今日の臨床サポート

蜂窩織炎

著者: 曾木美佐 社会福祉法人太陽会 安房地域医療センター 総合診療科

監修: 具芳明 東京医科歯科大学大学院医歯学総合研究科 統合臨床感染症学分野

著者校正/監修レビュー済:2022/03/16
参考ガイドライン:
  1. 米国感染症学会(IDSA):Practice guidelines for the diagnosis and management of skin and soft tissue infections(2014)
患者向け説明資料

概要・推奨   

  1. 蜂窩織炎のすべての患者で血液培養を採取することは推奨されない(推奨度3)
  1. 診察時、皮膚潰瘍や外傷による皮膚バリアーの破綻、褥瘡、皮膚病、下腿浮腫、静脈不全、リンパ浮腫、肥満といった蜂窩織炎のリスクファクターの有無に注意することが推奨される(推奨度2)
  1. 排膿やドレナージするような膿瘍はないが、膿性滲出液を伴うような化膿性蜂窩織炎には、エンピリカルに市中メチシリン耐性黄色ブドウ球菌(CA-MRSA)をカバーする抗菌薬投与を考慮することが推奨される(推奨度2)
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
曾木美佐 : 特に申告事項無し[2022年]
監修:具芳明 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、加筆・修正を行った。

病態・疫学・診察

疾患情報  
  1. 蜂窩織炎とは、真皮から皮下脂肪組織にかけての細菌感染症である。皮膚軟部組織感染のなかでも頻度が高く、米国の研究では年間救急外来を受診する患者の230万人が蜂窩織炎と診断され、全感染症関連で入院する患者の10%を占める[1]
  1. 蜂窩織炎は丹毒と比較して中年以降の高齢者に多い。
  1. 蜂窩織炎の診断基準はない。
  1. 蜂窩織炎に特異的な血液検査や画像検査はなく、基本的には皮膚所見で臨床的に診断される。皮膚の発赤、腫脹、熱感、疼痛、発赤部位に一致した圧痛を認め、リンパ管炎を伴うこともある。
 
蜂窩織炎の特徴的症例

a:左足先から下腿まで皮膚発赤、熱感、圧痛を認める。蜂窩織炎では、圧痛範囲が皮膚所見の範囲に一般的には一致する。経時的な経過をみるために、マーキングする。
b:足関節炎の合併がないか、関節の圧痛や関節の他動時痛がないかを確認する。
c、d:趾間白癬

出典

img1:  著者提供
 
 
問診・診察のポイント  
  1. 糖尿病、免疫不全(好中球減少、免疫抑制薬使用、肝硬変、HIV感染)、重度の末梢循環障害といった重症化リスクの有無を確認する。

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文献 

Qing Yu Weng, Adam B Raff, Jeffrey M Cohen, Nicole Gunasekera, Jean-Phillip Okhovat, Priyanka Vedak, Cara Joyce, Daniela Kroshinsky, Arash Mostaghimi
Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis.
JAMA Dermatol. 2017 Feb 1;153(2):141-146. doi: 10.1001/jamadermatol.2016.3816.
Abstract/Text Importance: Inflammatory dermatoses of the lower extremity are often misdiagnosed as cellulitis (aka "pseudocellulitis") and treated with antibiotics and/or hospitalization. There is limited data on the cost and complications from misdiagnosed cellulitis.
Objective: To characterize the national health care burden of misdiagnosed cellulitis in patients admitted for treatment of lower extremity cellulitis.
Design, Setting, and Participants: Cross-sectional study using patients admitted from the emergency department (ED) of a large urban hospital with a diagnosis of lower extremity cellulitis between June 2010 and December 2012. Patients who were discharged with a diagnosis of cellulitis were categorized as having cellulitis, while those who were given an alternative diagnosis during the hospital course, on discharge, or within 30 days of discharge were considered to have pseudocellulitis. A literature review was conducted for calculation of large-scale costs and complication rates. We obtained national cost figures from the Medical Expenditure Panel Survey (MEPS), provided by the Agency for Healthcare Research and Quality (AHRQ) for 2010 to calculate the hospitalization costs per year attributed to misdiagnosed lower extremity pseudocellulitis.
Exposures: The exposed group was composed of patients who presented to and were admitted from the ED with a diagnosis of lower extremity cellulitis.
Main Outcomes and Measures: Patient characteristics, hospital course, and complications during and after hospitalization were reviewed for each patient, and estimates of annual costs of misdiagnosed cellulitis in the United States.
Results: Of 259 patients, 79 (30.5%) were misdiagnosed with cellulitis, and 52 of these misdiagnosed patients were admitted primarily for the treatment of cellulitis. Forty-four of the 52 (84.6%) did not require hospitalization based on ultimate diagnosis, and 48 (92.3%) received unnecessary antibiotics. We estimate cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations and $195 million to $515 million in avoidable health care spending. Unnecessary antibiotics and hospitalization for misdiagnosed cellulitis are projected to cause more than 9000 nosocomial infections, 1000 to 5000 Clostridium difficile infections, and 2 to 6 cases of anaphylaxis annually.
Conclusions and Relevance: Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.

