Factors predisposing to acute and recurrent bacterial non-necrotizing cellulitis in hospitalized patients: a prospective case–control study

Prevention and treatment of recurrent cellulitis

PURPOSE OF REVIEW

Recurrent cellulitis is a challenging clinical condition affecting up to 47% of patients after the first episode, especially those with predisposing risk factors. The purpose of this review is to describe the state of the art of literature evidence and to highlight recent developments in its management.

RECENT FINDINGS

Recurrent cellulitis can occur after successful treatment of cellulitis. Conditions that commonly increase the risk of cellulitis include local and systemic modifiable and nonmodifiable factors. A rigorous approach to the management of risk factors and treatment of acute infection is important as the risk of recurrence rises with repeated episodes. Risk factors, if present, need to be targeted in association with antibiotic prophylaxis. Penicillin V is the preferred antibiotic for prevention but other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure.

SUMMARY

Recurrent cellulitis is associated with short term and long-term morbidity as well as significant healthcare costs. Management of underlying predisposing conditions is crucial to prevent recurrence in addition with evaluation of pharmacological measures, but specialized and multidisciplinary skills are needed. More efforts are needed to prevent and treat this underestimated problem.

Individuals with obesity who survive SARS-CoV-2 infection have preserved antigen-specific T cell frequencies

OBJECTIVE

Obesity is a major risk factor for severe disease in COVID-19, with increased hospitalization, intensive care unit admission, and mortality. This increased impact of COVID-19 in people with obesity (PWO) is likely driven, in part, by the well-described obesity-induced immune dysregulation. Obesity has also been associated with impaired immune memory in many settings, including weakened responses to hepatitis B, tetanus, rabies, and influenza vaccination. Recently, it was reported that PWO who have COVID-19 have reduced IgG antibody titers with defective neutralizing capabilities. However, it remains unknown whether PWO generate durable T cell immunity to SARS-CoV-2.

METHODS

This study investigated SARS-CoV-2-specific T cell responses in a cohort of 40 patients (n = 20 PWO and n = 20 matched control individuals) who had recovered from COVID-19. T cell (CD4⁺ , CD8⁺ ) cytokine responses (IFNγ, TNFα) to SARS-CoV-2 peptide pools (spike, membrane) were determined using multicolor flow cytometry.

RESULTS

Circulating T cells specific for SARS-CoV-2 were readily detected in the total cohort. PWO displayed comparable levels of SARS-CoV-2 spike- and membrane-specific T cells, with both T cell subsets responding.

CONCLUSIONS

These data indicate that PWO who survive COVID-19 generate robust and durable SARS-CoV-2-specific T cell immunity that is equivalent to that seen in those without obesity.

Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema

Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.

Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?

Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.

Factors Influencing Lower Limb Lymphedema After Cervical Cancer Surgery: A Case-Control Study

Background: To analyze the factors influencing lower limb lymphedema (LLL) after cervical cancer surgery and provide a scientific reference for its effective prevention and control. Methods and Results: Patients at a tertiary tumor hospital between January 2010 and January 2020 who received surgical treatment for cervical cancer were included in this study. Patients were divided into lymphedema case group (n = 253) and control group (n = 506) according to lymphedema occurrence, and univariate and multivariate analyses were used to analyze the factors influencing the occurrence of LLL after cervical cancer surgery. Multifactor conditional logistic regression analysis revealed that risk factors for lymphedema occurrence included body mass index, level of education, the presence of preoperative radiotherapy and chemotherapy, radiotherapy within 3 months after postoperative chemoradiotherapy, emergence of coronary heart disease within 3 months, vaginal disease, occurrence of postoperative complications, cervical cancer diagnosis before the manifestation of menstrual abnormalities, and a history of previous surgery. Conclusion: Postoperative LLL after cervical cancer surgery is a chronic progressive disease, and no cure for LLL has been identified. Thus, determining the risk factors associated with LLL occurrence after uterine and cervical cancer surgery and the development of targeted prevention and early intervention strategies is urgently needed.

Cellulitis: A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis

Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.

The causal relationship between obesity and skin and soft tissue infections: A two-sample Mendelian randomization study

OBJECTIVE

Many observational studies have shown that obesity strongly affects skin and soft tissue infections (SSTIs). However, whether a causal genetic relationship exists between obesity and SSTIs is unclear.

METHODS

A two-sample Mendelian randomization (MR) study was used to explore whether obesity is causally associated with SSTIs using a publicly released genome-wide association study (GWAS). An inverse-variance weighted (IVW) analysis was used as the primary analysis, and the results are reported as the odds ratios (ORs). Heterogeneity was tested using Cochran's Q test and the I² statistic, and horizontal pleiotropy was tested using the MR-Egger intercept and MR pleiotropy residual sum and outlier (MR-PRESSO).

RESULTS

The results of the MR analysis showed a positive effect of BMI on SSTIs (OR 1.544, 95% CI 1.399-1.704, P= 5.86 × 10^-18). After adjusting for the effect of type 2 diabetes (T2D) and peripheral vascular disease (PVD), the positive effect still existed. Then, we further assessed the effect of BMI on different types of SSTIs. The results showed that BMI caused an increased risk of impetigo, cutaneous abscess, furuncle and carbuncle, cellulitis, pilonidal cyst, and other local infections of skin and subcutaneous tissues, except for acute lymphadenitis. However, the associations disappeared after adjusting for the effect of T2D and PVD, and the associations between BMI and impetigo or cellulitis disappeared. Finally, we assessed the effects of several obesity-related characteristics on SSTIs. Waist circumference, hip circumference, body fat percentage, and whole-body fat mass, excluding waist-to-hip ratio, had a causal effect on an increased risk of SSTIs. However, the associations disappeared after adjusting for the effect of BMI.

CONCLUSION

This study found that obesity had a positive causal effect on SSTIs. Reasonable weight control is a possible way to reduce the occurrence of SSTIs, especially in patients undergoing surgery.

Factors associated with acute and recurrent erysipelas in a young population: a retrospective of 147 cases

BACKGROUND

erysipelas is a common infection of the superficial layer of the skin, predominantly caused by groups A β-hemolytic streptococci. It is an acute infection of the skin and frequently affects the legs. It is common in the elderly and favoured by the associated comorbidities. Its occurrence in young healthy people is rare.

AIM

The present study aimed to elucidate factors associated with acute and recurrent erysipelas in a young population.

METHODS

We retrospectively analyzed 147 cases of erysipelas admitted to the dermatology department of the Military Hospital of Tunis, Tunisia, over 18 years, identifying factors associated with recurrence. All patients were aged less than 35 years.

