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Cellulitis

See also: Leg Cellulitis
                  Arm Cellulitis

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Related Terms:  lymphedema, arm celllulitis, leg cellulitis, facial cellulitis, 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,  skin infection, chronic skin conditions, eczema, psoriasis, diabetes,  skin inflammation, connective tissue 
inflammation

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.

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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.

Risk Factors

• Cracks or peeling skin between the toes

• History of peripheral vascular disease 

• Injury or trauma with a break in the skin (skin wounds)

• Insect bites and stings animal bites, or human bites

• Ulcers from certain diseases, including diabetes and vascular disease

• Use of corticosteroid medications or medications that suppress the immune system

• Wound from a recent surgery

• Lymphedema

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. 

Diagnosis

The basic way of diagnosing cellulitis is through a physical exam of the effected  area, inconjunction with the above symptoms.  Rememer, the area may be very red, warm to the touch, swollen and painful.

The doctor will also look for any cuts, scrapes, bites, ulcers or bruises, each is where bacteria could have entered the body.

Additional tests such as a blood test or culture may also be needed to determine the type of bacteria causing the infection.

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.

Dental infections account for approximately eighty percent of cases of Ludwig's angina, or cellulitis of the submandibular space. Mixed infections, due to both aerobes and anaerobes, are commonly associated with the cellulitis of Ludwig's angina. Typically this includes alpha-hemolytic streptococci, staphylococci and bacteroides groups.

Predisposing conditions for cellulitis include insect or spider bite, blistering, animal bite, tattoos, pruritic (itchy) skin rash, recent surgery, athlete's foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted intravenous injection "misses" or blows the vein), pregnancy, diabetes and obesity, which can affect circulation, as well as burns and boils, though there is debate as to whether minor foot lesions contribute.

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.

Conditions that reduce the circulation of blood in the veins or that reduce circulation of the lymphatic fluid (such as venous insufficiency, obesity, pregnancy, or surgeries) also increase the risk of developing cellulitis.

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 meningitis (brain and spinal cord infection;  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. 

Osteomyelitis  Is a serious bone infection that commonly originates in another part of the body and is transported to the bone through the blood..  Symptoms of this infection may appear as: bone pain; fever; chills; low back pain; swelling of thre ankles; excessive sweating, Older age, as your circulation grows weaker with age, it' s easier for skin abrasions to become infected.

Calling the doctor

Call your doctor if you have any of the following signs or symptoms of cellulitis:

• Fevers or chills, Redness on the skin, increased warmth in the affected area,   red streaks on the skin,   swelling, tenderness, drainage from the skin.

I
If you have lymphedema, I would go even further and  urge  you to go immediately to the emergency
room, even with the above signs. 

Other advice is clear that you should go to the hospital's emergency department if you have any signs or symptoms of cellulitis, especially the following:

• High fevers or chills, nausea and vomiting, Obvious enlargement or hardening of the reddened area, in creasing pain, numbness of the reddened or tender area when lightly touched, other medical problems that may be affected by even a minorinfection, such as diabetes.

I
ITreatment

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. The types of antibiotic treatments include oral, topical (for a wound or skin cut) and intravenous antibiotics.  Often it is only the IV antibiotic that  can actually penetrate the fibrotic lympedema tissue to reach the bacteria.

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.  Lymphedema patients also need to elevate the effected limb, stop using compression garments and/or bandages until the infection has cleared.

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.

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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.

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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.

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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.
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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.

IIf 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.

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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.

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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.)

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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.

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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.
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Outdoors: Always when outdoors, use an insect repellant. A simple mosquito bite or flea bite can quickly send us to the hospital

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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.
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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.

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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

• It is very important to keep your skin clean by practicing good personal hygiene.

• If you notice pain or discomfort from an area of the skin, check to see what it looks like. If it appears inflamed and progresses from one day to the next, you will most likely need treatment.

• Avoid situations that may injure your skin, especially if you have swelling from circulatory problems.

