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Taggart M, Langworthy K, Hui S, Boyder C, Fulurija A, Morici M, Raby E, Manning L. Serological Responses to Streptococcus pyogenes Vaccine Candidate Antigens Suggests That Streptococcus dysgalactiae Is the Predominant Cause of Lower Limb Cellulitis. Open Forum Infect Dis 2024; 11:ofae272. [PMID: 38872850 PMCID: PMC11171425 DOI: 10.1093/ofid/ofae272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024] Open
Abstract
Background A future Streptococcus pyogenes (Strep A) vaccine will ideally prevent a significant burden of lower limb cellulitis; however, natural immune responses to proposed vaccine antigens following an episode of cellulitis remain uncharacterized. Methods We enrolled 63 patients with cellulitis and 26 with invasive beta hemolytic streptococci infection, using a multiplexed assay to measure immunoglobulin G against Strep A vaccine candidate antigens, including: streptolysin O (SLO), deoxyribonuclease B (DNB), group A carbohydrate (GAC), C5a peptidase (ScpA), cell envelope proteinase (SpyCEP), and adhesion and division protein (SpyAD). Responses in the invasive cohort were used to predict the infecting etiology in the cellulitis cohort. Results Of 41 patients with cellulitis and paired serological samples, 68.3% had evidence of beta hemolytic streptococci infection by conventional anti-SLO and/or anti-DNB criteria. A positive serological response to at least 1 of the tested antigens was seen in 78.0% of the cellulitis cohort. Individually, anti-SLO (58.5%), anti-SpyAD (46.3%), and anti-ScpA (39.0%) were the most common. Based on principal component analysis, increases in these 3 antibodies, without responses to DNB, GAC, and SpyCEP characterized Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection. Conclusions SDSE appears to be the predominant cause of lower limb cellulitis. Effective Strep A vaccines incorporating antigens that provide additional cross protection against SDSE may prevent a significant burden of lower limb cellulitis.
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Affiliation(s)
- Michael Taggart
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Kristyn Langworthy
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Siong Hui
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Conchita Boyder
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Alma Fulurija
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Morici
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Edward Raby
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
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Gawaz A, Gonser L, Strölin A, Kofler L, Häfner HM, Kofler K. Concomitant thrombosis in patients with cellulitis as incidental finding. Clin Hemorheol Microcirc 2022; 82:335-340. [PMID: 35938241 DOI: 10.3233/ch-221519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although inflammation and thrombosis are tightly connected, only 45% of patients with lower leg cellulitis receive anticoagulant therapy. Available data about the prevalence of concomitant deep venous thrombosis (DVT) in patients with cellulitis of the lower extremity is scarce and general guidelines regarding diagnosis and prevention of venous thromboembolism are missing. OBJECTIVE We sought to determine how frequently DVT occurs as an incidental finding in patients with cellulitis and to provide recommendations for diagnostics and anticoagulant therapy. METHODS Patients' records were analysed and 192 consecutive patients with cellulitis were included in this study. The prevalence of concomitant DVT was examined by duplex ultrasound, as well as comorbidities and risk factors. RESULTS We detected thrombosis in 12.0% of the patients with lower leg cellulitis, of which 43.5% were located in a proximal vein and 52.2% in the veins of the calf. CONCLUSIONS Our results clearly indicate that cellulitis is not only a differential diagnosis, but should be considered a risk factor for venous thrombosis. Therefore, prophylactic anticoagulation should be considered in patients suffering from cellulitis and a systematic screening for venous thrombosis in patients with cellulitis should be performed.
