[Risk factors for local complications in erysipelas]

Complicated Skin and Skin Structure Infection After Erysipelas

Erysipelas are common soft tissue infections responding to first-line antibiosis. Because of factors of related to responsible bacteria and host, complications can occur that need extensive surgery in addition to intensified drug therapy. We report on a 65-year-old woman with leg ulcer who developed an absceding and necrotizing panniculitis of the affected leg complicating erysipelas. Escherichia coli and Pseudomonas aeruginosa were identified. Debridement and surgical removal of inflamed subcutaneous adipose tissue was decisive to interrupt the process. Wound bed preparation was realized by vacuum-assisted closure. Final wound closure was done by split-skin mesh graft. Complicated skin and skin structure infections need a combined approach of intensified antibiosis and surgery to save life.

Risk factors associated with a reduced response in the treatment of erysipelas

BACKGROUND

In most cases, erysipelas may be adequately treated using first-line antibiotic therapy. However, clinicians are sometimes confronted with complicated cases, in which patients do not respond to initial antibiotic therapy. The objective of this study was to identify risk factors associated with a reduced response to antibiotic therapy and, thus, a more complicated disease course.

PATIENTS AND METHODS

We retrospectively analyzed the clinical course of 98 patients with erysipelas treated with standard antibiotic therapy. Patient groups showing different therapeutic responses were compared with respect to clinical data, medical history, and laboratory parameters.

RESULTS

Patients with bullous or hemorrhagic erysipelas (p = 0.0008), stasis dermatitis (p = 0.01) or chronic venous insufficiency (p = 0.0004) showed a significantly reduced response to initial therapy with cefuroxime or clindamycin, respectively. Furthermore, the response to initial therapy significantly depended on C-reactive protein (p = 0.007) and neutrophil (p = 0.02) levels.

CONCLUSION

In erysipelas patients with clinical complications, abnormal laboratory parameters or preexisting local skin damage, an intensified antibiotic regimen should be considered.

Microorganisms of the toe web and their importance for erysipelas of the leg

BACKGROUND

There has been a steady increase of the incidence of erysipelas in Germany in the recent past. Affected patients also often show defects in the cutaneous barrier caused by microorganisms. The aim of this non-interventional case-control study was to investigate a possible interrelationship between interdigital tinea pedis and bacterial toe web (interdigital space) infections and erysipelas of the leg, as well as a potential interaction among the microorganisms themselves.

MATERIAL AND METHODS

The patient population contained 150 people equally distributed among three groups, one retrospective and one prospective erysipelas group (EG = rEG + pEG) plus one control group (KG).

RESULTS

51 % of the patients with erysipelas and 32 % of the control group suffered from interdigital tinea pedis. There was a significant association between interdigital tinea pedis and the recurrence rate of erysipelas, but not with erysipelas itself. Staphylococcus aureus (EG: 30.34 %; KG: 3.23 %) and non-pathogenic aerobic bacteria were significantly associated with erysipelas in each statistical analysis. Staphylococcus aureus showed a positive, the non-pathogenic aerobic germs (EG: 28,09 %; KG: 80,65 %) a negative association.

CONCLUSIONS

This study demonstrates an association between the microorganisms of the toe web and erysipelas of the leg. Erysipelas itself is influenced to a great extent by the bacterial flora, while its recurrence relates more to interdigital tinea pedis.

Erysipelas of the thigh and the gluteal region: retrospective multicenter analysis of a very rare entity in 39 patients

BACKGROUND

Erysipelas of the thigh and the gluteal region are rarely described and not well characterized. Therefore we aim to describe the prevalence, clinical characteristics, and risk factors of these erysipelas types.

METHODS

The files of 1,423 patients with erysipelas were analyzed. Data from patients with erysipelas of the thigh or the gluteal region were compared between the two groups and with a control group with erysipelas of the lower leg.

RESULTS

The thigh was exclusively affected in 2.1%, and the gluteal region in 0.6% of erysipelas patients. Gluteal erysipelas had conspicuous irregular borders and sometimes appeared bilaterally. Major risk factors for erysipelas of both sites were previous surgical interventions. Gluteal erysipelas was common in patients with the metabolic syndrome and required a more intense antibiotic therapy.

CONCLUSION

Erysipelas of the thigh and the gluteal region are rare and significantly associated with prior surgical disruption of lymphatic vessels.

Local complications of erysipelas: a study of associated risk factors

BACKGROUND

Local complications of erysipelas include haemorrhagic, bullous, abscessing and necrotic lesions. The risk factors predisposing patients to local complications are not fully known.

AIM

To examine local complications of erysipelas and to identify possible risk factors predisposing to their appearance.