PMID 27806170
A Dupuy, H Benchikhi, J C Roujeau, P Bernard, L Vaillant, O Chosidow, B Sassolas, J C Guillaume, J J Grob, S Bastuji-Garin
Risk factors for erysipelas of the leg (cellulitis): case-control study.
BMJ. 1999 Jun 12;318(7198):1591-4.
Abstract/Text OBJECTIVE: To assess risk factors for erysipelas of the leg (cellulitis).
DESIGN: Case-control study.
SETTING: 7 hospital centres in France.
SUBJECTS: 167 patients admitted to hospital for erysipelas of the leg and 294 controls.
RESULTS: In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable risk for toe-web intertrigo was 61%.
CONCLUSION: This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg.

PMID 10364117
Jean-Claude Roujeau, Bardur Sigurgeirsson, Hans-Christian Korting, Helmut Kerl, Carle Paul
Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study.
Dermatology. 2004;209(4):301-7. doi: 10.1159/000080853.
Abstract/Text OBJECTIVE: To assess the role of foot dermatomycosis (tinea pedis and onychomycosis) and other candidate risk factors in the development of acute bacterial cellulitis of the leg.
METHODS: A case-control study, including 243 patients (cases) with acute bacterial cellulitis of the leg and 467 controls, 2 per case, individually matched for gender, age (+/-5 years), hospital and admission date (+/-2 months).
RESULTS: Overall, mycology-proven foot dermatomycosis was a significant risk factor for acute bacterial cellulitis (odds ratio, OR: 2.4; p < 0.001), as were tinea pedis interdigitalis (OR: 3.2; p < 0.001), tinea pedis plantaris (OR: 1.7; p = 0.005) and onychomycosis (OR: 2.2; p < 0.001) individually. Other risk factors included: disruption of the cutaneous barrier, history of bacterial cellulitis, chronic venous insufficiency and leg oedema.
CONCLUSIONS: Tinea pedis and onychomycosis were found to be significant risk factors for acute bacterial cellulitis of the leg that are readily amenable to treatment with effective pharmacological therapy.

Copyright (c) 2004 S. Karger AG, Basel.
PMID 15539893
Mourad Mokni, Alain Dupuy, Mohamed Denguezli, Raouf Dhaoui, Samir Bouassida, Montacer Amri, Sami Fenniche, Faten Zeglaoui, Nejib Doss, Rafiaa Nouira, Amel Ben Osman-Dhahri, Jamel Zili, Insaf Mokhtar, Mohamed Ridha Kamoun, Abdelmajid Zahaf, Olivier Chosidow
Risk factors for erysipelas of the leg in Tunisia: a multicenter case-control study.
Dermatology. 2006;212(2):108-12. doi: 10.1159/000090649.
Abstract/Text BACKGROUND: Risk factors for erysipelas (cellulitis) were rarely evaluated in controlled studies. Regional variations of these risk factors have never be assessed.
OBJECTIVE: To assess risk factors for erysipelas of the leg in Tunisia.
SUBJECTS AND METHODS: Case-control study in seven hospital centers in Tunisia. Cases were 114 consecutive patients with erysipelas of the leg [sudden onset (<24 h) of a well-demarcated dermo-hypodermatitis with fever or chills]. Two controls were matched to each case for age, sex, and hospital (n = 208). Main outcome measures are local and general suspected risk factors for erysipelas of the leg.
RESULTS: In multivariate analysis, disruption of the cutaneous barrier (i.e. traumatic wound, toe-web intertrigo, excoriated leg dermatosis or plantar squamous lesions) and leg edema were independently associated with erysipelas of the leg, with respective odds ratios of 13.6 (95% confidence interval: 6.0-31) and 7.0 (1.3-38). No association was observed with diabetes, alcoholism, or smoking.
CONCLUSIONS: We confirmed the major role of local risk factors and the minor role of general risk factors for erysipelas of the leg, in a setting different than the one previously studied. Detecting and treating toe-web intertrigo and traumatic wounds should be considered in the prevention of erysipelas of the leg.

