Recurrent Cellulitis Research Articles

Does the presence of lower extremity edema affect outcomes of patients with lower extremity cellulitis?

EVIDENCE-BASED ANSWER Edema in patients with cellulitis is associated with increased mortality by a year and triples the odds of recurrent cellulitis (SOR: B, cohort studies). Current guidelines recommend treatment of edema to prevent recurrent cellulitis (SOR: C, consensus guideline).

Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency?

Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions. This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis. Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source. A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined. Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.

Progress in surgery treatment of congenital pyriform sinus fistula

Congenital pyriform sinus fistula(CPSF) is a rare brancial cleft deformity in neck, characterized by acute suppurative thyroiditis, recurrent cervical abscesses and cellulitis. At present, surgical treatment of CPSF include traditional surgery and endoscopic cauterization. In the past,en block resection of the fistula by surgery is the only cure method. The late 90, relatively safe and effective endoscopic and minimally invasive aesthetic surgery is applied in treatment of CPSF, and was recommended as the preferred treatment for congenital pyriform sinus fistula. From the long term efficacy, which method is more dominant, yet to be elegant. Through the analysis of embryo principles and anatomy of CPSF,we introduce and summarize the indications, complications and prevention in conventional surgical treatment and endoscopic cauterization, and briefly descript the factors influencing the efficacy of the treatment of CPSF.

Cost of a lymphedema treatment mandate-10 years of experience in the Commonwealth of Virginia.

Treatment of chronic illness accounts for over 90 % of Medicare spending. Chronic lymphedema places over 3 million Americans at risk of recurrent cellulitis. Health insurers and legislators have taken an active role in fighting attempts to mandate the treatment of lymphedema for fear that provision of the physical therapy and compression materials would result in large and uncontrollable claim costs. The author knows of no open source of lymphedema treatment cost data based on population coverage or claims. Published studies compare cost of treatment versus cost of non-treatment for a select group of lymphedema patients. They do not provide the data necessary for insurance underwriters’ estimations of expected claim costs for a larger general population with a range of severities, or for legislators’ evaluations of the costs of proposed mandates to cover treatment of lymphedema according to current medical standards. These data are of interest to providers, advocates and legislators in Canada, Australia and England as well as the U.S.The Commonwealth of Virginia has had a lymphedema treatment mandate since 2004. Reported data for 2004–2013, representing 80 % of the Virginia healthcare insurance market, contains claims and utilization data and claims-based estimates of the premium impact of its lymphedema mandate. The average actual annual lymphedema claim cost was $1.59 per individual contract and $3.24 per group contract for the years reported, representing 0.053 and 0.089 % of average total claims. The estimated premium impact ranged 0.00–0.64 % of total average premium for all mandated coverage contracts. In this study actual costs are compared with pre-mandate state mandate commission estimates for proposed lymphedema mandates from Virginia, Massachusetts and California.Ten years of insurance experience with a lymphedema treatment mandate in Virginia shows that costs of lymphedema treatment are an insignificant part of insured healthcare costs, and that treatment of lymphedema may reduce costs of office visits and hospitalizations due to lymphedema and lymphedema-related cellulitis. Estimates based on more limited data overestimate these costs. Lymphedema treatment is a potent tool for reduction in healthcare costs while improving the quality of care for cancer survivors and others suffering with this chronic progressive condition.

Cellulitis: A Review.

Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650,000 admissions per year in the United States alone. In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S. aureus, with expansion for methicillin-resistant S. aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence. The diagnosis of cellulitis is based primarily on history and physical examination. Treatment of uncomplicated cellulitis should be directed against Streptococcus and methicillin-sensitive S. aureus. Failure to improve with appropriate first-line antibiotics should prompt consideration for resistant organisms, secondary conditions that mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic liver disease, or chronic kidney disease.

