Burden, risk factors, and infectious complications of cellulitis and erysipelas in US adults and children in the emergency department setting.

BACKGROUND: Little is known about the use and burden of emergency department (ED) visits for cellulitis/erysipelas in the United States. OBJECTIVE: To determine the prevalence, risk factors, complications, and cost of emergency care for cellulitis/erysipelas in the United States. METHODS: Cross-sectional study of the 2006 to 2016 National Emergency Department Sample, including a 20% sample of US ED visits (N = 320,080,467). RESULTS: The mean annual incidence of ED visits with a primary diagnosis of cellulitis/erysipelas was 2.42 to 3.55 per million adult and 1.14 to 2.09 per million pediatric ED visits. ED visits for cellulitis/erysipelas decreased significantly from 2006 to 2015 (Rao-Scott chi-square, P < .0001). ED visits with versus without a primary diagnosis of cellulitis/erysipelas were associated with public or no insurance and lower household income quartiles, and were more likely to occur during weekends and summer months. The mean cost of ED visits for cellulitis/erysipelas more than doubled in adults (from $720 to $1680) and tripled in children (from $939 to $2,823) from 2006 to 2016. ED visits for cellulitis/erysipelas were associated with multiple risk factors and increased infectious complications. LIMITATIONS: No data on cellulitis and erysipelas treatment or recurrence. CONCLUSION: There is a substantial and increasing burden of ED visits for cellulitis/erysipelas in the United States. Many ED visits occurred for uncomplicated cellulitis/erysipelas, in part because of health care disparities.

Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort.

Background: Skin and soft tissue infections (SSTIs) are increasing. Frequent over- and under-treatment has been reported, including non-purulent SSTIs where cases demanding surgery or broad-spectrum therapy often are hard to identify. Our aim was to measure the predictive power of a modified severity score and use it to identify areas of improvement in antimicrobial therapy of non-purulent SSTIs.Methods: We prospectively included adult patients admitted to hospital with non-purulent SSTIs. A modified Dundee score at admission was calculated retrospectively, and associations between severity and outcomes were analysed. We evaluated appropriateness of treatment in relation to severity scores, and assessed adverse effects of broad-spectrum therapy.Results: We included 200 cases with cellulitis and 19 cases with necrotising soft tissue infections (NSTIs). Thirty-two per cent were categorised as severity class I, 15% as class II, 28% as class III and 25% as class IV (most severe). In class I, 66 out of 69 cases did not have a complicated course. All but one NSTI case were identified by the class IV criteria. Over-treatment was common and mostly seen in class I. Broad-spectrum antibiotics or clindamycin use was associated with an increased risk of diarrhoea. Prolonged treatment (>14 days) was associated with age, severity and surgery.Conclusions: The modified Dundee score proved valuable in identifying those with the lowest risk of complication and the most severe infections, and could serve as a useful clinical tool in the emergency department. Frequent over-treatment and associated adverse effects were confirmed, underscoring the need for improved risk assessment.

Is coverage of S. aureus necessary in cellulitis/erysipelas? A literature review.

BACKGROUND: Empirical treatment of patients with cellulitis/erysipelas usually targets both streptococci and methicillin-sensitive S. aureus (MSSA). However, the recommendation to empirically cover MSSA is weak and based on low-quality evidence. METHODS AND OBJECTIVE: A systematic review was conducted in PubMed and clinical trial registries to assess the role of S. aureus in cellulitis/erysipelas and the need for empirical MSSA coverage. RESULTS: Combined microbiological and serological data, and response to penicillin monotherapy suggest that streptococci are responsible for the vast majority of cases of cellulitis/erysipelas. However, most cases are non-culturable and the specificity of microbiological and serological studies is questionable based on recent studies using molecular techniques. According to epidemiological data and three randomized controlled trials, empirical coverage of methicillin-resistant S. aureus (MRSA) is not recommended for most patients, despite the high prevalence of MRSA in many areas. If MRSA is indeed not an important cause of uncomplicated cellulitis/erysipelas, then the same may apply to MSSA. Based on indirect comparison of data from clinical studies, cure rates with penicillin monotherapy (to which most MSSA are resistant) are comparable to the cure rates reported in many studies using wider-spectrum antibiotics. CONCLUSION: Considering the limitations of microbiological studies in identifying the pathogens responsible for cellulitis/erysipelas, treatment needs to be guided by clinical trials. Trials comparing penicillin or amoxicillin monotherapy to MSSA-covering regimens are needed to definitively answer whether empirical coverage of MSSA is needed and to identify the subset of patients that can be safely treated with penicillin or amoxicillin monotherapy.

