In Search of Risk Factors for Recurrent Erysipelas and Cellulitis of the Lower Limb: A Cross-Sectional Study of Epidemiological Characteristics of Patients Hospitalized due to Skin and Soft-Tissue Infections

Demonstrating the benefit of a cellulitis-specific patient reported outcome measure (CELLUPROM©) as part of the National Cellulitis Improvement Programme in Wales

PURPOSE

Despite a known risk of cellulitis recurrence, the management of the wider impact and risk factors has been neglected. The innovative National Cellulitis Improvement Programme (NCIP) addresses this by providing evidence-based and individualised care to improve patient reported outcomes and reduce the risk of recurrence. The aim of this paper is to examine the longer-term impact of cellulitis and to identify a suitable and clinically relevant Patient Reported Outcome Measure (PROM).

METHODS

A review of existing cellulitis-specific PROMs was undertaken, alongside literature detailing the patient-focused impact of cellulitis, to identify a suitable PROM for clinical use. A group of expert therapists and patient representatives (n = 14) shared their individual and collective experiences over a series of events to discuss and debate the impact of cellulitis and review available PROMs. CELLUPROM© is introduced with anonymised PROM data and case study information reported to establish the impact of CELLUPROM© within usual NCIP care.

RESULTS

No cellulitis-specific PROMs were identified. Literature focused on the signs and symptoms of an acute episode of cellulitis, with outcome measures primarily used to evidence the impact of an intervention. An enduring physical, social and emotional impact of cellulitis was identified in this study, providing the basis for the new cellulitis-specific PROM (CELLUPROM©), which has been implemented with good effect in clinical care.

CONCLUSION

This study has highlighted the lasting impact of cellulitis. Using CELLUPROM© within the risk-reduction NCIP has helped develop Value-Based Healthcare and support programme evaluation.

Incidence and Causes of Cellulitis Among Patients at Tupua Tamasese Meaole Hospital in Upolu, Samoa in 2019

OBJECTIVE

To study the incidence and causes of cellulitis in patients who visited the only tertiary hospital in Samoa, i.e., Tupua Tamasese Meaole (TTM) Hospital, in 2019.

METHOD

Of the total of 14,198 patients who presented to TTM Hospital in 2019, a chart review of all 258 patients who presented with cellulitis was conducted. All charts with the final primary admitting diagnosis of cellulitis were extracted. No exclusion criteria were employed, and raw data were analyzed manually.

RESULTS

Of the 14,198 patients who sought care at TTM Hospital in 2019, 258 patients received care for cellulitis. This represents an incidence rate of 1.8%. Most patients were male (62.4%). Those in the age group of 41 to 80 years old accounted for 79.5% of the total. The leg (94.6%) was the major site of infection. Of those who had blood cultures drawn, 76.4% had negative results. Of the 56 patients with positive microbial growth, Staphylococcus and Streptococcus species accounted for a combined total of 71.4% of the cases. The mainstay of antibiotic treatment was flucloxacillin alone or in conjunction with other antibiotics (92.2%). Of the many comorbidities affecting patients, diabetes (44.2%) was the most prevalent. Hospital admission, ranging from three to 10 days was needed in 63.5% of patients.

CONCLUSION

The incidence rate of cellulitis at TTM in 2019 was 1.8%, which was marginally higher than noted in other parts of the world. Male patients and people over the age of 40 years are affected the most. The leg is affected the most mainly by Staphylococcus and Streptococcus species. Flucloxacillin is the main antibiotic used to treat cellulitis at the TTM Hospital. From the data analyses, it is inferred that a large proportion of patients who presented had moderate to severe cellulitis.

Clinical Impact of Severe Obesity in Patients with Lymphoedema

OBJECTIVE

With the rate of obesity increasing worldwide, patients with lymphoedema with and without a concomitant diagnosis of severe obesity (SO) were compared in regard to their baseline demographics, health related characteristics, treatment plans, and patient outcomes.

METHODS

This was a retrospective observational cohort study. The IBM MarketScan database was examined (2013 - 2019) for patients with a new diagnosis of lymphoedema. Of 60 284 patients with lymphoedema identified, 6 588 had SO defined by a body mass index > 40 kg/m2. The demographics and other characteristics of SO were compared with patients with lymphoedema without SO.

