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:2021/02/10
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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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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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[2021年]
監修:具芳明 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

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、米国の研究では下肢の蜂窩織炎の罹患率は10万人当たり約200人と報告されている。
  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 

著者: A Dupuy, H Benchikhi, J C Roujeau, P Bernard, L Vaillant, O Chosidow, B Sassolas, J C Guillaume, J J Grob, S Bastuji-Garin
雑誌名: 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  BMJ. 1999 Jun 12;318(7198):1591-4.
著者: Jean-Claude Roujeau, Bardur Sigurgeirsson, Hans-Christian Korting, Helmut Kerl, Carle Paul
雑誌名: 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  Dermatology. 2004;209(4):301-7. doi: 10.1159/000080853.・・・
著者: 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
雑誌名: 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  Dermatology. 2006;212(2):108-12. doi: 10.1159/000090649・・・
著者: 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
雑誌名: 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  N Engl J Med. 2013 May 2;368(18):1695-703. doi: 10.1056・・・
著者: B Perl, N P Gottehrer, D Raveh, Y Schlesinger, B Rudensky, A M Yinnon
雑誌名: 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  Clin Infect Dis. 1999 Dec;29(6):1483-8. doi: 10.1086/31・・・
著者: Anna Stevenson, Phil Hider, Martin Than
雑誌名: 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  N Z Med J. 2005 Mar 11;118(1211):U1351. Epub 2005 Mar 1・・・
著者: Craig G Gunderson, Richard A Martinello
雑誌名: 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  J Infect. 2012 Feb;64(2):148-55. doi: 10.1016/j.jinf.20・・・
著者: 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
雑誌名: 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  Clin Infect Dis. 2014 Jul 15;59(2):147-59. doi: 10.1093・・・
著者: 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
雑誌名: 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  N Engl J Med. 2006 Aug 17;355(7):666-74. doi: 10.1056/N・・・
著者: John D Szumowski, Daniel E Cohen, Fumihide Kanaya, Kenneth H Mayer
雑誌名: 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  Antimicrob Agents Chemother. 2007 Feb;51(2):423-8. doi:・・・
著者: Jörg J Ruhe, Anupama Menon
雑誌名: 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  Antimicrob Agents Chemother. 2007 Sep;51(9):3298-303. d・・・

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