Bacterial Cellulitis Research Articles

Failure of treatment with cephalexin for Lyme disease.

Lyme disease typically presents with a skin lesion called erythema migrans (EM), which though often distinctive in appearance may be confused with cellulitis. The first-generation cephalosporin, cephalexin monohydrate, is effective for treating bacterial cellulitis but has not been recommended or studied for treating Lyme disease because of poor in vitro activity. To describe the outcome of patients with EM who were treated with cephalexin. Patients presenting with EM to the Lyme Disease Diagnostic Center in Westchester, NY (May 1992-September 1997). A 2-mm punch biopsy specimen of the leading edge of the EM lesion and/or blood was cultured for Borrelia burgdorferi. Eleven (2.8%) of 393 study patients had been initially treated with cephalexin prior to our evaluation; 9 (82%) were originally diagnosed with cellulitis. Cephalexin was administered for 8.6 days (range, 2-21 days) prior to presentation. All 11 patients had clinical evidence of disease progression, including 8 whose rash enlarged, 2 who developed seventh-nerve palsy (1 with new EM lesions), and 1 who developed new EM lesions. Borrelia burgdorferi grew in cultures from 5 patients despite a mean of 9.8 days of treatment with cephalexin (range, 5-21 days). Cephalexin should not be used to treat early Lyme disease and should be prescribed with caution during the summer months for patients believed to have cellulitis in locations where Lyme disease is endemic.

An Algorithm for the Management of Acute Bacterial Cellulitis

Acute bacterial cellulitis is a common infection seen by family physicians; it is usually caused by beta‐hemolytic streptococci and/or Staphylococcus aureus. Cellulitis following bite wound injuries from animals and humans requires antibiotics directed at the mouth microflora characteristic of the biting animal. Depending on the severity and the rapidity of the progression of the infection, as well as patient compliance with oral therapy, intravenous antibiotics may be required for treatment, and this may often be accomplished with an outpatient administration program. In addition to intravenous and subsequent oral step‐down antibiotic therapy, special attention needs to be applied to reducing or eliminating predisposing factors such as pre‐existent edema and local fungi, or other forms of dermatitis. With effective antibiotic therapy, the erythema generated by acute cellulitis may resolve quickly or slowly, but usually does so progressively. Patients with persistent skin inflammation and swelling must be examined carefully for subcutaneous abscess formation.

Clinical Characteristics of Pneumococcal Bacteremia in Adults: The Effect of Penicillin Resistance on the Mortality of Patients with Pneumococcal Bacteremia

Backgrounds : The advent of penicillin has led to the marked reduction in the mortality from pneumococcal bacteremia, however, the mortality is still relatively high in this post-antibiotic era. Actually the prevalence of infection due to penicillin-resistant penumococci is increasing worldwide, and it is especially high in Korea due to irrelevant use of antibiotics. So, the high mortality of pneumococcal sepsis might be related to the emergence of penicillin-resistant strains, however, many other antibiotics, which eradicate pneumococci effectively, are available in these days. This has led us to suspect the role of penicillin-resistance in the high mortality rate. In this study, we evaluated the effect of penicillin resistance on the mortality of patients with penumococcal bacte remia. Methods: The study population consisted of 50 adult patients with penumococcal bacteremia who were admitted between Jan, 1990 and July, 1997. Medical records were analyzed retrospectively. Results: Most of the patients (96%) had underlying diseases. The most common local disease associated with pneumococcal bacteremia was pneumonia (42%), which was followed by spontaneous bacterial peritonitis (14%), cholangitis (10%), meningitis (8%), liver abscess (4%), pharyngotonsillitis (4%), sinusitis (2%) and cellulitis (2%). While the overall case-fatality rate in this study was 24%, it was higher when peumococcal bacteremia was associated with pneumonia (42%) or meningitis (50%). The rate of penicillin resistance was 40%, which was increased rapidly from 1991. The rate of penicillin resistance was significantly higher in patients with the history of recent antibiotics use and hospitalization within 3 months respectively. The clinical manifestations, that is, age, severity of underlying diseases, nosocomial infection, associated local diseases, and the presence of shock or acute renal failure were not statistically different between the patients with penicillin-resistant and -sensitive pneumococcal bacteremia. The mortality of patients infected with penicillin-resistant pneumococci was not statistically different from those with penicillin-sensitive pneumococcal bacteremia. Conclusion: Penicillin resistance is not associated with high mortality in adult patients with pneumococcal bacteremia. As the overall mortality is high, active penumococcal vaccination is recommended in patients with high risk of infection.