• Wear sturdy, well-fitting shoes or slippers with loose-fitting cotton socks. Avoid walking barefoot in areas where you do not have a good idea about what you are walking on, for example, in garages, on a littered beach, or in the woods.

• If you do injure your skin wash the area with soap and water and check to make sure that the injury is getting better over the next several days.
  
• Certain injuries may be at greater risk for infection than others. You may need to take antibiotics to prevent infection or have other preventive care. Be sure to contact your doctor if you have injuries such as these:
  

  • Animal or human bites

  • Puncture injuries deeper than a half-inch, such as stepping on a nail
    
  • Crushed tissue that bleeds, burns that blister, frostbite, or deep injuries with dirt in them
    
  • Injuries in contact with sea water, especially if you have liver disease
    
• Find out if you have diabetes or other significant medical conditions, such as liver or kidney disease. These conditions may be present without symptoms. Follow your doctor's instructions for improving these conditions.
  
• Talk to your doctor if you have swelling in your limbs that does not go away.

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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

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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. 

Lymphoedema Support Network

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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 )

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Cellulitis

Medline Plus Medical Encyclopedia 

National Institutes of Health

Alternative names 

Skin infection - bacterial

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:

• Insect bites and stings; animal bite or human bite
• Injury or trauma with a break in the skin (skin wounds)
• History of peripheral vascular disease
• Diabetes-related or ischemic ulcers
• Recent cardiovascular, pulmonary (lung), dental or other procedures
• Use of immunosuppressive or corticosteroid medications

Symptoms  

• Localized skin redness or inflammation that increases in size as the infection spreads
• Tight, glossy, "stretched" appearance of the skin
• Pain or tenderness of the area
• Skin lesion/rash (macule):
  • Sudden onset
  • Usually with sharp borders
  • Rapid growth within the first 24 hours
• Warmth over the area of redness
• Fever
• Other signs of infection:
  • Chills, shaking
  • Warm skin, sweating
  • Fatigue
  • Muscle aches, pains (myalgias)
  • General ill feeling (malaise)

Additional symptoms that may be associated with this disease:

• Nausea and vomiting
• Joint stiffness caused by swelling of the tissue over the joint
• Hair loss at the site of infection

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:

• A CBC may show an elevated white blood cell count, and indicates a bacterial infection.
• A blood culture may be performed if generalized infection is suspected.

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   

• Tissue death (gangrene)
• Sepsis, generalized infection and shock
• Meningitis (if cellulitis is on the face)
• Lymphangitis (inflammation of the lymph vessels)

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: 10/25/2002

Updated by: Michael Lehrer, M.D., Department of Dermatology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.   

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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

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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]

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Cellulitis

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. Prevent skin injury — Wear protective gloves while gardening and working outdoors. Wear long sleeves and trousers while hiking, and avoid going barefoot outdoors. Wear protective padding on elbows and knees while skating.TreatmentCellulitis 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.

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:

Periorbital cellulitis, a skin infection around the eye sockets (orbits) — Often, this is caused by Haemophilus influenza, a type of bacterial infection that is common in children. Because infection around the eye can spread to the brain, periorbital cellulitis requires prompt medical attention.

Erysipelas, a form of skin infection that produces raised, firm, bright red patches of skin — Usually, it is caused by Streptococcus bacteria. Erysipelas occurs most often on an arm or leg that has been damaged by previous surgery or is chronically swollen due to poor lymph flow (lymphedema). Erysipelas also can develop on the face, typically across the bridge of the nose and upper cheeks.

Necrotizing fasciitis, also known as "flesh-eating strep" — This is an infection of the tissues below the skin, rather than the skin itself. Often, the overlying skin is discolored and extremely painful. Fasciitis is a life-threatening infection that requires prompt medical attention.

Symptoms

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:

Had recent injuries such as cuts, scrapes, bites, or puncture wounds

Previously injured the area or been operated on there.

