[Erysipelas in the young population of a military hospital]

INTRODUCTION

Erysipelas usually affects either elderly patients or patients with predisposing factors. We studied erysipelas in a young healthy military population.

SUBJECTS AND METHODS

A retrospective study of patients, less than 30 years old, admitted to the Hôpital d'Instruction des Armées Robert Picqué between 1991 and 1997 was performed.

RESULTS

Eighty-one patients were studied, 80 were men, mean age was 21.4 years. Localization of erysipelas was: face: 2; leg: 74. Facilitating factors were: portal of entry in 100 p. 100; venous insufficiency in 1 case; alcohol abuse in 1 case. Anti-inflammatory agents had been given at the beginning of treatment in 32.1 p. 100 cases. 7.1 p. 100 patients had a recurrence.. Complications were: abscess in 8 cases and bursitis in 1 case. No facilitating factor was detected. The course was not related with bacterial findings. No thrombo-embolic complication was observed.

DISCUSSION

In a young healthy population, erysipelas is not a rare infection. Face is an exceptional localization of erysipelas in relation to older population. The main risk factor for developing this infection is local factor found in 100 p. 100 cases but general factors as repeated hikes, care access, long standing could also be incriminated. Use of anti-inflammatory agents is frequent but role of anti-inflammatory agents in developing complications is not clear. Complications are rare and benign except for frequence of recurrences while the good health.

[Etiology, pathogenesis and treatment of severe recurrent forms of erysipelas of the lower extremities]

The experience of treatment of 314 patients with erysipelas was summarized. The organizational principles of struggle against this disease are proposed.

[Cyclical intravenous antibiosis as an effective therapy concept in chronic recurrent erysipelas]

The treatment of choice for prevention of recurrent erysipelas is the long-term therapy with intramuscular penicillin. The results are often unsatisfactory. Usually erysipelas recurs when the treatment is stopped. The aim of the present study was to evaluate a new treatment regimen, consisting of intravenous penicillin combined with lymphatic drainage. Fifteen patients who had suffered from three or more episodes of erysipelas within the last two years received 10 Mega I.U. of penicillin per day over ten days every third month over a one year period (patients who were allergic to penicillin received erythromycin). Use of intravenous penicillin was combined with lymphatic drainage performed by a sequential pneumatic compressing device. The treatment results were assessed by clinical examination and laboratory tests as well as by laser Doppler imaging every third month. During the one year treatment period and a further year of follow-up, 14 of 15 patients had no recurrent erysipelas. Only a 65 year old patient suffering from Parkinson heart failure, chronic lymphedema and an extensive stasis ulcers had recurrent erysipelas. The present treatment regimen appears to be an effective therapy for prevention of recurrent erysipelas.

Relapse of erysipelas following treatment with prednisolone or placebo in addition to antibiotics: a 1-year follow-up

Of 112 patients with erysipelas, who were randomized to treatment with 8 d of either prednisolone or placebo in addition to antibiotics, 103 were followed-up for 12 months after they had been cured. The results of the period from 3 weeks up to 1 y after the day of cure are presented. 52 patients came from the prednisolone group and 6 of them had further episodes of erysipelas, whereas 13/51 patients from the placebo group relapsed. The difference is not statistically significant.

[Efficacy of pefloxacin in the treatment of complicated relapsing erysipelas]

The effect of antimicrobial agents on the clinical and immunological indices was comparatively studied in 30 patients with relapsing erysipelas complicated by pyoderma. The patients were treated with pefloxacin in a daily dose of 800 mg for 7-10 days (15 patients) and with the routine antibiotics such as benzylpenicillin, ampicillin and erythromycin (15 patients). The efficacy of the treatment was defined by disappearance of the clinical signs and normalization of the functional immunity status. The pefloxacin effect was evident at early stages of the treatment and observed at least for 3 months after the patient discharge from the hospital. Gradual elimination of the secondary immune deficiency in the convalescents due to sanitation of the infection chronic foci was recorded.

