Cellulitis
---------------------------------
Related Terms: lymphedema, erythema, staph aureus, strep A, gram-negative bacteria, gangrene, tissue necrosis, septicemia, regional lymphadenopathy, Keflex, Augmentin, penicillins, pneumococcus, hemophilus influenzae, pasturella multocide, erysipelothrix rhusiopathia, gram negative bacteria
Cellulitis
This is often our worst nightmare and sends us to the hospital more
than
anything else regarding lymphedema.
In this section there are many detailed
articles on cellulitis, complications of and treatment for cellulitis
and/or lymphangitis.
----------------------------
Discussion
Acute Cellulitis
Acute Cellulitis is one of the complications of lymphedema.
The patient
may not be aware of the source of the etiology.
Sometimes it may be a cut,
mosquito bite, open wound or other
infection in the body.
The first sign is increased or different quality of PAIN involving the lymphedema
limb. The patients often describe this as a "flu like symptom or an
ache" involving the Lymphedema arm or leg. This is usually followed by
sudden onset of ERYTHEMA(redness,
red streaks or blotches) on the involved limb.
The HYPERTHERMIA(lymphedema limb becomes warm, hot) will follow and the
patient
may experience the CHILLS and even HIGH FEVER.
The early intervention and treatment with antibiotics will resolve this
condition (it usually takes a very minimum ten day course of
antibiotics). Only
a Medical Doctor will be able to prescribe the
Antibiotics, thus a consultation
with a
Doctor is necessary. Severe Cellulitis may require
Inter venous
Antibiotic treatment and hospitalization. Again, elevation of
the affected limb
is important.
During that phase the patient should NOT massage the lymphedema
limb,
bandage, apply the pump,
wear tight elastic sleeve or exercise excessively.
Avoid the
blood pressure and
blood to be drawn from the involved arm. Keep the
limb elevated as much as possible while resting. Once the symptoms
dissipate the
treatment MLD/CDP
should be initiated.
How do we prevent this infection? The patient should be careful with
daily
activities and take all precautions to protect the skin (wear gloves
when
gardening, cleaning with detergents, etc... ). If an injury to
skin occurs on
the lymphedema limb it is necessary to clean the
wound with alcohol or
hydrogen peroxide and apply Neosporin/Polysporin antibiotic ointment.
If the
symptoms progress seek the attention of a physician immediately.
It is so very important to avoid getting cellulitus as it further
destroys the
lymphatic
system. Allowed to spread or continue it can become
systemic and can lead to gangrene,
amputation of the limb or even death.
Clinical
Cellulitis is clinically a spreading infection involving both the dermis and subcutaneous tissues. Unlike erysipelas, it will not have a clear raised border. Other features may include red streaking from the infected area, regional lymphadenopathy.
Symptoms
Symptoms include all over body ache, fever, severe pain of the infected area, chills, weakness. The skin color will be red, warm and very tender to the touch.
Causes
The most common bacteria responsible for cellulitis infections are staph aureus and strep A. Other less common bacterial agents include Strep B, gram-negative bacteria, and immunocompromised patients pneumococcus. Less common bacteria such as Hemophilus influenzae, Pasturella multocide, and erysipelothrix rhusiopathiae can cause it as well.
Entry foci for the bacteria includes nasal cavities, wound, cuts, scrapes (any type of skin break). Insect bites (especially spider) can cause the condition. Cat scratches, animal bites are another source of bacteria.
Risk Factors
Patients with any of the following disorders are more at risk for developing serious and or life threatening cellulitis:
Lymphedema, Diabetes, immunodeficiency (of any type), Varicella (cellulitis as a complication of), chemotherapy patients, venous insufficiency or venous stasis, chronic steroid users, post surgical patients, individuals with edema and finally age may also be a factor with infants and the elderly more susceptible to infections.
Complications
Complications can include septicemia (sepsis), tissue necrosis, gangrene, amputation of the affected limb, death. It should be noted also that cellulitis causes further damage to the lymphatics and thereby makes lymphedema worse. Other complications include lymphangitis, skin abcesses.
In compromised patients, physicians must be careful to observe for a complicating gram-negative super infection that can accompany regular gram-positive bacteria. This can occur as a result of the even further depletion of the body's immune system.
Other complications include bacteremia, septic shock, memingitis (if cellulitis is on the face), and lymphangitis.
It is critical for patients with lymphedema to understand that every cellulitis infection further damages and scars the lymphatics and thereby worsens lymphedema.
Treatment
Cellulitis responds well to antibiotic therapy. Generally, a ten day course of treatment is prescribed. Antibiotics used to treat cellulitis include Keflex, Augmentin, penicillins. Unasyn and vancomycin are standard IV antibiotics. In situations of a gram negative infection, Gentamicin is used.
For special at risk patients, blood work may also be indicated to assure the infection has not become systemic.
This group, which includes lymphedema patients may need extended IV antibiotic therapy.
Prognosis
With early diagnosis and subsequent rapid treatment the outcome is actually excellent with the overwhelming number of patients making full recovery. In special risk groups however, there is a heightened risk of complication and morbidity.
---------------------
How can you prevent cellulitis?
Preventative
Antibiotic Therapy
If you are particularly
susceptible to infections, you may wish to discuss with your doctor
about
undertaking preventative antibiotic therapy. There are a couple ways of
doing
this.
Either an oral antibiotic or if you are not allergic to penicillin, you
may well
consider taking long acting penicillin injections. This worked
wonderfully for
me during the 1970's. Until my family allergy to penicillin raised its
ugly
head, this was perhaps the most successful therapy I have had in
preventing
cellulitis.
Remember one important point regarding cellulitis. With
fibrosis the bacteria is
able to "hide" in pockets and may escape the antibiotic or the
fibrosis will make it much more difficult for the antibiotic to be
effective.
Doing all you can to prevent infections is critical.