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Affiliation(s)
- Andrea Gawaz
- Universitätshautklinik Tübingen, Liebermeisterstr, Tübingen, Germany
| | - Lena Gonser
- Universitätshautklinik Tübingen, Liebermeisterstr, Tübingen, Germany
| | - Anke Strölin
- Universitätshautklinik Tübingen, Liebermeisterstr, Tübingen, Germany
| | - Lukas Kofler
- Universitätshautklinik Tübingen, Liebermeisterstr, Tübingen, Germany
| | | | - Katrin Kofler
- Universitätshautklinik Tübingen, Liebermeisterstr, Tübingen, Germany
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Streptococcal infection in childhood Henoch-Schönlein purpura: a 5-year retrospective study from a single tertiary medical center in China, 2015-2019. Pediatr Rheumatol Online J 2021; 19:79. [PMID: 34078391 PMCID: PMC8173722 DOI: 10.1186/s12969-021-00569-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 05/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The present study focuses on the associations of streptococcal infection with the clinical phenotypes, relapse/recurrence and renal involvement in Henoch-Schönlein purpura (HSP) children. METHODS Two thousand seventy-four Chinese children with HSP were recruited from January 2015 to December 2019. Patients' histories associated with HSP onset were obtained by interviews and questionnaires. Laboratory data of urine tests, blood sample and infectious agents were collected. Renal biopsy was performed by the percutaneous technique. RESULTS (1) Streptococcal infection was identified in 393 (18.9%) HSP patients, and served as the most frequent infectious trigger. (2) Among the 393 cases with streptococcal infection, 43.0% of them had arthritis/arthralgia, 32.1% had abdominal pain and 29.3% had renal involvement. (3) 26.1% of HSP patients relapsed or recurred more than 1 time within a 5-year observational period, and the relapse/recurrence rate in streptococcal infectious group was subjected to a 0.4-fold decrease as compared with the non-infectious group. (4) No significant differences in renal pathological damage were identified among the streptococcal infectious group, the other infectious group and the non-infectious group. CONCLUSIONS Streptococcal infection is the most frequent trigger for childhood HSP and does not aggravate renal pathological damage; the possible elimination of streptococcal infection helps relieve the relapse/recurrence of HSP.
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostischer Wert von Laborparametern zur Unterscheidung zwischen Erysipel und begrenzter Phlegmone. J Dtsch Dermatol Ges 2020; 18:1417-1425. [PMID: 33373139 DOI: 10.1111/ddg.14252_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Cord Sunderkoetter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle/Saale
| | - Jan Ehrchen
- Klinik und Poliklinik für Hautkrankheiten, Universität Münster
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Drerup C, Eveslage M, Sunderkoetter C, Ehrchen J. Diagnostic value of laboratory parameters for the discrimination between erysipelas and limited cellulitis. J Dtsch Dermatol Ges 2020; 18:1417-1424. [PMID: 33035396 DOI: 10.1111/ddg.14252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Erysipelas, caused by beta-hemolytic streptococci, and limited cellulitis, frequently caused by Staphylococcus aureus or other bacteria, are skin and soft tissue infections characterized by typical clinical signs. However, despite the therapeutical relevance they are often not differentiated (e.g in clinical trials). Erysipelas are efficiently treated with penicillin, while limited cellulitis is treated with more wide-spectrum antibiotics. This study investigates whether parameters such as CRP, blood counts or novel parameters like immature granulocytes could serve as biomarkers to distinguish between these entities. PATIENTS AND METHODS For this retrospective analysis 163 patients were included. We compared laboratory markers in patients with erysipelas (n = 68) to those with limited cellulitis (n = 41) of the leg. Both erysipelas and limited cellulitis were defined clinically, with an additional aspect for erysipelas being a prompt response to penicillin. RESULTS Erysipelas were characterized by higher levels of inflammation. CRP and leukocyte counts are the best parameters to discriminate between both infections. A CRP value ≥ 3.27 mg/dl indicated the diagnosis of erysipelas with 75 % sensitivity and 73.2 % specificity. CONCLUSIONS Our results support the thesis that erysipelas and limited cellulitis are distinct infections as defined in the German guidelines and that an assessment of CRP and leukocytes is useful for differential diagnosis.