[Erysipelas of the leg in hospital environment in Lome (Togo)]

A study was conducted during 5 years to determine the epidemiological clinical profile and the evolution of legs erysipelas in patients attending Lome teaching hospital. During this period, 60 subjects (43 females et 17 males) were hospitalized for legs erysipelas. The average age was 40 years old. General facilitating factors were noted in 58% of the patients (n = 35), and local in 50% of cases (n = 30). The first line treatment was in all patients penicillin G. Satisfactory results were observed in 70%. Local complications were noted in 10% (n = 6), and recurrence in 17% (n = 10). The erysipela is common in hospital environment. The precocious penicillinotherapy allowed to have satisfactory results.

Antibiotic and prednisolone therapy of erysipelas: a randomized, double blind, placebo-controlled study

112 patients admitted to hospital with a diagnosis of erysipelas, were randomized to 8 days treatment with prednisolone or placebo in addition to antibiotics. 108 patients received the study drugs and were evaluated for time to cure, which was the primary end-point. The median healing time was significantly shorter in the prednisolone group, 5 days, vs 6 days in the placebo group (p < 0.01). The 90th percentile healing time was 10.0 days in the prednisolone group vs 14.6 days in the control group. The prednisolone-treated patients had a median length of hospital stay (secondary end-point) of 5 days vs 6 for the placebo-treated (p < 0.01). The median treatment time with intravenous antibiotics (secondary end-point) was 4 days in the placebo group, which was 1 day longer than in the prednisolone group (p < 0.05). 13 patients, 7 of whom received placebo, relapsed during the observation period of 3 weeks. The frequency of side effects attributable to the study drug was not higher in the prednisolone group.

[The pathogenetic characteristics and treatment of erysipelas in diabetics]

Pathogenetic role was studied of lipid peroxidation (LPO) in 65 patients with erysipelas with concurrent diabetes mellitus (DM) versus a group of 86 patients without DM. In the former case, significant increase in blood plasma hydroperoxides, such as malonic dialdegide and dienic conjugates, was recordable, which fact suggested activation of LPO processes. Positive correlation was established between blood content of hydroperoxides and levels of circulating immune complexes. A complex of drugs endowed with known antioxidant, anti-inflammatory and immunocorrective activity were found to have a beneficial effect on clinical, immune and biochemical indices.

Erysipelas and elephantiasis of the scrotum--surgery and drug therapy

Elephantiasis of the scrotum is the terminal stage of persistent refractory lymphedema. Its debilitating functional and cosmetic effects have significant psychological, emotional and social consequences for the affected patient. The causal relationship between etiology and recurrent disease is illustrated here by 2 cases. Therapy options are also discussed. Primary therapeutic success is determined by radical surgery, since chronic inflammation and chronic oedema mutually foster one another. Metabolic stability, sanitization of infected cutaneous areas and the prophylactic administration of antibiotics are essential to ensure that the treatment of recurrent erysipelas is successful in the long term.

[Erysipelas and impetigo]

Erysipela is a dermal or hypodermal infection of the skin, which predominantly involves the leg and is associated with high fever. Erysipela is most often caused by Streptococcus pyogenes. Venous insufficiency or lymphoedema are important local factors for the development of this infection which spreads from intertrigo, local wound or leg ulcer. Treatment is essentially based on parenteral penicillin G. Impetigo is a superficial infection of the skin due to Staphylococcus aureus or to Streptococcus pyogenes, and is frequent in children. Classical impetigo is made of yellow-brown crusts located around the mouth and nose, whereas bullous impetigo involves frequently the trunk and limbs. Secondary impetigo occurring in pediculosis or scabiosis is frequent. It is a contagious disease which is more frequent in patients with poor hygiene. It can be treated by general antibiotics, mainly macrolides, penicillin M or cephalosporins.