Causality evaluation of bacterial species isolated from patients with community‐acquired lower leg cellulitis

Lower leg cellulitis is a diffuse inflammation of the cutaneous connective tissue following invasion of microorganisms and with potential to recur. The causative agent is not routinely identified in clinical practice, and the empirical therapy initiated primarily targets the 'conventional' disease pathogens, Streptococcus pyogenes and Staphylococcus aureus. To evaluate at case level, the role of bacterial species isolated from lesional skin in the pathogenesis of community-acquired lower leg cellulitis. Two sampling methods (superficial swab and biopsy) were applied to isolate bacterial species from 40 patients hospitalized for first (N = 24 cases) and recurrent (N = 16 patients) lower leg cellulitis episodes. Subsequently, a clinical-laboratory heuristic algorithm was employed to interpret causality associations of isolated species with disease episodes at case level. In 37/40 cases (92.5%), at least one bacterial species was identified with either sampling method. The number of different species/specimen isolated from superficial swabs compared to punch biopsies was significantly more (P < 0.001). A causative agent was identified in 16 cases (40%); it was a 'conventional' pathogen in seven patients and strains belonging to one of six 'non-conventional' pathogens in nine cases. There was no concordance in the spectrum of isolated pathogens with the two sampling methods (kappa-index = 0.028). Another four species may have participated in five patients as co-pathogens in mixed infections. There was also no difference in microbiological disease features between patients with first and recurrent cellulitis episodes. The application of a clinical-laboratory causality algorithm coupled with pooled culture results of more than one sampling methods in patients with lower leg cellulitis is anticipated to permit the identification of responsible bacterial species at case level and offer incentive for therapeutic intervention studies.

Helicobacter cinaedi bacteremia resulting from antimicrobial resistance acquired during treatment for X-linked agammaglobulinemia

This is the first report of penicillin/cephalosporin-resistant Helicobacter cinaedi arising from prolonged treatment. H.cinaedi, common among immunocompromised patients, caused recurrent bacteremia and cellulitis in a 19-year-old Japanese man with X-linked agammaglobulinemia. The minimal inhibitory concentration of these drugs was raised, which subsequently resulted in clinical failure. Prolonged suboptimal treatment may cause bacterial resistance to β-lactam antibiotics in H.cinaedi. It is possible that this resistance may have contributed to the treatment failure.

Cellulitis of the Knee in a 16-Month-Old Boy: A Case Report

ObjectiveThe purpose of this case report is to describe the presentation of cellulitis in a 16-month-old boy to a chiropractic clinic. Clinical FeaturesThe patient presented with nontraumatic, sudden onset of nonpurulent erythema on the right knee. A plain film radiograph of the knee showed a 40-mm thickening of the anterior knee. A diagnosis of cellulitis was rendered based on the presentation of the rapidly spreading erythema and radiographically confirmed findings. Intervention and OutcomeThe patient was immediately referred to the local emergency room. The patient was hospitalized, treated with clindamycin and amoxicillin for 3 days, and then discharged. The patient’s pediatrician discontinued clindamycin treatment at the posthospitalization follow-up. Two weeks after treatment was discontinued, the patient was diagnosed with recurrent cellulitis. ConclusionThis case demonstrated that for this young patient with cellulitis of the knee, timely recognition and referral, together with patient or parent education and immediate treatment, were essential to a successful outcome.

Are prophylactic antibiotics beneficial for preventing cellulitis in patients with a history of recurrent cellulitis?

Evidence-Based Answer Prophylactic antibiotics decrease the risk of recurrence by 45% to 54% in patients with a history of recurrent cellulitis; however, the ideal antibiotic, method of administration, and duration of treatment are unclear (SOR: A, systematic review with meta-analysis). Once prophylactic antibiotics are stopped, the rate of recurrence rises again to baseline (SOR: B, RCT).