Simple
self-care techniques
Handwashing:
Hand washing is the most important thing you can do to prevent
infection. You
should wash your hands several times every day. Soap and water cannot
kill germs
but they loosen the normal skin oil where germs live. Always wash your
hands
after you have been to the bathroom. You should also wash your hands
every time
you cough, sneeze, or blow your nose. Wash your hands before and after
giving
patient care to a family member. Always wash your hands before you
prepare or
eat food.
..........
Bathing:
Shower often. Make sure to wash between folds of your skin. You should
bathe/shower every day to keep your body clean and to keep from getting
an
infection. If you work in a public place, outside, or with food or
animals, you
should bathe often. If you live in a warm humid climate - I would even
recommend
two showers a day.
Also, my rule of thumb is never use a towel, wash cloth twice. The
little extra
laundry is well worth the effort. Bacteria can build up quickly in a
damp cloth.
Wash your hair regularly.
It is also very important to wash thoroughly the feet, between the
toes, the
groin area. These are prime bacteria breeding grounds.
Trim your finger and toenails once a week. Doing this after a bath or
shower is
often easier because the nail is softer. Tell your caregiver if you
cannot see
or reach your nails to trim them.
I also advise against going to "nail" salons. The has been an epidemic
of nail infections from unsanitary tools.
..........
Dental Care: Each
family member should use his own toothbrush and drinking glass.
Infections in your mouth can be caused by food left on or between your
teeth.
Brush your teeth at least 2 times each day. It is best to do this in
the morning
and before bed. Gargle with mouthwash if you cannot brush after a meal.
Floss your teeth each time you brush. This helps to remove food from
between
your teeth.
Change the water in your denture cup every day if you have dentures.
It is very important to see your dentist at least once a year. Dental
caregivers
can give your teeth a deeper cleaning than you can. This prevents
cavities and
infections in your mouth.
If you have dental problems, take care of them as quickly as possible.
Mouth
infections can spread rapidly - even to the point of causing septicemia.
..........
Housecleaning:
Dust
and vacuum your house every week. I know how difficult this can be with
the pain
and fatigue we experience with
lymphedema (some with lymphedema and cancer).
Mop the kitchen and bathroom floor each week and when something is
spilled. This
includes all the nooks and crannies.
Wash trash containers with soap and water. Then spray the container
with a
disinfectant. Always use plastic garbage bags to help keep these clean.
Keep the inside of the refrigerator clean. Use soap and water to clean
it about
every month. Keep foods that can spoil in the refrigerator. Throw away
food that
is spoiled.
When using a cutting board, wash it with soap or put it in the
dishwasher often.
Always wash the cutting board carefully after you have put raw meats on
it.
Use a cleaning product to clean the kitchen counter. Many germs can
live on a
kitchen counter if it is not kept clean. You would be amazed at the
number of
and types of germs that live on what appears to be a clean counter top.
If you use a sponge in the kitchen replace it every few days. Also,
every time
that dishwasher is run, throw the sponge in it. Sponges are another
favorite
breeding ground for bacteria.
Bathrooms absolutely must be kept clean. In the old days there was
nothing like
Comet, Ajax or Bon Ami cleaner. Now there are many excellent spray
products that
help make this job much easier.
When you clean, also clean shower heads and faucets too. You may also
want to
use latex (or alternative if you are allergic to latex) gloves while
cleaning
your bathroom and/or kitchen.
..........
Clothing: A
rule of thumb I use is never wear a piece of clothing twice without
washing. It
may still look lean, but again
all clothing picks up bacteria. Also, clean sheets are a must! You may
wish to
change them every few days.
Shoes I use regularly an anti-fungal powder in my shoes. Not only does
it help
keep them smelling fresh but provides an extra added bit of protection
from
potentially catastrophic fungal infections.
..........
Gardening and
outdoor work:
Always, always
wear gloves when you are
working outside. I love gardening and seeing my yard explode with
flowers in the
Spring and Summer. When I plant those little seedlings, I trade my
regular
gloves for latex gloves. Its easier to handle the little plants in
those. Never
ever dig around in the soil with your bare hands. (I have learned the
hard way
about this.)
..........
Traveling:
I always carry my bottle of disinfectant when traveling. I will not use
a
bathroom in a motel until I have disinfected it. You may also wish to
carry your
own set of sheets.
..........
Skincare:
It is absolutely imperative that you maintain excellent skin care. Any
scratch,
wound or rash must be dealt with immediately. Those of us with
extensive stage 2
or 3 lymphedema have a double duty as our skin will get so dry and try
to crack.
Use skin moistening creams and lotions to help with this.
Those wounds we all get that leak lymphorrea? Take care of them
immediately. Not only does the lymphorrea severely damage surrounding
skin
tissue, but the wound provides a welcome mat to bacterial infections.
..........
Outdoors:
Always when outdoors, use an insect
repellant. A simple mosquito bite or flea bite can quickly send us to
the
hospital
..........
Lakes,
swimming pools, hot tubs:
A very good rule
of thumb is to stay away from
these. Especially ones that are used by a number of people. The
chlorine used in
these does NOT always kill bacteria.
..........
Nail Care: As
mentioned earlier, the best time to trim your nails is after a bath
when they
are softer. Never allow yourself to get a hang nail. And for women, I
strongly
urge not using the stick on nails. These also provide a safe haven for
bacteria.
Remember, we don't have to live in a cocoon. Nor do we have to live
every minute
in fear of a germ. But there are some very simple guidelines that will
help keep
us healthier and keep us out of the hospital.
..........
Alcohol: Consumption of alcohol should be limited with people having lymphedema. Your body can not metabolize alcohol and converts it into sugar. The sugar level then increases in your body system. It is this sugar that provides "food" for bacteria.