[Erysipelas and elephantiasis of the scrotum. Surgical and drug therapy]

Elephantiasis is the outcome of persistent lymphedema. It is refractory to different therapy modalities. The social approachability of patients with this disease is impaired by severe functional and cosmetic disturbances. The causal relationship between etiology and recurrent disease is demonstrated by two cases. Treatment options are discussed. Radical surgery is decisive for primary success since chronic inflammation and chronic edema support each other. Metabolic equilibrium, disinfecting skin areas and antibiotic prophylaxis are urgent steps in the successful treatment of Erysipelas disease.

[Facial erysipelas]

Facial erysipelas is quite uncommon today in Denmark. However, as the disease may be fatal without the proper treatment, the necessity for definite diagnosis is stressed on the basis of a case.

Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study

A prospective, randomized, multicentre trial was conducted to evaluate the efficacy and safety of roxithromycin (150 mg b.i.d. orally) and penicillin (2.5 MU x 8 daily intravenously, then 6 MU daily orally) in the treatment of hospitalized adult patients with erysipelas. Seventy-two patients entered the study. Thirty-one patients in the roxithromycin group and 38 patients in the penicillin group completed the trial. The overall efficacy rates (cure without additional antibiotics) were 84% (26/31) in the roxithromycin group and 76% (29/38) in the penicillin group (P = 0.43). No side-effects were observed in the roxithromycin-treated patients whereas rashes occurred in two cases in the penicillin group, leading to exclusion from the study. Oral roxithromycin can thus be considered an effective and well-tolerated treatment for erysipelas in adult hospitalized patients.

[Effect of indirect endolymphatic antibiotic therapy on clinical and immunological indicators in patients with erysipelas of the lower extremities]

Two groups of patients with erysipelas of the lower extremities underwent indirect endolymphatic therapy with bicillin-3 (58 patients) and routine penicillin therapy (79 patients). Comparative clinicoimmunological examinations in the two groups revealed that lymphotropic administration of the antibiotic had a more favourable effect on the disease process, as evidenced by more rapid reverse time courses of erysipelas clinical signs, less frequent incidence of early relapses and normalization of the majority of immunological parameters by the end of the treatment. For estimation of the anti-recurrence efficacy of the antibiotic therapy in the patients with erysipelas, it was recommended to use a specific scale based on the principles of the Wald successive alternative analysis.

[Use of vilozen and ketotifen combination for increasing the effectiveness and prevention of complications of antibiotic therapy of streptococcal infections]

The clinical efficacy of a vilozen and ketotifen (zaditen) combination in the treatment of streptococcal infections along with the routine therapy was studied. The use of the combination was shown advisable in the complex therapy and prevention of relapses in patients with streptococcal infections. The combined pharmacotherapy promoted better clinical indices, normalization of the immune status and a reduction in the incidence of allergic reactions to antibiotics and a decrease in sensitization to bacterial allergens.

Hip surgery skin cellulitis

Of 583 erysipelas/cellulitis seen in our Department between 1981 and 1991, six (1.04%) were localized to the buttock and hip. Five patients had had a dynamic hip screw implanted for coxarthritis on the side where the skin infection developed. This does not appear to be secondary to superinfection of the surgical wound as the erysipelas/cellulitis occurred weeks (7 to 520) after surgery. The possible surgical compromise of the venous/lymphatic circulation appears to be the causative factor. In all patients, the course was satisfactory upon systemic antibiotic therapy and no recurrence was seen after a mean follow up of 28 months.

Skin concentrations of phenoxymethylpenicillin in patients with erysipelas

In 45 patients hospitalized with febrile erysipelas that had been treated with oral penicillin, punch biopsies of infected skin were performed and analysed for phenoxymethylpenicillin (pcV) concentrations. The curves for the concurrent serum and tissue levels followed the same course, indicating a rapid diffusion of pcV from serum into tissue. Penicillin concentrations in infected skin exceeded the minimal inhibitory concentrations (MIC) of the streptococci isolated for the first 4 h after tablet ingestion. Venous insufficiency was highly prevalent and pcV concentrations in affected patients were slightly but not significantly higher. A theoretical basis for the successful treatment of erysipelas with oral penicillin is therefore at hand.