RESULTS

During the study period, 147 patients were registered with the diagnosis of erysipelas. There were 125 military soldiers and 22 non-military patients. The prevalence of erysipelas was 2.23%. The median age was 25 years. Almost 86.2% of patients were male. The main favorable factors were: obesity (9%), alcoholism (8%), chronic venous insufficiency (6.5%), chronic lymphedema (3%), leg fracture (2%), and diabetes mellitus (1%). The lesions were mostly located in the lower limbs in 94.9%. According to our multivariate analysis, there was an association between recurrence and diabetes mellitus (p=0.02), female sex (p=0.004), onychomycosis (p=0.004), and plantar dyshidrotic eczema (p<0.005).

CONCLUSION

Identifying factors associated with recurrent erysipelas in a young population remains essential for proposing primary and secondary prevention measures.

Diet-induced obesity promotes infection by impairment of the innate antimicrobial defense function of dermal adipocyte progenitors

Infections are a major complication of obesity, but the mechanisms responsible for impaired defense against microbes are not well understood. Here, we found that adipocyte progenitors were lost from the dermis during diet-induced obesity (DIO) in humans and mice. The loss of adipogenic fibroblasts from mice resulted in less antimicrobial peptide production and greatly increased susceptibility to Staphylococcus aureus infection. The decrease in adipocyte progenitors in DIO mice was explained by expression of transforming growth factor-β (TGFβ) by mature adipocytes that then inhibited adipocyte progenitors and the production of cathelicidin in vitro. Administration of a TGFβ receptor inhibitor or a peroxisome proliferator-activated receptor-γ agonist reversed this inhibition in both cultured adipocyte progenitors and in mice and subsequently restored the capacity of obese mice to defend against S. aureus skin infection. Together, these results explain how obesity promotes dysfunction of the antimicrobial function of reactive dermal adipogenesis and identifies potential therapeutic targets to manage skin infection associated with obesity.

Risk factors of recurrent erysipelas in adult Chinese patients: a prospective cohort study

BACKGROUND

Erysipelas is a common skin infection that is prone to recur. Recurrent erysipelas has a severe effect on the quality of life of patients. The present study aimed to investigate the risk factors of recurrent erysipelas in adult Chinese patients.

METHODS

A total of 428 Chinese patients with erysipelas who met the inclusion criteria were studied. The patients were divided into the nonrecurrent erysipelas group and the recurrent erysipelas group. Clinical data were collected on the first episode and relapse of erysipelas. The patients were followed up every 3 months. Statistical analysis was performed to analyze and determine the risk factors of erysipelas relapse.

RESULTS

Univariate analysis was performed to analyze the data, including surgery, types of antibiotics administered in the first episode, obesity, diabetes mellitus, venous insufficiency, lymphedema, and malignancy. The differences between the groups were statistically significant (p < 0.05). The Cox proportional hazards regression model analysis showed that the final risk factors included surgery, obesity, diabetes mellitus, venous insufficiency, and lymphedema.

CONCLUSIONS

Surgery, obesity, diabetes mellitus, venous insufficiency, and lymphedema are considered as risk factors for recurrent erysipelas.

[Bacterial acute non necrosing cellulitis (erysipelas) in adult]

Erysipelas is defined by a sudden onset (with fever) preceding the appearance of a painful, infiltrated, erythematous plaque, accompanied by regional lymphadenopathy. It is usually localized on the lower limbs, but it can occur on the face. It is due to β-hemolytic streptococcus A and more rarely to staphylococcus aureus. It is important to establish the diagnosis and eliminate the non-bacterial causes of inflammatory edema. The other diagnoses frequently found are contact eczema, acute arthritis, bursitis, inflammatory flare-up of chronic dermohypodermitis of venous origin, flare-up of chronic multifactorial eczema (venous insufficiency, vitamin deficiencies, senile xerosis and/or contact eczema), rare familial periodic fevers, rare neutrophilic dermatoses or eosinophilic cellulitis. It is necessary to identify signs of severity that would justify hospitalization. In front of a typical acute bacterial dermohypodermitis and in the absence of comorbidity, no additional investigation is necessary. Systematic blood cultures have low profitability. Locoregional causes must be identified in order to limit the risk of recurrence which remains the most frequent complication. In uncomplicated erysipelas, amoxicillin is the gold standard; treatment with oral antibiotic therapy is possible if there is no sign of severity or co-morbidity (diabetes, arteritis, cirrhosis, immune deficiency) or an unfavorable social context. In case of allergy to penicillin, pristinamycin or clindamycin should be prescribed. Prophylactic antibiotic therapy with delayed penicillin is recommended in the event of recurrent erysipelas.

Compression Therapy to Prevent Recurrent Cellulitis of the Leg

BACKGROUND

Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness.

METHODS

In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments.

RESULTS

A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial.

CONCLUSIONS

In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).

Obesity and risk of infections: results from men and women in the Swedish National March Cohort

BACKGROUND

Previous studies have shown an association between body mass index (BMI) and infections, but the literature on type-specific community acquired infections is still limited.

METHODS

We included 39 163 Swedish adults who completed a questionnaire in September 1997 and were followed through record-linkages until December 2016. Information on BMI was self-reported and infections were identified from the Swedish National Patient Register using International Classification of Diseases (ICD), Tenth Revision (ICD-10) codes. We fitted multivariable Cox proportional hazards models for time-to-first-event analysis, and we used extensions of the standard Cox model when repeated events were included.

RESULTS

During a 19-year follow-up 32% of the subjects had at least one infection requiring health care contact, leading to a total of 27 675 events. We found an increased incidence of any infection in obese women [hazard ratio (HR) = 1.22; 95% confidence interval (CI) = 1.12; 1.33] and obese men (HR = 1.25; 95% CI = 1.09; 1.43) compared with normal weight subjects. For specific infections, higher incidences were observed for skin infections in both genders (HR = 1.76; 95% CI = 1.47; 2.12 for obese females and HR = 1.74; 95% CI = 1.33; 2.28 for obese males) and gastrointestinal tract infections (HR = 1.44; 95% CI = 1.19; 1.75), urinary tract infections (HR = 1.30; 95% CI = 1.08; 1.55) and sepsis (HR = 2.09; 95% CI = 1.46; 2.99) in obese females. When accounting for repeated events, estimates similar to the aforementioned ones were found.

CONCLUSIONS

Obesity was associated with an increased risk of infections in both genders. Results from multiple-failure survival analysis were consistent with those from classic Cox models.

The risk factors of lower limb cellulitis: A case-control study in a tertiary centre

INTRODUCTION

Lower limb cellulitis is a common superficial skin infection that leads to morbidity and mortality. Cellulitis risk factors have been well studied in many countries, but to date, not in Malaysia. Geographical and climate variables may affect risk factors. Early identification of the preventable risk factors is vital to prevent cellulitis and improve holistic patient care.

OBJECTIVE

To determine the risk factors of lower limb cellulitis amongst hospitalized patients at a tertiary center.