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Prevention of Cellulitis
From eMedicine Health
Animal or human bites
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Signs of secondary infection - The signs of infection can often be negligible and the therapist must be extremely vigilant for them. The physician may prescribe antibiotic therapy if he or she suspects it. Signs of SAI can also be unmistakable with high fever and chills; the patient may require a ten-day hospitalization with intravenous antibiotic therapy.
Clinical signs of infections: - Minor rash or red streaks may be visible. Any of the following may be present or not:: Itching, tenderness, dull aching in a limb, blotchy areas, small blisters, general malaise, etc. In septicemia fever, chills and nausea are common. The signs may include aggravation of the lymphedema condition: Increase in edema volume so that the medical compression feels too tight for reasons that are unclear. Lymph nodes may become enlarged, or pain may occur in lymph nodes. There may be an elevation of temperature of the extremity. Pain may appear or increase, with tender spots, heaviness, tightness, tiredness, etc. Fistulae (lymphorrhea) may also occur; the reason for this is not known.
Chronic secondary infections are more difficult to assess, with slight elevation in skin temperature, increased sensitivity, slight itching or redness. Sometimes the redness (erythema) is not present if the infection is situated deep in the tissue. This condition may be pain-free in a patient whose affected limb is numb. Some episodes of infection are milder and resolve in a few days without antibiotic treatment. Fungusor staphylococcus may be the agents causing these kinds of infections.
D- Prevention of Secondary Infection: - Decongestion of the edema - Extremely careful skin care - Prophylactic antibiotic therapy may be suggested by the physician in cases of recurrent SAI. Allergic inquiry / test is recommended first.
E- Treatment: The therapist should be able to work with a medical team. It is imperative to check with a physician if there is any suspicion of secondary infection, and scrupulously treat any infection. Hands-on lymphatic drainage and medical compression (bandages, garments) should be interrupted until the condition is under control (at least 48 to 72 hours, up to 8 days). The signs of infections (edema, erythema, warmth, aching, etc.) should have clearly disappeared. Antibiotic therapy: Bacterial infection calls for immediate antibiotic therapy. The sensitivity of the bacteria to antibiotics (regular penicillin G) is generally good.
Suggested treatment (Olszewski W.L.): first episode: 3 months of antibiotic therapy. If there are more than two episodes, one year's antibiotic therapy may be indicated. Check for the few adverse effects of prolonged antibiotic therapy: change in intestinal flora, gastro-intestinal disorders, damage to liver, kidneys and bones, allergic reactions, etc. Where the patient is allergic to penicillin, erythromycin usually works well. After one episode of infection, it may be wise for lymphedema patients to carry a supply of antibiotics or a prescription with them, especially when traveling away from home.
Published with permission from the author of Silent Waves Theory And Practice Of Lymph Drainage Therapy (Ldt) With Applications For Lymphedema, Chronic Pain And Inflammation Author: Bruno Chikly, M.D.2000 Publisher: I.H.H. Publishing, Arizona. Isbn Hard Cover = 0-9700530-5-3 Part 3, Chapter 9, page 209-210
---------------------
This article is taken from the Spring 2002 issue of LymphLine, the
LSN's
quarterly newsletter available to all LSN members
Watch
point: The Importance of Antibiotics for Cellulitis
By Professor Peter Mortimer
Antibiotics are often recommended on a long term basis in patients who
have
recurrent attacks of cellulitis. The reason is quite simply because
nothing else
works (unless there has been a substantial improvement in the swelling
following
decongestive lymphatic therapy). Cellulitis results from the
compromised local
immunity within the swollen region (but not your overall body).
Treating with antibiotics as and when each attack of cellulitis occurs
is a bit
like 'shutting the stable door after the horse has bolted'! Each attack
of
cellulitis can not only make you ill but tends to cause a deterioration
in the
swelling and make the tissues (skin and underlying fat layer) harder
(fibrotic).
This does not help the long term control of the lymphoedema. Experience
has
shown that the best way of controlling recurrent attacks of cellulitis
is with a
low dose of antibiotic taken every day (usually penicillin or
erythromycin).
Unfortunately this approach, nor any other for that matter, may not
necessarily
cure the infection and an attack could start immediately if you
inadvertently
stop the antibiotic. Therefore please only comply with the
recommendations made
by your GP or lymphedema therapist.
There is no reason to believe that long term antibiotics are harmful or
affect
your whole body's immunity. For decades penicillin has been given life
long
without a problem to patients who have had their spleen removed.
Therefore
safety seems assured providing you are not allergic.
http://www.lymphoedema.org/lsn/lsn140.htm#TOP
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Treatment of Cellulitis
Shared discussion between
Bill and Bob from
LYMPHEDEMA@LISTSERV.ACOR.ORG
In discussing the treatment of cellulitis, international lymphedema
expert
Bruno Chikly, M.D. writes:
Treatment: The therapist should be able to work with a medical team. It
is
imperative to check with a physician if there is any suspicion of
secondary
infection, and scrupulously treat any infection. Hands-on lymphatic
drainage and
medical compression (bandages,
garments)
should be interrupted until the
condition is under control (at least 48 to 72 hours, up to 8 days). The
signs of
infections (edema, erythema, warmth, aching, etc.) should have clearly
disappeared.
Antibiotic therapy: Bacterial infection calls for immediate antibiotic
therapy.
The sensitivity of the bacteria to antibiotics (regular penicillin G)is
generally good.
Suggested treatment (quoting expert W. L. Olszewski M.D.): first
episode: 3
months of antibiotic therapy. If there are more than two episodes, one
year's
antibiotic therapy may be indicated. Check for the few adverse effects
of
prolonged antibiotic therapy: change in intestinal flora,
gastro-intestinal
disorders, damage to liver, kidneys and bones, allergic reactions, etc.
Where
the patient is allergic to penicillin, erythromycin usually works well.
After
one
episode of infection, it may be wise for lymphedema patients to carry a
supply
of antibiotics or a prescription with them, especially when traveling
away from
home.
