus conference study]

INTRODUCTION

A prospective hospital-based survey on the management of bacterial dermal-hypodermal infections was conducted before the consensus conference "How should Erysipelas-Necrotic Fasciitis be managed?". The results of the survey were circulated early in 2001. To assess the eventual impact of the guidelines from the conference on hospital practices with regard to erysipelas, we conducted a new prospective survey at the end of 2002.

PATIENTS AND METHODS

The questionnaire used was identical to that of the 2001 survey. It collected, anonymously, data on the clinical characteristics, supplementary examinations conducted (bacteriology, imaging), initial treatment and outcome. The questionnaire was mailed to the departments of dermatology, internal and/or infectious diseases and intensive care that had replied to the first survey (n = 124). The patients eligible for inclusion were those hospitalized between 09/01/2002 and 11/30/2002. Statistical analysis compared the results with those of the preceding survey.

RESULTS

The files of 245 patients were collected that came from 41 departments (15 from university hospitals, 23 from general hospitals and 3 from military hospitals) and 235 of whom had erysipelas. For those with erysipelas, the mean age was of 65 +/- 2.5 years, the M/F sex ratio was of 0.66 and the localization was the leg in 89.5 p. 100 of cases. A Doppler of the legs was performed in 33 p. 100 of cases. The initial antibiotherapy was penicillin G in 38 p. 100 of cases and pristinamycine in 18 p. 100 (others: 44 p. 100). The route of administration was initially intravenous in 73 p. 100 of cases. An anti-coagulant was associated in 60 p. 100. The outcome was favorable in 94 p. 100 of cases, with a mean duration of hospitalization of 11.2 +/- 1.2 days and antibiotics of 17.7 +/- 1.3 days. Dopplers and the blood cultures were performed more frequently than before the consensus conference, but no difference was found in the antibiotics or adjuvant therapies.

DISCUSSION

The follow-up survey showed the stability of hospital practices concerning erysipelas, notably with regard to treatment. In contrast, the clear tendency in limiting the supplementary examinations is in agreement with the consensus conference.

[Surgical therapy for hand infections Part 2]

Due to its function, anatomy, and exposition to multiple pathogens, the hand is highly susceptible to infection. Most of these infections are post-traumatic. Isolates of pathogens from infected hands contain mainly Staphylococcus aureus and ss-haemolytic group A streptococci. But differential diagnosis also includes pyoderma gangrenosum, tumors of the hand, rheumatoid arthritis, and articular gout, as they may mimic hand infections. Infections of the hand can lead to massive tissue damage that needs to be reconstructed. The selection of methods depends on the localization and size of defects and includes primary closure, split- and full-thickness skin grafts, and more complex operations such as local, regional, and distant flaps.

[Erysipelas. Retrospective study of 647 patients]

We conducted a retrospective at the department of dermatology of Charles Nicolle hospital of Tunis between January 1994 and December 2000 to determine the epidemiological, clinical profile and the evolution of erysipelas. A total of 647 patients were studied. The mean age was 44.73 years and sex ratio about 1.55. Erysipelas predominately involved in the lower limbs (91.2%). Antecedents of erysipelas were found in 26.12 %. Portal of entry was found in 76.66% represented essentially by toe-web intertrigo. 26.6% of patients were hospitalised. Erysipelas can be controlled with antibiotics; treatment is essentially based on penicillin G 4 mega units intramuscularly every day (60.58%) for mean duration of 10.13 days. Satisfying results were observed in 87.78%. Erysipelas is common disease source of over-morbidity. Many predisposing factors were incriminated, account for the frequency of recurrence, justifying implement of primary and secondary prevention.

Resting tachycardia, a warning sign in anorexia nervosa: case report

Background

Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80–90 bpm range, a supervening acute illness should be suspected.

Case presentation

A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight.

Conclusions

Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.