METHODS

A prospective case-control study of hospitalized patients with a clinical diagnosis of lower limb cellulitis was conducted at UKM Medical Centre, January-August 2015. Each patient was compared to two age and gender-matched control patients. All patients were interviewed and examined for risk factors of cellulitis.

RESULTS

A total of 96 cellulitis patients and 192 controls participated in this study. The cellulitis patients included 61 males and 35 females with a mean age of 62.07±15.43 years. The majority of patients were experiencing their first episode of cellulitis. Multivariate analysis showed a previous history of cellulitis (OR 25.53; 95% CI 4.73-137.79), sole anomalies (OR 16.32; 95% CI 6.65-40.06), ulceration (OR 14.86; 95% CI 1.00-219.39), venous insufficiency (OR 10.46 95% CI 1.98-55.22), interdigital intertrigo (OR 8.86; 95% CI 3.33-23.56), eczema (OR 5.74; 95% CI 0.96.-34.21), and limb edema (OR 3.95; 95% CI 1.82-8.59) were the significant risk factors for lower limb cellulitis.

CONCLUSION

Previous cellulitis and factors causing skin barrier disruption such as sole anomalies, ulceration, venous insufficiency, eczema, intertrigo, and limb edema were the risk factors for lower limb cellulitis. Physician awareness, early detection, and treatment of these factors at the primary care level may prevent hospital admission and morbidity associated with cellulitis.

Cellulitis in older people over 75 years - are there differences?

Aim

To examine differences in risk factors, clinical features and outcomes of cellulitis between those 75 + years and those <75 years admitted to a metropolitan hospital.

Methods

A prospective study of patients with limb cellulitis requiring intravenous antibiotics conducted at Bankstown-Lidcombe Hospital, Australia from June 2014 to April 2015.

Results

Thirty one patients were 75 + years and 69 less than 75 years. A greater proportion of older patients resided in nursing home (25.8% vs 2.9% respectively, p = 0.001) and mobilized with walking aid(s) (58.1% vs 11.6% respectively, p < 0.001). Significantly more older patients had documented hypertension (45.2% vs 23.2% respectively p = 0.035), atrial fibrillation (33.5% vs 5.8% respectively, p < 0.001), dementia (22.6% vs 1.4% respectively, p = 0.001) and malignancy (16.1% vs 1.4% respectively, p = 0.010). The clinical presentation of cellulitis and cellulitis severity (Eron classification) did not significantly differ in both groups; however older patients were more likely to have dependent edema (OR 4.0, 95%CI 1.3-12.6, p = 0.018) and less likely to be obese (OR 0.3, 95%CI 0.1-0.8, p = 0.012) or had a past history of cellulitis (OR 0.3, 95%CI 0.1-1.0, p = 0.044) on presentation. Despite the age difference, there were no major differences in intravenous antibiotic choice, hospital length of stay, and hospital readmission rates in both groups. Older patients however, were more likely to experience complications such as falls and/or decreased mobility (38.7% vs 15.9% respectively, p = 0.020) during the cellulitis episode.

Conclusion

There are minor differences in the risk factors and clinical features of cellulitis in older patients as compared to the young. Outcomes are similar except for a higher incidence of hospital related complications.

The bacteriostatic effect of controlled-flux electrolyzed acidic solution on healthy hallucal skin

BACKGROUND

There are various treatment protocols to manage the increased bacterial load in plantar ulcers. Recently, Controlled-Flux Electrolyzed Acidic Solution (CFEAS), with a pH less than 3, has appeared to be an effective option since its antimicrobial effect could help in the healing of those ulcers. In order to evaluate its potential in this sense, the aim of the present study was to compare bacterial growth on healthy hallucal skin using two types of bandaging (control and Controlled-Flux Electrolysed Acidic Solution).

MATERIAL AND METHODS

In a sample of 19 healthy subjects, two experiments were performed. In the first, for each subject, two identical hallux bandages were applied in the early morning. At random between left and right foot, either physiological saline (wetting every 2 h) was applied or nothing (control). In the second, two days later, new bandages were applied as before, but now either wetting with Controlled-Flux Electrolysed Acidic Solution (experimental, again wetting every 2 h) or nothing (control). In each experiment, the bacterial load in the nail fold was assessed at the first moment and after 10 h from standard counts of bacterial colony forming units (CFU).

RESULTS

In the first experiment, the CFU counts had increased significantly (p < 0.05) in both toes after the 10-h period. In the second experiment, while the bacterial load increased significantly (p = 0.001) from 0.68 ± 0.8 × 10⁴ CFU/cm² (the "pre" sample) to 1.3 ± 0.9 × 10⁴ CFU/cm² (the "post" sample) in the control toe, in the experimental CFEAS toe, the pre sample bacterial load was 0.61 ± 0.6 × 10⁴ CFU/cm², and the post sample 0.9 ± 0.8 × 10⁴ CFU/cm², with no significant difference between them (p = 0.221). Negative cultures were obtained in 3 cases (15.78%) of the experimental toe post sample, and equal post and pre counts in 2 cases (10.5%).

CONCLUSION

Controlled-Flux Electrolyzed Acidic Solution has an effect on healthy hallucal skin that is bacteriostatic, and in some cases bactericidal. This effect could be very helpful in treating plantar ulcers when there is a greatly increased bacterial load in the wound, thus potentially favoring the normal formation of granulation tissue in the skin and normal healing and closure of the ulcer.

Munchausen syndrome mimicking refractory subcutaneous abscess with bacteremia, diagnosed by repetitive element sequence-based polymerase chain reaction: a case report

Background

Rapid diagnosis and appropriate treatment of Munchausen syndrome is important not only for the patient but also for health care workers because a delay in diagnosis can worsen patients’ clinical outcomes, and result in a substantial medical cost.

Case presentation

A young and previously healthy 24-year-old Japanese woman, a nurse, presented with complaints of refractory abscess on her left upper limb for 3 months. A physical examination on admission revealed low-grade fever and a subcutaneous abscess in her left forearm. Laboratory data suggested mild systemic inflammation and liver dysfunction, but no abnormalities of the immune system, including changes in the number of lymphocytes and neutrophils, neutrophil phagocytic capacity, and natural killer (NK) cell activity, were observed. A human immunodeficiency virus test was also negative. Multiple modalities, including positron emission tomography-computed tomography, failed to detect any cause and focus of infection except her left upper limb. Streptococcus mitis and Prevotella buccae were detected from the wound, but no microorganisms were detected in a blood culture. The cellulitis promptly resolved; however, exacerbation of the subcutaneous abscess with polymicrobial bacteremia repeatedly occurred unexpectedly. Because of this puzzling clinical course, the possibility of self-injury was finally suspected. Three syringes with needles, with a turbid liquid, were found in our patient’s bag. Enterobacter cloacae and Enterococcus faecalis were detected in the liquid, and an analysis via repetitive element sequence-based polymerase chain reaction determined that Enterococcus faecalis in the wound and syringe contents were genetically identical. She was diagnosed as having Munchausen syndrome and treated with the collaboration of a psychiatrist. She finally confessed that she had injected her own saliva and toilet water into the drip line and wound.