[Clinical and Laboratory Factors Associated with Prolonged Hospital Stay among Patients with Cellulitis/Erysipelas]. / Fatores Clínico-Laboratoriais Associados ao Internamento Prolongado em Doentes com Celulite/Erisipela.

INTRODUCTION: Cellulitis and erysipelas represent the most frequent cause of hospitalization in the dermatology department of Santa Maria Hospital in Lisbon, Portugal. The aim of this study was to investigate whether patient demographics, comorbidities, previous episodes of cellulitis/erysipelas, the presence of complications, laboratory markers at admission, microbial isolation or previous use of antibiotics, are associated with prolonged stays. MATERIAL AND METHODS: Retrospective analysis, including patients admitted with cellulitis/erysipelas in the inpatient dermatology department of Santa Maria Hospital between July 1st 2012 and June 30th 2017. RESULTS: There were 372 admissions, corresponding to 348 patients. The median length of stay was 11 days. Increased age (p = 0.002, OR 1.03, 95% CI 1.01 - 1.04), previous episode of cellulitis/erysipelas requiring hospitalization (p = 0.005, OR 4.81, 95% CI 1.63 - 14.23), the presence of cellulitis/erysipelas-associated complications (p = 0.001, OR 3.28, 95% CI 1.63 - 6.59), leukocytosis (p = 0.049, OR 1.81, 95% CI 1.00 - 3.30), high levels of C-reactive protein (p = 0.035, OR 1.03, 95% CI 1.00 - 1.06) and a positive culture result (p = 0.002, OR 2.59, 95% CI 1.41 - 4.79) were associated with prolonged hospitalization. DISCUSSION: Prolonged hospitalization for cellulitis/erysipelas is associated with higher costs, additional clinical investigation, invasive treatments, prolonged courses of antibiotic therapy, risk of nosocomial infections, and delayed return to activities of daily living. Thus, the investigation of clinical-laboratory factors associated with prolonged hospitalization for cellulitis / erysipelas is essential and may be useful for the construction of a severity score. CONCLUSION: The knowledge of the characteristics that are associated with prolonged stay among patients with cellulitis/erysipelas may be relevant to improve health care, by reducing the length of hospital stay and associated risks and costs.

Introdução: A celulite e a erisipela constituem a causa mais frequente de internamento no Serviço de Dermatologia do Hospital Santa Maria. Este estudo teve como objetivo investigar se as características demográficas, as comorbilidades, a existência de episódios prévios de celulite/erisipela, a presença de complicações associadas, os parâmetros laboratoriais na admissão, o isolamento de microrganismo em cultura ou o uso prévio de antibióticos estão associados a internamentos prolongados.Material e Métodos: Estudo retrospetivo, incluindo os doentes internados no Serviço de Dermatologia do Hospital Santa Maria com o diagnóstico de celulite/erisipela, entre 1 de julho de 2012 e 30 de junho de 2017.Resultados: Existiram 372 internamentos, correspondendo a 348 doentes. A mediana do tempo de internamento foi de 11 dias. A idade (p = 0,002, OR 1,03, 95% IC 1,01 ­ 1,04), a existência de internamento prévio por celulite/erisipela (p = 0,005, OR 4,81, 95% IC 1,63 ­ 14,23), a presença de complicações associadas à celulite/erisipela (p = 0,001, OR 3,28, 95% IC 1,63 ­ 6,59), a leucocitose (p = 0,049, OR 1,81, 95% IC 1,00 ­ 3,30), valores elevados de proteína C reativa (p = 0,035, OR 1,03, 95% IC 1,00 - 1,06) e o isolamento de microrganismo em cultura (p = 0,002, OR 2,59, 95% IC 1,41 ­ 4,79) estiveram associados a internamentos prolongados.Discussão: A par dos maiores custos associados, o internamento prolongado por celulite/erisipela está frequentemente associado à necessidade de investigação clínica adicional, a tratamentos invasivos, a cursos prolongados de antibioterapia, ao risco de infeções nosocomiais e ao atraso no retorno às atividades da vida diária. Assim, o estudo dos fatores clínico-laboratoriais associados ao internamento prolongado por celulite/erisipela é fundamental e poderá ser útil para a construção de um score de gravidade.Conclusão: O conhecimento de características clínicas e laboratoriais associadas ao internamento prolongado poderá ser relevante para melhorar os cuidados de saúde, através da redução dos tempos de internamento e dos seus riscos e custos associados.