Copyright (c) 2006 S. Karger AG, Basel.
PMID 16484815
Kim S Thomas, Angela M Crook, Andrew J Nunn, Katharine A Foster, James M Mason, Joanne R Chalmers, Ibrahim S Nasr, Richard J Brindle, John English, Sarah K Meredith, Nicholas J Reynolds, David de Berker, Peter S Mortimer, Hywel C Williams, U.K. Dermatology Clinical Trials Network's PATCH I Trial Team
Penicillin to prevent recurrent leg cellulitis.
N Engl J Med. 2013 May 2;368(18):1695-703. doi: 10.1056/NEJMoa1206300.
Abstract/Text BACKGROUND: Cellulitis of the leg is a common bacterial infection of the skin and underlying tissue. We compared prophylactic low-dose penicillin with placebo for the prevention of recurrent cellulitis.
METHODS: We conducted a double-blind, randomized, controlled trial involving patients with two or more episodes of cellulitis of the leg who were recruited in 28 hospitals in the United Kingdom and Ireland. Randomization was performed according to a computer-generated code, and study medications (penicillin [250 mg twice a day] or placebo for 12 months) were dispensed by a central pharmacy. The primary outcome was the time to a first recurrence. Participants were followed for up to 3 years. Because the risk of recurrence was not constant over the 3-year period, the primary hypothesis was tested during prophylaxis only.
RESULTS: A total of 274 patients were recruited. Baseline characteristics were similar in the two groups. 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 prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence, as compared with 51 of 138 participants in the placebo group (37%) (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P=0.01), yielding a number needed to treat to prevent one recurrent cellulitis episode of 5 (95% CI, 4 to 9). During the no-intervention follow-up period, there was no difference between groups in the rate of a first recurrence (27% in both groups). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 vs. 164, P=0.02 for trend). There was no significant between-group difference in the number of participants with adverse events (37 in the penicillin group and 48 in the placebo group, P=0.50).
CONCLUSIONS: In patients with recurrent cellulitis of the leg, penicillin was effective in preventing subsequent attacks during prophylaxis, but the protective effect diminished progressively once drug therapy was stopped. (Funded by Action Medical Research; PATCH I Controlled-Trials.com number, ISRCTN34716921.).

PMID 23635049
B Perl, N P Gottehrer, D Raveh, Y Schlesinger, B Rudensky, A M Yinnon
Cost-effectiveness of blood cultures for adult patients with cellulitis.
Clin Infect Dis. 1999 Dec;29(6):1483-8. doi: 10.1086/313525.
Abstract/Text To assess the cost-effectiveness of blood cultures for patients with cellulitis, a retrospective review was conducted of clinical and microbiological data for all 757 patients admitted to a medical center because of community-acquired cellulitis during a 41-month period. Blood cultures were performed for 553 patients (73%); there were a total of 710 blood samples (i.e., a mean of 1.3 cultures were performed per patient). In only 11 cases (2.0%) was a significant patient-specific microbial strain isolated, mainly beta-hemolytic streptococci (8 patients [73%]). An organism that was considered a contaminant was isolated from an additional 20 culture bottles (3. 6%). The cost of laboratory workup of the 710 culture sets was $36, 050. Isolation of streptococci led to a change from empirical treatment with cefazolin to penicillin therapy for 8 patients. All patients recovered. In conclusion, the yield of blood cultures is very low, has a marginal impact on clinical management, and does not appear to be cost-effective for most patients with cellulitis.

PMID 10585800
Anna Stevenson, Phil Hider, Martin Than
The utility of blood cultures in the management of non-facial cellulitis appears to be low.
N Z Med J. 2005 Mar 11;118(1211):U1351. Epub 2005 Mar 11.
Abstract/Text AIM: To assess the utility of blood cultures in the management of patients presenting to the Emergency Department at Christchurch Hospital from the community with non-facial cellulitis (or soft tissue infection) and no other morbidity.
METHODS: A multidisciplinary team formulated the search protocol. A systematic review methodology was used. Seven electronic databases were searched for clinical studies of blood culture utility in patients with non-facial cellulitis. Relevant studies were appraised using predetermined validity assessment criteria. Conclusions were presented based on an assessment of the validity and applicability of the evidence.
RESULTS: Seventeen studies were identified as addressing the topic at least as part of a secondary objective for the study. All were retrospective reviews or case series and were often associated with significant methodological limitations.
CONCLUSIONS: Blood cultures are rarely positive in patients presenting from the community with non-facial cellulitis. When they are positive, initial empiric therapy is usually adequate to treat pathogenic bacteria. The available evidence does not support the routine use of blood cultures in the clinical management of healthy adults presenting with non-facial cellulitis at the Emergency Department.