Facial erysipelas: report of a case and review of the literature

The diagnosis of erysipelas is usually made clinically. Features that help distinguish erysipelas are acute onset, erythema, warmth, edema, pain, fever, and isolated regional involvement with clearly demarcated margins. High ASO titers and response to penicillin therapy are reassuring. Simple uncomplicated erysipelas or cellulitis in adults can usually be treated on an outpatient basis. Extensive facial involvement with fever and a toxic appearance warrants hospitalization. Facial cellulitis or erysipelas in children, unless quite limited, requires hospitalization because of the high risk of Hemophilus influenzae infection and sepsis. Hospitalized patients should show visible signs of resolution and be afebrile for at least 24 hours prior to discharge. They should be maintained on oral antibiotic therapy at home for an additional 7 to 10 days.

[The heparin and trental treatment of patients with the hemorrhagic form of erysipelas]

Activation of procoagulant hemostasis and signs of increased consumption of thrombocytes were indications for the treatment of patients with hemorrhagic erysipelas by means of heparine (60 patients) and trental (30 patients). Heparine was introduced subcutaneously as "minidoses" by means of electrophoresis into the inflammation focus. Heparine produced a positive effect on hemostasis and fibrinolysis, favoured rapid disappearance of the hemorrhagic syndrome, prevention of complications of erysipelas. Trental effected positively thrombocytic hemostasis, local manifestations of the hemorrhagic syndrome but did not prevent the development of thrombophlebitis as complication of the disease.

[The dynamics of the immunological indices during the treatment of recurrent erysipelas with the new immunostimulant bemitil]

Bemitil, administered orally in a dose of 0.25-0.5 g a day for 5-7 days at the acute period of the relapse of erysipelas as an immunostimulant, enhanced the effectiveness of the basic therapy including antibiotics, anti-inflammatory and antiallergic drugs, vitamins, plasma-substituting fluids and saline solutions, as well as ultraviolet irradiation of the focus of lesion. Bemitil therapy was associated with an increase in the number of T-lymphocytes, normalization of the balance between the peripheral lymphocyte preparations, an increase of blood serum levels of IgA and IgM.

Upper airway obstruction due to erysipelas

Erysipelas is a rare cause of airway compromise. A case of a 57-year-old female is described who developed upper airway obstruction secondary to erysipelas of the neck. Emergency treatment by awake fiberoptic bronchoscopy with intubation over the bronchoscope followed by intravenous antibiotics produced rapid clinical improvement. Lymphatic obstruction of the laryngeal structures is the most likely physiologic mechanism.

[The treatment of patients with the hemorrhagic form of erysipelas by using amben and parmidine]

Amben (fibrinolysis inhibitor) and parmidin (bradykinin inhibitor) were used as pathogenetic treatment of 38 and 36 patients with hemorrhagic erysipelas respectively. Early amben treatment proved clinically rather effective and was accompanied by normalization of fibrinolysis and kallikrein-kinin system. Parmidin treatment resulted only in pain control, other subjective signs, normalization of the kallikrein-kinin system while fibrinolysis activity was maintained at former levels.

Degree and stability of tolerance to penicillin in Streptococcus pyogenes

The degree of antibiotic tolerance may be assessed by determining the tolerance percentage of a bacterial strain, defined as the surviving fraction of an inoculum that has been exposed for 24 hours to a high concentration of a beta-lactam antibiotic. In 61 clinical isolates of Streptococcus pyogenes, tolerance percentages ranged from 0 to 0.43. From the slopes of the killing curves it can be deduced that killing starts to be delayed at a tolerance percentage of 0.1. Although a tolerance percentage exceeding 0.1 was observed in 41.4% of the strains, the incidence of clinically relevant forms of tolerance is expected to occur in a smaller fraction of the strains. Tolerance percentages of two strains stored at 20 degrees C, 4 degrees C or -70 degrees C (tolerance percentages 0.43 and 0.36) decreased to 0.03 or less in six weeks. Tolerance percentages could be completely restored in these strains, but not in sensitive strains, by successive selection for this property on penicillin gradients of increasing concentration. In four strains isolated from a family outbreak, identical levels of tolerance percentage could be selected for with the same technique.