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Affiliation(s)
- Christian Drerup
- Department of Dermatology, University of Muenster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Cord Sunderkoetter
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Jan Ehrchen
- Department of Dermatology, University of Muenster, Muenster, Germany
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Karakonstantis S. Is coverage of S. aureus necessary in cellulitis/erysipelas? A literature review. Infection 2019; 48:183-191. [PMID: 31845187 DOI: 10.1007/s15010-019-01382-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/06/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Empirical treatment of patients with cellulitis/erysipelas usually targets both streptococci and methicillin-sensitive S. aureus (MSSA). However, the recommendation to empirically cover MSSA is weak and based on low-quality evidence. METHODS AND OBJECTIVE A systematic review was conducted in PubMed and clinical trial registries to assess the role of S. aureus in cellulitis/erysipelas and the need for empirical MSSA coverage. RESULTS Combined microbiological and serological data, and response to penicillin monotherapy suggest that streptococci are responsible for the vast majority of cases of cellulitis/erysipelas. However, most cases are non-culturable and the specificity of microbiological and serological studies is questionable based on recent studies using molecular techniques. According to epidemiological data and three randomized controlled trials, empirical coverage of methicillin-resistant S. aureus (MRSA) is not recommended for most patients, despite the high prevalence of MRSA in many areas. If MRSA is indeed not an important cause of uncomplicated cellulitis/erysipelas, then the same may apply to MSSA. Based on indirect comparison of data from clinical studies, cure rates with penicillin monotherapy (to which most MSSA are resistant) are comparable to the cure rates reported in many studies using wider-spectrum antibiotics. CONCLUSION Considering the limitations of microbiological studies in identifying the pathogens responsible for cellulitis/erysipelas, treatment needs to be guided by clinical trials. Trials comparing penicillin or amoxicillin monotherapy to MSSA-covering regimens are needed to definitively answer whether empirical coverage of MSSA is needed and to identify the subset of patients that can be safely treated with penicillin or amoxicillin monotherapy.
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Affiliation(s)
- Stamatis Karakonstantis
- Infectious Diseases Unit, School of Medicine, University of Crete, Voutes, Heraklion, Postal code 71110, Greece.
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Eriksson BKG, Karkkonen K, Jorup-Rönström C, Wretlind B. Frequent colonization of betahaemolytic streptococci at various body sites including the perineum and anal canal during erysipelas and cellulitis. Infect Dis (Lond) 2019; 51:534-540. [PMID: 31088328 DOI: 10.1080/23744235.2019.1606934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: Erysipelas and cellulitis are usually caused by betahaemolytic streptococci but the aetiology is often difficult to verify in clinical practice. Methods: Patients with erysipelas or cellulitis were analysed for betahaemolytic streptococci in samples from multiple body sites, including the perineum and the anal canal, during the acute episode and at follow up. Healthy control persons were sampled from the same sites. Results: Betahaemolytic streptococci group A, C or G were identified in 23/28 (82%) patients, most commonly group G. A wound or ulcer, present in 16/28 (57%), was colonized in 8/16 (50%). The perineum and anal canal were colonized in 11/28 (39%) and 10/28 (36%), respectively. At follow-up after about 4 weeks, only 4/28 (14%) were colonized (p<.001). In 39 healthy control persons, no betahaemolytic streptococci group A were found, groups C or G were found in 4/39 (10%). Group B streptococci were more often identified in controls, than in patients,12/39 (31%). Conclusions: Acute episodes of erysipelas or cellulitis are associated with colonization of betahaemolytic streptococci at multiple sites including the perineum and anal canal, in particular serogroup G. This may be important for choice of primary antibiotic therapy and possibilities for prevention of relapses.
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Affiliation(s)
- Björn K G Eriksson
- a Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Kerstin Karkkonen
- a Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | | | - Bengt Wretlind
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden
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A Case of Recurrent Erysipelas Caused by Streptococcus mitis Group. Case Rep Infect Dis 2018; 2018:5156085. [PMID: 30018832 PMCID: PMC6029475 DOI: 10.1155/2018/5156085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/31/2018] [Indexed: 12/15/2022] Open
Abstract
The aetiology of erysipelas remains poorly defined though beta-haemolytic streptococci are considered as the main causative pathogens. We describe a case of a 70-year-old woman with recurrent erysipelas in her left arm due to infection with streptococci of the mitis group. Her past medical history includes lymphoedema of the left arm secondary to lymph node dissection due to breast cancer surgery. On seven different occasions during a decade, she has presented a clinical picture of erysipelas and in three of them with Streptococcus mitis group bacteraemia. The results indicate that two cases were caused by Streptococcus mitis and one case was caused by Streptococcus oralis. This is, to our knowledge, the first reported cases of S. mitis and of S. oralis as the causative agents of erysipelas.