[Mitigated erysipelas after implantation of foreign material]

When an infection occurs in the incisional area following surgery where foreign materials (i. e. endoprostheses, metal plates or plastic meshes) are implanted, a revision may become necessary because an infection in the area of the implant and involvement of the implant itself cannot be ruled out. In the case of a mitigated erysipelas, cultures taken during the revision seldom show bacterial growth. The disease progresses because surgery does not solve the problem of a weakened immune system and lymph stasis; on the contrary, it usually deteriorates the situation. A high dose antibiotic regimen is recommended as therapy for the mitigated erysipelas instead of an operative revision orally given. levofloxacin has proven to be successful reducing the recurrence rate. The course of two patients with mitigated erysipelas is represented for example in form of case studies. The patients were underwent several surgical revisions. But we had not to explant the endoprostheses at all. Finally both patients were treated with levofloxacin without further relapses.

Intramuscular bipenicillin vs. intravenous penicillin in the treatment of erysipelas in adults: randomized controlled study

The objective of the study was to evaluate the efficacy of intramuscular penicillin: mixture of benzyl penicillin and procain penicillin (2 MU x 2 times daily) and intravenous benzyl penicillin (4 MU x 6 times daily) in the treatment of hospitalized adult patients with erysipelas. A prospective randomized unicentric trial was conducted. In total, 112 patients entered the study; 57 in the intramuscular group and 55 patients in the intravenous group completed the trial. The failure rate was 14% for intramuscular group and 20% for the intravenous group (P = 0.40). Local complications such as of the leg abscesses were observed in the two groups (intravenous 9.1%, intramuscular 7%; P = 0477). Of the patients treated with intravenous benzyl penicillin, 25.5% presented complications related to the route (venitis). Intramuscular penicillin should be considered an effective and well-tolerated treatment of erysipelas in adult patients.

Érysipèle. Profil épidémiologique, clinique et évolutif dans la région de Marrakech (100 observations)

OBJECTIVE

We aimed to determine the epidemiological and clinical profile, and to study the evolution of this disease in the Marrakech region.

MATERIAL AND METHODS

We retrospectively studied all patients with a diagnosis of erysipelas admitted in the Department of Dermatology from 1990 to 2002, in the Marrakech Mohamed VI hospital.

RESULTS

A total of 100 patients were included in the study, 58 male (58%) and 42 female (42%) patients, age range 9-95 years (mean age: 47 years). The lesions were most frequently located on the lower limbs (87% of the cases), with 82 cases occurring in the legs, whereas the face was affected in 10% of the cases. Erysipelas relapsed in 12 patients (12%). All patients had at least one risk factor: portal of entry (80 cases, with 67 cases of toe web intertrigo), obesity (10% of the cases), lymphedema (6% of the cases), diabetes (3% of the cases). The first line treatment was intravenous penicillin G in 76 cases (76%). Satisfactory results were observed in 78% of the cases.

COMMENTS

Erysipelas is common in hospital environment. An early penicillin therapy associated to the treatment of the portal of entry leads to satisfactory results.

[Diagnostic image (180). A woman with painful erythema after breast -conserving surgery. Erysipelas caused by group B Streptococcus agalactiae]

A 60-year-old woman presented a year after breast-conserving surgery with severe erysipelas caused by a group-B Streptococcus agalactiae. She recovered after treatment with intravenous penicillin.

Arthroscopic treatment of septic arthritis in a patient with posterior stabilized total knee arthroplasty

We report on a case of arthroscopic treatment of septic arthritis of the knee in a 73-year-old woman with a posterior stabilized knee endoprosthesis. Six months after arthroplasty of the right knee joint because of osteoarthritis, the patient experienced an erysipelas of the right lower leg after a cat bite. Although given intravenous antibiotic therapy, the patient developed septic arthritis of the right knee. Pasteurella multocida could be identified as the causative organism. The joint infection was classified as stage I according to Gächter. Via arthroscopic joint debridement, partial synovialectomy, the use of continuous irrigation-suction drains, and intravenous antibiotic therapy, the empyema could be cured without removal of the total endoprosthesis of the right knee.

Common infections in clinical practice: dealing with the daily uncertainties

Common infections we see every day in the office--urinary tract infections, vaginitis, upper respiratory tract infections, and soft-tissue infections--present a number of diagnostic and treatment uncertainties. In this age of growing antibiotic resistance, these include if and when to start antibiotic therapy, and which agents to use.