Extrapolating evidence about preventing recurrent cellulitis for an individual patient concern

A critical appraisal and clinical application of Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis, N Engl J Med. 2013, May 2;368(18):1695-1703. doi: 10.1056/NEJMoa1206300

STING-associated vasculopathy with onset in infancy: new clinical findings and mutation in three Turkish children

Results Case 1 was a 17 year old boy who presented with tachypnea in infancy and had cold-induced acral necrosis of fingers, toes and ear. His skin biopsy revealed Periodic acid-Schiff (PAS) positive fibrin thrombi in the lumen of ectatic vessels beneath the epidermis. The vessel walls also had PAS-positive thickening, immunofluorescence staining showed fibrinogen and C3. He was initially diagnosed with probable cryofibrinogenemia due to the presence of serum cryofibrinogen in one test. On follow up he had features of interstitial lung disease. His mutation analysis revealed an N154S mutation. Case 2 was a 14 year old girl presenting with joint contracture since infancy, cold induced gangrene of fingers, toes and recurrent sinusitis and cellulitis. Because of high transaminase levels, a liver biopsy was done revealing inflammation, hepatosteatosis and focal fibrosis. Paranasal sinus tomography showed extensive opacification of sinuses and left maxillary sinus medial wall defect. Case 3 was a 17 year old boy presented with cold induced ischemic acral lesions since 3 years of age and progressive spasticity of lower limbs since 12 years of age. Brain CT had showed basal ganglia calcification. Mutation analysis of case 2 and 3 revealed a novel compound heterozygous mutation of V155E/L170Q in TMEM173.

The experience of intramuscular benzathine penicillin for prophylaxis of recurrent cellulitis: A cohort study

Recurrent cellulitis is an important clinical issue but the optimal strategy for prophylaxis is not determined. Intramuscular benzathine penicillin at a 4-week interval had been adopted in our hospital and the study was conducted to evaluate the efficacy. From January 1, 2009 to May 31, 2013, all patients aged ≥ 18 year, with a history of recurrent cellulitis and having received at least three shots of intramuscular benzathine penicillin for prophylaxis were retrospectively recruited for analysis. Two treatment periods (prophylaxis period and nonprophylaxis period) were defined. The effects of benzathine penicillin prophylaxis and patient characteristics on the incidence rate of recurrent cellulitis were analyzed using Poisson regression model. A total of 72 patients were enrolled, including 26 (36.1%) men. The most common underlying conditions were past surgery at the proximal side of the affected limb (38, 52.8%), malignancy (31, 43.1%), and diabetes mellitus (24, 33.3%). The incidence rate of recurrent cellulitis in the prophylaxis period was 0.73 episode/patient-year, significantly lower than that of 1.25 episodes/patient-year in the nonprophylaxis period (p<0.001). Tinea pedis was a significant factor associated with increasing incidence of recurrent cellulitis in our cohort. Intramuscular benzathine penicillin at a 4-week interval may be an effective prophylactic strategy to reduce the incidence of cellulitis. Further studies are necessary to determine the factors associated with failure of prophylaxis as well as optimal individualized dosage and dosing interval of the prophylactic agent.

Endoscopic sinus surgery for chronic rhinosinusitis in patients previously treated for sinonasal malignancy.

Patients with a history of sinonasal malignancy can develop chronic rhinosinusitis (CRS) as a consequence of their oncologic treatment. Some patients will fail medical management and require endoscopic sinus surgery (ESS). This study reviews the use of ESS in the management of CRS in patients previously treated for sinonasal malignancy. Retrospective review. All patients with a history of sinonasal malignancy who developed CRS and underwent ESS were reviewed. Preoperative and postoperative imaging and symptoms were collected. Major complications (bleeding, orbital injury, and cerebrospinal fluid leak) and minor complications (adhesion formation) and postoperative healing were reviewed. Eighteen patients were identified. All patients presented with symptoms of CRS and sinonasal crusting. Additionally, five patients presented with recurrent facial cellulitis, and six patients had mucoceles. No major complications were encountered. Postoperatively, all patients reported a subjective improvement in their sinonasal symptoms. Comparison of pre- and post-ESS imaging revealed a significant improvement in Lund-Mackay scores after ESS (P < 0.001) from 12.8 (range 5-22) to 7 (range). Despite symptomatic improvement, all patients continued to have nasal crusting. All patients who initially presented with recurrent facial cellulitis had no further episodes after ESS. None of the endoscopically drained mucoceles recurred. For patients previously treated for sinonasal malignancy with refractory CRS, ESS appears to be a safe and effective treatment option. ESS in these patients results in subjective improvement in sinonasal symptoms as well as objective improvement in radiographic CRS disease burden, although sinonasal crusting will likely not resolve. 4.

