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Newton H. Diagnosing, assessing and managing cellulitis. Nurs Stand 2024; 39:39-44. [PMID: 38044818 DOI: 10.7748/ns.2023.e12187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 12/05/2023]
Abstract
Cellulitis is an acute bacterial infection that affects the deep dermis and surrounding subcutaneous tissue. Although it is a common condition, it is often misdiagnosed because it can mimic a range of conditions that also cause inflamed, red, irritated and painful skin. Such misdiagnoses may lead to unnecessary hospital admissions and antibiotic overuse, with most alternative diagnoses being non-infectious. Undertaking a holistic patient assessment, skin assessment and thorough clinical history is important in the diagnosis of cellulitis, and it is vital to use a collaborative multidisciplinary approach in its acute management and to prevent recurrence. This article defines the term cellulitis and explores its presenting features. The author also discusses the associated risk factors, clinical assessment techniques and effective management strategies, as well as outlining the actions that nurses can take to prevent recurrence.
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Burian EA, Franks PJ, Borman P, Quéré I, Karlsmark T, Keeley V, Sugama J, Cestari M, Moffatt CJ. Factors associated with cellulitis in lymphoedema of the arm - an international cross-sectional study (LIMPRINT). BMC Infect Dis 2024; 24:102. [PMID: 38238718 PMCID: PMC10797905 DOI: 10.1186/s12879-023-08839-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/22/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Lymphoedema is a globally neglected health care problem and a common complication following breast cancer treatment. Lymphoedema is a well-known predisposing factor for cellulitis, but few have investigated the risk factors for cellulitis in this patient cohort on an international level. The aim of this study was to identify the frequency of cellulitis in patients with lymphoedema of the arm, including potential risk factors for cellulitis. METHODS An international, multi-centre, cross-sectional study including patients with clinically assessed arm lymphoedema. The primary outcome was the incidence of cellulitis located to the arm with lymphoedema within the last 12 months, and its potential associated risk factors. The secondary outcome was life-time prevalence of cellulitis. Adults with clinically-assessed arm lymphoedema/chronic oedema (all causes) and able to give informed consent were included. End-of-life-patients or those judged as not in the patient's best interest were excluded. Both univariable and multivariable analysis were performed. RESULTS A total of 2160 patients were included from Australia, Denmark, France, Ireland, Italy, Japan, Turkey and United Kingdom. Secondary lymphoedema was present in 98% of the patients; 95% of these were judged as related to cancer or its treatment. The lifetime prevalence of cellulitis was 22% and 1-year incidence 11%. Following multivariable analysis, factors associated with recent cellulitis were longer swelling duration and having poorly controlled lymphoedema. Compared to having lymphoedema less than 1 year, the risk increased with duration: 1-2 years (OR 2.15), 2-5 years (OR 2.86), 5-10 years (OR 3.15). Patients with well-controlled lymphoedema had a 46% lower risk of cellulitis (OR 0.54, 95% CI 0.39-0.73, p < 0.001). More advanced stages of lymphoedema were associated with cellulitis even after adjustment for swelling duration and control of swelling by logistic regression (stage II OR 5.44, stage III OR 9.13, p = 0.002), demonstrated in a subgroup analysis. CONCLUSION Patients with advanced arm lymphoedema are at particular risk of developing cellulitis. Prevention of lymphoedema progression is crucial. The results lend towards a positive effect of having well-treated lymphoedema on the frequency of cellulitis.
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Affiliation(s)
- Ewa Anna Burian
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark.
| | - Peter J Franks
- Centre for Research and Implementation of Clinical Practice, London, UK
| | - Pinar Borman
- Medical Faculty, Department of Physical Medicine and Rehabilitation, Ankara Medipol University, Ankara, Turkey
| | - Isabelle Quéré
- CHU Montpellier, University of Montpellier, IDESP, Montpellier, France
| | - Tonny Karlsmark
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Trust, Derby and University of Nottingham Medical School, Nottingham, UK
| | - Junko Sugama
- Research Centre for Implementation Nursing Science Initiative, Research Promotion Headquarters, Fujita Health University, Aichi, Japan
| | | | - Christine J Moffatt
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Grunwald J, Korownyk CS, Thomas B. Compression stockings for recurrent cellulitis. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:194. [PMID: 35292457 PMCID: PMC9833186 DOI: 10.46747/cfp.6803194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Jamie Grunwald
- Medical student at the University of Alberta in Edmonton
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Ioannou P, Karakonstantis S, Schouten J, Kostyanev T, Charani E, Vlahovic-Palcevski V, Kofteridis DP. Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review. Clin Microbiol Infect 2021; 28:362-370. [PMID: 34653572 DOI: 10.1016/j.cmi.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed. AIMS To identify targets for AMS interventions for medical AP in adult patients. SOURCES Targeted searches were conducted in PubMed. CONTENT The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis. IMPLICATIONS This review summarizes current trends in AP and proposes targets for AMS interventions.