Conclusions

This case report is valuable in that it is the first case in which this syndrome was diagnosed by a genetic method. Munchausen syndrome should not be neglected as a possible cause of refractory and recurrent infection.

Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol

INTRODUCTION

Cellulitis represents a significant burden to patients' quality of life (QOL) and cost to the healthcare system, especially due to its recurrent nature. Chronic oedema is a strong risk factor for both an initial episode of cellulitis and cellulitis recurrence. Expert consensus advises compression therapy to prevent cellulitis recurrence in individuals with chronic oedema, however, there is little supporting evidence. This research aims to determine if the management of chronic oedema using compression therapy effectively delays the recurrence of lower limb cellulitis.

METHODS AND ANALYSIS

A randomised controlled trial with cross-over will be used to assess the impact of compression therapy on clinical outcomes (time to next episode of cellulitis, rate of cellulitis-related hospital presentations, QOL and leg volume). Using concealed allocation, 162 participants will be randomised into the intervention (compression) or control (no compression) group. Randomisation will be stratified by prophylactic antibiotic use. Participants will be followed up at 6 monthly intervals for up to 3 years or until 45 episodes of cellulitis occur across the cohort. Following an episode of recurrent cellulitis, control group participants will cross-over to the intervention group. Survival analysis will be undertaken to assess the primary outcome measure of time to cellulitis recurrence. The hypotheses are that compression therapy to control lower limb chronic oedema will delay recurrent lower limb cellulitis, reduce the rate of associated hospitalisations, minimise affected limb volume and improve the QOL of this population.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the ethics committees of all relevant institutions. Results will be disseminated through relevant peer-reviewed journal articles and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617000412336; Pre-results. The ICTOC trial is currently in progress. Participant recruitment started in May 2017 and is expected to continue until December 2019.

Management of cellulitis and the role of the nurse: a 5-year retrospective multicentre study in Fako, Cameroon

Objective

This was a 5 year retrospective study of patients’ hospital records to find out how patients with cellulitis are managed and the care provided by nurses to these patients in some hospitals in Fako, Cameroon.

Results

Of the 236 cases of cellulitis identified from a study of hospital records, 202 were included in the study. Most of the participants (55%) were female and the mean (SD) age was 43 (1.1) years. Cellulitis accounted for 2.3% of admissions in this study. The predisposing factors identified were; the presence of trauma (60.5%), HIV infection (18.6%), alcohol consumption (8.4%) and tobacco use (4.8%). Commonly recorded complications were necrosis (32.2%), sepsis (23%), abscess formation (19.5%), and ulcer development (19.5%). Medical management was with antibiotic therapy, including mostly penicillin (26.5%), aminoglycoside (22.1%), nitroimidazole (20.2%) and cephalosporin (19.6%). Debridement (46.7%), and incision and drainage (44.4%) were the most implemented surgical interventions. Nursing care, as found in patients’ hospital records were predominantly on medication administration (98.0%), vital signs assessment (90.5%) and patient assessment (53%). Cellulitis therefore was found among a substantial number of patients and management was predominantly with combination antibiotics therapy and inadequate nursing care.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4497-4) contains supplementary material, which is available to authorized users.

When to switch to an oral treatment and/or to discharge a patient with skin and soft tissue infections

PURPOSE OF REVIEW

Skin and soft tissue infections prevalence is increasing and represent a frequent cause of hospital admission. New guidelines have become available in order to better define these infections and their response to antimicrobial treatment. Gram-positive bacteria, in particular Staphylococcus aureus, remain the most frequently isolated pathogens in skin and soft tissue infections. To treat complicated forms and infections caused by drug-resistant bacteria, hospital admission and administration of intravenous antibiotics are often required, impacting on healthcare costs and patients' morbidity.

RECENT FINDINGS

New therapeutic options offer efficacy against drug-resistant Gram-positive bacteria as well as potential to favor early patients' discharge, including the possibility for intravenous to oral switch and infrequent drug administration because of prolonged drug half-life. Although data from real-world studies on new antimicrobials is awaited, clinicians need clear direction on how to optimize the treatment of skin and soft tissue infections in order to avoid prolonged hospitalizations and extra costs. Early assessment of patient's clinical conditions and response to treatment appear useful in order to facilitate patients' discharge.

SUMMARY

We have reported the evidence for early intravenous to oral switch and early hospital discharge for patients with skin and soft tissue infections. New therapeutic options that represent promising tools in promoting an optimized management of these infections have also been reviewed.

Warmer Weather as a Risk Factor for Cellulitis: A Population-based Investigation

Background

The incidence of cellulitis is highly seasonal and this seasonality may be explained by changes in the weather, specifically, temperature.

Methods

Using data from the Nationwide Inpatient Sample (years 1998 to 2011), we identified the geographic location for 773719 admissions with the primary diagnosis (ICD-9-CM code) of cellulitis and abscess of finger and toe (681.XX) and other cellulitis and abscess (682.XX). Next, we used data from the National Climatic Data Center to estimate the monthly average temperature for each of these different locations. We modeled the odds of an admission having a primary diagnosis of cellulitis as a function of demographics, payer, location, patient severity, admission month, year, and the average temperature in the month of admission.

Results

We found that the odds of an admission with a primary diagnosis of cellulitis increase with higher temperatures in a dose-response fashion. For example, relative to a cold February with average temperatures under 40° F, an admission in a hot July with an average temperature exceeding 90°F has 66.63% higher odds of being diagnosed with cellulitis (95% confidence interval [CI]: [61.2, 72.3]). After controlling for temperature, the estimated amplitude of seasonality of cellulitis decreased by approximately 71%.

Conclusion

At a population level, admissions to the hospital for cellulitis risk are strongly associated with warmer weather.