Clinical characteristics of patients with lower limb cellulitis and antibiotic usage in Hospital Kuala Lumpur: a 7-year retrospective study.

Cellulitis commonly involved lower limbs. This study was carried out to determine the demography, clinical characteristics, risk factors, microbiological aspects, and antibiotics usage in this group of patients in Hospital Kuala Lumpur. A total of one hundred and twenty four patients with lower limb cellulitis treated in the Department of Dermatology, Hospital Kuala Lumpur, between January 2008 and May 2013 were included in this study. There were 70 male and 54 female patients, aged between 13 and 87 years (mean 57.23±12.854). Thirty-one of them (25%) had recurrent cellulitis. Fifty-seven (46%) had fever at presentation, 55 (44.4%) had bullous cellulitis. The top risk factors identified were toe web intertrigo (n = 79, 63.7%), hypertension (n=76, 61.3%), obesity (n = 55, 44.4%), and diabetes (n = 55, 44.4%). However, only toe web intertrigo (p= 0.003), peripheral vascular disease (p = 0.01), and varicose veins (p = 0.02) were significantly higher in recurrent cellulitis. Thirty patients (24.2%) were complicated with lipodermatosclerosis, and six (4.8%) had lymphostasis verrucosa cutis. Skin swab cultures were positive in 54 (43.5%) patients, and Pseudomonas sp. was the most frequently identified organism. Mean number of antibiotics given for one episode of cellulitis was1.7±1. The antibiotics most given were cloxacillin (n=57, 46%) and other penicillins (n= 71, 57%), followed by cephalosporins (n = 40, 32%). Identifying clinical characteristics of those at risk may help to prevent recurrence of cellulitis and long-term complications.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile.

Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety. A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed. Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001). MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Acquired lymphangiectasis following surgery and radiotherapy of breast cancer.

Acquired lymphangiectasia (AL) is a significant and rare complication of surgery and radiotherapy. We report lymphangiectasia in a 40-year-old woman who had undergone radical mastectomy and radiotherapy. After 4 years of combined therapy, she developed multiple vesicles and bullae. Skin biopsy confirmed the diagnosis of lymphangiectasia. The case is unique as it is not associated with lymphedema, which is a usual accompaniment of lymphangiectasia following surgery and radiotherapy. AL is usually asymptomatic, but trauma may cause recurrent cellulitis. Treatment modalities include electrodessication, surgical excision, sclerotherapy and carbon dioxide laser ablation.

Penicillin to prevent recurrent leg cellulitis: a critical appraisal.

Thomas et al. compared the effectiveness of prophylactic low‐dose penicillin vs. placebo in patients with recurrent cellulitis for preventing the disease. Participants of this double‐blind randomized controlled trial were recruited at 28 hospitals in the U.K. and Ireland between July 2006 and January 2010. Patients with two or more episodes of cellulitis of the leg were randomized to receive low‐dose oral penicillin (250 mg twice daily) or placebo over 12 months with a follow‐up period of up to 3 years. The primary outcome was the time to a first recurrence. Secondary outcome measures were the proportion of participants with a repeat episode of cellulitis during the prophylaxis phase and during the follow‐up phase, the number of repeat episodes of cellulitis, the proportion of participants with new oedema or ulceration during the prophylaxis phase and during the follow‐up phase, the number of nights in hospital for cellulitis, the number of adverse drug reactions or adverse events of interest (death, nausea, diarrhoea, thrush, rash, severe skin reactions, sepsis and renal failure), cost–effectiveness and predictors of response. Of the 533 patients screened, 274 were eligible and included in the trial (136 were assigned to the penicillin group and 138 to the placebo group). The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the 12 months of treatment 30 (22%) of 136 patients in the penicillin group had a recurrence compared with 51 (37%) in the placebo group [hazard ratio 0·55, 95% confidence interval (CI) 0·35–0·86, P = 0·01; number needed to treat 7, 95% CI 4–9]. After the 12‐month treatment period, during the follow‐up there was no difference in the rate of first recurrence (27% in both groups). There were fewer repeat episodes in the penicillin group than in the placebo group during the treatment period (76 vs. 122, P = 0·03) and no difference during subsequent follow‐up (43 vs. 42). There was no statistically significant difference between the groups in the number of participants with an adverse event (37 in the penicillin group vs. 48 in the placebo group, P = 0·50). Thomas et al. concluded that low‐dose penicillin was effective in preventing recurrent cellulitis in people with recurrent disease during prophylactic treatment, but that the effect reduced progressively after the discontinuation of penicillin.