Filariasis and Erisipela in Santo Domingo

This study examined acute-convalescent changes in diagnostic anti-streptococcal antibodies by the anti-streptolysin O (ASO) and anti-DNAase B (ADAB) tests among patients (n 28) with lymphedema and recurrent erisipela of the lower limb, comparing them with endemic normal control residents (n=25). The study was based in Villa Francisca, an urban focus of Bancroftian filariasis in eastern Santo Domingo, capital of the Dominican Republic. The acute signs and symptoms of erisipela were consistent with a diagnosis of bacterial cellulitis. The ASO test was especially successful at demonstrating a rise in mean titer during convalescence, whereas the ADAB produced about the same frequency of significant increases (0.2 log titer) as did the ASO. When subjects were scored as responders if mounting a minimal titer increase by either test, patients were found more frequently positive than were controls (chi2=5.3, P=0.02). About half (54%) of all patients mounted at least a minimal antibody increase. Filaria-specific IgG4 antibodies were absent from all sera of 20 residents of a nonendemic Dominican mountain town but appeared in about two-thirds of the sampled residents of the endemic barrio. Notably however, levels did not change between the acute phase and convalescence. These findings are consistent with the hypothesis that recurrent streptococcal invasion of the lymphatics may be a significant factor triggering or amplifying lymphedema and elephantiasis in patients with chronic filariasis.

Wells’ syndrome associated with idiopathic hypereosinophilic syndrome

Wells' syndrome, or eosinophilic cellulitis, is characterized by recurrent cutaneous swellings which resemble acute bacterial cellulitis, and by distinctive histopathological changes. Skin lesions show dermal eosinophilic infiltration and the characteristic 'flame figures', which are composed of eosinophil major protein deposited on collagen bundles. The idiopathic hypereosinophilic syndrome is a multisystem disease with a high mortality rate. It is characterized by peripheral blood eosinophilia and eosinophilic infiltration of many organs, including the skin. The most common skin lesions are pruritic maculopapules and nodules over the trunk and limbs, with urticaria and angio-oedema. In contrast to Wells' syndrome, the pathology of these skin lesions is non-specific with variable eosinophil infiltration. We report overlapping clinical and histopathological findings characteristic of both syndromes in one patient. Our data favour the hypothesis that both syndromes represent an abnormal eosinophilic, response to a variety of underlying diseases or causative agents and thus are different expressions of one disease entity linked to the immunobiology of eosinophils.

35-Year-Old Woman With Ulcerating Skin Lesions

A 35-year-old female day-care worker sought medical assis­ tance because of a history of small tender nodules develop­ ing on the left lateral buttock area. These nodules had appeared 4 days earlier, after the patient had been working in her garden; therefore, they were ascribed to a possible insect bite. The skin lesions began as red, warm, tender, and indurated areas (Fig. 1) associated, 4 to 5 days later, with spontaneous drainage of serosanguineous fluid. For the next few months, multiple ulcerated lesions (up to 3 by 2 em) developed on the buttocks and thighs (Fig. 2). The lesions then stopped draining and healed, but subcutaneous atrophy and hyperpigmentation remained. A skin biopsy specimen obtained by her local physician revealed nonspecific chronic dermatitis. Topically applied corticosteroids seemed to ex­ acerbate the lesions. During this time, she remained afebrile and had no chills, sweats, cough, arthralgia, fatigue, or dyspnea. During the 3 months before the patient was exam­ ined at our institution, several regimens of antibiotics and oral corticosteroid therapy yielded no appreciable improve­ ment or cessation of recurrent ulcerations. 1. Which one of the following is the most likely dermatologic diagnosis at this point? a. Erythema nodosum b. Pyoderma gangrenosum c. Panniculitis d. Bacterial cellulitis e. Cutaneous polyarteritis nodosa Eruption due to erythema nodosum can be associated with various disease processes, although it is not character­ ized by ulcerating lesions. Recurrence, as noted in this patient, is uncommon in erythema nodosum. Pyoderma gangrenosum, considered noninfectious in origin, clinically exhibits a painful nodule or pustule that ulcerates and drains a purulent exudate and has a necrotic base. In our patient, the lesions did not demonstrate the rapid expansion and ulcer

