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Cellulitis

Cellulitis. Timothy F. Brewer, MD, MPH February 24, 2011. You are in the ER. 82 year old woman presents with 2 days of fever and inability to walk for 24 hours Started on ciprofloxacin when fever started for possible UTI

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Cellulitis

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  1. Cellulitis Timothy F. Brewer, MD, MPH February 24, 2011

  2. You are in the ER • 82 year old woman presents with 2 days of fever and inability to walk for 24 hours • Started on ciprofloxacin when fever started for possible UTI • Yesterday noted redness, swelling pain of left foot, progressing so that she is unable to bear weight • PMH: NKA, cellulitis in right leg 4 years ago; trip to Florida 3 months ago, no animal exposures

  3. Physical Examination • Alert, oriented, uncomfortable but not in distress, overweight • T-39.1°; P-73; 119/81 • Leg warm, tender and swollen, no streaking • Labs • WBC 15.0 (90.2% neuts), plts 192 Hct 0.35 • Creat 78; CK 1307; CRP 231.4; Urine-no growth http://www.dermnetnz.org/bacterial/.html

  4. Next steps • Patient admitted and started on timentin and clindamycin. Appropriate management at this point would include: • Urgent/emergent surgical consultation • Switch to Cefazolin intravenously • Continue current antibiotics and add IVIG • Continue current antibiotics and get CT scan

  5. Overview of discussion • Things we will not cover in detail today • Impetigo, folliculitis, boils (abscesses) • Epidemiology of cellulitis • Frequency, risk factors, organisms • Management • Blood cultures • Outpatient vs. inpatient; oral vs. IV antibiotics • Special situations • Unusual exposures, unusual hosts

  6. Definitions • Cellulitis • Acute pyogenic inflammation of the dermis and subcutaneous tissue associated with redness, swelling and pain • Usually lacks a well-demarcated border • Erysipelas • Superficial cellulitis with prominent lymphatic involvement causing induration “peau d‘ orange” and raised border • Swartz. New Engl J Med 2004:350:904.

  7. Location of Infection Stevens. Ann Intern Med 2009; Jan In the Clinic

  8. Some non-cellulitic skin infections • Impetigo • Usually Staph aureusor β-hemolytic Streptococci • More common in children • Blisters, sores, crusting lesions and exudate • Topical therapy (mupirocin) for limited lesions or oral antibiotics • Swartz. New Engl J Med 2004;350:904. • Folliculitis • Staph aureus • Candida, M. furfurand non-infectious causes • Hot tubs: P. aeruginosa • Pustules in hair follicles & apocrine region • Lesions at different stages (buttocks, axilla) • Local care, mupirocin/antifungal cream • Pasternack. In Mandell’s Principles & Practice of Infectious Diseases 2009.

  9. Impetigo and folliculitis http://www.dermnetnz.org/bacterial/.html

  10. Epidemiology • Approximately 28,000 cases of erysipelas and cellulitis in the Netherlands in 2001 • Outpatient rate 179.6/100,000 • Hospitalization rate 12.1/100,000 • Increased with age (>100/100,000 over 85 yrs old) • Median length of stay 9 days • 1.9% in-patient mortality • Goettsch. JEADV 2006;20:834.

  11. Epidemiology • Population-based study of 7438 cellulitis cases among Mormons ≤ 64 yrs old in Western US, 1997-2002 identified through insurance claims • Overall rate of 2,460/100,000 • Increased with age, male > females • 39.9% occurred on the legs • 32.8% other/unspecified • 73.8% seen in outpatient clinics; 5.7% hospitalized • 11.1% 1 year recurrence rate • Simonson. Epidemiol Infect 2006;134:293.