RESULTS

SO and lymphoedema diagnosis increased two fold from 2013 to 2019. The lymphoedema SO+ group was younger (57.8 vs. 60.8 years, p < .001) and with a higher proportion of men (37.7% vs. 24.9%, p < .001) than the lymphoedema SO- group. More comorbidities were observed in the lymphoedema SO+ group than the lymphoedema SO- group: diabetes 46.0% vs. 24.9 % (p < .001), heart failure 18.3% vs. 7.4% (p < .001), hypertension 75.0% vs. 47.6% (p < .001), and renal disease 24.8% vs. 11.9% (p < .001). Use of diuretics in the lymphoedema SO+ group was greater: 57.6% vs. 38.0% (p < .001). Patients with lymphoedema SO+ had higher risk of cellulitis: 34.5% vs. 13.5% (p < .001). Specific lymphoedema treatment was given more often to lymphoedema SO-: 66.3% vs. 64.3% (p = .003). This was significant for manual lymphatic drainage (46.6% vs. 40.0%; p < .001) and physical therapy (55.4% vs. 51.6%; p<.001), but not for compression garments (18.2% vs. 17.7%; p = .38). However, more patients with lymphoedema SO+ received pneumatic compression device treatment: 20.9% vs. 13.7% (p < .001).

CONCLUSION

There was an increase in SO associated lymphoedema. Patients with lymphoedema SO+ have over a two and half fold increase in cellulitis incidence, with a significant increase in medical resource use and cost. Despite this, patients with lymphoedema and SO receive less specific therapy such as compression, which has proven to reduce cellulitis incidence.

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.

Liposuction and Controlled Compression Therapy Reduce the Erysipelas Incidence in Primary and Secondary Lymphedema

BACKGROUND

Skin infections are a recurring problem for people with lymphedema, and lymphedema has been proven to be the single most important risk factor for developing erysipelas in the leg. This study aimed to determine whether liposuction for late-stage lymphedema reduces the rate of erysipelas in lower extremity lymphedema.

METHODS

One-hundred twenty-four patients with a median age of 49 years who had liposuction and controlled compression therapy for lower extremity lymphedema were included. Excess volumes were calculated before and after surgery. Median preoperative and postoperative patient years at risk were 11 and 5 years, respectively.

RESULTS

With a total of 1680 preoperative person years at risk and 335 bouts of erysipelas experienced in 64 patients, the preoperative incidence rate was 0.20 bouts per person per year, and the period prevalence was 52%. Postoperatively, the patients were followed over a total of 763 person years at risk, and 28 patients experienced a total of 53 bouts of erysipelas, resulting in a postoperative incidence rate of 0.07 bouts per person per year, and a period prevalence of 23%. This represents a 65% decrease in the erysipelas incidence rate (P < 0.001). The preoperative median excess volume of 3158 ml was reduced with a median of 100% (P < 0.0001).

CONCLUSIONS

Liposuction and controlled compression therapy significantly reduce the risk for erysipelas in lower extremity lymphedema and completely reduces the excess volume. This finding is similar to our previous research including patients with upper extremity lymphedema.

Erysipelas of the leg: A cross-sectional study of risk factors for recurrence

BACKGROUND

Erysipelas is a common infection of the superficial layer of skin. The main causative agent is group A β-hemolytic streptococci. One of the most challenging aspects of this disease is its high rate of recurrence.

OBJECTIVES

To identify risk factors for recurrence of erysipelas of the leg.

PATIENTS AND METHODS

We included in a cross-sectional study all patients hospitalized for erysipelas of the leg seen at the dermatology department of the Ibn Rochd University Hospital in Casablanca, Morocco, from January 2015 to April 2020. Patients were divided into two groups: those with a single episode (SE) and those with recurrent erysipelas (RE). These two groups were compared for clinical and laboratory characteristics, with particular focus on systemic and local risk factors.

RESULTS

The study included 270 patients, of whom 132 had SE and 138 had RE. Age, gender, hospital stay as well as laboratory findings did not differ significantly between the two groups. In multivariable analysis, cutaneous disruption [adjusted odds ratio (aOR)=1.9; 95% confidence interval (95% CI): 1.0-3.71], lymphedema [aOR=19.6; 95% CI: 8.0-57.2], and obesity [aOR=2.3; 95% CI: 1.1-5.2] were significantly associated with RE. Venous insufficiency and diabetes were not found to be associated with risk of recurrence.

CONCLUSION

Our results suggest that erysipelas is a potentially chronic disease and patients with identified local risk factors or obesity should be considered as exposed to recurrence and considered as targets for antibiotic prophylaxis and other preventive methods.