Metabolic Obesity Phenotypes and Risk of Cellulitis: A Cohort Study

No cohort studies have evaluated the effect of obesity on the risk of cellulitis according to metabolic health status. We investigated an association of BMI and metabolic health status with the development of cellulitis. We conducted a cohort study of 171,322 Korean adults who underwent a health checkup examination and were followed from 2011 to 2016 for cellulitis and hospital admission related to cellulitis, which were ascertained through the linkage to the Health Insurance and Review Agency database. Being metabolically healthy was defined as not having any metabolic syndrome component and having a homeostasis model assessment of insulin resistance <2.5. During 638,240.4 person-years of follow-up, 14,672 cases of incident cellulitis were identified with 225 cases of cellulitis-related admission. After adjustment for possible confounders, the multivariable-adjusted hazard ratios (95% CI) for incident cellulitis comparing BMIs 23–24.9, 25–29.9, and ≥30 with a BMI of 18.5–22.9 kg/m² as the reference were 1.07 (1.02–1.11), 1.09 (1.04-1.13), and 1.19 (1.08–1.31), respectively, whereas the corresponding multivariable-adjusted hazard ratios (95% CI) for cellulitis-related admission were 1.55 (1.05–2.3), 2.47 (1.73–3.53), and 4.8 (2.86–8.05), respectively. These associations were consistently observed in both metabolically healthy and unhealthy individuals with no significant interaction. In a large cohort of apparently healthy adults, increased BMI was associated with an increased risk of cellulitis and hospitalization for cellulitis in both metabolically healthy and unhealthy individuals. Obesity appears to be an independent risk factor for cellulitis regardless of metabolic phenotype.

Frequent colonization of betahaemolytic streptococci at various body sites including the perineum and anal canal during erysipelas and cellulitis

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.

Epidemiology of Invasive Group B Streptococcal Infections Among Nonpregnant Adults in the United States, 2008-2016

Importance

Group B Streptococcus (GBS) is an important cause of invasive bacterial disease. Previous studies have shown a substantial and increasing burden of GBS infections among nonpregnant adults, particularly older adults and those with underlying medical conditions.

Objective

To update trends of invasive GBS disease among US adults using population-based surveillance data.

Design, Setting, and Participants

In this population-based surveillance study, a case was defined as isolation of GBS from a sterile site between January 1, 2008, and December 31, 2016. Demographic and clinical data were abstracted from medical records. Rates were calculated using US Census data. Antimicrobial susceptibility testing and serotyping were performed on a subset of isolates. Case patients were residents of 1 of 10 catchment areas of the Active Bacterial Core surveillance (ABCs) network, representing approximately 11.5% of the US adult population. Patients were included in the study if they were nonpregnant, were 18 years or older, were residents of an ABCs catchment site, and had a positive GBS culture from a normally sterile body site.

Main Outcomes and Measures

Trends in GBS cases overall and by demographic characteristics (sex, age, and race), underlying clinical conditions of patients, and isolate characteristics are described.

Results

The ABCs network detected 21 250 patients with invasive GBS among nonpregnant adults from 2008 through 2016. The GBS incidence in this population increased from 8.1 cases per 100 000 population in 2008 to 10.9 in 2016 (P = .002 for trend). There were 3146 cases reported in 2016 (59% male; median age, 64 years; age range, 18-103 years). The GBS incidence was higher among men than women and among blacks than whites and increased with age. Projected to the US population, an estimated 27 729 cases of invasive disease and 1541 deaths occurred in the United States in 2016. Ninety-five percent of cases in 2016 occurred in someone with at least 1 underlying condition, most commonly obesity (53.9%) and diabetes (53.4%). Resistance to clindamycin increased from 37.0% of isolates in 2011 to 43.2% in 2016 (P = .02). Serotypes Ia, Ib, II, III, and V accounted for 86.4% of isolates in 2016; serotype IV increased from 4.7% in 2008 to 11.3% in 2016 (P < .001 for trend).

Conclusions and Relevance

The public health burden of invasive GBS disease among nonpregnant adults is substantial and continues to increase. Chronic diseases, such as obesity and diabetes, may contribute.

Comorbidities as Risk Factors for Acute and Recurrent Erysipelas

BACKGROUND:

Erysipelas is a common infectious skin disease. A typical feature of erysipelas, especially on the lower limbs, is the tendency to reoccur and the study aimed to define the comorbidities associated with it.

AIM:

We aimed to investigate systemic and local comorbidities in patients diagnosed with erysipelas on the lower limbs.

MATERIAL AND METHODS:

We conducted a retrospectively-prospective, population-based cohort study which included all patients diagnosed with erysipelas on the lower limbs, during two years. Patients were divided into two groups: patients with first episode and patients with recurrent erysipelas. These two groups were compared, with particular emphasis on systemic and local comorbidities.

RESULTS:

The study included 313 patients, of which 187 with the first episode of erysipelas and 126 with a recurrent. Regarding the analyzed systemic risk factors, the recurrent erysipelas was significantly associated with obesity (p < 0.0001), insulin dependent diabetes mellitus (p = 0.0015), history of malignant disease (p = 0.02) and tonsillectomy (p = 0.000001). For a p-value < 0.0001, significantly more frequent finding of peripheral arterial occlusive disease, chronic oedema/lymphoedema, fungal infections of the affected leg and chronic ulcer was confirmed in recurrent erysipelas. Neuropathy had 23% of the recurrent cases and 8.6% in patients without recurrence, and the difference was found to be significant for p = 0.0003. The only dissection of the lymph nodes was found more frequently in recurrent erysipelas (p = 0.017), but no associations with other analysed local surgery on the affected leg. Patients with recurrent erysipelas had ipsilateral coexisting dermatitis p = 0.00003 significantly more frequent. Minor trauma often preceded the first episode of erysipelas p = 0.005.

CONCLUSION:

Identification and treatment of modifiable risk factors are expected to reduce the risk of a subsequent episode of erysipelas on the lower limbs.

Clinical Presentation and Laboratory Characteristics in Acute and Recurrent Erysipelas

AIM:

Typical feature of erysipelas, especially on the lower limbs, is the tendency to reoccur. The study aimed to identify clinical and laboratory characteristics of acute and recurrent erysipelas.

MATERIAL AND METHODS:

We prospectively included patients diagnosed with erysipelas on the lower limbs in the period from January 2016 to December 2017.

Patients were divided into two groups:

patients with the first episode and recurrent erysipelas. The groups were compared by their demographics, clinical and laboratory characteristics.

RESULTS:

The study included 187 patients with the first episode of erysipelas and 126 patients with recurrent erysipelas. Both groups were homogeneous in terms of demographic characteristics, gender and age. Mean age of patients with the first episode of erysipelas was 64.18 ± 12.5 years; patients with recurrent erysipelas were inconsiderably mean younger (62.98 ± 12.5 years). Patients in both groups had a significantly different anatomical localisation of skin infection (p = 0.008). Tibial localisation was more frequent in patients with the first episode of erysipelas 77% vs 62.7%, while recurrent erysipelas was more frequent on the foot 36.5% vs 23%. No significant difference was found, about the affected side of the limb (p = 0.95). Patients with recurrent erysipelas had a pronounced inflammatory response, seen through significantly higher values of C reactive protein (p = 0.02), granulocytes (p = 0.03), fibrinogen (p < 0.0001), and higher body temperature, (37.22 ± 0.97 p = 0.006). Length of hospital stay was increased in the recurrent group.