  12. Microbiology of cellulitis • Approximately 80% of cellulitis cases assumed to be due to Streptococcal species or S. aureus • Swartz. New Engl J Med 2004;350:904. • Systematic review of studies of patients with intact skin and cellulitis who underwent punch biopsy or needle aspiration for culture • 127/808 (15.7%) had a positive culture • 65 positive for Staph aureus(51% of positive cultures) • 35 positive for Group A Strep (28%) • 37 positive for other organisms or mixed cultures (29%) • Chira. Epidemiol Infect 2010;138:313.

  13. Role of blood cultures • 757 cases of community-acquired cellulitis from 1995-1998 • 553 patients (73%) had blood cultures done • 11 patients (2%) had positive cultures; • 8 Streptococci, 1 S. aureus, 1 V. vulnificus, 1 M. morganii • 20 cultures (3.6%) were considered contaminants • Perl. Clin Infect Dis 1999;29:1483. • 2,678 cases of community-acquired cellulitis from 1997-2004 • 308 patients (12%) had blood cultures done • 57 patients (18.5%) had positive cultures; • 24 Streptococci, 14 gram-negative bacteria1 S. aureus, • Proximal limb, ≥ 2 comorbid diseases, no recent antibiotics • Peralta. Eur J ClinMicrobiol Infect Dis 2006;25;619

  14. Risk factors for disease • 167 patients ≥ 15 years old with leg erysipelas admitted to 1 of 7 French hospitals in1995-96 • Matched with 294 age, sex & hospital controls Dupuy. BMJ 1999;318:1591.

  15. Risk factors for disease • 100 patients hospitalized in Iceland between 2000-2004 with acute lower limb cellulitis • 200 controls hospitalized controls matched for age (± 5 years) and sex • Median age 66.5; BMI 27.7 in cases, 25.8 in controls • History of cellulitis OR 31.04 (95% CI 4.15-232.20) • S. aureusor β-hemolytic Strep in toe webs OR 28.97 (95% CI 5.47-153.48) • Erosions, ulcers or wounds OR 11.80 (2.47-56.33) • Saphenectomy OR 8.49 (1.62-44.52) • Bjornsdottir. Clin Infect Dis 2005;41:1416.

  16. You are called back to the ER • 78 yr old man presents with 1 month history of a swollen, itchy left ankle and 3 weeks of progressive redness, swelling pain of ankle & calf; still able to walk • PMH Type II diabetes, hypothyroidism, CABG x 4 in 2008, Lt hip prosthesis, hernia repair, ex-smoker, allergic to penicillin (? Reaction as child) • No recent hospitalizations or travel

  17. Physical Examination • Alert, no distress • T-36.4°; P-89; 124/89 • Decreased breath sounds bilaterally, ventral hernia • Lt ankle and calf warm, tender and swollen, no streaking, excoriations on skin • Labs • WBC 6.7, plts 187, Hb 122 • Creat 79; CK 1433; lactate 1.2 • CXR bilateral pleural effusions http://www.dermnetnz.org/bacterial/.html

  18. What now? • Patient started on timentin (? Penicillin stress test). Appropriate next steps include: • Switch to oral therapy and arrange outpatient follow-up • Switch to IV ertapenem and arrange to see in the medical day clinic tomorrow • Switch to IV vancomycin and admit to the hospital • Switch to IV cefazolin and admit to the hospital

  19. Whose at risk for bad outcomes? • 332 cases of community-acquired cellulitis from 1995-2000 in Spanish hospital • Mean age 59.7, 52% women • 82 (25%) with diabetes, 66 (20%) with cancer, 41 (12%) with cirrhosis, 21 (6%) with necrotizing soft tissue infection • Mean duration of hospitalization 11.8 days • 8 early deaths (<72 hours); 5% (16) 1 month mortality • Mortality associated with multiple comorbid conditions, CHF, renal insufficiency, obesity, shock and P. aeruginosainfection • Carratala. Eur J ClinMicrobiol Infect Dis 2003;22:151.