PMID 15778752
Craig G Gunderson, Richard A Martinello
A systematic review of bacteremias in cellulitis and erysipelas.
J Infect. 2012 Feb;64(2):148-55. doi: 10.1016/j.jinf.2011.11.004. Epub 2011 Nov 11.
Abstract/Text OBJECTIVES: Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.
METHODS: OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.
RESULTS: For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. For cellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.
CONCLUSIONS: Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis and erysipelas in terms of the relative proportion of infections due to S. aureus.

Published by Elsevier Ltd.
PMID 22101078
Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Sheldon L Kaplan, Jose G Montoya, James C Wade
Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America.
Clin Infect Dis. 2014 Jul 15;59(2):147-59. doi: 10.1093/cid/ciu296. Epub 2014 Jun 18.
Abstract/Text A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
PMID 24947530
Lauren N Ko, Anna C Garza-Mayers, Jessica St John, Lauren Strazzula, Priyanka Vedak, Radhika Shah, Allison S Dobry, Sowmya R Rao, Leslie W Milne, Blair Alden Parry, Daniela Kroshinsky
Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial.
JAMA Dermatol. 2018 May 1;154(5):529-536. doi: 10.1001/jamadermatol.2017.6196.
Abstract/Text Importance: Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost.
Objective: To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis.
Design, Setting, and Participants: This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups.
Interventions: Dermatology consultation within 24 hours of hospitalization.
Main Outcomes and Measures: Length of hospital stay and duration of intravenous antibiotic treatment.
Results: Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines.
Conclusions and Relevance: Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment.
Trial Registration: clinicaltrials.gov Identifier: NCT01706913.

PMID 29453872
David G Li, Fan Di Xia, Hasan Khosravi, Anna K Dewan, Daniel J Pallin, Christopher W Baugh, Karl Laskowski, Cara Joyce, Arash Mostaghimi
Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis.
JAMA Dermatol. 2018 May 1;154(5):537-543. doi: 10.1001/jamadermatol.2017.6197.
Abstract/Text Importance: Many inflammatory skin dermatoses mimic cellulitis (pseudocellulitis) and are treated with antibiotics and/or hospitalization, leading to unnecessary patient morbidity and substantial health care spending.
Objective: To evaluate the impact of early dermatology consultation on clinical and economic outcomes associated with misdiagnosed cellulitis.
Design, Setting, and Participants: This prospective cohort study enrolled patients with presumed diagnosis of cellulitis in the emergency department, in the emergency department observation unit, or within 24 hours of admission to an inpatient unit of a large urban teaching hospital between February and September 2017. Patients were provided with telephone and clinic follow-up during the 30-day postdischarge period. We screened 165 patients with the primary concern of cellulitis. Of these, we excluded 44 who required antibiotics for cutaneous, soft-tissue, and deeper-tissue and/or bone infections irrespective of cellulitis status, and 5 who were scheduled to be discharged by the emergency department.
Interventions: Early dermatology consultation for presumed cellulitis.
Main Outcomes and Measures: Primary outcomes were patient disposition and rates of antibiotic use.
Results: Of 116 patients (63 [54.3%] women; 91 [78.4%] non-Hispanic white; mean [SD] age, 58.4 [19.1] years), 39 (33.6%) were diagnosed with pseudocellulitis by dermatologists. Of these, 34 (87.2%) had started using antibiotics for presumed cellulitis as prescribed by the primary team at the time of enrollment. The dermatology team recommended antibiotic discontinuation in 28 of 34 patients (82.4%), and antibiotics were stopped in 26 of 28 cases (92.9%). The dermatologists also recommended discharge from planned observation or inpatient admission in 20 of 39 patients with pseudocellulitis (51.3%), and the primary team acted on this recommendation in 17 of 20 cases (85.0%). No patients diagnosed with pseudocellulitis experienced worsening condition after discharge based on phone and clinic follow-up (30 of 39 [76.9%] follow-up rate). Extrapolating the impact of dermatology consultation for presumed cellulitis nationally, we estimate 97 000 to 256 000 avoided hospitalization days, 34 000 to 91 000 patients avoiding unnecessary antibiotic exposure, and $80 million to $210 million in net cost savings annually.
Conclusions and Relevance: Early consultation by dermatologists for patients with presumed cellulitis represents a cost-effective intervention to improve health-related outcomes through the reduction of inappropriate antibiotic use and hospitalization.