Had unusual exposures such as fish tanks, pond water, or animals

Underlying medical problems that increase your risk for complications

Shaking chills or other symptoms that suggest the infection has spread to the bloodstream or to surrounding organs

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:

Treat minor skin wounds promptly — Gently wipe away any dirt, wash with antibiotic soap, apply antibiotic ointment, and cover with a clean bandage.

Seek medical attention — Medical attention is needed for all deep puncture wounds and animal bites and for all deep wounds involving a joint, hand or foot.

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

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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

Top Abstract Introduction Methods Results Discussion References

 
Cellulitis, an acute bacterial infection of the skin and subcutaneous tissues, is a common condition that often requires treatment with intravenously administered antibiotics. This treatment is delivered in hospital in most countries, but intravenous treatment at home is used increasingly, particularly in the United States where insurance companies are reluctant to fund more expensive hospital treatment.¹ Many retrospective reports exist on the outcomes of intravenous antibiotic treatment for cellulitis at home, which indicate that this is a safe alternative to inpatient treatment in hospital.^2-6 Only one small prospective randomised trial has been reported that compared treatment at home with treatment in hospital, which included 37 patients with cellulitis.⁷ This study concluded that home treatment for conditions such as cellulitis and pneumonia was safe and associated with fewer adverse complications in elderly patients.

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.

View this table: [in this window] [in a new window]   Table 1 Characteristics of patients at baseline. Values are percentages (numbers) of patients unless otherwise indicated

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.

View larger version (32K): [in this window] [in a new window]   Fig 2 Kaplan-Meier plots for primary and secondary outcomes

 

View this table: [in this window] [in a new window]   Table 2 Home care versus hospital care: hazard ratios with 95% confidence intervals

 Patients' functional outcomes
We used independent t tests to analyse modified SF-36 questionnaires administered at baseline and at days 3 and 6 and found no significant differences in levels of physical functioning or pain between the two treatment arms (see appendix and table A on bmj.com))

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.

View this table: [in this window] [in a new window]   Table 3 Patients' satisfaction with care after one week on oral antibiotics

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.

What is already known on this subject Intravenous antibiotic treatment of cellulitis can be delivered in the home The safety, efficacy, and costs of home treatment compared with hospital treatment have not been studied extensively What this study adds Intravenous antibiotic treatment can be delivered safely and effectively in patients' homes Patients prefer home treatment This home based treatment programme was initiated and delivered from primary care rather than a hospital outreach programme

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.

An appendix and table showing mean scores on the SF-36 with standard deviations for days 3 and 6 are on bmj.com

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

1. Nathwani D, Tice A. Ambulatory antimicrobial use: the value of an outcomes registry. J. Antimicrob. Chemother 2002;49: 149-54. [Abstract/Free Full Text]
2. Grayson ML, Silvers J, Turnidge J. Home intravenous antibiotic therapy. A safe and effective alternative to inpatient care. Med J Aust 1995;162: 249-53. [ISI][Medline]
3. Leder K, Turnidge JD, Grayson ML. Home-based treatment of cellulitis with twice-daily cefazolin. Med J Aust 1998;169: 519-22. [ISI][Medline]
4. Montalto M, Dunt D. Home and hospital intravenous therapy for two acute infections: an early study. Aust N Z J Med 1997;27: 19-23. [ISI][Medline]
5. Tice AD. Experience with a physician-directed, clinic-based program for outpatient parenteral antibiotic therapy in the USA. Eur J Clin Microbiol Infect Dis 1995;14: 655-61. [ISI][Medline]
6. Dall L, Peddicord T, Peterson S, Simmons T, Dall T. Hospitalist treatment of CAP and Cellulitis using objective criteria to select patients. Infect Med 2003;20: 379-90. [ISI]
7. Caplan GA, Ward JA, Brennan NJ, Coconis J, Board N, Brown A. Hospital in the home: a randomised controlled trial. Med J Aust 1999;170: 156-60. [ISI][Medline]
8. Eron LJ, Passos S. Early discharge of infected patients through appropriate antibiotic use. Arch Intern Med 2001;161: 61-5. [Abstract/Free Full Text]
9. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. ACCP/SCCM Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101: 1644-55. [Abstract]
10. Australia/New Zealand Standard SF-36 Health Survey: Medical Outcomes Trust, 1994.
11. Grayson ML, McDonald M, Gibson K, Athan E, Munckhof WJ, Paull P, et al. Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the treatment of moderate-to-severe cellulitis in adults. Clin Infect Dis 2002;34: 1440-8. [CrossRef][ISI][Medline]
12. Outpatients Parenteral Antimicrobials Therapy. OPAT outcomes registry.www.opat.com/usregistry/ (accessed 29 Nov 2004).
13. Montalto M. Patients' and carers' satisfaction with hospital-in-the-home care. Int J Qual Health Care 1996;8: 243-51. [Abstract]
14. Dubois A, Santos-Eggimann B. Evaluation of patients' satisfaction with hospital-at-home care. Eval Health Prof 2001;24: 84-98. [Abstract/Free Full Text]
15. Board N, Brennan NJ, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health 2000;24: 05-11. 