Author response to van Zuuren et al., Penicillin to prevent recurrent cellulitis: a critical appraisal.

Author response to van Zuuren et al., Penicillin to prevent recurrent cellulitis: a critical appraisal.

Predictors of recurrent cellulitis in five years. Clinical risk factors and the role of PTX3 and CRP

To identify risk factors for recurrence of cellulitis, and to assess the predictive value of pentraxin 3 (PTX3) and C-reactive protein (CRP) measured at baseline. A follow up study of 90 hospitalised patients with acute non-necrotising cellulitis was conducted. Clinical risk factors were assessed and PTX3 and CRP values were measured at baseline. Patients were contacted by phone at a median of 4.6 years after the baseline episode and the medical records were reviewed. Overall, 41% of the patients had a recurrence in the follow up. Of the patients with a history of a previous cellulitis in the baseline study 57% had a recurrence in five year follow up as compared to 26% of those without previous episodes (p=0.003). In multivariate analysis, only the history of previous cellulitis was identified as an independent predicting factor for recurrence. The levels of pentraxin 3 (PTX3) or C-reactive protein (CRP) in the acute phase did not predict recurrence. Risk of recurrence is considerably higher after a recurrent episode than after the first episode. Clinical risk factors predisposing to the first cellulitis episode plausibly predispose also to recurrences.

Patterns of Recurrence and Role of Pelvic Radiotherapy in Ovarian Clear Cell Adenocarcinoma

The aims of this study were to analyze patterns of recurrence in patients with ovarian clear cell adenocarcinoma (CCA) and to evaluate the role of pelvic radiotherapy (RT). All patients with ovarian CCA treated at a single institution between 1989 and 2012 were identified, and their medical records were reviewed. Eligibility criteria included histologic diagnosis of pure CCA of the ovary, surgical staging for International Federation of Gynecology and Obstetrics stage I-to-IIIC disease, and adjuvant or neoadjuvant chemotherapy. Selected end points were 3-, 5-, and 8-year cumulative incidence of pelvic recurrence (CIPR). Fifty-six patients met eligibility criteria. Most received intravenous carboplatin and paclitaxel for a median of 6 cycles. Six patients (10.7%) received pelvic RT, and 50 (89.3%) did not. Pelvic RT patients had stage I-to-IIC disease. Median follow-up was 39 months (range, 1-69 months). For the group as a whole, 14 patients (25%) had initial disease recurrence involving the pelvis, whereas 6 (10.7%) had first recurrence outside the pelvis. Three-, 5- and 8-year CIPR were 28.2%, 38.5%, and 43.2%, respectively. There was no significant difference in 3-, 5-, or 8-year CIPR between the group of patients receiving RT (20%, 20%, and 20%) and a group of patients with stages I to IIC who did not receive RT (9.9%, 22.4%, and 30.2%), P = 0.22. During RT, patients developed mild grade 1-to-2 side effects. After RT, 1 patient developed lower extremity lymphedema with recurrent cellulitis. One patient who developed small bowel obstruction before RT developed small bowel radiation enteritis and obstruction after RT, ultimately requiring surgical intervention. These findings suggest that ovarian CCA exhibits a propensity for pelvic recurrence after surgery and chemotherapy. RT, a local treatment that can effectively sterilize microscopic tumor cells, may benefit patients with this disease. Prospective studies with sufficient statistical power are warranted to further evaluate the role of RT.