Class of 2012 Abstract / Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi- square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost- effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.

Background: Cellulitis is a common infectious disease. Although blood culture is frequently used in the diagnosis and subsequent treatment of cellulitis, it is a contentious diagnostic test. To help clinicians determine which patients should undergo blood culture for the management of cellulitis, a diagnostic scoring system referred to as the Bacteremia Score of Cellulitis was developed. Methods: Univariable and multivariable logistic regression analyses were performed as part of a retrospective cohort study of all adults diagnosed with cellulitis in a tertiary teaching hospital in Taiwan in 2013. Patients who underwent blood culture were used to develop a diagnostic prediction model where the main outcome measures were true bacteremia in cellulitis cases. Area under the receiver operating characteristics curve (AUC) was used to demonstrate the predictive power of the model, and bootstrapping was then used to validate the performance. Results: Three hundred fifty one cases with cellulitis who underwent blood culture were enrolled. The overall prevalence of true bacteremia was 33/351 cases (9.4 %). Multivariable logistic regression analysis showed optimal diagnostic discrimination for the combination of age >= 65 years (odds ratio [OR] = 3.9; 95 % confidence interval (CI), 1.5-10.1), involvement of non-lower extremities (OR = 4.0; 95 % CI, 1.5-10.6), liver cirrhosis (OR = 6.8; 95 % CI, 1.8-25.3), and systemic inflammatory response syndrome (SIRS) (OR = 15.2; 95 % CI, 4.8-48.0). These four independent factors were included in the initial formula, and the AUC for this combination of factors was 0.867 (95 % CI, 0.806-0.928). The rounded formula was 1 x (age >= 65 years) + 1.5 x (involvement of non-lower extremities) + 2 x (liver cirrhosis) + 2.5 x (SIRS). The overall prevalence of true bacteremia (9.4 %) in this study could be lowered to 1.0 % (low risk group, score <= 1.5) or raised to 14.7 % (medium risk group, score 2-3.5) and 41.2 % (high risk group, score >= 4.0), depending on different clinical scores. Conclusions: Determining the risk of bacteremia in patients with cellulitis will allow a more efficient use of blood cultures in the diagnosis and treatment of this condition. External validation of this preliminary scoring system in future trials is needed to optimize the test.

Background: Cellulitis is a common skin and soft-tissue infection that often recurs in some patients. Patients with presenting comorbid conditions may require hospitalization which increases the cost of treatment. However, little is known about comorbid conditions as determinants for a patient’s hospital length-of-stay. Objective: 1) To profile the characteristics of patients admitted to Ontario hospitals with a diagnosis of cellulitis according to key demographic, clinical and geographic factors; 2) To examine, among patients hospitalized with cellulitis, comorbidities as possible determinants of hospital length-of-stay. Methods: A retrospective cohort of 7863 patients was identified from the Discharge Abstract Database from April 1, 2006 to March 31, 2008. The Charlson Comorbidity Index was used to measure patients’ comorbidities. Univariate analyses were performed to describe the study population. The chi-square test was used to assess the association between categorical variables. The Kaplan-Meier product-limit method and log-rank test were used to estimate and to test the difference in the distributions of hospital lengths-of-stay between patients with and without comorbidities. Cox regression modeling was used to estimate the comorbidities’ effect on hospital length-of-stay while adjusting for confounding factors. The restricted means of lengths-of-stay were given to estimate and compare the average duration of hospitalization. The effects of specific Charlson comorbidities on hospital length-of-stay were similarly investigated. Results: Forty-six percent (3588/7863) of patients were diagnosed with Charlson comorbidities. Those patients were significantly older (p<.0001), and more likely to be female (p=.006) and to have lower limb cellulitis (p<.001) and C. difficile infections (p<.0001), compared to patients without comorbidities. Patients with comorbidities stayed significantly longer in hospital (8.0 vs. 5.3 days, p<.0001). Comorbidities independently decreased the instantaneous discharge rate by 37% (95% CI, 34% to 40%, p<.001). Hospital lengths-of-stay increased with increasing index of comorbidity. The means of hospital lengths-of-stay for patients with a cumulative index of 1, 2, 3, and 4 (or more than 4) were 7.4, 7.6, 8.8, and 9.7 days, respectively. Conclusion: The Charlson Comorbidity Index is predictive of longer hospital lengths-of-stay in adult patients diagnosed with cellulitis and may be a useful tool in the decision-making process during clinical management of these patients. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2009-11-18 11:43:07.897