CONCLUSION:

Erysipelas is more frequent in older people; it has seasonal character and tendency to reoccur. Identifying clinical and laboratories characteristics of those at risk may prevent recurrence and long term comorbidities.

Factors associated with readmission and mortality in adult patients with skin and soft tissue infections

BACKGROUND

Skin and soft tissue infections (SSTIs) are a common cause of consultation, and complicated cases require hospitalization. We describe factors that are related to readmission and/or mortality of hospitalized patients diagnosed with SSTIs.

METHODS

Retrospective review of hospital-admitted patients with a diagnosis of cellulitis, abscess, hidradenitis, fasciitis, and Fournier's gangrene. Cases from January 2002 to October 2015 were extracted from the diagnostic codification database of the Archives and Clinical Documentation Department.

FINDINGS

We studied 1,482 episodes of hospitalized patients diagnosed with SSTIs. There were 187 (12.3%) readmissions, the most frequent diagnosis was cellulitis (72.7%), and the most commonly isolated microorganism was Staphylococcus aureus (25; 30.1%). Factors associated with readmissions were healthcare-related infections (P = 0.002), prior antibiotic therapy (P < 0.001), ischemic heart disease (P = 0.01), chronic liver disease (P = 0.001), and diabetes mellitus (DM) (P = 0.006). The number of patients who died as a result of an infection was 34 (2.2%) and, in these patients, the most common diagnosis was also cellulitis (79.4%), which in 52.9% (P = 0.001) was community acquired. DM (P = 0.01), heart failure (P = 0.001), and chronic liver disease (P = 0.003) were the most frequent comorbidities. This group presented more complications (P < 0.005) such as endocarditis (P < 0.005), amputation (P = 0.018), severe sepsis (P < 0.005), and septic shock (P < 0.001).

CONCLUSIONS

Readmitted patients had healthcare-related S. aureus infection, had received prior antibiotic therapy, and presented comorbid conditions such as ischemic heart disease, peripheral vascular disease, chronic liver disease, or DM. Comorbidities such as advanced age, DM, heart failure, and chronic liver disease were associated with complications and higher infection-related mortality.

Intracellular Streptococcal Uptake and Persistence: A Potential Cause of Erysipelas Recurrence

Erysipelas is a severe streptococcal infection of the skin primarily spreading through the lymphatic vessels. Penicillin is the treatment of choice. The most common complication consists in relapses which occur in up to 40% or more of patients despite appropriate antibiotic treatment. They cause lymphatic damage resulting in irreversible lymphedema and ultimately elephantiasis nostras and lead to major health restrictions and high socio-medical costs. Prevention of relapses is an unmet need, because even long-term prophylactic penicillin application does eventually not reduce the risk of recurrence. In this article we assess risk factors and causes of erysipelas recurrence. A systematic literature search for clinical studies addressing potential causes and measures for prevention of erysipelas recurrence was combined with a review of experimental and clinical data assessing the ability and clinical relevance of streptococci for intracellular uptake and persistence. The literature review found that venous insufficiency, lymphedema, and intertrigo from fungal infections are considered to be major risk factors for recurrence of erysipelas but cannot adequately explain the high recurrence rate. As hitherto unrecognized likely cause of erysipelas relapses we identify the ability of streptococci for intracellular uptake into and persistence within epithelial and endothelial cells and macrophages. This creates intracellular streptococcal reservoirs out of reach of penicillins which do not reach sufficient bactericidal intracellular concentrations. Incomplete streptococcal elimination due to intracellular streptococcal persistence has been observed in various deep tissue infections and is considered as cause of relapsing streptococcal pharyngitis despite proper antibiotic treatment. It may also serves as endogenous infectious source of erysipelas relapses. We conclude that the current antibiotic treatment strategies and elimination of conventional risk factors employed in erysipelas management are insufficient to prevent erysipelas recurrence. The reactivation of streptococcal infection from intracellular reservoirs represents a plausible explanation for the frequent occurrence erysipelas relapses. Prevention of erysipelas relapses therefore demands for novel antibiotic strategies capable of eradicating intracellular streptococcal persistence.

Cellulitis in adult patients: A large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment

Background

Cellulitis is a frequent cause of hospital admission of adult patients. Increasing prevalence of multiresistant microorganisms, comorbidities, predisposing factors and medical and surgical therapies might affect cellulitis response and recurrence rate.

Methods

Prospective and observational study of 606 adult patients with cellulitis admitted to several Spanish hospitals. Comorbidities, microbiological, clinical, diagnostic, treatment (surgical and antibiotic) data were analyzed according to the cellulitis response. Good response implied cure. Poor response implied failure to cure or initial cure but relapse within 30 days of hospital discharge.

Results

Mean age was 63.3 years and 51.8% were men. Poor responses were significantly associated with age, previous episodes of cellulitis, prior wounds and skin lesions, venous insufficiency, lymphedema, immunosuppression and lower limbs involvement. No differences in ESR or CRP blood levels, leukocyte counts, pus or blood cultures positivity or microbiological or imaging aspects were observed in those with good or poor responses. Regarding antimicrobials, no differences in previous exposition before hospital admission, treatment with single or more than one antibiotic, antibiotic switch, days on antimicrobials or surgical treatment were observed regarding good or poor cellulitis response. Prior episodes of cellulitis (P = 0.0001), venous insufficiency (P = 0.004), immunosuppression (P = 0.03), and development of sepsis (P = 0.05) were associated with poor treatment responses, and non-surgical trauma (P = 0.015) with good responses, in the multivariate analysis.

Conclusions

Prior episodes of cellulitis, non-surgical trauma, venous insufficiency, sepsis and immunosuppression were independently associated with treatment response to cellulitis, but not the causative microorganism, the number of antimicrobials administered or its duration.

Clinical Study of an Online Tool for Standardizing Hospital Care

We assessed if use of an online clinical decision support tool improved standardization and quality of care in hospitalized patients with lower extremity cellulitis (LEC). This was a 14-month preintervention and postintervention study of 85 LEC admissions. There was significantly higher usage of the online LEC care process model (CPM) in the postintervention phase (p < .001). There was a trend toward higher rates of appropriate antibiotic regimen in the postintervention group both initially and at discharge (p = .063 for both). A sensitivity analysis of CPM users versus nonusers demonstrated a significantly higher rate of appropriate initial antibiotics prescribed when the CPM was used (p < .001). Use of this online CPM was associated with improved standardization, as demonstrated by increased ordering of an appropriate initial antibiotic regimen for hospitalized patients with LEC.

Severe lower limb cellulitis: defining the epidemiology and risk factors for primary episodes in a population-based case-control study

OBJECTIVE

To describe the epidemiology and risk factors for primary episodes of severe lower leg cellulitis (LLC).

METHODS

This was a longitudinal cohort study using state-wide data linkage of adults presenting to Western Australian (WA) hospitals with a first ever LLC from January 2002 to December 2013. The study aimed at determining risk factors, medical records from the index patient, together with comparable data from controls matched by age, sex, postcode, and month of admission.