(Published with permission from the author of Silent Waves Theory And
Practice Of Lymph Drainage Therapy (Ldt) With Applications For
Lymphedema,
Chronic Pain And Inflammation Author: Bruno Chikly, M.D.2000 Publisher:
I.H.H.
Publishing, Arizona. Isbn Hard Cover = 0-9700530-5-3 Part 3, Chapter 9,
page
209-210 )
---------------------
Cellulitis
Medline Plus Medical Encyclopedia
National Institutes of Health
Alternative names
Definition
Cellulitis is an acute inflammation of the connective tissue of the skin, caused by infection with staphylococcus, streptococcus or other bacteria (see also cellulitis - streptococcal).
Causes, incidence, and risk factors
The skin
normally has many types of bacteria living on it, but intact skin is
an effective barrier that keeps these bacteria from entering and
growing within
the body. When there is a break in the skin, however, bacteria can
enter the
body and grow there, causing infection and inflammation. The skin
tissues in the
infected area become red, hot, irritated and painful.
Cellulitis is most common on the face and lower legs, although skin on
other
areas of the body may sometimes be involved.
Risk factors for cellulitis include:
Symptoms
Signs and tests
During a physical examination, the doctor may find localized swelling. Occasionally, swollen glands (lymph nodes) can be detected near the cellulitis.
Tests that may be used:
Treatment
Cellulitis treatment may require hospitalization if
it
is severe enough to warrant intravenous antibiotics and close
observation. At
other times, oral antibiotics and close outpatient follow-up suffice.
Treatment
is focused on control of the infection and prevention of complications.
Antibiotics are given to control infection, and analgesics
may be needed to control pain.
Elevate the infected area, usually higher than the heart, to minimize swelling.
Apply warm, moist compresses to the site to aid the body in fighting
infection
by increasing blood supply to the tissues. Rest until symptoms improve
Expectations (prognosis)
Cure is possible with 7 to 10 days of treatment. Cellulitis may be more severe in people with chronic diseases and people who are susceptible to infection (immunosuppressed).
Complications
Calling your health care provider
** Immediately as a patient with lymphedema**
Call your health care provider if symptoms indicate
that cellulitis may be present.
Call your health care provider if you are being treated for cellulitis
and new
symptoms develop, such as persistent fever,
drowsiness,
lethargy,
blistering
over the cellulitis, or extension of the red streaks.
Prevention
Avoid skin damage by wearing appropriate protective equipment when participating in work or sports. Also clean any breaks in the skin carefully and watch for redness, pain, drainage, or other signs of infection.
Finally, maintain good general health and control chronic medical conditions. A body that is healthy can more easily fight bacteria before they multiply and cause infection, while a body that is run down has less protection against infection.
Update Date: 10/25/2002Updated by: Michael Lehrer, M.D., Department of Dermatology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.
---------------------
Cellulitis
Last Updated: October 20, 2003
Synonyms and related keywords: gram-positive bacteria, group A
beta-hemolytic
Streptococcus, GABHS, Staphylococcus aureus, S aureus, Streptococcus
pyogenes, S
pyogenes, systemic toxins, bacteremia, sepsis, buccal cellulitis,
Haemophilus
influenzae type B, HIB, facial cellulitis, perianal cellulitis, group B
Streptococcus cellulitis, Pseudomonas osteomyelitis, septic arthritis,
thrombophlebitis, Pasteurella multocida, P multocida, Vibrio
vulnificus, V
vulnificus, Aeromonas species, Clostridium perfringens, C perfringens,
crepitus,
crepitation, Escherichia coli cellulitis, E coli
Author: Dennis Cunningham, MD, Assistant Professor of Clinical
Pediatrics,
Section of Infectious Diseases, Children's Hospital
http://www.emedicine.com/med/topic310.htm
---------------------
Cellulitis complicating lymphoedema.
Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY.
Department of Microbiology, The University of Hong Kong, Queen Mary
Hospital.
In ten hospitalised patients with cellulitis complicating lymphoedema
encountered over a 3-year period (1996-1998), the underlying diseases
were
carcinoma of the cervix (n = 4), uterus (n = 1), vagina (n = 1), breast
(n=2)
and nasopharynx (n= 1), and retroperitoneal squamous cell carcinoma (n
= 1).
Three of the ten patients had positive blood cultures, compared to none
of the
20 age-matched, sex-matched controls hospitalised for cellulitis
without
lymphoedema. The mean duration of fever, tachycardia and cellulitis was
significantly longer in patients with lymphoedema than in those without
(P<0.05, P<0.05, and P<0.005 respectively). Early
treatment initiated
by patients themselves may help stop bacterial replication in the
initial stages
and minimise further damage to the lymphatic system.
PMID: 10834819 [PubMed - indexed for MEDLINE]
---------------------
Cellulitis
What Is It?
Cellulitis is a serious bacterial infection of the skin. In cellulitis, bacteria penetrate the skin's protective outer layer, typically at the site of an injury, such as a cut, puncture, sore, burn or bite. Cellulitis also can occur at the site of surgery, or where the skin was punctured for a small plastic tube (intravenous catheter) used to administer medications. Once inside the skin, the invading bacteria multiply and produce chemicals that cause inflammation within the skin.
Cellulitis usually occurs on the legs and feet. However, it can develop on any part of the body, including the trunk, arms and face. It often develops near an area where there already is swelling, poor blood flow, or another skin condition such as a fungus infection between the toes (athlete's foot).
Many different types of bacteria can cause cellulitis. However, most cases are caused by Streptococcus pyogenes (strep) or Staphylococcus aureus (staph). Other types of bacteria can cause infection after certain types of skin injuries, such as animal bites, puncture wounds through wet shoes, and wounds exposed to freshwater lakes, aquariums, or swimming pools.