[Erysipelatous inflammation: a new view on a long-standing problem]

Under observation there were 72 patients with primary and recurring forms of erysipelatous inflammation. The data obtained have shown the reliable (p<0.001) effectiveness of antimitotic treatment with terbinaphin hydrochloride (lamizil) for prophylactics of recurrences of erysipelatous inflammation: the frequency of recurrences in the group of the treatment was 7.1%, in the control group it was 45.5%.

Antibiotics / anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs

BACKGROUND

Lymphoedema is a chronic and progressive condition and current debate revolves around the best course of management for infective/inflammatory episodes.

OBJECTIVES

To determine whether antibiotic/anti-inflammatory drugs given prophylactically reduce the number and severity of infective/inflammatory episodes in patients with lymphoedema.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group register in September 2003, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), CINAHL, MEDLINE, PASCAL, SIGLE, UnCover, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and the International Society of Lymphology congress proceedings.

SELECTION CRITERIA

Types of studies considered for review were randomised controlled trials testing an antibiotic or anti-inflammatory drug against placebo (with or without physical therapies).

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two blinded reviewers who screened the papers independently using a checklist of criteria relating to the randomisation and blinding of a trial. Both reviewers extracted data from the eligible studies using a data extraction form.

MAIN RESULTS

Overall, four studies (364 randomised patients) were included. Two of these studied the effects of intensive physical treatment plus selenium or placebo in preventing AIE, and two studied the effects of Ivermectin, Diethylcarbamazine (DEC) (anti-filarial agents) and penicillin as prophylactic treatment for adeno lymphangitis(ADL) versus placebo. Both selenium trials reported no inflammatory episodes during the trial period in the treated group but one case of infection in the two placebo groups respectively during the first three weeks of each trial. Seven additional cases of infection in trial one and 14 cases in trial two required treatment in the three month follow up period. One anti filarial trial reported a total of 127 ADL episodes for all groups during the treatment year (compared with 684 episodes reported for the same participants during the pre-treatment year). Another 228 ADL episodes were reported during the trial follow-up year but no significant differences were found between the three groups. No apparent link was found between the grade of oedema and the frequency of ADL episodes. However, there was a significant link between increased episodes and the rainy season. In the penicillin group the mean number of inflammatory episodes was reduced from 4.6 to 0.5 after treatment and increased to 1.9 at the end of the follow-up year.

REVIEWERS' CONCLUSIONS

The effectiveness of selenium in preventing AIE in lymphoedema remains inconclusive in the absence of properly conducted randomised controlled trials. Anti-filarials (DEC and Ivermectin) do not appear to reduce ADL episodes in filarial lymphoedema. Foot care may be important in reducing ADL episodes, and penicillin appears to contribute to a significant reduction in ADL, when combined with foot-care. It seems reasonable to emphasise the importance of foot-care to patients and practitioners in preventing infection and this may also apply to care of the arm in women who develop lymphoedema following breast cancer treatment. However, properly conducted trials are needed to demonstrate any efficacy of these interventions.

Oral pristinamycin versus standard penicillin regimen to treat erysipelas in adults: randomised, non-inferiority, open trial

OBJECTIVE

To assess the efficacy and safety of oral pristinamycin versus intravenous then oral penicillin to treat erysipelas in patients in hospital.

DESIGN

Multicentre, parallel group, open labelled, randomised non-inferiority trial.

SETTING

22 French hospitals.

PARTICIPANTS

289 adults admitted to hospital with erysipelas.

RESULTS

At follow up (day 25-45) the cure rate (primary efficacy end point) for the per protocol populations was 81% (83/102) for pristinamycin and 67% (68/102) for penicillin. The planned interim analysis (global one sided type I error 5%) showed that the one sided 97.06% confidence interval of the observed difference (pristinamycin-penicillin) between cure rates (3.3% to infinity ) exceeded the -10% non-inferiority threshold. For the intention to treat populations the cure rate at follow up was 65% (90/138) for pristinamycin and 53% (79/150) for penicillin, with the one sided 97.06% confidence interval of the observed difference between cure rates (1.7% to infinity ) exceeding the -10% non-inferiority threshold. That the lower limit of the confidence interval exceeded the -10% threshold and was also >0 supports the hypothesis that pristinamycin is significantly superior at the 5% level. More adverse events related to treatment, as assessed by the investigators, were reported in the pristinamycin group than in the penicillin group. Most adverse events involved the gastrointestinal tract (nausea, vomiting, and diarrhoea) but were minor and usually did not require discontinuation of treatment.