Flashlamp-excited dye laser therapy of idiopathic vulvodynia is safe and efficacious

Objective: The management of chronic vulvovaginal pain, not explicable on specific histologic grounds, presents a major problem in referral centers for lower genital tract diseases. Study design: This article reports on a two-step protocol in a sample of 175 medical nonresponders, drawn from a 2-year cohort of 725 women with vulvovaginal pain. The first maneuver was the use of a flashlamp-excited dye laser to selectively photocoagulate symptomatic subepithelial blood vessels in 168 women; the second was the microsurgical removal of chronically painful Bartholin's glands in 52 women not responsive or not suited to flashlamp-excited dye laser photothermolysis. Results: Dye laser response rates werer independent of whether patients manifested macroscopic focl of painful erythema (“vestibular adenitis”) or just colposcopically apparent hyperemia-ectasia of the individual blood vessels (“pruritic papillomatosis”) (55% vs 45% after a single surgical procedure; 76% vs 65% after serial retreatment; p not significant). Conversely, response rates were much lower among women in whom pressure on the Bartholin's glands produced sharp, lancinating pain (15% vs 66% after a single surgical procedure; 22% vs 93% after serial retreatment; p < 0.001). Forty-two (85%) of 50 patients with flashlamp-excited dye laser failure had deep pain; however, the impasse to progress was broken by gland removal. Final response rates were 92.5% (complete response 62%; partial response 30%) in the “surface-only” group and 80.3% in the “surface-plus-deep” group (χ 2 = 14.9; p < 0.001). The major complication was acute bacterial cellulitis, occurring in the first postoperative week. Modification of the treatment protocol to include topical antibiotics with an occlusive dressing reduced the cellulitis rate from 17.2% to 2.5%. In four women (1.8%) Koebner-like exophytic condylomas also developed within 1 month of flashlamp-excited dye laser surgery. Conclusion: The availability of a safe, efficacious, and relatively noninvasive treatment should reduce the need for resective surgery in most patients with idiopathic vulvodynia. 1995; 172; 1684–1701.)

Cutaneous cryptococcosis mimicking bacterial cellulitis in a liver transplant recipient: Case report and review in solid organ transplant recipients

Cutaneous cryptococcosis mimicking bacterial cellulitis in a liver transplant recipient: Case report and review in solid organ transplant recipients

Cryptococcal cellulitis in a diabetic, kidney transplant patient

The cutaneous manifestations of disseminated cryptococcosis are variable and include papules, plaques, nodules, draining sinuses, acneiform lesions, tumors, abscesses, ulcers, pustules, bullae, molluscum-like lesions, and cellulitis.8-1 0 Cryptococcal cellulitis has only been seen in patients with severe underlying diseases such as leukemiaf myeloma,8.11 systemic lupus erythematosusj chronic active hepatitis,'? intestinal lymphangiectasia and congenital lymphedema.P as well as in kidney transplant recipients. 1-7 These patients had received immunosuppressive therapy, which in all cases included prednisone. Only a few cases of cryptococcal cellulitis in kidney transplant patients have been reported. 1-7 Most lesions occurred on an extremity and appeared abruptly as a single, tender, indurated, erythematous plaque that was initially mistaken for bacterial cellulitis and erroneously treated with antibiotics. Ours is only the third reported case of cryptococcal cellulitis with multiple sites of involvement.': 7 Methods of directly diagnosing cryptococcal cellulitis include Gram's stain or india ink preparation of tissue aspirates and cultures of skin specimens. Cryptococcal cellulitis may histologically demonstrate a variable lymphohistiocytic infiltrate in the Hugh M. Gloster, Jr., MD, Robert A. Swerlick, MD, and Alvin R. Solomon, MD Atlanta, Georgia