Cellulitis can take several specific forms, including:
Symptoms
In cellulitis, the affected area of skin feels warm and usually is red, swollen and painful. The redness can be vague or can stand out compared to surrounding skin. The area of warmth can be felt with the back of the hand, especially when compared to surrounding skin. There may be a spreading network of red streaks in the skin, caused by infection in the vessels that carry lymph (tissue fluid), as well as enlarged lymph nodes (swollen glands) near the area of infection.
Fever and malaise (a generally sick feeling) often accompany cellulitis. Severe infections can cause low blood pressure if bacteria get into the bloodstream. Bloodstream infections (blood poisoning) from cellulitis are particularly dangerous in the very young and very old, as well as in those with weakened immune systems or abnormal heart valves.
Diagnosis
Your doctor will ask you about how your cellulitis developed and your symptoms, including whether you have:
Many people who develop cellulitis have no underlying medical problems and no obvious injury or skin damage that allowed the infection to occur.
Your doctor can diagnose cellulitis based on the history of your injury, your symptoms, and the results of a physical examination. If your skin wound is draining fluid or pus, your doctor may take a sample of wound drainage for tests to identify the type of bacteria and use specific antibiotics to eliminate the bacteria.
Expected Duration
How long cellulitis lasts depends on the type of skin injury, the bacteria that caused the infection, and your general health. Without proper antibiotic treatment, some forms of cellulitis can cause serious complications within a few days, even in otherwise healthy patients.
Prevention
To help prevent cellulitis:
Treatment
Cellulitis is treated with antibiotics. Your doctor will choose a specific antibiotic depending on the location of your cellulitis and the likely cause of your infection. Most cases of cellulitis improve quickly once antibiotics are given.
If you have mild cellulitis, you probably can be treated at home with antibiotics taken by mouth. However, you must keep in close contact with your doctor to be sure that the infection is improving as expected. At home, warm compresses, such as a warm, moist washcloth, and elevation of the infected area can help. If you have severe cellulitis, you may need to be treated in the hospital with antibiotics given intravenously (into a vein).
When To Call A Professional
Call your doctor whenever a skin injury becomes red, warm, swollen or tender. Call your doctor promptly if you get a deep puncture wound, especially on a hand or foot, or if you are bitten by an animal or human.
Prognosis
In most cases, symptoms of cellulitis begin to improve within 24 to 48 hours of starting treatment with appropriate antibiotics. You should always take all the antibiotics prescribed by your doctor, even if you think your infection has been cured.
Additional Info
National
Center for Infectious Diseases
Office of Health Communication
Centers for Disease Control and Prevention
Mailstop C-14
1600 Clifton Rd., NE
Atlanta, GA 30333
Toll-Free: (888) 232-3228
http://www.cdc.gov/ncidod/
---------------------
Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital
Paul Corwin, senior lecturer1, Les Toop, professor1, Graham McGeoch, general practitioner2, Martin Than, consultant in emergency medicine3, Simon Wynn-Thomas, medical director community care2, J Elisabeth Wells, biostatistician1, Robin Dawson, research fellow1, Paul Abernethy, manager community care2, Alan Pithie, consultant physician of infectious diseases3, Stephen Chambers, clinical director of infectious diseases3, Lynn Fletcher, biostatistician1, Dee Richards, senior lecturer1
1 Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand, 2 Pegasus Health PO Box 741, Christchurch, New Zealand, 3 Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand
Correspondence to P Corwin paul.corwin@chmeds.ac.nz
Abstract
Objectives To compare the efficacy, safety, and acceptability of treatment with intravenous antibiotics for cellulitis at home and in hospital.
Design Prospective randomised controlled trial.
Setting Christchurch, New Zealand.
Participants 200 patients presenting or referred to the only emergency department in Christchurch who were thought to require intravenous antibiotic treatment for cellulitis and who did not have any contraindications to home care were randomly assigned to receive treatment either at home or in hospital.
Main outcome measures Days to no advancement of cellulitis was the primary outcome measure. Days on intravenous and oral antibiotics, days in hospital or in the home care programme, complications, degree of functioning and pain, and satisfaction with site of care were also recorded.
Results The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients' satisfaction, which was greater in patients treated at home.
Conclusions Treatment of cellulitis requiring intravenous antibiotics can be safely delivered at home. Patients prefer home treatment, but in this study only about one third of patients presenting t hospital for intravenous treatment of cellulitis were considered suitable for home treatment.
 |
Introduction |
|---|
 TopAbstract Introduction MethodsResultsDiscussionReferences |
|---|
In the three years before this study, Christchurch Hospital admitted more than 500 patients each year for inpatient treatment of cellulitis. In the year before this study 1.7% of all adult medical admissions and 0.7% of surgical admissions were patients with the principal diagnosis of cellulitis. In 2001 Pegasus Health, an independent practitioners' association of 230 general practitioners in Christchurch, started a community care programme that delivered medical and nursing care to patients who would otherwise require hospital admission. The advent of this community care service initiated from general practice provided an ideal opportunity to mount a prospective, randomised trial with the objectives of comparing the safety, efficacy, and acceptability of home treatment with hospital treatment of cellulitis requiring intravenous antibiotics. Our hypothesis was that home treatment of cellulitis with intravenous antibiotics was as effective as hospital treatment and more acceptable to patients.
Methods
No clearcut guidelines exist for when cellulitis requires treatment with intravenous antibiotic other than in case oral antibiotics fail. In this study the decision whether intravenous antibiotics were required was left to the attending doctors in the emergency department who assessed the patient.