CONCLUSION

Pristinamycin could be an alternative to the standard intravenous then oral penicillin regimen used to treat erysipelas in adults in hospital, with the advantages of oral first line therapy.

The CD14+CD16+ monocytes in erysipelas are expanded and show reduced cytokine production

In human peripheral blood the classical CD14(++)DR(+) monocytes and the pro-inflammatory CD14(+)CD16(+)DR(++) monocytes can be distinguished. In erysipelas we found strongly increased numbers of CD14(+)CD16(+) monocytes on the day of diagnosis (day 1) in 11 patients with an average of 150.5+/-76.0 cells/microl, while 1 patient had low levels (35 cells/microl, control donors 48.8+/-19.8 cells/microl). The classical monocytes were only moderately elevated in the erysipelas patients (factor 1.7 as compared to controls). Patients exhibited increased body temperature, erythrocyte sedimentation rate and increased serum levels for C-reactive protein (CRP), IL-6 and macrophage-colony-stimulating factor. Among these, body temperature and CRP showed a significant correlation to the numbers of CD14(+)CD16(+) monocytes. In 4 of 4 patients with high levels of CD14(+)CD16(+) monocytes, these levels returned to that seen in controls by day 5 of antibiotic therapy. Determination of intracellular TNF was performed by three-color immunofluorescence and flow cytometry after ex vivo stimulation with lipoteichoic acid, a typical constituent of streptococci. Here, patient CD14(+)DR(++) pro-inflammatory monocytes showed a twofold lower level of intracellular TNF. By contrast, expression of TNF was unaltered in the classical CD14(++) monocytes. These data show that in erysipelas the pro-inflammatory CD14(+)CD16(+)DR(++) monocytes are substantially expanded and selectively tolerant to stimulation by streptococcal products.

[Hospitalization criteria for erysipelas: prospective study in 145 cases]

INTRODUCTION

Two recent studies conducted in France among general practitioners have shown that they only hospitalized between 20 to 50 percent of patients with erysipelas seen in private practice. We therefore conducted a hospital-based, prospective study designed to determine the hospitalization criteria for erysipelas, since a number of patients are also hospitalized directly through the emergency department.

PATIENTS AND METHODS

This prospective, hospital-based study, included patients hospitalized for clinical diagnosis of erysipelas in 9 centres in north-eastern France. Clinical data were recorded using a standard questionnaire filled-in during the first 72 hours of hospitalization. They included: demographic (name and first name initials, age, sex) and clinical (location of erysipelas) characteristics, as well as the origin of the patient (home, emergency department, other department), the reasons for hospitalization (severity of local or systemic signs, suspicion of deep vein thrombosis, location on the face, age over 60 years, associated diseases, absence of improvement after ambulatory treatment, socioeconomic reasons or on principle hospitalization). Patients hospitalized by (or without) a general practitioner were compared using Chi-2 and Student t tests.

RESULTS

One hundred forty-five adults (80 women and 65 men; mean age 61 +/- 20 years) were included in the study: 89 patients (61 p. 100) were hospitalized by a general practitioner whereas 56 (39 percent) went directly to the emergency department. In 128/145 cases (88 p. 100), erysipelas was localized on the lower limbs. The mean number of reasons for hospitalization per patient was of 2.2 +/- 1.2. The most frequent reason for hospitalization was an associated disease (diabetes, obesity, alcoholism, immunodeficiency), present in 77 cases (53 p. 100). Patients hospitalized through a general practitioner were older than those hospitalized directly through the emergency department (68 vs 51 years; p<0.001). Patients hospitalized by a general practitioner more frequently had an erysipelas located on the lower limbs (94 p. 100 vs 79 p. 100; p<0.001) and the mean number of reasons for hospitalization was greater (2.4 vs 1.7; p<0.001), especially suspicion of deep vein thrombosis and elevated mean age. The treatment started during hospitalization was intravenous penicillin G in 67 cases (46 p. 100), oral pristinamycin in 28 cases (19 p. 100) and intravenous or oral amoxicillin in 9 cases (6 p. 100).