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Yassaie E, Kelly M, Tan ST. Review of empiric antibiotic use in plastic and reconstructive surgery. ANZ J Surg 2018; 88:531-533. [PMID: 29864261 DOI: 10.1111/ans.14406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/19/2017] [Accepted: 01/02/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Emily Yassaie
- Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital, Wellington, New Zealand
| | - Matthew Kelly
- Department of Medicine, Hutt Hospital, Wellington, New Zealand
| | - Swee T Tan
- Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital, Wellington, New Zealand.,Gillies McIndoe Research Institute, Wellington, New Zealand
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WHO/IVI global stakeholder consultation on group A Streptococcus vaccine development: Report from a meeting held on 12–13 December 2016. Vaccine 2018; 36:3397-3405. [DOI: 10.1016/j.vaccine.2018.02.068] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/02/2018] [Accepted: 02/16/2018] [Indexed: 12/21/2022]
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Jääskeläinen IH, Hagberg L, Schyman T, Järvinen A. A potential benefit from infectious disease specialist and stationary ward in rational antibiotic therapy of complicated skin and skin structure infections. Infect Dis (Lond) 2017; 50:107-116. [PMID: 28789580 DOI: 10.1080/23744235.2017.1362706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Management practices of complicated skin and skin structure infections (cSSSI) were compared between two areas with similar healthcare structure and low prevalence of antimicrobial resistance. METHODS The high affinity to public health-care in the Nordic countries enabled population-based approach used in this retrospective study. The study population (n = 460) consisted of all adult residents from Helsinki (Finland) and Gothenburg (Sweden) treated in hospital due to cSSSI during 2008-2011. RESULTS The majority of patients in Helsinki (57%) visited more than one ward during their hospital stay while in Gothenburg the majority of patients (85%) were treated in one ward only. Background and disease characteristics were largely similar in both cities but patients in Helsinki were younger [mean(SD) 59(18) versus 63(19) years, p = .0117], and greater proportions had diabetes (50% versus 32%, p < .0001) and polymicrobial infections (34% versus 13%, p < .0001). Patients in Helsinki received antimicrobials with Gram-negative coverage (in initial therapy 96%) more frequently than in Gothenburg (47%, p < .0001), had more treatment modifications (mean 4.3 versus 2.7 antibiotic agents used per patient, p < .0001), and longer median duration of antimicrobial therapy (29 versus 12 days, p < .0001) and median length of hospital stay (17 versus 11 days, p < .0001). CONCLUSIONS This real-life study revealed remarkable differences in the management of cSSSI between the two Nordic cities. Compared to mainly Infectious Disease Specialist guided treatment in Gothenburg, the more frequent transfer from one ward to another in Helsinki was linked to longer antimicrobial therapy and hospital stay and to more frequent changes in antimicrobial treatment.
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Affiliation(s)
- Iiro H Jääskeläinen
- a Department of Infectious Diseases , Inflammation Center, Helsinki University Central Hospital, and Helsinki University , Helsinki , Finland
| | - Lars Hagberg
- b Department of Infectious Diseases , Institute of Biomedicine, Sahlgrenska Academy University of Gothenburg , Gothenburg , Sweden
| | | | - Asko Järvinen
- a Department of Infectious Diseases , Inflammation Center, Helsinki University Central Hospital, and Helsinki University , Helsinki , Finland
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Rath E, Skrede S, Mylvaganam H, Bruun T. Aetiology and clinical features of facial cellulitis: a prospective study. Infect Dis (Lond) 2017; 50:27-34. [PMID: 28768452 DOI: 10.1080/23744235.2017.1354130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis. METHODS Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages. RESULTS Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities. CONCLUSIONS Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.