PMID 29453874
Lauren Strazzula, Jonathan Cotliar, Lindy P Fox, Lauren Hughey, Kanade Shinkai, Sarah N Gee, Daniela Kroshinsky
Inpatient dermatology consultation aids diagnosis of cellulitis among hospitalized patients: A multi-institutional analysis.
J Am Acad Dermatol. 2015 Jul;73(1):70-5. doi: 10.1016/j.jaad.2014.11.012.
Abstract/Text BACKGROUND: Given its nonspecific physical examination findings, accurately distinguishing cellulitis from a cellulitis mimicker (pseudocellulitis) is challenging.
OBJECTIVE: We sought to investigate the national incidence of cellulitis misdiagnosis among inpatients.
METHODS: We conducted a retrospective review of inpatient dermatology consultations at Massachusetts General Hospital, University of Alabama at Birmingham Medical Center, University of California Los Angeles Medical Center, and University of California San Francisco Medical Center in 2008. All consults requested for the evaluation of cellulitis were included. The primary outcomes were determining the incidence of cellulitis misdiagnosis, evaluating the prevalence of associated risk factors, and identifying common pseudocellulitides.
RESULTS: Of the 1430 inpatient dermatology consultations conducted in 2008, 74 (5.17%) were requested for the evaluation of cellulitis. In all, 55 (74.32%) patients evaluated for cellulitis were given a diagnosis of pseudocellulitis. There was no statistically significant difference in the rate of misdiagnosis across institutions (P = .12). Patient demographics and associated risk factor prevalence did not statistically vary in patients given a diagnosis of cellulitis versus those with pseudocellulitis (P > .05).
LIMITATIONS: This study was unable to evaluate all patients admitted with cellulitis and was conducted at tertiary care centers, which may affect the generalizability of the results.
CONCLUSIONS: Cellulitis is commonly misdiagnosed in the inpatient setting. Involving dermatologists may improve diagnostic accuracy and decrease unnecessary antibiotic use.

Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
PMID 26089048
Ryan Y Arakaki, Lauren Strazzula, Elaine Woo, Daniela Kroshinsky
The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial.
JAMA Dermatol. 2014 Oct;150(10):1056-61. doi: 10.1001/jamadermatol.2014.1085.
Abstract/Text IMPORTANCE: Cellulitis is a common and costly problem, often diagnosed in the outpatient setting. Many cutaneous conditions may clinically mimic cellulitis, but little research has been done to assess the magnitude of the problem.
OBJECTIVE: To determine if obtaining dermatology consultations in the outpatient primary care setting could assist in the diagnosis of pseudocellulitic conditions and reduce the rate of unnecessary antibiotic use.
DESIGN, SETTING, AND PARTICIPANTS: Nonblinded randomized clinical trial of competent adults who were diagnosed as having cellulitis by their primary care physicians (PCPs), conducted at outpatient internal medical primary care offices affiliated with a large academic medical center.
INTERVENTIONS: Outpatient dermatology consultation.
MAIN OUTCOMES AND MEASURES: Primary outcomes were final diagnosis, antibiotic use, and need for hospitalization.
RESULTS: A total of 29 patients (12 male and 17 female) were enrolled for participation in this trial. Nine patients were randomized to continue with PCP management (control group), and 20 patients were randomized to receive a dermatology consultation (treatment group). Of the 20 patients in the dermatology consultation group, 2 (10%) were diagnosed as having cellulitis. In the control group, all 9 patients were diagnosed as having cellulitis by PCPs, but dermatologist evaluation determined that 6 (67%) of these patients had a psuedocellulitis rather than true infection. All 9 patients (100%) in the control group were treated for cellulitis with antibiotics vs 2 patients (10%) in the treatment group (P < .001). One patient in the control group was hospitalized. All patients in the treatment group reported improvement of their cutaneous condition at the 1-week follow-up examination.
CONCLUSIONS AND RELEVANCE: Dermatology consultation in the primary care setting improves the diagnostic accuracy of suspected cellulitis and decreases unnecessary antibiotic use in patients with pseudocellulitic conditions. Obtaining an outpatient dermatology consultation may be a cost-effective strategy that improves quality of care.
TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT01795092.

PMID 25143179
S Shimizu, H Shimizu
Cutaneous manifestations of Helicobacter cinaedi: a review.
Br J Dermatol. 2016 Jul;175(1):62-8. doi: 10.1111/bjd.14353. Epub 2016 Feb 18.
Abstract/Text Helicobacter cinaedi is an emerging Gram-negative spiral bacillus that was first reported in 1984. It has been implicated as a cause of gastroenteritis and bacteraemia in immunocompromised individuals. Helicobacter cinaedi-associated bacteraemia is sometimes accompanied by skin lesions; however, the cutaneous manifestations of this pathogen are not widely known. To our knowledge, a comprehensive review with detailed analysis of skin lesions associated with H. cinaedi has not been conducted. This article summarizes the clinical appearance of H. cinaedi cellulitis and its management. In addition, we conducted a retrospective review of 73 patients with H. cinaedi bacteraemia at a single institution, to further clarify the characteristic cutaneous features. It was found that 30% (22/73) of the cases of H. cinaedi bacteraemia had sudden-onset erythema accompanied by high fever. The most common cutaneous symptom of H. cinaedi bacteraemia was found to be mild cellulitis, appearing as multiple painful infiltrated erythemas on the extremities. As H. cinaedi is not always detectable in routine blood culture techniques, evaluation of these characteristic cutaneous manifestations seems important in diagnosis. Helicobacter cinaedi infection should be added to the diagnostic list of unspecified fever with painful infiltrated erythemas.