No validated objective measures seem to exist of when cellulitis is improving or when patients can be switched from intravenous to oral antibiotics. We chose as our primary outcome measure the time to when the cellulitis failed to advance. This outcome has been used in one previous study.8 Other outcomes recorded included the total numbers of days when patients received intravenous antibiotics and oral antibiotics, and calendar days in hospital or looked after by the home care team. The decision when to switch patients from intravenous to oral antibiotics was left entirely to the attending doctor in the hospital or home. We recorded patients' transfers from home to hospital and the reasons for transfer. We kept a record of all serious complications experienced by patients. We used questionnaires to assess patients' level of functioning and pain as well as satisfaction with their care.
Christchurch Hospital serves the whole metropolitan area of Christchurch (population in 2001 was 318 000), and all acutely referred patients are treated there. We informed all general practitioners in Christchurch and emergency department staff at Christchurch Hospital of this trial before it started.
Protocol
We recruited participants from patients with cellulitis
who were attending Christchurch Hospital's
emergency department,
whether self referred or referred by their general
practitioner or
a general practitioner after hours. Patients who were considered
to
require intravenous antibiotic treatment for cellulitis
by the emergency doctor and who met the
eligibility criteria received
an invitation to take part in the trial.
Patients were eligible for the trial if they had clinical signs of cellulitis, were assessed as requiring intravenous antibiotic treatment because of severity of cellulitis or failure of oral antibiotic treatment, were 16 years or older and mentally competent to give informed consent, had a telephone at home and a caregiver nearby, and were currently resident in the Christchurch metropolitan area.
Exclusion criteria were pregnancy; treatment with intravenous antibiotics for cellulitis of the same site in the preceding month; two or more signs of systemic sepsis (temperature > 38°C or < 36°C, heart rate > 90/min, respiratory rate > 20/min); and a blood count showing a white cell count above 12x109/l or less than 4x109/l and more than 0.1x109/l immature neutrophils.9
Other possible exclusion criteria were signs of severe cellulitis or serious comorbidities such as cellulitis of the face, hands, or over joints; presence of tissue necrosis, severe lymphangitis, blistering, or a very large affected area; comorbidities such as immunosupression, peripheral vascular disease, obesity, alcoholism, or severe diabetes. The more of these relative exclusion criteria were present the more hospital admission was recommended.
Routine blood tests were not required, and the criteria for exclusion were deliberately kept flexible as ultimately the staff in the emergency department often had to make a subjective judgment about the suitability of a patient for entry into the trial. This decision was made independently from the investigators conducting the trial, and junior staff in the emergency department always conferred with consultant staff in making the decision to enrol patients in the trial. Between the hours of 8.00 and 22.00, a member of the study team visited the patient in the emergency department and, after the patient had read the trial information and consent sheets, obtained informed consent. Outside this time patients received an initial dose of intravenous cephazolin and were looked after in the emergency department's observation ward until the following morning when study staff obtained informed consent.
Assignment
Once a patient had given consent he or she was assigned a unique
study
number, and allocation to home or hospital treatment was determined
by phoning an off-site coordinator who kept the randomisation
list
and assigned each study number to either home or hospital treatment.
The randomisation list was produced by SAS code from the
SAS
statistical package (SAS Institute, Cary, NC 27513-2414, USA)
using
randomly allocated block sizes with a maximum of 20.
In each block,
equal allocations were made to the two arms of
the trial.
The study team collected information on the participants in the emergency department, including demographic information (sex, date of birth, ethnicity, address, occupation, community card status); details of any current or recent use of antibiotics, the location of cellulitis; and the presence of any skin necrosis, lymphangitis, blistering, or ulceration.
The researcher drew an indelible line with a marker pen around the peripheral margin of the cellulitis and dated this for comparison on following days.
Before leaving the emergency department, every participant received his or her first intravenous dose of 2 g of cephazolin. If renal impairment was suspected or known, the creatinine concentration was measured and the dose adjusted. Those participants randomly allocated to hospital treatment were then admitted to a hospital ward under the care of the on-call medical team who managed the subsequent clinical treatment, including the choice of ongoing intravenous antibiotic. Participants allocated to hospital treatment were visited each day by the study team to record clinical progress.
Patients who were randomly allocated to community treatment continued with 2 g of intravenous cephazolin (modified in renal impairment) twice daily. Their own general practitioner or a general practitioner from the community care team visited them daily for medical review, and community care nursing staff attended twice daily to monitor the cellulitis and administer intravenous antibiotics. Research staff reviewed community and hospital participant clinical records in all cases. This review included duration of stay, details of antibiotic treatment, and complications.
At entry into the trial and at days 3 and 6, we administered a questionnaire modified from the short form 36 (SF-36) instrument, which focused on functional and physical aspects of health.10 At trial entry we asked patients to respond about their health before the infection, whereas at days 3 and 6, we asked them to respond about their health in the previous 24 hours. We administered questionnaires face to face at trial entry and when participants remained in hospital or by telephone if the patients had left hospital. Patients completed a patient satisfaction questionnaire four weeks after entry into the trial.
Statistical
methods
The study was designed to have 200 participants, 100 in each
arm.
With power of 80% and 
2
= 0.05, a moderate difference of 0.40 standard
deviations was
detectable between the two arms for the primary
outcome of no
advancement of cellulitis.
The clinician researchers thought that a
difference of up to two
days would be acceptable. The standard deviation in each
group was
not known, but as long as it was less than five days the study
had
adequate power. We used survival analysis for the main
clinical
outcomes and, to compare the groups, 
2
tests for contingency tables and t
tests for continuous
variables. We carried out our analyses in SAS,
version 8.02 (SAS
Institute, Cary, NC 27513-2414, USA).
Results
The trial ran from July 2002 until June 2003. We randomised 200 patients meeting the inclusion criteria to receive treatment either at home or in hospital. At the end of the trial we excluded six patients, three from each trial arm (owing to the randomisation process 101 patients were randomised initially to home treatment and 99 to hospital treatment) from the final analysis. Three of these patients had their diagnosis changed after trial entry to dermatitis, erythema nodosum, and a ruptured Baker's cyst. One patient was lost to follow up, one withdrew consent, and one home patient was allergic to cephazolin and had to be withdrawn from the trial as we did not have available an alternative intravenous antibiotic for home treatment at that time. Figure 1 shows the flow of participants through the trial.
|
Clinical
outcomes
The primary clinical outcome was days to no advancement of cellulitis.