COMMENTS

This study demonstrates the existence of two distinct courses of hospitalization for erysipelas. Patients hospitalized by a general practitioner were older and their erysipelas more frequently located on the lower limbs and deep vein thrombosis was suspected. Our study also shows the emergence of a population of patients younger and without medical supervision, for whom the general practitioner is replaced by the emergency department of the local hospital. Nevertheless, the most frequent reason for hospitalization in both groups is the existence of an associated disease, possibly responsible for further complications.

Antibiotic use in patients with erysipelas: a retrospective study

BACKGROUND

Erysipelas is a skin infection generally caused by group A streptococci. Although penicillin is the drug of choice, some physicians tend to treat erysipelas with antibiotics other than penicillin.

OBJECTIVES

To define the pattern of antibiotic use, factors affecting antibiotic selection, and outcome of patients treated with penicillin versus those treated with other antimicrobial agents.

METHODS

A retrospective review of charts of adult patients with discharge diagnosis of erysipelas was conducted for the years 1993-1996.

RESULTS

The study group comprised 365 patients (median age 67 years). In 76% of the cases infection involved the leg/s. Predisposing condition/s were present in 82% of cases. Microorganisms were isolated from blood cultures in only 6 of 176 cases (3%), and Streptococcus spp. was recovered in four of these six patients. Cultures from skin specimens were positive in 3 of 23 cases. Penicillin alone was given to 164 patients (45%). Other antibiotics were more commonly used in the second half of the study period (P < 0.0001) in patients with underlying conditions (P = 0.06) and in those hospitalized in the dermatology ward (P < 0.0001). Hospitalization was significantly shorter in the penicillin group (P = 0.004). There were no in-hospital deaths.

CONCLUSIONS

We found no advantage in using antibiotics other than penicillin for treating erysipelas. The low yield of skin and blood cultures and their marginal impact on management, as well as the excellent outcome suggest that this infection can probably be treated empirically on an outpatient basis.

[A prospective study on erysipelas and infectious cellulitis: how are they dealt within hospital?]

771 cases of erysipelas and 52 cases of infectious cellulitis were collected over 3 months in a prospective study carried out in French hospitals. The mean age was 62.7 +/- 19.3 years for the erysipelas patients and 69.7 +/- 16 years for the cellulitis patients. Sex-ratios were respectively 0.92 and 2.7. The infection was mainly localized in the lower limbs in both categories (90.9 p. 100 and 71 p. 100); the upper limbs and the face were more often involved in cellulitis than in erysipelas (13 p. 100 versus 5.2 p. 100 and 10 p. 100 versus 2.5 p. 100). Penicillin G was the initial antimicrobial treatment in 45 p. 100 of the erysipelas cases, whereas amoxicillin-clavulanic acid was used in 32.7 p. 100 of the cellulitis cases. Other antibiotics used were pristinamycin, antistaphylococcal penicillin, and amoxicillin. Combinations of antibiotics were used to treat 50 p. 100 of the cellulitis cases but only 11 p. 100 of the erysipelas cases. Anticoagulants were used in 67.4 p. 100 of the erysipelas cases and in 59.7 p. 100 of the cellulitis cases. Surgery was performed in 52 p. 100 of the cellulitis cases, and hyperbaric oxygen in 4.2 p. 100. The outcome was quite different for the 2 diseases: cure rate without complications reached 86.6 p. 100 for erysipelas, and only 48.1 p. 100 for cellulitis; death rates reached respectively 0.77 p. 100 and 5.7 p. 100, median length of hospitalization 8 days and 21 days, and median length of antibiotic treatment 15 days and 21 days.