© 2015 British Association of Dermatologists.
PMID 26678698
David A Talan, William R Mower, Anusha Krishnadasan, Fredrick M Abrahamian, Frank Lovecchio, David J Karras, Mark T Steele, Richard E Rothman, Rebecca Hoagland, Gregory J Moran
Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess.
N Engl J Med. 2016 Mar 3;374(9):823-32. doi: 10.1056/NEJMoa1507476.
Abstract/Text BACKGROUND: U.S. emergency department visits for cutaneous abscess have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). The role of antibiotics for patients with a drained abscess is unclear.
METHODS: We conducted a randomized trial at five U.S. emergency departments to determine whether trimethoprim-sulfamethoxazole (at doses of 320 mg and 1600 mg, respectively, twice daily, for 7 days) would be superior to placebo in outpatients older than 12 years of age who had an uncomplicated abscess that was being treated with drainage. The primary outcome was clinical cure of the abscess, assessed 7 to 14 days after the end of the treatment period.
RESULTS: The median age of the participants was 35 years (range, 14 to 73); 45.3% of the participants had wound cultures that were positive for MRSA. In the modified intention-to-treat population, clinical cure of the abscess occurred in 507 of 630 participants (80.5%) in the trimethoprim-sulfamethoxazole group versus 454 of 617 participants (73.6%) in the placebo group (difference, 6.9 percentage points; 95% confidence interval [CI], 2.1 to 11.7; P=0.005). In the per-protocol population, clinical cure occurred in 487 of 524 participants (92.9%) in the trimethoprim-sulfamethoxazole group versus 457 of 533 participants (85.7%) in the placebo group (difference, 7.2 percentage points; 95% CI, 3.2 to 11.2; P<0.001). Trimethoprim-sulfamethoxazole was superior to placebo with respect to most secondary outcomes in the per-protocol population, resulting in lower rates of subsequent surgical drainage procedures (3.4% vs. 8.6%; difference, -5.2 percentage points; 95% CI, -8.2 to -2.2), skin infections at new sites (3.1% vs. 10.3%; difference, -7.2 percentage points; 95% CI, -10.4 to -4.1), and infections in household members (1.7% vs. 4.1%; difference, -2.4 percentage points; 95% CI, -4.6 to -0.2) 7 to 14 days after the treatment period. Trimethoprim-sulfamethoxazole was associated with slightly more gastrointestinal side effects (mostly mild) than placebo. At 7 to 14 days after the treatment period, invasive infections had developed in 2 of 524 participants (0.4%) in the trimethoprim-sulfamethoxazole group and in 2 of 533 participants (0.4%) in the placebo group; at 42 to 56 days after the treatment period, an invasive infection had developed in 1 participant (0.2%) in the trimethoprim-sulfamethoxazole group.
CONCLUSIONS: In settings in which MRSA was prevalent, trimethoprim-sulfamethoxazole treatment resulted in a higher cure rate among patients with a drained cutaneous abscess than placebo. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00729937.).