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Affiliation(s)
- Eivind Rath
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Steinar Skrede
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Haima Mylvaganam
- c Department of Microbiology and Immunology , Haukeland University Hospital , Bergen , Norway
| | - Trond Bruun
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Brindle R, Williams OM, Davies P, Harris T, Jarman H, Hay AD, Featherstone P. Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis. BMJ Open 2017; 7:e013260. [PMID: 28314743 PMCID: PMC5372109 DOI: 10.1136/bmjopen-2016-013260] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis. DESIGN Parallel, double-blinded, randomised controlled trial. SETTING Emergency department attendances and general practice referrals within 20 hospitals in England. INTERVENTIONS Flucloxacillin, at a minimum of 500 mg 4 times per day for 5 days, with clindamycin 300 mg 4 times per day for 2 days given orally versus flucloxacillin given alone. MAIN OUTCOME MEASURES The primary outcome was improvement at day 5. This was defined as being afebrile with either a reduction in affected skin surface temperature or a reduction in the circumference of the affected area. Secondary outcomes included resolution of systemic features, resolution of inflammatory markers, recovery of renal function, reduction in the affected area, decrease in pain, return to work or normal activities and the absence of increased side effects. RESULTS 410 patients were included in the trial. No significant difference was seen in improvement at day 5 for flucloxacillin with clindamycin (136/156, 87%) versus flucloxacillin alone (140/172, 81%)-OR 1.55 (95% CI 0.81 to 3.01), p=0.174. There was a significant difference in the number of patients with diarrhoea at day 5 in the flucloxacillin with clindamycin allocation (34/160, 22%) versus flucloxacillin alone (16/176, 9%)-OR 2.7 (95% CI 1.41 to 5.07), p=0.002. There was no clinically significant difference in any secondary outcome measures. There was no significant difference in the number of patients stating that they had returned to normal activities at the day 30 interview in the flucloxacillin with clindamycin allocation (99/121, 82%) versus flucloxacillin alone (104/129, 81%)-adjusted OR 0.90 (95% CI 0.44 to 1.84). CONCLUSIONS The addition of a short course of clindamycin to flucloxacillin early on in limb cellulitis does not improve outcome. The addition of clindamycin doubles the likelihood of diarrhoea within the first few days. TRIAL REGISTRATION NUMBER NCT01876628, Results.
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Affiliation(s)
- Richard Brindle
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - O Martin Williams
- Microbiology and Infectious Diseases, Bristol Royal Infirmary, Bristol, UK
| | - Paul Davies
- General Practice Support Unit, Bristol Royal Infirmary, Bristol, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Heather Jarman
- Department of Emergency Medicine, St George's University Hospitals, London, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Pallin DJ, Bry L, Dwyer RC, Lipworth AD, Leung DY, Camargo CA, Kupper TS, Filbin MR, Murphy GF. Toward an Objective Diagnostic Test for Bacterial Cellulitis. PLoS One 2016; 11:e0162947. [PMID: 27656884 PMCID: PMC5033594 DOI: 10.1371/journal.pone.0162947] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/31/2016] [Indexed: 11/24/2022] Open
Abstract
Background Prior studies repeatedly showed that cultures of skin lesions diagnosed as "cellulitis" are usually negative. However, lack of a gold standard for diagnosis (against which culture might be judged) and failure to assess the human immune response are important limitations of prior work. In this pilot study, we aimed to develop a criterion standard for research on bacterial cellulitis, to evaluate the sensitivity of procalcitonin for bacterial cellulitis, and to use gene expression analysis to find other candidate diagnostic markers. Methods We classified lesions via biopsies, 16s rRNA gene detection, culture, and histopathology. We quantified procalcitonin expression in blood. We also used Nanostring technology to quantify transcription of immunomodulators that may distinguish cases from inflamed controls. Results Of 28 participants, 15 had a clinical diagnosis of cellulitis, six had a diagnosis of non-infectious dermatitis, and seven were normal volunteers. Of the “cellulitis” patients, three (20%) had pathogens isolated, and were designated confirmed cases. Procalcitonin was undetectable in all three. HLA-DQA1 was expressed 34-fold more in confirmed cases vs. controls (fold change of geometric mean). Heat maps depicting multiplex gene expression analysis revealed a distinct profile of gene expression in confirmed cases relative to comparators. Conclusions Most “cellulitis” patients had microbiologically-negative biopsies. Procalcitonin was undetectable, and HLA-DQA1 elevated, in confirmed bacterial cases. Multivariable transcriptomic profiling results supported our algorithm’s ability to identify patients with true bacterial cellulitis. A larger sample may allow discovery of an immunological signature capable of distinguishing bacterial cellulitis from its mimics in clinical practice.