  20. Summary so far • Cellulitis is common • 2-24 cases/1,000 person-years • Age, lymphedema, obesity, previous cellulitis, saphenectomy/mastectomy, leg edema, ulcers, wounds and fungal infections increase risk • Most commonly caused by S. aureusor Strep species • But many bacteria and fungi capable of causing cellulitis • Majority (approximately 70-80%) can be treated as outpatient • Increased risk of mortality with • Co-morbid conditions, heart failure, obesity, gram-negative infections

  21. Treatment recommendations • Erysipelas • Penicillin • Cellulitis • 1st generation cephalosporin • Cephalexin, cefazolin • Penicillinase-resistant semi-synthetic penicillin • Dicloxacillin, nafcillin, oxacillin • Penicillin allergic patients • Clindamycin, erythromycin or vancomycin • Treatment based on clinical response • Ranges from 5-14 days (average 7 days) • Stevens. IDSA Practice Guidelines. Clin Infect Dis 2005;41:1373.

  22. IDSA treatment guidelines • Stevens. IDSA Practice Guidelines. Clin Infect Dis 2005;41:1373.

  23. Ancillary treatments • Elevation • Treatment of leg edema • Compression dressings once acute inflammation diminished • Treatment of interdigitaldermatophyic infections with topical antifungals • Clotrimazole, miconazole, terbinafine, ciclopirox • Swartz. New Engl J Med 2004:350:904. • Stevens. IDSA Practice Guidelines. Clin Infect Dis 2005;41:1373.

  24. Some special situations • Swartz. New Engl J Med 2004:350:904. Stevens. Ann Intern Med 2009; Jan In the Clinic

  25. Day 3, things are no better • Right diagnosis, correct but insufficient treatment • Elevation, time, inadequate antibiotics • Correct diagnosis, wrong treatment • Unusual or resistant organisms (MRSA) • Wrong diagnosis

  26. Failure in outpatient treatment • Retrospective review of 405 outpatients treated with oral antibiotics (aged 18-86 years old) between 2005-2007 • 70 (17%) had treatment failure at follow-up visit; risk factors for failure included: • upper limb cellulitis (OR 2.06), • moderately severe disease (OR 3.74), • antibiotic not active against MRSA (OR 4.22) • Lack of drainage when abscess present (OR 4.38) • 134/180 (74%) successfully treated with cephalexin • 138/152 (91%) success with TMP-SMX • 34/40 (855) success with clindamycin • Khawcharoenporn. Amer J Med 2010;123:924.

  27. Treatments for community-acquired MRSA Moellering. JAMA 2008;229:79.

  28. Differential diagnosis: likely and possible • Likely • Chronic venous stasis • Cool • Gout • Associated joint involvement, tophus • Contact dermatitis • History, unusual pattern or location • Drug reactions • history Kroshinsky. SeminCutan Med Surg 2007;26:168.

  29. Differential diagnosis: things that look like cellulitis but are not • Swartz. New Engl J Med 2004:350:904.

  30. Rashes of Sweet’s and Wells Syndromes Katoulis. ClinExperDerm 2009;34:e375. Ratzinger. Amer J Dermatopath 2007;29:125.

  31. Risk factors for recurrence • Case-control study of 47 male patients with recurrent cellulitis followed in a VA center 1998-2002, median age 59 yrs old • 94 age, sex matched controls with 1 episode cellulits • Leg edema (OR 4.43, 95% CI 1.82-10.82) • BMI (OR 1.09, 95% CI 1.03-1.16) • Tobacco use (OR 3.12, 95% CI 1.18-8.23) • Homelessness (OR 3.62, 95% CI 1.03-12.69) • Lewis. Amer J Med Sci 2006;332;304h. • Case-control study of 90 patients with cellulitis, 2004-2005, 44 with a history of previous disease, median age 58 yrs old • 46 patients with single episode • Obesity (OR 9.5, 95% CI 2.2-40.8) • Previous operation (OR 3.4, 95% CI 1.3-9.2) • Karppelin. ClinMicrobiol Infect 2010;16;729.