BMJournals

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Clinical Abstracts and Related Articles:

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Oxacillin or cefalotin treatment of hospitalized children with cellulitis. 

Jan 2012

NIH.go.jp

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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.  

Blackwell

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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-year increment.

The incidence of cellulitis significantly increased with age (P less than .001 in Poisson regression) but was not statistically significantly different between the sexes. 

CONCLUSIONS: The incidence of lower-extremity cellulitis in this population-based study was high and was affected by age. In contrast, not allowed did not influence infection incidence.

The need for hospitalization and the prevalence of recurrence of lower-extremity cellulitis added to the burden of disease in Olmsted County.

llink no longer available Mayo Clinic

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Cellulitis and treatment: a qualitative study of experiences

Br J Nurs. 2007 Mar

Carter K, Kilburn S, Featherstone P.
Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth.

Although cellulitis is usually a relatively mild condition, it is potentially life-threatening, often necessitating emergency treatment in either the acute or community care settings. The treatment of cellulitis with antibiotics is well established, with effectiveness generally measured against purely biochemical and clinical outcomes (Cox, 2002).

Although important, these outcomes are centred purely on the disease process from the medical perspective and little is known about patients' experiences of cellulitis. This qualitative study explores patients' views on the management of community-acquired cellulitis in the secondary healthcare setting. Data were collected through semi-structured groups and individual telephone interviews. Participants were selected through purposive sampling and the Framework Analysis Technique was used to analyse the data.

Three superordinate themes emerged: initial presentation/motivation for seeking help; confidence and satisfaction; anxiety and dissatisfaction.

Severe pain was almost universally a cause of distress and flu-like symptoms delayed recognition. Health information and communication was generally poor. Participants largely welcomed a move from inpatient to day-patient or outpatient care provided there was adequate information and support.

To meet the diverse needs of cellulitis patients, services must be more flexible and tailored to the needs of the individual. Patients are often not told what they can do to prevent recurrence.

PubMed

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A predictive model of recurrent lower extremity cellulitis in a population-based cohort

Arch Intern Med. 2007 Apr 9

Department of Medicine, College of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. mcnamara.david@mayo.edu

BACKGROUND: Cellulitis is common and recurs in some patients. The study described herein derived a predictive model for the recurrence of lower extremity cellulitis in a population-based cohort. 

METHODS: We conducted a retrospective, population-based cohort study using the Rochester Epidemiology Project. We reviewed the medical records of Olmsted County, Minnesota, residents with lower extremity cellulitis occurring from January 1, 1999, to June 30, 2000. Univariate and multivariate Cox proportional hazards analyses were performed to evaluate risk factors in patients who experienced recurrent lower extremity cellulitis within 2 years. A predictive model was developed to estimate risk of recurrence based on a score of risk factors identified by multivariate analysis.