PMID 26962903
Robert S Daum, Loren G Miller, Lilly Immergluck, Stephanie Fritz, C Buddy Creech, David Young, Neha Kumar, Michele Downing, Stephanie Pettibone, Rebecca Hoagland, Samantha J Eells, Mary G Boyle, Trisha Chan Parker, Henry F Chambers, DMID 07-0051 Team
A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses.
N Engl J Med. 2017 Jun 29;376(26):2545-2555. doi: 10.1056/NEJMoa1607033.
Abstract/Text BACKGROUND: Uncomplicated skin abscesses are common, yet the appropriate management of the condition in the era of community-associated methicillin-resistant Staphylococcus aureus (MRSA) is unclear.
METHODS: We conducted a multicenter, prospective, double-blind trial involving outpatient adults and children. Patients were stratified according to the presence of a surgically drainable abscess, abscess size, the number of sites of skin infection, and the presence of nonpurulent cellulitis. Participants with a skin abscess 5 cm or smaller in diameter were enrolled. After abscess incision and drainage, participants were randomly assigned to receive clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The primary outcome was clinical cure 7 to 10 days after the end of treatment.
RESULTS: We enrolled 786 participants: 505 (64.2%) were adults and 281 (35.8%) were children. A total of 448 (57.0%) of the participants were male. S. aureus was isolated from 527 participants (67.0%), and MRSA was isolated from 388 (49.4%). Ten days after therapy in the intention-to-treat population, the cure rate among participants in the clindamycin group was similar to that in the TMP-SMX group (221 of 266 participants [83.1%] and 215 of 263 participants [81.7%], respectively; P=0.73), and the cure rate in each active-treatment group was higher than that in the placebo group (177 of 257 participants [68.9%], P<0.001 for both comparisons). The results in the population of patients who could be evaluated were similar. This beneficial effect was restricted to participants with S. aureus infection. Among the participants who were initially cured, new infections at 1 month of follow-up were less common in the clindamycin group (15 of 221, 6.8%) than in the TMP-SMX group (29 of 215 [13.5%], P=0.03) or the placebo group (22 of 177 [12.4%], P=0.06). Adverse events were more frequent with clindamycin (58 of 265 [21.9%]) than with TMP-SMX (29 of 261 [11.1%]) or placebo (32 of 255 [12.5%]); all adverse events resolved without sequelae. One participant who received TMP-SMX had a hypersensitivity reaction.
CONCLUSIONS: As compared with incision and drainage alone, clindamycin or TMP-SMX in conjunction with incision and drainage improves short-term outcomes in patients who have a simple abscess. This benefit must be weighed against the known side-effect profile of these antimicrobials. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00730028 .).

PMID 28657870
Michael Gottlieb, Joshua M DeMott, Marilyn Hallock, Gary D Peksa
Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis.
Ann Emerg Med. 2019 Jan;73(1):8-16. doi: 10.1016/j.annemergmed.2018.02.011. Epub 2018 Mar 9.
Abstract/Text STUDY OBJECTIVE: The addition of antibiotics to standard incision and drainage is controversial, with earlier studies demonstrating no significant benefit. However, 2 large, multicenter trials have recently been published that have challenged the previous literature. The goal of this review was to determine whether systemic antibiotics for abscesses after incision and drainage improve cure rates.
METHODS: PubMed, the Cumulative Index of Nursing and Allied Health Literature, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all randomized controlled trials comparing adjuvant antibiotics with placebo in the treatment of drained abscesses, with an outcome of treatment failure assessed within 21 days. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Cochrane Risk of Bias tool.
RESULTS: Four studies (n=2,406 participants) were identified. There were 89 treatment failures (7.7%) in the antibiotic group and 150 (16.1%) in the placebo group. The calculated risk difference was 7.4% (95% confidence interval [CI] 2.8% to 12.1%), with an odds ratio for clinical cure of 2.32 (95% CI 1.75 to 3.08) in favor of the antibiotic group. There was also a decreased incidence of new lesions in the antibiotic group (risk difference -10.0%, 95% CI -12.8% to -7.2%; odds ratio 0.32, 95% CI 0.23 to 0.44), with a minimally increased risk of minor adverse events (risk difference 4.4%, 95% CI 1.0% to 7.8%; odds ratio 1.29, 95% CI 1.06 to 1.58).
CONCLUSION: The use of systemic antibiotics for skin and soft tissue abscesses after incision and drainage resulted in an increased rate of clinical cure. Providers should consider the use of antibiotics while balancing the risk of adverse events.

Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 29530658
Gregory J Moran, Anusha Krishnadasan, Rachel J Gorwitz, Gregory E Fosheim, Linda K McDougal, Roberta B Carey, David A Talan, EMERGEncy ID Net Study Group
Methicillin-resistant S. aureus infections among patients in the emergency department.
N Engl J Med. 2006 Aug 17;355(7):666-74. doi: 10.1056/NEJMoa055356.
Abstract/Text BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized in infections among persons in the community without established risk factors for MRSA.
METHODS: We enrolled adult patients with acute, purulent skin and soft-tissue infections presenting to 11 university-affiliated emergency departments during the month of August 2004. Cultures were obtained, and clinical information was collected. Available S. aureus isolates were characterized by antimicrobial-susceptibility testing, pulsed-field gel electrophoresis, and detection of toxin genes. On MRSA isolates, we performed typing of the staphylococcal cassette chromosome mec (SCCmec), the genetic element that carries the mecA gene encoding methicillin resistance.
RESULTS: S. aureus was isolated from 320 of 422 patients with skin and soft-tissue infections (76 percent). The prevalence of MRSA was 59 percent overall and ranged from 15 to 74 percent. Pulsed-field type USA300 isolates accounted for 97 percent of MRSA isolates; 74 percent of these were a single strain (USA300-0114). SCCmec type IV and the Panton-Valentine leukocidin toxin gene were detected in 98 percent of MRSA isolates. Other toxin genes were detected rarely. Among the MRSA isolates, 95 percent were susceptible to clindamycin, 6 percent to erythromycin, 60 percent to fluoroquinolones, 100 percent to rifampin and trimethoprim-sulfamethoxazole, and 92 percent to tetracycline. Antibiotic therapy was not concordant with the results of susceptibility testing in 100 of 175 patients with MRSA infection who received antibiotics (57 percent). Among methicillin-susceptible S. aureus isolates, 31 percent were USA300 and 42 percent contained pvl genes.
CONCLUSIONS: MRSA is the most common identifiable cause of skin and soft-tissue infections among patients presenting to emergency departments in 11 U.S. cities. When antimicrobial therapy is indicated for the treatment of skin and soft-tissue infections, clinicians should consider obtaining cultures and modifying empirical therapy to provide MRSA coverage.