The mean was 1.50 (SD 0.11) days for the home treatment
group and
1.49 (0.10) days for the hospital group (mean difference 0.01
days,
95% confidence interval -0.3 to 0.28). Because of the
marked skew in
all clinical outcomes we also compared the treatment
arms by survival
analysis, as shown in figure 2
and table
2. We found no significant differences on any of these
outcomes,
neither for simple comparisons of the two types of care
nor when
controlling for age, sex, location of cellulitis,
and prior use of antibiotics.
|
|
Patients'
satisfaction with site of treatment
Table 3 summarises the patients'
level of satisfaction after
one week of oral antibiotic treatment with the care they
received as
well as their theoretical preference for location of care. Most
patients in both treatment arms were satisfied with the care
they
received. However, only one in 20 of the community arm
would prefer
hospital treatment, whereas one in three of those
receiving hospital
care felt that home care was preferable. These
results strongly imply
that home care is the preferred treatment
choice of cellulitis
patients, particularly those who have
experienced community care.
|
Complications
Eleven patients (12%) randomised to home treatment required transfer
to hospital. Four did not show satisfactory clinical improvement;
one
required surgical drainage under general anaesthetic; and
two needed
insertion of peripherally inserted central catheters. One
patient was
admitted because of an ischaemic toe, one because of
a severe rash,
one because of nausea and vomiting after starting oral
antibiotics,
and one because she was not coping at home.
Three hospital patients (3%) required readmission within one month of discharge for further treatment of their cellulitis. Two hospital patients received peripherally inserted central catheters while in hospital, and two patients required surgical drainage under general or spinal anaesthetic.
Discussion
Many patients with cellulitis thought to require intravenous antibiotics can safely be treated at home under a primary care home treatment programme. The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients' satisfaction, which was greater in patients treated at home.
Strengths
and weaknesses of this study
We conducted a large randomised controlled trial of home treatment
compared
with hospital treatment for cellulitis
requiring intravenous antibiotics. The clinical
outcomes we have
reported of failure of cellulitis
margin to advance, time on intravenous antibiotics, and
time spent in
hospital or in home care are practical clinical outcomes
that could
be used in further reports of cellulitis
treatment. General practitioners could not obtain home
intravenous antibiotic
treatment for their patients in any other way during this
trial,
which ensured that we had good "capture" of patients suitable
for home intravenous treatment. We were not able to keep
a record of cellulitis
patients who declined to be randomised into
this trial as emergency
doctors notified trial staff only of cellulitis
patients thought to be suitable and willing to enter
this study. Only
one trial patient withdrew consent, ensuring a
high participation
rate among randomised patients.
Comparison
with other studies
Our study can be compared with other reports of intravenous treatment
for cellulitis
at home. A study from Australia of 100 patients
being treated for a
variety of conditions generally requiring
hospital treatment (cellulitis,
pneumonia, pyelonephritis, etc) randomised half
to home treatment.7
This study included 37 patients with cellulitis,
but the outcomes for this group of patients was
not described
separately. This study found that patients
treated in hospital had
higher rates of confusion and urinary and bowel
complications.
Overall, the patients treated at home spent
10.1 days in the
programme, whereas the hospital patients stayed
in hospital 7.4 days.
Three other studies from Australia have
described the results of
intravenous treatment of cellulitis
at home.3 4 11
Patients in these studies all needed 5.5-6.5
days of intravenous
treatment at home. In these studies, 5.8-7.8%
of patients treated at
home required transfer to hospital. These
figures are broadly in
keeping with our results, but patients in both
of our treatment arms
were kept on intravenous treatment for a
shorter duration than in the
above studies. Other reports of outpatient
treatment with parenteral
antibiotics exist, but they do not give
sufficient detail on the
outcomes of cellulitis
treatment to compare usefully with this study. A US based
registry for
outcomes of outpatient treatment with parenteral antibiotics
collects
information from 24 participating sites. This registry has
recorded a
12.6% rate of transfer to hospital for more than 5000
patients
treated outside hospital with intravenous antibiotics.12
Other studies may have had a different threshold of severity of cellulitis in assessing the need for intravenous treatment and for when hospital admission should be considered mandatory. Almost 75% of our patients started receiving intravenous antibiotics after oral antibiotics had failed. This is a much higher proportion than reported in other studies and indicates that our threshold for giving intravenous antibiotics was appropriate.2 4 7
The high degree of satisfaction with home treatment we found has been reported from other studies of "hospital at home" programmes.13 14
Two studies from Australia and one from the United States have compared the costs of treatment for cellulitis and other acute medical conditions at home and in hospital.2 6 15 These studies found that home treatment was about half as costly as hospital treatment.
Other
reports of home intravenous treatment have been hospital outreach
programmes, and this study shows that a programme initiated and
delivered from general practice can achieve satisfactory clinical
outcomes. The successful operation of this programme was
dependent on
a small group of trained nurses and general practitioners
who were
able to offer support to their colleagues in
delivering treatment
with intravenous antibiotics.
|
Meaning of this
study
Patients in the two treatment arms were comparable. These findings
should
be generalisable to other settings with comparable systems of
healthcare delivery. It must be noted that only about a third
of
patients requiring intravenous antibiotics for cellulitis
were considered suitable for home treatment during the study
period.
In total 558 adult patients with a primary diagnosis of
cellulitis
(including those in this study who were randomised to
hospital
treatment) were admitted to Christchurch Hospital during
the study
period. Many patients with cellulitis
will require admission to hospital because of
their frailty,
comorbidities, home situations, or the severity
of their cellulitis.