RESULTS: A total of 209 episodes met the definition of lower extremity cellulitis. Thirty-five patients (16.7%) experienced recurrence within 2 years. Multivariate analysis identified tibial area involvement, prior malignancy, and dermatitis affecting the ipsilateral limb as independent risk factors for recurrence, with hazard ratios of 5.02, 3.87, and 2.99 (P<.01), respectively. A score calculated from these variables (a count of 0, 1, 2, or 3) was developed to measure risk of recurrence. Based on the predictive model, the estimated probability of recurrence (95% confidence interval [CI]) within 2 years was 5.0% (95% CI, 1.6%-8.2%), 17.3% (95% CI, 11.1%-23.0%), 50.6% (95% CI, 34.2%-63.0%), or 92.8% (95% CI, 51.9%-98.9%) for a score of 0, 1, 2 or 3, respectively.

CONCLUSIONS: We derived a model including tibial area involvement, history of cancer, and dermatitis to predict recurrence of lower extremity cellulitis. Potential interventions can be incorporated into treatment to diminish the proclivity for recurrence in high-risk patients.

Archives of Internal Medicine * Link not available

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Lower limb cellulitis: features associated with length of hospital stay

J Infect. 2006 Jan

Morpeth SC, Chambers ST, Gallagher K, Frampton C, Pithie AD.
Department of Infectious Diseases, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand.

AIMS: This study aimed to identify features associated with length of hospital stay (LOHS), length of intravenous antibiotic therapy (LIVAT) and six-week outcomes for patients with lower limb cellulitis, and to test the Eron/Passos classification of cellulitis in the New Zealand system.

METHODS: Eighty-five variables were collected prospectively from a cohort of 51 inpatients admitted to Christchurch hospital. The primary end-point for analysis was LOHS. LIVAT and six-week outcomes were secondary end-points.

RESULTS: On univariate analysis use of diuretics, living alone, cellulitis acuity, a creatinine concentration of >0.1 mmol/l, poor mobility, pulse >90 bpm, age >70 years, oedema extent, chronic oedema, ulceration, neutrophil count >10x10(9)/l, erythema area >1000 cm2 and haemoglobin concentration less than normal were significantly (P= or <0.05) or ="3">7 days was associated with use of diuretics, living alone, age >70 years, more oedema, erythema area >1000 cm2, haemoglobin less than normal, ulceration, creatinine >0.1 mmol/l and poor mobility. The presence of a discharge was associated with LIVAT. Multivariate analysis accounted for 48% of the variance in LOHS and 16% for LIVAT. Use of diuretics, neutrophil count >10x10(9)/l and oedema score were independently associated with LOHS, with oedema score associated with short stay and diuretic use with long stay. The Eron/Passos system was not helpful so a new scoring system was devised which successfully classified patients into length of stay groups.

CONCLUSIONS: The clinical features analysed accounted for half of the variance in LOHS. An important reason may be physician discretion. If so, our scoring system based on these results could be used in a clinical pathway to improve patient care. This tool would need to be evaluated prospectively.

Science Direct * Link not available

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Delayed breast cellulitis: an evolving complication of breast conservation

Int J Radiat Oncol Biol Phys. 2006 Dec

Indelicato DJ, Grobmyer SR, Newlin H, Morris CG, Haigh LS, Copeland EM, Mendenhall NP.
Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA.

Keywords: Breast cancer, Delayed breast cellulitis, Breast conservation therapy, Radiation therapy, Lymphedema, Infection

PURPOSE: Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC.

METHODS AND MATERIALS: From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome.

RESULTS: Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC.

CONCLUSION: Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.

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Bacterial cellulitis. Forms borderline between medical and surgical (3 cases)

Pavlovic M, Le Breton C, Granier F, Fouchard N, Saiag P.
Service de Dermatologie, Hopital Ambroise Pare, Boulogne, France.

BACKGROUND:

An acute infectious cellulitis may be managed medically (erysipelas or non-necrotizing infectious cellulitis) or surgically (necrotizing infectious cellulitis, necrotizing fasciitis). We report 3 cases of non-necrotizing infectious cellulitis borderline between medical and surgical forms, complicated by compartment syndrome, the surgical decompression of which permitted patients' cure.