Colonization of ß-hemolytic streptococci in patients with erysipelas-a prospective study.

Erysipelas is a common skin infection causing significant morbidity. At present there are no established procedures for bacteriological sampling. Here we investigate the possibility of using cultures for diagnostic purposes by determining the perianal colonization with beta-hemolytic streptococci (BHS) in patients with erysipelas. Patients with erysipelas and a control group of patients with fever without signs of skin infection were prospectively included and cultures for BHS were taken from the tonsils, the perianal area, and wounds. BHS were grouped according to Lancefield antigen, species-determined, and emm-typed. Renewed cultures were taken after four weeks from patients with erysipelas and a positive culture for BHS. 25 patients with erysipelas and 25 with fever were included. In the group with erysipelas, 11 patients (44%) were colonized with BHS, ten patients were colonized in the perianal area, and one patient in the throat. In contrast, only one patient in the control group was colonized (p = 0.005 for difference). All of the patients with erysipelas colonized with BHS had an erythema located to the lower limb. The BHS were then subjected to MALDI-TOF MS and most commonly found to be Streptococcus dysgalactiae. Renewed cultures were taken from nine of the 11 patients with BHS and three of these were still colonized. Streptococcus dysgalactiae colonizes the perianal area in a substantial proportion of patients with erysipelas. The possibility of using cultures from this area as a diagnostic method in patients with erysipelas seems promising.

Frequent colonization of betahaemolytic streptococci at various body sites including the perineum and anal canal during erysipelas and cellulitis.

Background: Erysipelas and cellulitis are usually caused by betahaemolytic streptococci but the aetiology is often difficult to verify in clinical practice. Methods: Patients with erysipelas or cellulitis were analysed for betahaemolytic streptococci in samples from multiple body sites, including the perineum and the anal canal, during the acute episode and at follow up. Healthy control persons were sampled from the same sites. Results: Betahaemolytic streptococci group A, C or G were identified in 23/28 (82%) patients, most commonly group G. A wound or ulcer, present in 16/28 (57%), was colonized in 8/16 (50%). The perineum and anal canal were colonized in 11/28 (39%) and 10/28 (36%), respectively. At follow-up after about 4 weeks, only 4/28 (14%) were colonized (p<.001). In 39 healthy control persons, no betahaemolytic streptococci group A were found, groups C or G were found in 4/39 (10%). Group B streptococci were more often identified in controls, than in patients,12/39 (31%). Conclusions: Acute episodes of erysipelas or cellulitis are associated with colonization of betahaemolytic streptococci at multiple sites including the perineum and anal canal, in particular serogroup G. This may be important for choice of primary antibiotic therapy and possibilities for prevention of relapses.

Analysis of Serum Cytokines and Single-Nucleotide Polymorphisms of SOD1, SOD2, and CAT in Erysipelas Patients.

Increased free radical production had been documented in group A (ß-hemolytic) streptococcus infection cases. Comparing 71 erysipelas patients to 55 age-matched healthy individuals, we sought for CAT, SOD1, and SOD2 single polymorphism mutation (SNPs) interactions with erysipelas' predisposition and serum cytokine levels in the acute and recovery phases of erysipelas infection. Whereas female patients had a higher predisposition to erysipelas, male patients were prone to having a facial localization of the infection. The presence of SOD1 G7958, SOD2 T2734, and CAT C262 alleles was linked to erysipelas' predisposition. T and C alleles of SOD2 T2734C individually were linked to patients with bullous and erythematous erysipelas, respectively. G and A alleles of SOD1 G7958A individually were associated with lower limbs and higher body part localizations of the infection, respectively. Serum levels of IL-1ß, CCL11, IL-2Rα, CXCL9, TRAIL, PDGF-BB, and CCL4 were associated with symptoms accompanying the infection, while IL-6, IL-9, IL-10, IL-13, IL-15, IL-17, G-CSF, and VEGF were associated with predisposition and recurrence of erysipelas. While variations of IL-1ß, IL-7, IL-8, IL-17, CCL5, and HGF were associated with the SOD2 T2734C SNP, variations of PDFG-BB and CCL2 were associated with the CAT C262T SNP.