  32. You are back in the ER • 36 year old man presents with 2 days of right hand swelling and pain, no history of trauma • 24 hours of fever, chills, nausea and vomiting • PMH unremarkable except for seasonal allergies and hernia repair, no recent travel, lived on farm with horses, dogs and cats • Smokes, occasional ETOH, no other drug use

  33. Physical Examination • Acutely ill and confused • T-37.9°; P-145; 73/25, R-30 with 100% O2 on 6L • Rt hand mottled, cool and swollen, no crepitus • Labs • WBC 17.9 (24% bands), plts 133 Hct 0.44 • Creat 211; CK 2,934; Lactate 2.3 Filbin. New Engl J Med 2009;360:281.

  34. Next steps • Patient started on early goal-directed therapy for sepsis including 10 L fluid, pressors, ceftriaxone, piperacillin-tazobactam, steroids and Benadryl. CT scan shows subcutaneous fluid without gas, abscess or bone involvement. Optimal management at this point would be: • Switch piperacillin-tazobactam to clindamycin • Add vancomycin IV • IVIG • Emergent surgical debridement

  35. Next steps • Emergent surgical debridement Filbin. New Engl J Med 2009;360:281.

  36. Necrotizing fasciitis and gas gangrene • Type I • Mixed infections with Staph, Strep, gram-negative bacteria and anaerobes • Portal of entry often obvious (recent surgery), gas usually present, bulla and necrosis of skin • Diabetes is risk factor • Fournier’s gangrene when involving the groin • Type II • Streptococcus pyogenes(Group A Strep, “flesh-eating bacteria”) • Acute, may not have clear portal of entry, gas absent, severe systemic symptoms and shock, pain out of proportion to appearance of skin • Anaerobic myonecrosis (Type III or gas gangrene) • Clostridium perfringensand other species • Usually associated with previous injury or trauma, crepitus and extensive gas in tissues, marked edema and bulla; C. septicumassociated with occult colonic tumors • Swartz. New Engl J Med 2004;350:904. • Stevens. Ann Intern Med 2009; Jan In the Clinic

  37. Necrotizing fasciitis treatment • Type I • Broad-spectrum antibiotics (meropenem & vancomycin) • Type II • Penicillin (ceftriaxone or vancomycin) and clindamycin • Clindamycin to interfere with toxin production, more active against non-replicating bacteria • Myonecrosis • Penicillin (vancomycin) and clindamycin • All require emergent surgical evaluation, septic shock treatment as appropriate • Value of IVIG unproven, but used sometimes in Type II • Swartz. New Engl J Med 2004;350:904. • Stevens. Ann Intern Med 2009; Jan In the Clinic • Stevens. IDSA Practice Guidelines. Clin Infect Dis 2005;41:1373

  38. Bringing it all home-outpatients • Cellulitis usually treated as an outpatient • Dicloxacillin, cefadroxil, clindamycin • Gram-positive fluoroquinolones (levofloxacin) also okay • Abscess or boil think Staph aureus • Need incision and drainage • Antibiotics not needed if no cellulitis • For CA-MRSA, TMP-SMX (not great for Strep), doxycycline or clindamycin (can be resistance) • Usually treat for 5-7 days

  39. In the hospital • Consider admitting • Older patients, those with co-morbid diseases such as heart or renal failure, those with significant edema, recurrent disease • Inpatient therapy (simple cellulitis) • Cefazolin, nafcillin, oxacillin, vancomycin • Think MRSA in recent hospitalizations, antibiotics, treatment failures • Vancomycin, daptomycin, linezolid • Elevation, elevation, elevation

  40. When to get ID Consult • Orbital cellulitis • Suspected necrotizing fasciitis or gas gangrene • Cellulitis with sepsis • Immunocompromised hosts • Unusual exposures • When you are not sure what is going on

  41. A final note Patients are not canvases If you feel the need to draw, do it in the medical chart. http://www.manyirons.com/Puker/Drawings/picasso_stravinsky_1920.jpg

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