CASE REPORTS:

Three patients, 27, 52 and 84 years old, were admitted for an acute infectious cellulitis of the leg. At admission, the leg area involved was erythematous, painful, indurated, with one or several bullae, purpura, pustules, hypoesthesia or limited skin necrosis, and no immediate need for surgical exploration. The clinical evolution was characterized by the slow appearance or extension of signs of severity, despite the modification in antibiotic treatment. Magnetic resonance imaging findings were indicative of a non-necrotizing infectious cellulitis in 2 patients. In one patient, necrotizing fasciitis could not be excluded. In all patients, surgical exploration showed an important quantity of non-purulent fluid between muscles and hypodermis, with no evidence of abscess or necrosis. A large incision rapidly cured all patients.

DISCUSSION:

These three observations were characterized by the initial signs of moderate severity and no response to an appropriate medical treatment, which led to surgical exploration. Surgery showed no abscess or necrosis but an important quantity of sterile fluid; it also permitted rapid cure of patients. These cases present a borderline form of infectious cellulitis, with severe local inflammation caused by a compartment syndrome. Surgical decompression was needed for cure. The potential value of magnetic resonance imaging in this situation should also be stressed.

Masson.fr 

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Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study.

1: J Eur Acad Dermatol Venereol. 2006 Aug;20(7):818-22

Vignes S, Dupuy A.
Department of Lymphology, Hopital Cognacq-Jay, Paris, France. stephane.vignes@hopital-cognacq-jay.fr

OBJECTIVE: To identify the predictors of successful antibiotic prophylactic treatment using benzathin-penicillin G to prevent recurrence of erysipelas in patients with secondary upper limb lymphoedema. 

DESIGN: A retrospective cohort study.

SETTING AND PATIENTS: Patients with secondary arm lymphoedema were recruited in a single lymphology unit between 1990 and 2003. All patients had had at least three recurrences of erysipelas. Patients were given 2.4 MU benzathin-penicillin G intramuscularly at 14-day intervals. For each patient, the following data were recorded: characteristics of breast cancer treatment (type of surgery, radiotherapy, hormone therapy), number of erysipelas recurrences before inclusion, patient characteristics including body mass index (BMI) and lymphoedema volume at inclusion.

MAIN OUTCOME MEASURES: The outcome studied was the occurrence of erysipelas on the affected arm under antibiotic prophylactic treatment.

RESULTS: With a 4.2-year median follow-up from the onset of antibiotic prophylactic treatment, 23 of 48 women experienced recurrence of erysipelas. The median duration of erysipelas recurrence-free period under this treatment was 2.7 years. The estimated rate of recurrence was 26%[95% confidence interval (CI) 13-38%] at 1 year and 36% (95% CI 22-50%) at 2 years. No patient stopped the treatment because of side-effects. No predictive factor of erysipelas recurrence under antibiotic prophylactic treatment was identified.

CONCLUSIONS: Antibiotic prophylaxis using benzathin-penicillin is a well-tolerated treatment of erysipelas recurrence in patients with upper limb lymphoedema secondary to breast cancer. The rate of erysipelas recurrence was 26% at 1 year in patients who had a history of at least one erysipelas. We did not find any predictor

Blackwell Synergy

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Cellulitis of the breast as a complication of breast-conserving surgery and irradiation.

Hughes LL, Styblo TM, Thoms WW, Schwarzmann SW, Landry JC, Heaton D, Carlson GW, Wood WC.
Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA.

Breast-conserving therapy (BCT) has become a standard treatment option for patients with early-stage breast cancer. We have observed cellulitis of the treated breast as a complication occurring before, during, and after breast irradiation. The cases of five women (median follow-up, 28 months; range, 24-65 months) who developed cellulitis before (n = 1), during (n = 2), or after (n = 2) breast irradiation were reviewed. A consecutive series of BCT patients at Emory University was reviewed to determine the incidence of this complication. Four of five women had an axillary dissection, yielding a median of 14 negative lymph nodes (range, 6-22 nodes).