[Which treatment for erysipelas? Antibiotic treatment: drugs and methods of administering]

Erysipelas is an acute, bacterial cellulitis involving the derma and hypoderma, without necrosis, usually due to Streptococcus pyogenes. Penicilline remains the 'gold standard' treatment. However, others drugs, given their pharmacodynamic properties, may have an excellent indication here. Reccurence is the main evolutive risk.

[Is anticoagulant therapy useful when treating erysipelas?]

INTRODUCTION

Low or high dosage heparin adjuvant therapy for Erysipelas (E) has become frequent, especially in France.

MATERIAL AND METHODS

Publications on erysipelas complications were reviewed, and 2 studies were found in which the detection of deep venous thrombosis (DVT) was systematically performed: Mahe A (6DVT/40E), and Perrot JL (4DVP/155E). We calculated the relative incidence (CRI) at 4.9 p. 100, for all studies systematically detecting the DVT (whether symptomatic or not). The other studies reported clinical DVT. CRI was at 0.7 p. 100 without heparin adjuvant therapy. CRI was at 0, not statistically significant, with low or high dosage heparin adjuvant therapy. The most frequent complications for heparin treatment were: thrombocytopenia (5.7 and 0.9 p. 100 respectively with standard and low weight heparin), and hemorrhage (less than 3 p. 100 for DVT treatment).

DISCUSSION

The risk of DVT associated with E is inferior to 10 p. 100 (the level of risk for DVT is small according to consensus conferences on thromboembolism). The incidence of asymptomatic DVT is superior to that of symptomatic DVT. But we do not know if asymptomatic DVT is equivalent to symptomatic DVT. Consensus conferences on thromboembolism do not recommend the preventive administration of heparin to bedfast patients with a low risk of DVT.

CONCLUSION

There is no indication of adjuvant anticoagulant therapy for erysipelas. There is no indication for systematic prophylactic anticoagulant therapy for erysipelas. Prophylactic anticoagulant therapy is used depending on other risk factors of DVT. Wearing stockings may be another indication for patients.

[Should NSAID/corticoids be considered when treating erysipelas?]

Using non-steroidal anti-inflammatory drugs (NSAID) in association with a suitable antibiotherapy in the treatment of erysipelas, is still being largely discussed in medical publications. When compared to other fields of medicine, here their use might be justified by their ability to reduce local inflammation processes, to relieve patients more quickly, and to prevent potential sequels due to an inflammatory process. Numerous reports have suggested an association between the use of NSAID and the progression of an invasive streptococcal infection, particularly necrotizing fasciitis. The exact mechanism is still unclear. No controlled survey (NSAID versus placebo) checking the efficiency and the safety of these treatments is currently available. Only one comparative study showed a gain of one single day for prednisolone The prednisolone-treated patients had a shorter median length of hospital stay (5 days vs. 6) than the placebo-treated ones. The median treatment time with intravenous antibiotics, in the placebo group, was 1 day longer than in the prednisolone group. The occurrence of side effects was not higher in the prednisolone group. If this currently available data is not sufficient to establish a relationship between severe infectious complications and the use of NSAID, one should be cautious when using them to treat erysipelas, since their efficiency has not been positively proved.

[Erysipelas: evolution under treatment, complications]

OBJECTIVE

The authors studied the evolution and the complications of lower limb erysipelas under antibiotherapy.

METHOD

The following parameters were studied in literature over the last 20 years (keyword=erysipelas): percentage of favorable course, delay for cure, local or systemic complications, prognostic factors, and mortality.

RESULTS

Data was only available in series of hospitalized patients. The lower limbs were the exclusive or the most frequently involved areas. Under systemic antibiotherapy, the overall efficacy rates reached 76-84 p. 100, with apyrexia within 24 to 48 h, and regression of local symptoms within 4 to 6 days. The median hospital stay was 10-13 days. A longer hospital stay was observed for: older patients, associated diseases, longer duration of illness prior to admission, and presence of a leg ulcer. Complications were observed: abscess or superficial necrosis (3-12 p. 100), deep thrombophlebitis in 1.4 p. 100 of retrospective studies vs. 2.6-15 p. 100 in prospective series. Mortality was low (0.5 p. 100) due to systemic complications more than to the severity of local symptoms. Relapse was frequent (15-25 p. 100).