Single nucleotide polymorphism genotyping of Erysipelothrix rhusiopathiae isolates from pigs affected with chronic erysipelas in Japan.

Over the past decades, Erysipelothrix rhusiopathiae strains displaying similar phenotypic and genetic profiles of the attenuated, acriflavine-resistant E. rhusiopathiae Koganei 65-0.15 strain (serovar 1a) have been frequently isolated from pigs affected with chronic erysipelas in Japan. In this study, using the conventional PCR assay that was designed to detect strain-specific single nucleotide polymorphism (SNP) sites found in the genome of the vaccine strain, we analyzed E. rhusiopathiae isolates from pigs with chronic disease in farms where the Koganei vaccine was used. Out of a total of 155 isolates, 101 isolates (65.2%) were determined to be the vaccine strain by SNP-based PCR. Among the 101 PCR-positive isolates, four isolates were found to be sensitive to acriflavine.

How to treat a fulminant erysipelas and sepsis caused by Myroides odoratimimus: case report and literature review.

We report a case of a 77-year old male who developed a fulminant erysipelas and sepsis, caused by Myroides odoratimimus. Selecting the optimal antibiotic therapy for the treatment of infections with M. odoratimimus is challenging due to limited clinical experience with this micro-organism and its reported multidrug-resistance. Review of previous studies concerning in vitro antibacterial susceptibility and clinical experience with M. odoratimimus resulted in six case reports describing bacteremia, soft tissue and bone infections, pneumonia and urinary tract infections. In vitro susceptibility to aminoglycosides, fluoroquinolones and trimethoprim/sulfamethoxazole is variable. Treatment of M. odoratimimus infections should be based on antimicrobial susceptibility testing results. In a majority of the case reports, including the present one, treatment with fluoroquinolones proved to be a good therapeutic option.

Genomic and proteomic characterization of SE-I, a temperate bacteriophage infecting Erysipelothrix rhusiopathiae.

A bacteriophage infecting pathogenic Erysipelothrix rhusiopathiae was isolated from a swine farm experiencing an outbreak of acute swine erysipelas; we designated this phage SE-I. SE-I has an icosahedral head, a long tail and a double-stranded DNA genome. The 34,997-bp genome has a GC content of 34 % and contains 43 open reading frames (ORFs) encoding packaging, structural, lysin-holin, and hypothetical proteins. Components of purified SE-I were separated using SDS-PAGE and analyzed using liquid chromatography-mass spectrometry. Nine proteins were identified, encoded by ORF9, ORF15, ORF23, ORF30, ORF31, ORF33, ORF39, ORF40 and ORF 42. A phylogenetic tree constructed based on the sequence of the large terminase subunit revealed that SE-I is closely related to Staphylococcus phages P954 and phi3396. The CHAP-domain-containing protein encoded by ORF25 was expressed in E. coli and which was able to inactivate host bacteria. SE-I was able to infect 7 of 13 E. rhusiopathiae strains, but was unable to infect Salmonella, Streptococcus suis, and Staphylococcus aureus. This is the first report of the isolation, characterization, and genomic and proteomic analysis of a temperate phage infecting E. rhusiopathiae, and it might lead to the development of new anti- E. rhusiopathiae agents.

Erysipelas, a large retrospective study of aetiology and clinical presentation.