Copyright 2006 Massachusetts Medical Society.
PMID 16914702
John D Szumowski, Daniel E Cohen, Fumihide Kanaya, Kenneth H Mayer
Treatment and outcomes of infections by methicillin-resistant Staphylococcus aureus at an ambulatory clinic.
Antimicrob Agents Chemother. 2007 Feb;51(2):423-8. doi: 10.1128/AAC.01244-06. Epub 2006 Nov 20.
Abstract/Text Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTI) have become increasingly common. This study's objectives were to describe the clinical spectrum of MRSA in a community health center and to determine whether the use of specific antimicrobials correlated with increased probability of clinical resolution of SSTI. A retrospective chart review of 399 sequential cases of culture-confirmed S. aureus SSTI, including 227 cases of MRSA SSTI, among outpatients at Fenway Community Health (Boston, MA) from 1998 to 2005 was done. The proportion of S. aureus SSTI due to MRSA increased significantly from 1998 to 2005 (P<0.0001). Resistance to clindamycin was common (48.2% of isolates). At the beginning of the study period, most patients with MRSA SSTI empirically treated with antibiotics received a beta-lactam, whereas by 2005, 76% received trimethoprim-sulfamethoxazole (TMP-SMX) (P<0.0001). Initially, few MRSA isolates were sensitive to the empirical antibiotic, but 77% were susceptible by 2005 (P<0.0001). A significantly higher percentage of patients with MRSA isolates had clinical resolution on the empirical antibiotic by 2005 (P=0.037). Use of an empirical antibiotic to which the clinical isolate was sensitive was associated with increased odds of clinical resolution on empirical therapy (odds ratio=5.91), controlling for incision and drainage and HIV status. MRSA now accounts for the majority of SSTI due to S. aureus at Fenway, and improved rates of clinical resolution on empirical antibiotic therapy have paralleled increasing use of empirical TMP-SMX for these infections. TMP-SMX appears to be an appropriate empirical antibiotic for suspected MRSA SSTI, especially where clindamycin resistance is common.

PMID 17116664
Jörg J Ruhe, Anupama Menon
Tetracyclines as an oral treatment option for patients with community onset skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus.
Antimicrob Agents Chemother. 2007 Sep;51(9):3298-303. doi: 10.1128/AAC.00262-07. Epub 2007 Jun 18.
Abstract/Text Few data exist on the clinical utility of the expanded-spectrum tetracyclines doxycycline and minocycline for the treatment of community-associated methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTI). We performed a retrospective cohort study of 276 patients who presented with 282 episodes of MRSA SSTI to the emergency room or outpatient clinic at two tertiary medical centers between October 2002 and February 2007. The median percentage of patients infected with MRSA strains that were susceptible to tetracycline was 95%. Time zero was defined as the time of the first incision and drainage procedure or, if none was performed, the time of the first positive wound culture. The median patient age was 48 years. Abscesses constituted the majority of clinical presentations (75%), followed by furuncles or carbuncles (13%) and cellulitis originating from a purulent focus of infection (12%). A total of 225 patients (80%) underwent incision and drainage. Doxycycline or minocycline was administered in 90 episodes (32%); the other 192 SSTI were treated with beta-lactams. Treatment failure, defined as the need for a second incision and drainage procedure and/or admission to the hospital within at least 2 days after time zero, was diagnosed in 28 episodes (10%) at a median of 3 days after time zero. On logistic regression analysis, receipt of a beta-lactam agent was the only clinical characteristic associated with treatment failure (adjusted odds ratio, 3.94; 95% confidence interval, 1.28 to 12.15; P = 0.02). The expanded-spectrum tetracyclines appear to be a reasonable oral treatment option for patients with community onset MRSA SSTI in areas where MRSA strains are susceptible to the tetracyclines.

PMID 17576834

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