[Indicators of nonspecific resistance of the body in patients with erysipelas]

A study is presented of indices of unspecific resistance of the body in 63 patients with erysipelas during the acute period of the disease and during recovery. In the acute period of the disease all patients revealed depending on the degree of endogenous intoxication: reduction of the content of fibronectin in the blood, significant reduction of the resistance of erythrocytes--increase of the per cent of peroxidation hemolysis, increase of the content of malonic dialdehyde--an index of disorders of lipid peroxidation, increased content middlemolecular peptides, circulating immune complexes and products of fibrin-fibrinogen degradation. The authors substantiate the expediency of using sodium thiosulfate possessing detoxicating, antiinflammatory and antiallergic antioxidant properties and the capacity to bind circulating immune complexes.

[The effectiveness of ciprofloxacin in bacterial skin infections]

Ciprofloxacin in a low dosage of 250 mg twice a day was applied in the treatment of bacterial infections of the skin. All cultured staphylococci, streptococci, and pseudomonas proved to be highly sensitive to ciprofloxacin. The cases of pyoderma showed quick healing, but there were relapses of Lyme borrelia within 6 weeks. As the titers of IgM and IgG steadily increased during the following months, additional therapy was necessary. The tolerance of ciprofloxacin was generally very good.

[Efficacy of sultamicillin fine granules in pyoderma, particularly in impetigo contagiosa]

Sultamicillin fine granules were administered orally to 21 patients with impetigo contagiosa and 1 patient with erysipelas, and its clinical efficacy and safety were assessed. The dosage was 10-30 mg/kg daily. Clinical efficacies of impetigo contagiosa were "excellent" in 20 cases and "fair" in 1 case, with an overall efficacy rate of 95%. The result of treatment in erysipelas was "good". Out of 19 strains of Staphylococcus aureus isolated from foci, 17 strains had high beta-lactamase activities. In these 17 strains, sensitivity to the drug was 2-32-fold higher than to ampicillin, and in 14 out of these 17 strains 4-8-fold higher sensitivity was noted. As side effects, mild diarrhea was seen in 2 patients, but those recovered spontaneously in 3-4 days without particular treatment.

[Penicillin-induced acute renal failure as a rare severe complication of erysipelas treatment]

Penicillins are the most commonly used antibiotics in dermatology owing to their bacteriocidal effect and the high responsiveness of most bacterial dermatoses to penicillin treatment. Although there is a wide range of adverse reactions to penicillins, severe complications are seen very rarely. We report on two cases of penicillin-induced acute interstitial nephritis and summarize the characteristic features of this serious adverse reaction to penicillin administration.

Teicoplanin, a new antibiotic effective against gram-positive bacterial infections of the skin and soft tissues

Teicoplanin is a new glycopeptide antibiotic chemically related to vancomycin with a similar bactericidal activity against aerobic and anaerobic Gram-positive bacteria but with a longer plasma elimination half-life of 40-100 h allowing a once daily parenteral administration. In an open prospective study, we treated 20 patients with skin and soft tissue infections such as erysipelas, cellulitis, folliculitis and furunculosis with a a success rate of 84%. The peak and trough serum levels of teicoplanin were above the minimal inhibitory concentrations of the bacteria isolated and the therapeutic index measured at the plateau level was between 24 and 146. We observed a moderate increase of the transaminases in 3 patients which returned to normal at the end of treatment. We conclude that this new antibiotic, teicoplanin, is safe and effective in the treatment of skin and soft tissue infections. It can be administered once daily and is well tolerated even in long-term therapy.

Cellulitis and related skin infections

The location, appearance and clinical course of a skin infection can be used to make a reasonable assumption about its etiology. By carefully considering such factors as entry site and immunocompetence, the physician can make a rational decision about hospitalization and treatment. When appropriate, traditional antibiotics should be used initially, thereby avoiding the temptation to "overkill" the infection with newer, more expensive agents.