BACKGROUND: Erysipelas is a common and severe infection where the aetiology and optimal management is not well-studied. Here, we investigate the clinical features, bacteriological aetiology, and treatment of erysipelas. METHODS: Episodes of erysipelas in a seven-years period in our institution were studied retrospectively using a pre-specified protocol and is presented with descriptive and comparative statistics. RESULTS: 1142 episodes of erysipelas were identified in 981 patients. Patients had a median age of 61 years, 59 % were male, a majority had underlying diseases or predisposing conditions, and the leg was most often affected. Wound cultures were taken in 343 episodes and 56 grew group A streptococci (GAS), 53 grew group G streptococci (GGS), 11 grew group C streptococci (GCS), and 153 grew Staphylococcus aureus. Blood cultures were drawn in 49 % of episodes and 50 cultures were positive with GGS as the most common finding (21 cultures) followed by GAS in 13, group B streptococci in 5, S. aureus in 4, and GCS in 3 cultures. In 45 % of episodes, patients received antibiotics with activity against S. aureus. CONCLUSIONS: GGS is the most common streptococcus isolated in erysipelas and the role of S. aureus in erysipelas remains elusive.

[Risk factors associated with leg erysipelas (cellulitis) in sub-Saharan Africa: A multicentre case-control study]. / Facteurs de risque associés à l'érysipèle de jambe en Afrique subsaharienne: étude multicentrique cas-témoins.

BACKGROUND: Acute bacterial cellulitis of the leg (erysipelas) is a common problem involving considerable morbidity in dermatology practice in Africa. Previous studies conducted in Europe and North Africa have highlighted lymphoedema and toe-web intertrigo as independent factors associated with leg erysipelas. The aim of this case-control study was to identify risk factors associated with leg erysipelas in sub-Saharan Africa, within a different socio-economic and culture context. PATIENTS AND METHODS: We conducted a prospective case-control study in hospital dermatology departments in 8 sub-Saharan African countries over a 12-month period (October 2013 to September 2014). Each case of acute leg cellulitis was matched with 2 controls for age (±5 years) and sex. We analysed the general and local factors. RESULTS: During the study period, 364 cases (223 female, 141 male) were matched with 728 controls. The mean age was 42.15±15.15 years for patients and 42.11±36 years for controls. Multivariate analysis showed the following to be independent risk factors associated with leg erysipelas in our study: obesity (odds ratio [OR]=2.82 ; 95% confidence interval: 2.11-3.76), lymphoedema (OR=3.87, 95%CI: 2.17-6.89), voluntary cosmetic depigmentation (OR=4.29, 95%CI: 2.35-7.83), neglected traumatic wound (OR=37.2, 95%CI: 24.9-57.72) and toe-web intertrigo (OR=37.86, 95%CI: 22.27-64.5). CONCLUSION: The results of this study confirms the major role of local risk factors (toe-web intertrigo, lymphoedema) previously identified in other geographical settings. However, the originality of our study consists of the identification of voluntary cosmetic depigmentation as a risk factor for leg erysipelas in sub-Saharan Africa.

Endogenous endophthalmitis secondary to erysipelas.

A 64-year-old woman with chronic right arm lymphoedema presented with progressive and painful vision loss in the right eye following diagnosis of erysipelas in the ipsilateral arm. Visual acuity was light perception. Biomicroscopy revealed marked conjunctival injection, decreased corneal transparency and an inflammatory mass in the anterior chamber, which precluded fundoscopy. The ocular ultrasonography features were consistent with acute endophthalmitis, and the patient was admitted to the hospital. A systemic evaluation, including complete physical examination, echocardiography and blood tests, ruled out other sources of infection besides the cutaneous site. Blood cultures were positive for group A Streptococcus. A diagnosis of unilateral acute endophthalmitis due to group A Streptococcus bacteraemia secondary to erysipelas was made and successfully treated with optimal medical care, including prompt intravitreal and systemic antibiotic administration. Despite resolution of the infectious process, visual acuity did not improve.

[Recurrent erysipelas and cellulitis: management]. / Erysipèle et dermohypodermite récidivants: prise en charge.

Erysipelas and infectious cellulitis are skin infections that develop following the entry of bacteria through gaps in the skin. The most common complication is recurrence. Control of predisposing factors remains essential to prevent it. Prophylactic antibiotics are sometimes prescribed, but this approach is based on small studies and expert opinion. This article reflects the current state of knowledge and the standard of care.