Patients with cellulitis
require careful and daily monitoring as some will
require transfer to
hospital. It is possible that more patients
with cellulitis
could have been considered for home treatment.
Patients clearly much
prefer home treatment for cellulitis.
Unanswered
questions and future research
Having twice daily visits from the nurse increased the costs
of home
treatment in this study. A report of home treatment using
once daily
intravenous antibiotics and nurse visits has shown
that this is a
safe option.11
We considered that only about
one third of patients requiring intravenous antibiotics for
cellulitis
were suitable for home treatment, and it is possible that
a higher
proportion of cellulitis
patients could have been safely treated at
home. This study was too
small to study predictors of failure of home
intravenous antibiotic
treatment.
We thank Pegasus Health and their extended care nurses and the staff of the emergency department of Christchurch Hospital and Felicity Beats, Margaret Sutherland, and Alison Parsons.
Contributors: PC, LT, SC, AP, and GM conceived the study. PC wrote the protocol and supervised the trial and interpretation and drafted the paper with contributions from the other authors and is guarantor. EW worked on the design of the study and supervised the data analysis and LF provided statistical advice and performed the data analysis.
Funding: This study was supported by Pegasus Health. RD was a research fellow funded by Pegasus Health. The guarantor accepts full responsibility for the conduct of the study, had full access to the data and controlled the decision to publish and received no funding from Pegasus Health.
Competing interests: None declared.
Ethical approval: Canterbury Ethics Committee.
References
---------------------
Clinical Abstracts and Related Articles:
Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings
Clin Infect Dis. 2008 Mar
Department of Bacterial and Inflammatory Diseases, National Public Health Institute, Helsinki, Finland. tuula.siljander@ktl.fi
BACKGROUND: Bacterial, nonnecrotizing cellulitis is a localized and often recurrent infection of the skin. The aim of this study was to identify the beta-hemolytic streptococci that cause acute nonnecrotizing cellulitis infection in Finland.
METHODS: A case-control study of 90 patients hospitalized for acute cellulitis and 90 control subjects was conducted during the period of April 2004-March 2005. Bacterial swab samples were obtained from skin lesions or any abrasion or fissured toe web. Blood culture samples were taken for detection of bacteremia. The patients, their household members, and control subjects were assessed for pharyngeal carrier status. beta-Hemolytic streptococci and Staphylococcus aureus were isolated and identified, and group A and G streptococcal isolates were further analyzed by T serotyping and emm and pulsed-field gel electrophoresis typing.
RESULTS: beta-Hemolytic streptococci were isolated from 26 (29%) of 90 patients, 2 isolates of which were blood-culture positive for group G streptococci, and 24 patients had culture-positive skin lesions. Group G Streptococcus (Streptococcus dysgalactiae subsp. equisimilis) was found most often and was isolated from 22% of patient samples of either skin lesions or blood, followed by group A Streptococcus, which was found in 7% of patients. Group G streptococci were also carried in the pharynx of 7% of patients and 13% of household members but was missing from control subjects. Several emm and pulsed-field gel electrophoresis types were present among the isolates. Six patients (7%) had recurrent infections during the study. In 2 patients, the group G streptococcal isolates recovered from skin lesions during 2 consecutive episodes had identical emm and pulsed-field gel electrophoresis types.
CONCLUSIONS: Group G streptococci, instead of group A streptococci, predominated in bacterial cellulitis. No clear predominance of a specific emm type was seen. The recurrent nature of cellulitis became evident during this study.
PMID: 18260753 [PubMed - indexed for MEDLINE]
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Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis
Br J Dermatol. 2008 Jan 30
Department of Dermatology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.
Background Cellulitis is a common cause for admission to hospital, and repeated episodes are thought to damage the lymphatic system. Lymphoedema is recognized as a condition predisposing to cellulitis but there are no data to suggest its prevalence among a population presenting to hospital with acute cellulitis. Objectives To ascertain whether lymphatic abnormalities represent a common problem in patients with lower limb cellulitis. Methods Patients admitted with cellulitis of the lower limb were invited to undergo clinical examination and lymphoscintigraphy. Results Thirty patients agreed to participate in the study. Fifteen underwent lymphoscintigraphy. Thirteen had abnormal scans indicating impaired lymph drainage (seven patients had clinical lymphoedema). Conclusions Lymphatic abnormalities represent an important but unrecognized problem in patients with leg cellulitis.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2133.2007.08423.x
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Incidence
of lower-extremity cellulitis: a population-based study in olmsted
county,
Minnesota.
Mayo Clin Proc. 2007 Jul
McNamara DR, Tleyjeh IM, Berbari EF, Lahr BD, Martinez JW, Mirzoyev SA,
Baddour
LM.
Division of Infectious Diseases, MeritCare Health System, PO Box MC,
Fargo, ND
58122 (e-mail: mcnamara.david@mayo.edu).
OBJECTIVE:
To determine the
population-based incidence of lower-extremity cellulitis.
METHODS: We
performed a population-based
survey with the resources of the Rochester Epidemiology Project in
Olmsted
County, Minnesota. We identified residents of Olmsted County who sought
care for
cellulitis from January 1, 1999, through December 31, 1999, reviewed
medical
records to ascertain agreement with a case definition of
lower-extremity
cellulitis, and calculated the population-based incidence of
lower-extremity
cellulitis.
RESULTS:
During 1999, 176 episodes met
the case definition of lower-extremity cellulitis; the incidence of
lower-extremity cellulitis in Olmsted County was 199 per 100,000
person-years.
not allowed-specific incidence was 197 per 100,000 person-years for
women and
201 per 100,000 person-years for men. In a not allowed-adjusted model,
the
incidence increased 3.7% (95% confidence interval, 2.9%-4.5%) per year
increment
in age or 43.8% (95% confidence interval, 33.6%-54.7%) per 10-y