Two of four patients developed axillary seromas requiring aspiration. In these four patients, only the breast was irradiated. A fifth patient had no axillary dissection and had breast and supraclavicular/axillary irradiation. The median whole breast dose was 50 Gy (range, 46-50.4 Gy). The clinical features of cellulitis included erythema, edema, tenderness, and warmth in all patients. Cellulitis was a relapsing problem for four of the five patients. The incidence of this complication in our series of BCT patients was approximately 1%. Cellulitis in the ipsilateral breast can be a relapsing complication of BCT and can be seen before, during, or after breast irradiation. Axillary seromas and aspiration seem to indicate a subset of patients at risk of early cellulitis.

Late cellulitis may be caused by a variety of factors related to modifications of vascular and skin integrity by surgery and radiotherapy. Prompt diagnosis and appropriate antibiotic therapy is recommended. This problem need not interrupt a course of breast irradiation, and does not necessarily lead to a poor cosmetic result.

PMID: 9256885 [PubMed - indexed for MEDLINE]

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A systematic review of bacteremias in cellulitis and erysipelas. 

Nov 2011

External Links:

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Burden of facial cellulitis: estimates from the Nationwide Emergency Department Sample. Jan 2012

Elsevier

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Streptococcus salivarius cellulitis and bacteremia in a cirrhotic patient 

Jan 2012

ElsevierDoyma

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Risk factors of cellulitis treatment failure with once-daily intravenous cefazolin plus oral probenecid. 

Dec. 2011

Lippincott Williams Wilkins

http://journals.lww.com/smajournalonline/pages/articleviewer.aspx?year=2011&issue=12000&article=00003&type=abstract

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Sudden orbital cellulitis in the emergency unit 

Oct 2011 

PubMed

http://www.ncbi.nlm.nih.gov/pubmed/22141256

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Intramuscular metastasis of malignant melanoma mimicking leg cellulitis. 

Nov 2011 

John Libbey Eurotext European Journal of Dermatology

http://www.jle.com/en/revues/medecine/ejd/e-docs/00/04/6E/F2/resume.phtml

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Mediastinitis complicating a cervical cellulitis of dental gateway: report of a case and literature review 2011 

PubMed Central

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201590/?tool=pubmed

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Periorbital mass with cellulitis caused by dirofilaria.  

Oct 2011 

Indian Journal of Medical Microbiology

http://www.ijmm.org/article.asp?issn=0255-0857;year=2011;volume=29;issue=4;spage=431;epage=433;aulast=Joseph

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Risk factors for acute cellulitis of the lower limb: a prospective case-control study

UnivChicago

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Risk factors for bacteremia in patients with limb cellulitis

Springerlink

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Delayd cellulitis associated with conservative therapy for breast cancer.

PubMed

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Delayed breast cellulitis following breast conserving operation.

PubMed

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Breast cellulitis after conservative surgery and radiotherapy.

PubMed

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Cellulitis - The Merck Manual

http://www.merck.com/mmhe/sec18/ch211/ch211b.html

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Cellulitis Staphylococcal

http://www.fpnotebook.com/DER/Bacteria/Clts.htm

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Article: The Use of Compression Therapy During Infections

By Renee Romero, RN, BSN, MS, LMT

http://www.elymphnotes.org/detail.asp?ci=54&it=IPI

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Cellulitis

Last Updated: January 11, 2002

Author: Danny Lee Curtis, MD, Consulting Staff, Department of Emergency Medicine, Community Hospital of New Port Richey

http://www.emedicine.com/emerg/topic88.htm

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Cellulitis

Medline Plus

http://www.nlm.nih.gov/medlineplus/cellulitis.html

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Cellulitis

MedicineNet.com

http://www.medicinenet.com/Cellulitis/article.htm

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Cellulitis

New Zealand Derm Net

http://www.dermnetnz.org/bacterial/cellulitis.html

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Cellulitis

http://www.mayoclinic.com/health/cellulitis/DS00450

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ICD9 - ICD10 - Related Resource Information