Home Intravenous Self‐Injection of Antibiotic Therapy

The current medical climate has forced all health care providers to search for alternative methods for the delivery of health care. This search has led to the use of sites outside the conventional hospital walls for peritoneal dialysis, parenteral hyperalimentation, blood or blood product transfusions, etc. Home intravenous self‐injection of antibiotics is such an alternative to prolonged and/or repeated hospitalization for patients requiring intravenous antibiotics administration only. This alternative was started as a pilot study and soon became a usual service in the Centre hospitalier de l’Université Laval following receipt of a grant from the National Health Research and Development Program. After careful development of inclusion/exclusion criteria and a teaching manual for patient and health care providers. and the standardization of medical. pharmaceutical and nursing approach, a clinical, psychosocial and economical analysis of patients who agreed to participate in a clinical study comparing the two methods of health care delivery (hospital versus home) was started. Patients who met inclusion/exclusion criteria, agreeing to finish their treatment at home instead of staying hospitalized to receive intravenous antibiotics only, were taught the various techniques of intravenous self‐injection. Once they were judged to be able to self‐administer the antibiotics, they were sent home with the material needed to carry on their treatment, To date, more than 100 patients have participated in the home‐treatment, of which 50 were analyzed. The duration of home treatment varied from two days to several months. Most patients had osteomyelitis, septic arthritis, septic bursitis, bacterial cellulitis or lung infections. The therapy allowed some newly defined patients with complicated infections (AIDS patients with cytomegalovirus retinitis) to continue their treatment at home. The clinical outcome of patients treated at home was identical to the outcomes of those treated in the hospital. Side effects were comparable with the hospital treatment and were mainly catheter‐related. Compared with hospitalization. home treatment was preferred by the majority of patients. Psychological analysis of the patients showed that those who choose home therapy had a higher internal “locus of control” than those who preferred to stay in the hospital for the entire length of therapy. The economical analysis showed a potential reduction of cost varying between $941.00 and $3325.00 per treatment. Home intravenous self‐injection of antibiotics allowed health self‐monitoring by the patients or/and their friends or family and increased health care efficiency.

Increased Infection Rate in Diabetic Dialysis Patients Exposed to Cocaine

Three hundred ninety-seven insulin-dependent diabetic dialysis patients were screened by nursing staff for analgesic-seeking behavior. Thirty-eight patients were identified and classified as prescription abusers (n = 26) or illicit drug users (n = 12). The nine cocaine users, when compared with 14 insulin-dependent diabetics on dialysis matched by protocol, were found to be similar in terms of diabetic retinopathy and metabolic neuropathy. Although statistically not significant, cerebrovascular and cardiovascular complications were more common in the study group. Gastroenteropathy with malnutrition was more common the study group (P less than 0.025). Infection rate and severity were markedly worse in the cocaine group: bacterial cellulitis, sepsis, and abscess each increased greater than fourfold. All the visceral infections were in the cocaine-using group. Hepatitis viral antigen and antibody was increased 10-fold in the cocaine users. Recommendations for management of dialysis patients with analgesic-seeking behavior are formulated in light of these findings.

Solitary extramedullary plasmacytoma of the maxillary antrum and orbit presenting as acute bacterial orbital cellulitis.

Orbital involvement by plasma cell tumours is rare. Orbital tumours do not generally present as an acute orbital inflammatory disease in adults, though tumours such as rhabdomyosarcoma may cause clinical signs similar to an acute orbital cellulitis in children. We describe a patient with bacterial orbital cellulitis and sinusitis who was found to have an extra-medullary plasmacytoma of the maxillary antrum and orbit and coexisting testicular seminoma.