RESULTS

During the period, 36 276 patients presented with their first episode of LLC. The incidence increased by 4.7% per annum, reaching 204.8 (95% CI 198.6-211.1) per 100 000 population by December 2013. Analysis of 29 062 case-control pairs showed several conditions with lower limb pathology were independently associated with LLC, including varicose veins (AOR 2.95, 95% CI 2.50-3.48, p < 0.001), lymphoedema (AOR 2.65, 95% CI 1.71-4.10, p < 0.001), tinea pedis (AOR 3.05, 95% CI 1.45-6.42, p 0.003), and saphenous vein harvest during coronary artery bypass grafting (AOR 1.74, 95% CI 1.32-2.30, p < 0.001). Also associated with LLC was obesity (AOR 2.05, 95% CI 1.82-2.31, p < 0.001), renal disease (AOR 1.28, 95% CI 1.14-1.44, p < 0.001), rheumatologic conditions (AOR 2.12, 95% CI 1.72-2.60, p < 0.001), hemiplegia/paraplegia (AOR 1.31, 95% CI 1.13-1.52, p < 0.001), and liver disease (AOR 1.77, 95% CI 1.51-2.06, p < 0.001).

CONCLUSIONS

LLC presents a major burden to the health sector and is increasing with an ageing population. Given the high rates of recurrence, long-term morbidity, and economic impact, efforts to reduce primary episodes should be incorporated into the infectious diseases and healthy ageing research agenda.

Estimating the health care costs associated with recurrent cellulitis managed in the outpatient setting

BACKGROUND

Recurrent cellulitis is diagnosed in 22% to 49% of all cellulitis cases, but little is known about the costs associated with these cases.

OBJECTIVE

To characterize patients with recurrent cellulitis in the outpatient setting and estimate the associated costs.

METHODS

A retrospective chart review was conducted for adult patients who presented to the outpatient facilities at our institution from January 1, 2007, to December 31, 2011, with recurrent cellulitis. Data provided by the Centers for Medicare and Medicaid Services were used.

RESULTS

A total of 157 patients were identified; 56% were male, with a mean age of 62.7 years. The mean number of episodes of cellulitis per patient was 3. Antibiotics were prescribed for all patients with a diagnosis of recurrent cellulitis, with 93% treated with oral antibiotics and 17.6% treated with intravenous antibiotics. A total of 1081 laboratory and 175 radiologic imaging tests were ordered. The minimum average cost per cellulitis episode was $586.91; the average cost per visit was $292.50.

LIMITATIONS

Retrospective study; use of a single, large academic institution; and utilization of cost estimates that may not adequately reflect the variation of costs across closed-system sites or geographic regions. There was no accounting for the nonfinancial or opportunity costs associated with hospitalization, such as lost days of employment or child care and any long-term morbidities, among others.

CONCLUSIONS

Recurrent cellulitis in the outpatient setting costs about $586.91 per episode. Although there is no criterion standard for diagnosis or treatment of cellulitis, our analysis demonstrates the need for more evidence-based management to achieve better outcomes and reduce the significant health care costs.

Epidemiology and risk factors for recurrent severe lower limb cellulitis: a longitudinal cohort study

OBJECTIVE

To describe the epidemiology and risk factors for recurrence of severe lower leg cellulitis (LLC).

METHODS

A longitudinal cohort study using state-wide data of adults presenting with recurrent LLC following a primary episode occurring between January 2002 and December 2013. The incidence of recurrent LLC was estimated using the cumulative incidence function, accounting for mortality. Independent risk factors for recurrence were identified using Fine-Gray sub-distribution and Cox proportional hazards models.

RESULTS

Of 36 276 patients presenting with their first episode of LLC, 4598 had at least one recurrence during the follow-up period. The cumulative incidence of first, second, and third recurrences at 12 months since previous infection was 6.3% (95% CI 6.0-6.5), 17.2% (95% CI 16.1-18.4), and 29.4% (95% CI 26.8-31.9), respectively, and at 5 years was 13.9% (95% CI 13.5-14.3), 35.9% (95% CI 34.2-37.5), and 52.9% (95% CI 49.5-56.2), respectively. The length of hospitalization increased from 3 days for the primary episode to 4 and 5 days for first and all subsequent recurrences, respectively. Independent risk factors for recurrent LLC included age, ethnicity (Indigenous Australian), local factors relating to lower leg pathology, conditions that commonly result in peripheral oedema, and systemic conditions that may be associated with increased leg size.

CONCLUSIONS

LLC recurrences are frequent, and each episode increases the likelihood of subsequent recurrence and length of hospitalization. These data provide context and scope to develop workable and effective strategies to prevent secondary episodes for all cases of primary LLC.

Interventions for the prevention of recurrent erysipelas and cellulitis

BACKGROUND

Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear.

OBJECTIVES

To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16.

SEARCH METHODS

We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews.

SELECTION CRITERIA

Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality.

MAIN RESULTS

We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding.

AUTHORS' CONCLUSIONS

In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.

Diagnosis and management of skin and soft-tissue infections (SSTI). A literature review and consensus statement: an update

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges. Fourteen members of the Italian Society of Infectious Diseases, after a careful review of the most recent literature using Medline database and their own clinical experience, updated a previous paper published in 2011 by preparing a draught manuscript of the statements. The manuscript was successively reviewed by all members and ultimately re-formulated the present manuscript during a full day consensus meeting. The microbiological and clinical aspects together with diagnostic features were considered for necrotizing and not necrotizing SSTIs in the light of the most recent guidelines and evidences published in the last five years. The antimicrobial therapy was considered as well - both empirical and targeted to methicillin-resistant Staphylococcus aureus and/or other pathogens, also taking into account the epidemiological and bacterial resistance data and the availability of new antibacterial agents.

Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection

Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommendations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipelas and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets community-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline.

Early Response in Cellulitis: A Prospective Study of Dynamics and Predictors

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.