Clostridial dermatitis (CD) is a multifactorial disease of rapidly-growing turkeys. Clostridium septicum (Cs) has been identified as the primary cause, although C. perfringens (Cp) has also been implicated. Pathogenesis is not fully understood; however, it is hypothesized that Clostridia translocate from the gastrointestinal tract and spread hematogenously to capillary beds of skeletal muscles. Intense genetic selection has produced a rapidly growing bird that is heavier and less active. This may predispose birds to development of CD due to positional restriction of blood flow to the caudal breast and medial thigh. Subsequent reduction in oxygen tension within these tissues produces conditions conducive to germination, proliferation, and toxin production by previously trapped, non-replicative Clostridia. Studies were undertaken to investigate the epidemiology and pathophysiology of CD. Retrospective epidemiologic investigations evaluated incidence, risk factors, and economic impact of CD. Cs and Cp qPCR were performed on blood and tissue samples to demonstrate hematogenous spread in asymptomatic birds. Studies assessed the effect of prolonged recumbency by measuring oxygen saturation and surface temperature in dependent tissues. Tissues from CD cases were evaluated for Cs and Cp alpha toxin mRNA (CsA and CpA). Analyses were conducted to determine associations between these toxins and severity of histopathologic lesions. Whole genome sequencing was performed on the Cs type strain to identify other toxin genes. Flock type, breed, weight at time of processing, and stocking density affected disease incidence. Detection of Clostridium spp. in intestine, liver, and muscle from asymptomatic turkeys without cutaneous trauma implies hematogenous spread from an endogenous source. Focal polyphasic myonecrosis in dependent muscles of asymptomatic turkeys suggests an underlying predisposition to development of CD. Recumbency appeared to be associated with decreased perfusion to these tissues. Cs DNA was present in asymptomatic birds without corresponding CsA mRNA expression suggesting that organisms were present in a quiescent form. CsA was associated with CD while CpA did not appear to be involved in pathogenesis. Genome sequencing identified several coding regions which may correspond to other potentially active Cs toxins. These results support the proposed mechanism of pathogenesis and provide targets for further investigation of disease pathophysiology and vaccine development. / Ph. D.

Class of 2012 Abstract / Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi-square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost-effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.

No description available.

No description available.

PURPOSE: This study investigated the risk factors for cellulitis infection, the median time to onset of low volume swelling (5 to 10% relative volume change (RVC) and breast cancer-related lymphedema (BCRL) (≥10% RVC) after an incidence of cellulitis, and the impact of common risk factors of both cellulitis and lymphedema on low volume swelling and BCRL. METHODS: We reviewed electronic medical records of 98 patients who underwent unilateral breast cancer (BC) surgery in the year 2011, who had a presurgical baseline perometry measurement and at least two postsurgical follow-up measurements. Clinicopathologic data, edema, and cellulitis incidence were obtained by medical record review. RESULTS: 18.37% of patients (18/98) experienced at least one incidence of cellulitis at a median of 1.03 years postoperatively. Of those 18 patients, 44.44% (eight out of 18) developed low volume swelling and 11.11% (two out of 18) developed BCRL at a median of 1.08 years and 2.33 years postoperatively, respectively. The median time to cellulitis incidence was 0.94 years and 2.91 years after the onset of low volume swelling and BCLR, respectively. Univariate logistic regression revealed that regional lymph node radiation (RLNR) (OR 4.4; p = 0.032) and low volume swelling (OR 6.56; p = 0.004) are significant risk factors for BCRL. RLNR remained a significant risk factor for the development of BCRL by multivariate logistic regression (OR 9.43; p = 0.031). CONCLUSION: Cellulitis may not incite or worsen pre-existing BCRL or affect the median time to BCRL development. However, lymphedema may put patients at risk of cellulitis infection. Sample size may have precluded statistical significance and further research is required to definitively identify the effect of cellulitis infection on lymphedema risk. / 2022-06-04T00:00:00Z

A patient presented with scrotal cellulitis as a complication of infusing 900 ml saline into his scrotum. He had obtained a kit along with explicit instructions for performing the infusion through the Internet. This practice may be more widespread than expected. An Internet search revealed many references to this procedure, but a MEDLINE search showed virtually no information in the medical literature. Patients who are considering scrotal inflation, as it is called in the lay literature, should be warned of the potential complications of this procedure.

We report a rare case of Wells syndrome in which a 61-year-old Caucasian male presented with three distinct skin lesions including a cutaneous bulla, an erythematous plaque, and a linear streak located on the patient’s left anterior thigh, left dorsal wrist, and left anterior forearm, respectively. Histologic examination revealed diffuse and interstitial eosinophilic infiltrate admixed with lymphocytes and macrophages that predominantly involve the dermis. Nodular aggregates of eosinophils surrounding dermal collagen fibers suggestive of ‘flame figures’ were identified. Luna histochemical stain was used and highlighted the deposition of eosinophilic granules over the collagen bundles confirming the presence of flame figures. Laboratory workup revealed peripheral eosinophilia, but a comprehensive clinical evaluation failed to reveal a systemic disease and ultimately the diagnosis of eosinophilic cellulitis ‘Wells Syndrome’ was rendered. After a short course of immunosuppressive therapy, the patient experienced a complete resolution of the skin lesions on his last follow-up visit several weeks from the initial diagnosis. This case highlights the various clinical forms that Wells syndrome may present with and may serve as a good example for the use of Luna stain as a simple and cost-effective diagnostic tool that can help to arrive at the accurate diagnosis and inform therapy.