DISCUSSION

The unavailability of data concerning outpatients limits the formulation of valid conclusions. Nevertheless the medical course was favorable (80 p. 100) with apyrexia within 2 days, and absence of local symptoms within 4 to 6 days. Mortality or longer duration of hospital stay was linked to age or to associated diseases. The risk of deep thrombophlebitis was rare in absence of predisposing factors. Systematic prevention should be suggested and care given to local predisposing factors responsible for frequent recurrent forms.

[Erysipelas. A retrospective series of 92 patients in a department of internal medicine]

Erysipleas, also known as Saint Anthony's fire, is an acute infection of the skin caused, in most of cases, by group A streptococci. In the past, the most common site of involvement was the face and, in the pre-antibiotic era, mortality was high. In this retrospective study, we highlight the clinical and bacteriological features and report follow-up in 92 patients hospitalized in an internal medicine unit between 1st March 1992 and 31st December 1996 for 94 episodes of erysipelas. The involvement of the lower limbs predominated as involvement of the face is becoming very rare. Streptococci from others groups and Staphylococcus aureus have been implicated on occasions. Recovery is usual even if this infection may greatly weaken these often fragilized patients. In this paper, antibiotic treatment as well as the place of anticoagulants and Doppler ultrasound are discussed. Hospitalization is often necessary but it must not be systematic.

[Erysipelas, cellulitis and other severe Streptococcus pyogenes skin infections]

INCIDENCE AND GRAVITY: Invasive Streptococcus pyogenes infections are a common reason for hospitalization. Serious forms may occur in patients with no known risk factor, including young patients. Inversely, erysipela is observed more readily in the elderly population with a more vulnerable venous system. Disease gravity is related to the high risk of recurrence. For cellulitis, predominantly a disease of young subjects with no past history, severity is related to local extension and development of shock syndrome. Besides the immediate life-threatening situation, functional prognosis may be compromised, depending on the localization of the infection.

PATHOGENESIS OF GROUP A STREPTOCOCCAL INFECTIONS

Adherence and invasion properties of group A streptococci, particularly the capsule and protein M, as well as streptococcal toxins cause severe septic and toxinic syndromes. Strains most frequently associated with invasive infections are: biotype 1, serotype M1 and biotype 3, serotype M3.

TREATMENT

An antibiotic regimen by intravenous infusion of penicillin G is the gold standard treatment. Clindamycin should be added in case of septic shock. Extensive cellulitis or necrotizing fasciitis requires surgical debridement of the necrotic tissue and intensive care for the shock syndrome.

Bullous erysipelas: A retrospective study of 26 patients

BACKGROUND

Erysipelas is a superficial form of cellulitis caused by a variety of microbes, and it responds to antibiotic treatment. During the past few years we treated several patients with a bullous form of erysipelas involving the lower legs. We believe their disease had a more protracted course than patients with nonbullous erysipelas.

OBJECTIVE

We studied bullous erysipelas by conducting a retrospective analysis of 26 patients with bullous erysipelas of the legs treated by the authors during a 5-year period.

METHODS

We conducted a retrospective review of the records of all patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, Hadassah Medical Center, Jerusalem, between the years 1992 and 1996. Data regarding patients with nonbullous erysipelas were obtained from the medical center's computerized data pool.

RESULTS

A total of 26 cases of bullous erysipelas were found, comprising 22 women and 4 men whose ages ranged from 28 to 87 (mean, 58.8) years. The average hospital stay was 20.57 days (range, 12 to 46 days). The average hospital stay for patients with nonbullous erysipelas and cellulitis treated in the same department by the authors during the study period was 10.6 days (range, 2 to 54 days).

CONCLUSION

Bulla formation is a complication of erysipelas, seen in our series in 5.2% of the patients (26 of 498 admissions for erysipelas and cellulitis). The course of the disease is protracted, requiring longer medical attention.