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Affiliation(s)
- Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- * E-mail:
| | - Lynn Bry
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Richard C. Dwyer
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Adam D. Lipworth
- Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Donald Y. Leung
- Department of Pediatrics, National Jewish Medical Health, Denver, CO, United States of America
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas S. Kupper
- Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Michael R. Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - George F. Murphy
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States of America
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15
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Chaniotakis I, Gartzonika C, Gaitanis G, Levidiotou-Stefanou S, Bassukas I. Causality evaluation of bacterial species isolated from patients with community-acquired lower leg cellulitis. J Eur Acad Dermatol Venereol 2016; 30:1583-9. [DOI: 10.1111/jdv.13688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/25/2016] [Indexed: 11/28/2022]
Affiliation(s)
- I. Chaniotakis
- Department of Skin and Venereal Diseases; Faculty of Medicine; School of Health Sciences; University of Ioannina and University Hospital of Ioannina; Ioannina Greece
| | - C.G. Gartzonika
- Department of Microbiology; Faculty of Medicine; School of Health Sciences; University of Ioannina and University Hospital of Ioannina; Ioannina Greece
| | - G. Gaitanis
- Department of Skin and Venereal Diseases; Faculty of Medicine; School of Health Sciences; University of Ioannina and University Hospital of Ioannina; Ioannina Greece
| | - S. Levidiotou-Stefanou
- Department of Microbiology; Faculty of Medicine; School of Health Sciences; University of Ioannina and University Hospital of Ioannina; Ioannina Greece
| | - I.D. Bassukas
- Department of Skin and Venereal Diseases; Faculty of Medicine; School of Health Sciences; University of Ioannina and University Hospital of Ioannina; Ioannina Greece
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16
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Bruun T, Oppegaard O, Hufthammer KO, Langeland N, Skrede S. Early Response in Cellulitis: A Prospective Study of Dynamics and Predictors. Clin Infect Dis 2016; 63:1034-1041. [PMID: 27402819 PMCID: PMC5036916 DOI: 10.1093/cid/ciw463] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/30/2016] [Indexed: 11/15/2022] Open
Abstract
In this prospective study of cellulitis, several nonpharmacological factors were associated with lack of early response. Such early nonresponse was rarely related to inappropriate therapy but strongly predictive of early treatment escalation, suggesting that broadening antibiotic treatment often may be premature. Background. Skin and soft tissue infections are common reasons for medical care. Use of broad-spectrum therapy and costs have increased. Assessment of early treatment response has been given a central role both in clinical trials and everyday practice. However, there is a paucity of data on the dynamics of response, causes of early nonresponse, and how early nonresponse affects resource use and predicts outcome. Methods. We prospectively enrolled 216 patients hospitalized with cellulitis. Clinical and biochemical response data during the first 3 days of treatment were analyzed in relation to baseline factors, antibiotic use, surgery, and outcome. Multivariable analysis included logistic lasso regression. Results. Clinical or biochemical response was observed in the majority of patients the day after treatment initiation. Concordance between clinical and biochemical response was strongest at days 2 and 3. Female sex, cardiovascular disease, higher body mass index, shorter duration of symptoms, and cellulitis other than typical erysipelas were predictors of nonresponse at day 3. In contrast, baseline factors were not predictive of clinical failure assessed posttreatment. Among cases with antibiotic treatment escalation by day 2, 90% (37/41) had nonresponse at day 1, but only 5% (2/40) had inappropriate initial therapy. Nonresponse at day 3 was a predictor of treatment duration >14 days, but not of clinical failure. Conclusions. Nonpharmacological factors had a major impact on early response dynamics. Delayed response was rarely related to inappropriate therapy but strongly predictive of early treatment escalation, suggesting that broadening antibiotic treatment may often be premature.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen.,Department of Medicine
| | - Oddvar Oppegaard
- Department of Clinical Science, University of Bergen.,Department of Medicine
| | | | - Nina Langeland
- Department of Clinical Science, University of Bergen.,National Centre for Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen.,Department of Medicine
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17
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Toleman MS, Vipond IB, Brindle R. Specific PCR, bacterial culture, serology and pharyngeal sampling to enhance the aetiological diagnosis of cellulitis. J Med Microbiol 2016; 65:44-47. [PMID: 26487664 DOI: 10.1099/jmm.0.000191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
It is often difficult to obtain a bacteriological diagnosis in patients with cellulitis. We examined the utility of molecular techniques and skin and throat cultures, as well as serology, in providing evidence of either Staphylococcus aureus or group A Streptococcus (GAS) presence inpatients with cellulitis. Samples were collected from patients with a clinical diagnosis of cellulitis who were recruited into a prospective placebo-controlled clinical trial (C4C study, EudraCT 2013-001218-14). Specific PCR, paired serology and culture for both organisms were carried out on a variety of samples where appropriate. Despite utilizing a range of diagnostic methods,a bacteriological diagnosis was only achieved in 43 % of patients with a clinical diagnosis of cellulitis. Seventeen per cent of patients tested positive for GAS by any method but only 4 % were positive by PCR, whilst S. aureus was detected in 34% of samples. Bacterial diagnosis in cases of cellulitis remains challenging. This is probably due to a very low bacterial burden with toxin production resulting in inflammation mediating skin damage. Further consideration for the need for long courses of antimicrobial therapy for cellulitis therefore appears merited.