METHODS

Medical records from all patients hospitalized with complications of erysipelas (purpura, bullae, abscesses and necrosis), admitted to the University Hospital of Heraklion between 1994 and 2002, were retrospectively studied. Clinical and laboratory data were compared with those from patients with erysipelas without local complications.

RESULTS

In total, 145 patients were analysed, of whom 46 had local disease complications. Using bivariate analysis, the factors significantly associated with disease complications were found to be age ≥ 51 years, obesity, longer duration of local symptoms, and fever on admission. During hospitalization, increased C-reactive protein level, isolation of pathogens, longer duration of fever and/or presence of leucocytosis, absence of response to initial antibiotic therapy, and longer length of hospitalization were also associated with complications in the bivariate analysis. However, in the multivariate analysis, obesity (OR 4.489, 95% CI 1.719-11.725, P = 0.002) was the only independent factor associated with complicated erysipelas.

CONCLUSIONS

This study found obesity to be an independent risk factor for local complications, of erysipelas. Hence, obese patients with erysipelas are prone to complications, and should be carefully evaluated because of the potential severity of disease and the increased risk of failure of empirical antimicrobial therapy.

[Erysipelas today]

INTRODUCTION

Erysipelas is a form of cellulitis and a bacterial infection affecting the most superficial layers of the skin which is caused by group A--hemolytic Streptococcus. The symptoms of erysipelas usually arise quite suddenly and they are often accompanied by fever, chill and shivering. The affected skin is distinguished from other forms of cellulitis by well-defined, raised edge. The affected skin is red, swollen and may be finely dimpled (like an orange skin). TREATMENT OF ERYSIPELAS: Uncomplicated erysipelas can be treated on an outpatient basis. Indications for hospitalization include a severe clinical picture and socioeconomics factors. Most patients suffering from erysipelas in Belgrade are treated at the Institute of Infectious and Tropical Diseases, and the aim of this study was to analyze patients treated during 2002 and 2003, in order to determine characteristics of erysipelas at the beginning of the XXI century.

MATERIAL AND METHODS

During the studied period, we treated 60 patients (26.7%) of all registrated erysipelas cases in Belgrade. The male/female ratio was 1:1.6.

DISCUSSION AND CONCLUSION

Prevalence was higher during the summer months. In most cases, the severity and the need for hospitalization were recognized at the beginning; therefore, 74% of patients were hospitalized during the first five days from the onset of nonspecific signs of illness. Laboratory tests showed mild leukocytosis (med 12.05 x 10/9/l), with predominant neutrophils (74.8%) and increased fibrinogen (med 5.4 g/l). Predisposing factors were present in 83.3% of cases; of them, in 35% of cases this was not the first episode of this illness. In 85% of cases erysipelas of the leg was established, and it was the most frequent localization of all.

Bullous Erysipelas: Clinical Presentation, Staphylococcal Involvement and Methicillin Resistance

BACKGROUND

Erysipelas is a bacterial infection of the dermis and hypodermis, mostly of streptococcal origin. Bullous erysipelas represents a severe form of the disease.

OBJECTIVE

To evaluate the clinical and microbiological characteristics and treatment of bullous erysipelas.

METHODS

Patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, University Hospital of Heraklion, Crete, Greece, between the years 1996 and 2001 were retrospectively studied.

RESULTS

Fourteen patients (11 women, 3 men) with bullous erysipelas were evaluated. The lesions were located on the legs and face in 9 and 4 patients, respectively. The median duration of disease before hospital admission was 4 days. Eight patients had fever at presentation. Local trauma and various lesions were common causes for pathogen entry. The initial empirical antibiotic treatment included intravenous beta-lactams and was modified according to the sensitivities of the isolated strains. Staphylococcus aureus was isolated from 7 (50%), while S. warneri, Streptococcus pyogenes and Escherichia coli grew from the lesions of 3 other patients. Six out of 7 S. aureus strains were methicillin resistant (MRSA) but susceptible to several other non-beta-lactam antibiotics such as quinolones, vancomycin, rifampicin and trimethoprim/sulfamethoxazole.

CONCLUSION

Our findings suggest that S. aureus is frequently involved in and probably contributes in synergy with beta-hemolytic streptococci to the complicated course of bullous erysipelas. The frequency of MRSA isolation suggests that beta-lactam antibiotics may not be sufficient for the treatment of bullous erysipelas anymore, at least in areas with a high incidence of MRSA strains. The role of other classes of antibiotics providing adequate coverage for MRSA has to be evaluated in prospective clinical trials.

Erysipelas of the upper extremity following locoregional therapy for breast cancer

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.