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Affiliation(s)
- Petros Ioannou
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Stamatis Karakonstantis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Vera Vlahovic-Palcevski
- Department of Clinical Pharmacology, University Hospital Rijeka / Medical Faculty and Faculty of Health Studies, University of Rijeka, Rijeka, Croatia
| | - Diamantis P Kofteridis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece.
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Dai M, Nakagami G, Sato A, Koyanagi H, Kohta M, Moffatt CJ, Murray S, Franks PJ, Sanada H, Sugama J. Association Between Access to Specialists and History of Cellulitis Among Patients with Lymphedema: Secondary Analysis Using the National LIMPRINT Database. Lymphat Res Biol 2021; 19:442-446. [PMID: 34582714 DOI: 10.1089/lrb.2021.0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Cellulitis is frequently encountered in patients with lymphedema despite existing prevention protocols. To resolve this issue, social aspects surrounding patients, such as communication with patients and professionals, are necessary to consider new approaches. This study aimed to clarify the association between the history of cellulitis in patients with lymphedema and access to specialists after adjustment for relevant confounding factors. Methods and Results: This study was a secondary analysis of the Lymphoedema IMpact and PRevalence-INTernational (LIMPRINT) study using a national Japanese database of adult lymphedema compiled between 2014 and 2015 (n = 113). Descriptive data were collected for patient characteristics. Multivariate logistic regression analysis was conducted to explore possible risk factors for patients having experienced cellulitis. The duration of edema ranged from <6 months (16.2%) to 10 years or longer (25.2%), with varying severity. History of cellulitis was observed in 31.9% of patients. The prevalent treatment techniques within the context of complex decongestive therapy included skin care advice (52.2%), compression garments (55.8%), exercise advice (41.6%), multilayer bandages (38.1%), cellulitis advice (49.6%), and massage (61.1%). Overall, 57.1% of patients had access to lymphedema specialists. Longer duration of lymphedema (adjusted odds ratio [AOR] = 4.10, p = 0.005) and access to lymphedema specialists (AOR = 0.28, p = 0.009) were significantly associated with a history of cellulitis. Conclusions: A history of cellulitis in patients with lymphedema is associated with limited access to specialists. To support self-care in this patient population, reasonable consideration systems, including telehealth, should be developed to facilitate communication between specialists and patients and decrease the occurrence of cellulitis in lymphedema.
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Affiliation(s)
- Misako Dai
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, Aichi, Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Care Innovation, Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Aya Sato
- Kawasaki City College of Nursing, Kanagawa, Japan
| | - Hiroe Koyanagi
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, Aichi, Japan
| | - Masushi Kohta
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, Aichi, Japan
| | - Christine J Moffatt
- Nottingham University Hospital Care Excellence Institute, Nottingham, United Kingdom
| | - Susie Murray
- Centre for Research and Implementation of Clinical Practice, Nottingham, United Kingdom
| | - Peter J Franks
- Centre for Research and Implementation of Clinical Practice, Nottingham, United Kingdom
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Care Innovation, Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Sugama
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, Aichi, Japan
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O'Brien G, White P. The Red Legs RATED tool to improve diagnosis of lower limb cellulitis in the emergency department. ACTA ACUST UNITED AC 2021; 30:S22-S29. [PMID: 34170719 DOI: 10.12968/bjon.2021.30.12.s22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lower limb cellulitis poses a significant burden for the Irish healthcare system. Accurate diagnosis is difficult, with a lack of validated evidence-based tools and treatment guidelines, and difficulties distinguishing cellulitis from its imitators. It has been suggested that around 30% of suspected lower limb cellulitis is misdiagnosed. An audit of 132 patients between May 2017 and May 2018 identified a pattern of misdiagnosis in approximately 34% of this cohort. OBJECTIVE The aim of this pilot project was to develop a streamlined service for those presenting to the emergency department with red legs/suspected cellulitis, through introduction of the 'Red Leg RATED' tool for clinicians. METHOD The tool was developed and introduced to emergency department clinicians. Individuals (n=24) presenting with suspected cellulitis over 4 weeks in 2018 were invited to participate in data gathering. Finally, clinician questionnaire feedback regarding the tool was evaluated. RESULTS Fourteen participants consented, 6 female and 8 male with mean age of 65 years. The tool identified 50% (n=7) as having cellulitis, of those 57% (n=4) required admission, 43% (n=3) were discharged. The remainder who did not have cellulitis (n=7) were discharged. Before introduction of the tool, all would typically have been admitted to hospital for further assessment and management of suspected lower limb cellulitis. Overall, 72% (n=10) of patients who initially presented with suspected cellulitis were discharged, suggesting positive impact of the tool. Clinician feedback suggested all were satisfied with the tool and contents. CONCLUSION The Red Leg RATED tool is user friendly and impacts positively on diagnosis treatment and discharge. Further evaluation is warranted.