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Affiliation(s)
- Michelle S Toleman
- Public Health England, Microbiology, Level 8, Queens Building, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - I Barry Vipond
- Specialist Virology Centre, Public Health Laboratory Bristol, Public Health England, Myrtle Road, Bristol BS2 8EL, UK
| | - Richard Brindle
- Public Health England, Microbiology, Level 8, Queens Building, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK.,University of Bristol, School of Social and Community Medicine, Canynge Hall, Bristol BS8 2PS, UK
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18
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Talan DA, Crisp JG, Moran GJ. Reply to Bruun et al. Clin Infect Dis 2016; 62:955-6. [DOI: 10.1093/cid/ciw005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Bruun T, Oppegaard O, Kittang BR, Mylvaganam H, Langeland N, Skrede S. Etiology of Cellulitis and the Validity of New and Old Methods. Clin Infect Dis 2016; 62:954-5. [DOI: 10.1093/cid/ciw003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Bruun T, Oppegaard O, Kittang BR, Mylvaganam H, Langeland N, Skrede S. Etiology of Cellulitis and Clinical Prediction of Streptococcal Disease: A Prospective Study. Open Forum Infect Dis 2015; 3:ofv181. [PMID: 26734653 PMCID: PMC4699398 DOI: 10.1093/ofid/ofv181] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 11/15/2015] [Indexed: 11/14/2022] Open
Abstract
Background. The importance of bacteria other than group A streptococci (GAS) in different clinical presentations of cellulitis is unclear, commonly leading to treatment with broad-spectrum antibiotics. The aim of this study was to describe the etiological and clinical spectrum of cellulitis and identify clinical features predicting streptococcal etiology. Methods. We prospectively enrolled 216 patients hospitalized with cellulitis. Clinical details were registered. Bacterial culture was performed from blood, cutaneous or subcutaneous tissue, and/or swabs from skin lesions. Paired serum samples were analyzed for anti-streptolysin O and anti-deoxyribonuclease B antibodies. Results. Serology or blood or tissue culture confirmed β-hemolytic streptococcal (BHS) etiology in 72% (146 of 203) of cases. An additional 13% (27 of 203) of cases had probable BHS infection, indicated by penicillin response or BHS cultured from skin swabs. β-hemolytic streptococcal etiology was predominant in all clinical subgroups, including patients without sharply demarcated erythema. β-hemolytic group C or G streptococci (GCS/GGS) were more commonly isolated than GAS (36 vs 22 cases). This predominance was found in the lower extremity infections. Group C or G streptococci in swabs were associated with seropositivity just as often as GAS. Staphylococcus aureus was cultured from swabs as a single pathogen in 24 cases, 14 (64%) of which had confirmed BHS etiology. Individual BHS-associated clinical characteristics increased the likelihood of confirmed BHS disease only slightly; positive likelihood ratios did not exceed 2.1. Conclusions. β-hemolytic streptococci were the dominating cause of cellulitis in all clinical subgroups and among cases with S aureus in cutaneous swabs. Group C or G streptococci were more frequently detected than GAS. No single clinical feature substantially increased the probability of confirmed BHS etiology.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Oddvar Oppegaard
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Bård R Kittang
- Department of Clinical Science, University of Bergen; Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | | | - Nina Langeland
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen; Departments of Medicine
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21
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Bläckberg A, Trell K, Rasmussen M. Erysipelas, a large retrospective study of aetiology and clinical presentation. BMC Infect Dis 2015; 15:402. [PMID: 26424182 PMCID: PMC4590694 DOI: 10.1186/s12879-015-1134-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 09/21/2015] [Indexed: 11/20/2022] Open
Abstract
Background Erysipelas is a common and severe infection where the aetiology and optimal management is not well-studied. Here, we investigate the clinical features, bacteriological aetiology, and treatment of erysipelas. Methods Episodes of erysipelas in a seven-years period in our institution were studied retrospectively using a pre-specified protocol and is presented with descriptive and comparative statistics. Results 1142 episodes of erysipelas were identified in 981 patients. Patients had a median age of 61 years, 59 % were male, a majority had underlying diseases or predisposing conditions, and the leg was most often affected. Wound cultures were taken in 343 episodes and 56 grew group A streptococci (GAS), 53 grew group G streptococci (GGS), 11 grew group C streptococci (GCS), and 153 grew Staphylococcus aureus. Blood cultures were drawn in 49 % of episodes and 50 cultures were positive with GGS as the most common finding (21 cultures) followed by GAS in 13, group B streptococci in 5, S. aureus in 4, and GCS in 3 cultures. In 45 % of episodes, patients received antibiotics with activity against S. aureus. Conclusions GGS is the most common streptococcus isolated in erysipelas and the role of S. aureus in erysipelas remains elusive.