Guidelines for treatment of skin diseases in children with HIV infection

Bacterial infection. Bacterial skin infections, including impetigo, ecthyma, and cellulitis, may occur in the child with HIV infection. Most skin lesions are caused by infection with staphylococci or streptococci; if there is doubt as to the cause of the skin infection, a skin biopsy specimen should be taken for both culture and histologic examination. Obvious impetigo may be treated with appropriate oral antibiotics effective against both staphylococci and streptococci; most HIV-infected children will require hospitalization and intravenous antibiotic therapy effective against staphylococci and streptococci for therapy of more involved skin infections. Candidiasis. Oral thrush and recalcitrant monilial diaper dermatitis are the most common mucocutaneous manifestations of HIV infection in children. Monilial infection also may involve intertriginal areas (axilla, neck folds) and the proximal nail folds (paronychia). In addition to topical therapy, a therapeutic regimen for these infections may include oral therapy to eradicate a gastrointestinal source of the fungus. The first line of therapy for oral thrush during infancy consists of nystatin solution (100,000 U/ml) in a dose of 1 to 2 ml four times per day. In older children clotrimazole troches may be more effective. For infants who do not respond to nystatin, these troches also may be inserted into a plastic nipple and used four times a day as a pacifier. Ketoconazole at 5 to 10 mg/kg /day or fluconazole (not licensed for use in children) at 3 to 6 mg/kg /day may be required for the treatment of oral thrush that does not respond to these measures. The development of feeding difficulty or dysphagia in the child with oral thrush may signal the presence of candidal esophagitis. Topical nystatin or an imidazole cream are effective in treating candidal infection of the skin. Dermatophyte infection. Children with HIV infection may develop severe or widespread tinea corporis or tinea capitis. The presence of fungal infection should be verified by either a potassium hydroxide preparation or a fungal culture. Tinea corporis may be treated with twice daily application of an imidazole cream. Tinea capitis will not respond to topical antifungals and requires a 4to 6-week course of oral griseofulvin 10 to 20 mg/kg/day. Viral infection Herpes simplex. Severe, chronic, or recurrent infection with herpes simplex virus is a complication of HIV infection in children. The most common presentation is the development of severe and persistent erosions of the lips and tongue. However, vesicular and ulcerative lesions of the fingers and other cutaneous surfaces sometimes are seen. Any chronic ulcer of the mouth or skin should be cultured for herpes simplex.

Clinical experience with aztreonam.

Aztreonam, the first of the new class of monobactams, has a narrow and specific range of bactericidal activity; it is highly active against Gram-negative aerobic pathogens but is essentially inactive against Gram-positive or anaerobic bacteria. Several unique features indicate that aztreonam may provide an attractive choice for the treatment of serious Gram-negative infection in adults and children. Clinical study in adults has shown aztreonam to be highly effective against infections of the urinary and lower respiratory tracts, the musculoskeletal system and the female genitourinary tract. It also has proved useful in neutropenic patients, including those with cancer, and for treatment of bacterial peritonitis, gonorrhea, cellulitis and wound infections. Reported clinical and microbiologic cure rates have been comparable to those associated with traditional therapeutic approaches (85 to 100%). In the treatment of children with urinary tract infection as well as other types of infections, aztreonam therapy in a dosage of 30 mg/kg given every 6 to 8 hours was associated with satisfactory clinical and microbiologic cure rates. There appear to be specific clinical situations for which aztreonam may be an appropriate alternative to more toxic therapies, although comparative trials are needed to delineate the exact place of aztreonam in the armamentarium against bacterial infection.

The etiology of bacterial cellulitis as determined by fine-needle aspiration.

Bacterial cellulitis is a common problem, etiologic diagnosis often unrewarding and opinions differ on empiric therapy. The purpose of this study was to determine the major microbiologic causes of bacterial cellulitis in a walk-in Emergency Room setting. 94 cases in 89 patients with clinical signs of cellulitis were studied. The infection was closed in 74 cases and associated with an open skin lesion in 22. The infection site was aspirated with a suction air-buffer technique employing a Cameco handle for easier handling and stabilization of the aspiration needle. After exclusion of contaminated samples, positive cultures were obtained from 30 cases (31.9%). Cultures were positive in 30.6% of open lesions and in 36.4% of closed ones. Staphylococcus aureus was the most common organism, present in 11 cases, S. epidermidis in 8 and group A beta-hemolytic streptococci in 5. All S. aureus strains were methicillin-sensitive and only 1 was sensitive to penicillin. The most common site of infection was the lower extremity (59%). According to these data the optimal initial therapy for bacterial cellulitis in adults should be with drugs active against both staphylococci and streptococci.