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Affiliation(s)
- Gillian O'Brien
- Registered Advanced Nurse Practitioner Tissue Viability, Naas General Hospital, Naas, County Kildare
| | - Patricia White
- Research Fellow, Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin
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Confidence of recurrent cellulitis self-diagnosis among people with lymphoedema: a qualitative interview study. Br J Gen Pract 2020; 70:e130-e137. [PMID: 31848202 DOI: 10.3399/bjgp19x707909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cellulitis can sometimes be challenging for healthcare professionals to diagnose, with no validated diagnostic criteria available. Supporting healthcare professionals to make a more accurate diagnosis of cellulitis in different groups, such as those with lymphoedema, is a cellulitis research priority. However, to the authors knowledge, no previous studies have looked at the involvement of non-healthcare professionals in the diagnostic process. AIM To explore the experience of people with lymphoedema and recurrent cellulitis in the diagnosis of lower-limb cellulitis. DESIGN AND SETTING Single, semi-structured, qualitative interviews carried out between 29 October and 19 December 2018. METHOD Adults with a suspected episode of cellulitis who had been diagnosed in the last 12 months or had a history of recurrent cellulitis were interviewed. RESULTS Three key themes emerged: the recurrent nature of cellulitis symptoms, participants' experience of getting a cellulitis diagnosis, and participants' suggestions of how cellulitis diagnosis might be improved. Generally, people with lymphoedema experienced similar clinical features during each of their own recurrent cellulitis episodes and were confident that they could make a self-diagnosis of cellulitis. This is also reflected in the participants' perceived trust from the healthcare professional in being able to make a self-diagnosis. A diagnostic checklist and educational resources were suggested as methods to improve diagnosis. CONCLUSION Selected people with lymphoedema who have recurrent cellulitis are confident in self-diagnosing their own recurrent cellulitis episodes. There may be a role for greater involvement of people with lymphoedema in their cellulitis diagnosis.
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Ingen-Housz-Oro S. Quoi de neuf en dermatologie clinique? Ann Dermatol Venereol 2019; 146:12S1-12S10. [DOI: 10.1016/s0151-9638(20)30100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Levell N. Cellulitis: how can we know what patients don't know? Br J Dermatol 2019; 180:705-706. [DOI: 10.1111/bjd.17613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- N.J. Levell
- Dermatology Department Norfolk and Norwich University Hospital Norwich NR4 7UY U.K
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Patients' understanding of cellulitis and their information needs: a mixed-methods study in primary and secondary care. Br J Gen Pract 2019; 69:e279-e286. [PMID: 30858335 PMCID: PMC6428464 DOI: 10.3399/bjgp19x701873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/14/2018] [Indexed: 12/01/2022] Open
Abstract
Background Cellulitis is a painful infection of the skin and underlying tissues, commonly affecting the lower leg. Approximately one-third of people experience recurrence. Patients’ ability to recover from cellulitis or prevent recurrence is likely to be influenced by their understanding of the condition. Aim To explore patients’ perceptions of cellulitis, and their information needs. Design and setting Mixed-methods study comprising semi-structured, face-to-face interviews and a cross-sectional survey, recruiting through primary and secondary care, and advertising. Method Adults aged ≥18 years with a history of cellulitis were invited to take part in a survey, qualitative interview, or both. Results In all, 30 interviews were conducted between August 2016 and July 2017. Qualitative data highlighted a low awareness of cellulitis before the first episode, uncertainty about when it had been diagnosed, concern/surprise at the severity of cellulitis, and a perceived insufficient information provision. People were surprised that they had never heard of cellulitis and that they had not received advice or leaflets giving self-care information. Some sought information from the internet and found this confusing. A total of 240 surveys were completed (response rate 17%). These showed that, although many participants had received information on the treatment of cellulitis (60.0%, n = 144), they often reported receiving no information about causes (60.8%, n = 146) or prevention of recurrence (73.3%, n = 176). Conclusion There is a need to provide information for people with cellulitis, particularly in regard to naming their condition, the management of acute episodes, and how to reduce the risk of recurrences.
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