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Affiliation(s)
- Anna Bläckberg
- Division of Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Kristina Trell
- Division of Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Magnus Rasmussen
- Division of Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
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22
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Lee CY, Tsai HC, Kunin CM, Lee SSJ, Chen YS. Clinical and microbiological characteristics of purulent and non-purulent cellulitis in hospitalized Taiwanese adults in the era of community-associated methicillin-resistant Staphylococcus aureus. BMC Infect Dis 2015; 15:311. [PMID: 26242240 PMCID: PMC4526200 DOI: 10.1186/s12879-015-1064-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/28/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The risk factors, microbial etiology, differentiation, and clinical features of purulent and non-purulent cellulitis are not well defined in Taiwan. METHODS We conducted a retrospective cohort study of hospitalized adults with cellulitis in Taiwan in 2013. The demographic characteristics, underlying diseases, clinical manifestations, laboratory and microbiological findings, treatments, and outcomes were compared for patients with purulent and non-purulent cellulitis. RESULTS Of the 465 patients, 369 had non-purulent cellulitis and 96 had purulent cellulitis. The non-purulent group was significantly older (p = 0.001) and was more likely to have lower limb involvement (p < 0.001), tinea pedis (p = 0.003), stasis dermatitis (p = 0.025), a higher Charlson comorbidity score (p = 0.03), and recurrence at 6 months post-infection (p = 0.001) than the purulent group. The purulent group was more likely to have a wound (p < 0.001) and a longer hospital stay (p = 0.001) and duration of antimicrobial therapy (p = 0.003) than the non-purulent group. The etiological agent was identified in 35.5 % of the non-purulent cases, with β-hemolytic streptococci the most frequent cause (70.2 %). The etiological agent was identified in 83.3 % of the purulent cases, with Staphylococcus aureus the predominant pathogen (60 %): 50 % of these were methicillin-resistant S. aureus (MRSA). In multivariable analysis, purulent group (odds ratio (OR), 5.188; 95 % confidence interval (CI), 1.995-13.493; p = 0.001) was a positive predictor of MRSA. The prescribed antimicrobial agents were significantly different between the purulent and non-purulent groups, with penicillin the most frequently used antimicrobial agent in the non-purulent group (35.2 %), and oxacillin the most frequent in the purulent group (39.6 %). The appropriate antimicrobial agent was more frequently prescribed in the non-purulent group than in the purulent group (83.2 % vs. 53.8 %, p < 0.001). CONCLUSIONS The epidemiology, clinical features, and microbiology of purulent and non-purulent cellulitis were significantly different in hospitalized Taiwanese adults. Purulence was a positive predictor of MRSA as the causal agent of cellulitis. These findings provide added support for the adoption of the IDSA guidelines for empirical antimicrobial therapy of cellulitis in Taiwan.
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Affiliation(s)
- Chun-Yuan Lee
- Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Hung-Chin Tsai
- Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Calvin M Kunin
- Department of Internal Medicine (CMK), Ohio State University, Columbus, Ohio and the University of Arizona, Tucson, Arizona, USA. .,University of Arizona, Tucson, AZ, USA.
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan.
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