ICD-10	L03. -  L03.0) Cellulitis of finger and toe Paronychia (L03.1) Cellulitis of other parts of limb (L03.2) Cellulitis of face (L03.3) Cellulitis of trunk (L03.8) Cellulitis of other sites (L03.9) Cellulitis, unspecified
ICD-9	2008 ICD-9-CM Diagnosis 682.9 Cellulitis and abscess of unspecified sites 682.9 is a specific code that can be used to specify a diagnosis 682.9 contains 27 index entries View the ICD-9-CM Volume 1 682.* hierarchy 682.9 also known as: Abscess NOS Cellulitis NOS Lymphangitis, acute NOS 682.9 excludes: lymphangitis NOS (457.2)
DiseasesDB	29806
eMedicine	med/310  emerg/88 derm/464
MeSH	D002481

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Diagnostic Images

Google Images

http://images.google.com/images?hl=en&q=cellulitis&gbv=2

Yahoo images

http://images.search.yahoo.com/search/images;_ylt=A0geu5m5t_VHPQ8B_qVXNyoA?ei=UTF-8&p=cellulitis&fr2=tab-web&fr=yfp-t-501

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Related Lymphedema People Medical Blogs and Pages:

Bacterial Infections

http://bacteriainfections.blogspot.com

Antibiotics

http://antibioticinformation.blogspot.com/

Cellulitis

http://cellulitisinfections.blogspot.com/

MRSA Information

http://mrsainformation.blogspot.com/

Antibiotic Glossary

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=34

Antibiotic Therapy, Types of Antibiotics

http://www.lymphedemapeople.com/thesite/lymphedema_antibiotics.htm

===========================

Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe:

AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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For information about Lymphedema

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For Information about Lymphedema Complications

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For Lymphedema Personal Stories

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For information about How to Treat a Lymphedema Wound

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For information about Lymphedema Treatment 

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For information about Exercises for Lymphedema 

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For information on Infections Associated with Lymphedema

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For information on Lymphedema in Children

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Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

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Lymphedema People - Support Groups

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

......................

Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

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Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

===========================

Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet?  Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more.  Come and take a stroll! 

Lymphedema Glossary 

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing 

Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema 

Arm Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema 

Leg Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema 

Acute Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema 

The Lymphedema Diet 

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet 

Exercises for Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema 

Diuretics are not for Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=diuretics_are_not_for_lymphedema 

Lymphedema People Online Support Groups 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_people_online_support_groups 

Lipedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lipedema 

Treatment 

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment 

Lymphedema and Pain Management 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pain_management 

Manual Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)

http://www.lymphedemapeople.com/wiki/doku.php?id=manual_lymphatic_drainage_mld_complex_decongestive_therapy_cdt 

Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema 

How to Treat a Lymphedema Wound 

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound 

Fungal Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=fungal_infections_associated_with_lymphedema 

Lymphedema in Children 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children 

Lymphoscintigraphy 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphoscintigraphy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Extraperitoneal para-aortic lymph node dissection (EPLND) 

http://www.lymphedemapeople.com/wiki/doku.php?id=extraperitoneal_para-aortic_lymph_node_dissection_eplnd 

Axillary node biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=axillary_node_biopsy

Sentinel Node Biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=sentinel_node_biopsy

 Small Needle Biopsy - Fine Needle Aspiration 

http://www.lymphedemapeople.com/wiki/doku.php?id=small_needle_biopsy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Lymphedema Gene FOXC2

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_foxc2

 Lymphedema Gene VEGFC

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_vegfc

 Lymphedema Gene SOX18

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18

 Lymphedema and Pregnancy

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pregnancy

Home page: Lymphedema People

http://www.lymphedemapeople.com

Page Updated: Feb. 1, 2012