Once-Daily Administration of Ceftriaxone for the Treatment of Selected Serious Bacterial Infections in Children

Ceftriaxone treatment (50 to 80 mg/kg once daily) was given to 201 children between 1 month and 18 years of age. There were 201 serious bacterial infections, including epiglottitis, pneumonia, cellulitis, osteomyelitis, septic arthritis, pyelonephritis, sepsis, and meningitis. The common pathogens responsible for pediatric infections isolated from these patients included Haemophilus influenzae, Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli. The overall clinic cure rate was 94%. Ten patients were clinically improved but not cured. There were two clinical failures. Bacteriologic failure occurred in six patients. The overall bacteriologic cure rate was 97%. Twenty patients (10%) experienced adverse effects; none required discontinuation of therapy. The efficacy, safety, spectrum, and convenience of ceftriaxone monotherapy make this antimicrobial agent a candidate for the treatment of choice of selected serious pediatric infections.

Solitary Eosinophilic Granuloma of the Lateral Orbital Wall

Two children (aged 18 and 23 months at the initial examinations) were each ultimately found at surgery to have a solitary eosinophilic granuloma of the lateral orbital wall. Both patients had a symptomatic period of six weeks during which time other diagnoses were considered: bacterial preseptal cellulitis and mumps dacryoadenitis in the first case and traumatic recurrent orbital hematoma in the second. Diagnostic difficulties stemmed from confusing features in their histories, as well as the location of the lesion and the deceptively minimal swelling relative to the actual size of the lesion. Follow-up ten and 18 months after curettage of the two lesions showed no recurrence or evidence of systemic involvement. Although most reported cases describe the orbital frontal bone as the site of origin in the orbit, our cases demonstrated that unifocal eosinophilic granuloma may occur in the lateral wall of the orbit.

Management of orbital inflammatory disease. A protocol

A step-by-step practical approach to orbital inflammatory disease is presented. In our hands, this proposed protocol has been useful. In any patient with orbital inflammatory disease, the ophthalmologist must initially rule out a life-threatening bacterial orbital cellulitis. Because the orbital disease presentation may be part of a systemic process, a good history and appropriate systemic work-up are mandatory. If any suspicion of bacterial orbital cellulitis exists, we recommend that intravenous antibiotics be instituted. Concurrently, orbital computerized tomographic scan may be extremely helpful in the work-up. Specifically, three findings — presence of an orbital-mass lesion without sinus involvement or bone erosion, presence of an orbital-mass lesion with sinus involvement or bone changes, or thickened extraocular muscles on CT scan — lead to the differential diagnosis, decision to biopsy, and appropriate treatment.

688 PERIORBITAL AND ORBITAL CELLULITIS-A REAPPRAISAL

Important differences between periorbital cellulitis (PC),orbital cellulitis or abscess (OC), and periorbital swelling (PS) associated with sinusitis have been obscured because these terms are often used interchangeably. All cases of PC and OC with a positive blood,tissue aspirate,or abscess culture seen at Children's or Eye and Ear Hospital in the past 10 years were analyzed. Results (including median age):PC caused by HIB and SP, characterized by bacteremia, fever and periorbital swelling, discoloration, induration and pain, is a distinct clinical entity occurring in young children;sinus radiographs frequently demonstrated “cloudy” sinuses,but interpretation of the radiographs was complicated by the small size and indistinct bony margins of the sinuses of infants, and by concurrent upper respiratory infection and overlying soft tissue swelling. Ophthalmoplegia and proptosis, never present in cases of PC, always accompanied OC as did radiographic evidence of sinusitis. OC due to HIB has not been documented in this study or in the literature. PS secondary to sinusitis is characterized by non-tender, non-indurated edema due to venous congestion, not bacterial cellulitis. Careful differentiation of PC,OC and PS secondary to sinusitis is necessary for the selection of appropriate therapy.

An unusual organism causing orbital cellulitis.

Bacterial orbital cellulitis is a feared complication of paranasal sinus infection. Staphylococcus and Streptococcus species are the commoner pathogens involved in these cases. However, anaerobic bacteria and unusual Gram-negative organisms should be suspected as well. We treated a case of bacterial orbital cellulitis due to foci of infected paranasal sinuses caused by Eikenella corrodens, a Gram-negative rod. The patient was managed with intensive antibiotic coverage and surgical intervention.