Body Mass Index and Risk of Infections Among Women in the Danish National Birth Cohort

We investigated the possible association between body mass index (BMI; weight (kg)/height (m)(2)) and hospitalization or treatment for acute infection in a prospective cohort study. We linked 75,001 women enrolled in the Danish National Birth Cohort from 1996 to 2002, who had information on BMI and a broad range of confounders, to data on infectious diseases and use of antimicrobial agents from the National Patient Register and the Danish Prescription Register. Associations were tested using Cox proportional hazards models. During 12 years of follow-up, we observed a U-shaped association between baseline BMI and later hospitalization for 1) any infectious disease and 2) infections of the respiratory tract, whereas a dose-response relationship was seen for skin infections. The most pronounced associations were seen for acute upper respiratory infections at multiple and unspecified sites (underweight (BMI <18.5): hazard ratio (HR) = 4.26, 95% confidence interval (CI): 1.69, 10.7; obesity (BMI ≥30): HR = 3.64, 95% CI: 1.62, 8.18), erysipelas (obesity: HR = 5.19, 95% CI: 3.38, 7.95), and fungal infections (underweight: HR = 3.19, 95% CI: 1.53, 6.66). Slightly greater use of antimicrobials was observed among overweight (BMI 25-<30; HR = 1.08, 95% CI: 1.06, 1.10) and obese (HR = 1.21, 95% CI: 1.17, 1.24) women. Among Danish women, underweight and obesity were associated with increased risk of community-acquired infectious diseases, especially infections of the upper respiratory tract and skin.

The Impact of Obesity and Diabetes on the Risk of Disease and Death due to Invasive Group A Streptococcus Infections in Adults

BACKGROUND

Invasive group A Streptococcus (iGAS) infections cause significant morbidity and mortality worldwide. We analyzed whether obesity and diabetes were associated with iGAS infections and worse outcomes among an adult US population.

METHODS

We determined the incidence of iGAS infections using 2010-2012 cases in adults aged ≥ 18 years from Active Bacterial Core surveillance (ABCs), a population-based surveillance system, as the numerator. For the denominator, we used ABCs catchment area population estimates from the 2011 to 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. The relative risk (RR) of iGAS was determined by obesity and diabetes status after adjusting for age group, gender, race, and other underlying conditions through binomial logistic regression. Multivariable logistic regression was used to determine whether obesity or diabetes was associated with increased odds of death due to iGAS compared to normal weight and nondiabetic patients, respectively.

RESULTS

Between 2010 and 2012, 2927 iGAS cases were identified. Diabetes was associated with an increased risk of iGAS in all racial groups (adjusted risk ratio [aRR] ranged from 2.71 to 5.08). Grade 3 obesity (body mass index [BMI] ≥ 40) was associated with an increased risk of iGAS for whites (aRR = 3.47; 95% confidence interval [CI], 3.00-4.01). Grades 1-2 (BMI = 30.0-<40.0) and grade 3 obesity were associated with an increased odds of death (odds ratio [OR] = 1.55, [95% CI, 1.05, 2.29] and OR = 1.62 [95% CI, 1.01, 2.61], respectively) when compared to normal weight patients.

CONCLUSIONS

These results may help target vaccines against GAS that are currently under development. Efforts to develop enhanced treatment regimens for iGAS may improve prognoses for obese patients.

Obesity: impact of infections and response to vaccines

Obesity is a common condition that has rapidly increased in both the industrialised and developing world in recent decades. Obese individuals show increased risk factors for severe infections and significant immune system dysregulation that may impair the immune response to vaccines. The main aim of this paper was to review the current knowledge regarding the association between obesity and the risk and outcome of infections as well as immune response to vaccines. The results showed that obesity is a highly complex clinical condition in which the functions of several organ and body systems, including the immune system, are modified. However, only a small minority of the biological mechanisms that lead to reduced host defences have been elucidated. Relevant efforts for future research should focus on obese children, as the available data on this population are scarce compared with the adult population. Even if most vaccines are given in the first months of life when obesity is rare, some vaccines require booster doses at preschool age, and other vaccines, such as the influenza vaccine, are recommended yearly in the obese population, but it is not known whether response to vaccines of obese patients is impaired. The reduced immune response of obese patients to vaccination can be deleterious not only for the patient but also for the community.

Antimicrobial therapy in obesity: a multicentre cross-sectional study

Objectives

Evidence indicates a relationship between obesity and infection. We assessed the prevalence of obesity in hospitalized patients and evaluated its impact on antimicrobial management.

Methods

Three National Health Service hospitals in London in 2011–12 were included in a cross-sectional study. Data from all adult admissions units and medical and surgical wards were collected. Patient data were collected from the medication charts and nursing and medical notes. Antimicrobial therapy was defined as ‘complicated’ if the patient's therapy met two or more of the following criteria: (i) second- or third-line therapy according to local policy; (ii) intravenous therapy where an alternative oral therapy was appropriate; (iii) longer than the recommended duration of therapy as per local policy recommendations; (iv) repeated courses of therapy to treat the same infection; and (v) specialist advice on antimicrobial therapy provided by the medical microbiology or infectious diseases teams.

Results

Of the 1014 patients included in this study, 22% (225) were obese, 69% (696) were normal/overweight and 9% (93) were underweight. Obese patients were significantly more likely to have more complicated antimicrobial therapy than normal/overweight and underweight patients (36% versus 19% and 23%, respectively, P = 0.002). After adjustment for hospital, age group, comorbidities and the type of infection, obese patients remained at significantly increased odds of receiving complicated antimicrobial therapy compared with normal/overweight patients (OR = 2.01, 95% CI 1.75–3.45).

Conclusions

One in five hospitalized patients is obese. Compared with the underweight and normal/overweight, the antimicrobial management in the obese is significantly more complicated.

Obesity-related chronic lymphoedema-like swelling and physical function

BACKGROUND

People with severe obesity (body mass index [BMI] > 40 kg/m(2)) have an 85% higher mortality than people with a healthy BMI. Poor physical function may contribute to this excess mortality. Lymphoedema-like swelling can affect the legs of severely obese people with normal lymphoscintigraphy.

AIM

We sought to determine the relationship between the presence of lymphoedema-like swelling and physical function in the severely obese.

DESIGN AND METHODS

In people with severe obesity, we ascertained whether lower leg lymphoedema-like swelling was present and determined the circumference of the lower leg, time taken to ascend and descend a 17-cm step 50 times and time taken to walk 500 m.

RESULTS

The 330 participants, 33% of whom were male, were aged 43.4 ± 12.7 years (mean ± standard deviation) and had a BMI of 51.7 ± 8.4 kg/m(2). Lymphoedema-like swelling was present in approximately one-third (n = 108) in whom a prior history of cellulitis and venous thromboembolism was more common (relative risks 6.16 and 3.86, respectively) than in those without lymphoedema-like swelling. Participants with lymphoedema-like swelling, compared with non-affected counterparts, had a higher lower leg circumference (35.0 ± 7.1 vs. 32.4 ± 4.8 cm), a slower step speed (0.40 ± 0.12 vs. 0.43 ± 0.10 steps/s) and a slower walking speed (0.97 ± 0.37 vs. 1.08 ± 0.30 m/s, P < 0.05 for all comparisons).

CONCLUSIONS

In this cross-sectional study, 33% of our severely obese participants had lymphoedema-like swelling. Participants with lymphoedema-like swelling had worse physical function than those without. This association was independent of BMI. The presence of obesity-related chronic lymphoedema-like swelling should lead to interventions that improve physical function.