Cellulitis Hospitalization: Mortality Rates and Necessity of Inpatient Care

12.03.197618.10.2021 by alexxlab

What are the mortality rates for hospitalized cellulitis patients. How do these rates compare to outpatient-managed pneumonia cases. Is hospitalization necessary for all cellulitis cases. What factors should guide admission decisions for cellulitis patients.

Содержание

Understanding Cellulitis and Its Impact on Healthcare Systems

Cellulitis is a common bacterial skin infection that affects the deeper layers of skin and underlying tissue. It’s a significant cause of hospital admissions, accounting for approximately 1.4% of all admissions in the United States. The financial impact is substantial, with annual costs reaching $5.5 billion. Given these figures, it’s crucial to examine whether hospitalization is always necessary for cellulitis patients.

The Infectious Diseases Society of America (IDSA) provides guidelines for cellulitis hospitalization. They recommend considering inpatient care for patients with systemic signs of infection, altered mental status, hemodynamic instability, concerns about deep infection, poor adherence to treatment, severe immunocompromise, or those who have failed outpatient treatment. However, the evidence supporting these recommendations is limited.

Methodology of the Systematic Review and Meta-analysis

To address the question of cellulitis hospitalization necessity, researchers conducted a systematic review and meta-analysis. They searched for studies that met specific criteria:

Included consecutive patients hospitalized with cellulitis or erysipelas
Reported inpatient mortality rates

The quality of the studies was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. To analyze the data, the researchers used a random effects model to pool mortality rates from the included studies. They also used the I2 statistic to estimate heterogeneity among the studies.

Key Findings on Cellulitis Mortality Rates

The meta-analysis yielded several important findings regarding mortality rates for hospitalized cellulitis patients:

Overall worldwide mortality rate: 1.1% (95% confidence interval: 0.7–1.8%)
Mortality rate in the United States: 0.5% (95% confidence interval: 0.3–0.9%)

It’s important to note that the actual cause of death was often poorly described in the studies. Only about one-third of the reported deaths appeared to be directly attributable to the infection itself.

Comparing Cellulitis and Community-Acquired Pneumonia Management

To put these mortality rates into perspective, the researchers compared them to those of community-acquired pneumonia patients who are typically managed as outpatients. Tools like the Pneumonia Severity Index and CURB65 prediction models are used to identify low-risk pneumonia patients suitable for outpatient care.

Interestingly, the mortality rates for hospitalized cellulitis patients were found to be comparable to those of pneumonia patients recommended for outpatient management. This finding raises questions about the necessity of hospitalization for many cellulitis cases.

Potential Benefits of Outpatient Management for Cellulitis

Considering the low mortality rates and the comparison with outpatient-managed pneumonia cases, there are potential benefits to treating more cellulitis patients on an outpatient basis:

Cost savings: Reducing unnecessary hospitalizations could lead to significant reductions in healthcare costs.
Patient preference: Many patients may prefer outpatient treatment, allowing them to recover in the comfort of their own homes.
Resource allocation: Freeing up hospital beds for more critical cases could improve overall healthcare efficiency.

Factors to Consider in Cellulitis Admission Decisions

While the study suggests that many cellulitis patients could potentially be managed as outpatients, it’s important to consider various factors when making admission decisions:

Severity of infection: Patients with severe systemic symptoms or signs of sepsis may still require hospitalization.
Comorbidities: Underlying health conditions that could complicate treatment or increase risk should be taken into account.
Social factors: The patient’s ability to adhere to treatment and follow-up care at home should be assessed.
Access to care: Availability of outpatient parenteral antibiotic therapy and close follow-up should be considered.

Implications for Clinical Practice and Future Research

The findings of this meta-analysis have several implications for clinical practice and future research in cellulitis management:

Clinical Practice Recommendations

Reevaluate admission criteria: Healthcare providers should consider reassessing their criteria for hospitalizing cellulitis patients, potentially developing risk stratification tools similar to those used for pneumonia.
Enhance outpatient infrastructure: Improving outpatient parenteral antibiotic therapy programs and follow-up care could facilitate more outpatient management of cellulitis.
Patient education: Providing clear instructions and education to patients managed as outpatients is crucial for ensuring successful treatment outcomes.

Future Research Directions

Develop and validate cellulitis-specific risk stratification tools to guide admission decisions.
Conduct prospective studies comparing outcomes of inpatient versus outpatient management for cellulitis patients.
Investigate the cost-effectiveness of various cellulitis management strategies.
Explore patient preferences and experiences with different treatment approaches for cellulitis.

Limitations of the Current Study

While this meta-analysis provides valuable insights, it’s important to acknowledge its limitations:

Heterogeneity among included studies: Variations in study design, patient populations, and healthcare systems may affect the generalizability of results.
Limited information on causes of death: The poor description of death causes in many studies makes it challenging to fully understand the direct impact of cellulitis on mortality.
Lack of comparison with outpatient outcomes: The study doesn’t directly compare outcomes between hospitalized and outpatient-managed cellulitis cases.
Potential selection bias: Studies may have included more severe cases, potentially overestimating the overall mortality rate for all cellulitis patients.

Despite these limitations, the study provides a valuable starting point for reevaluating cellulitis management strategies and highlights the need for further research in this area.

Conclusion and Future Perspectives

The systematic review and meta-analysis of cellulitis hospitalization mortality rates reveal that the risk of death for many hospitalized cellulitis patients is relatively low and comparable to that of pneumonia patients managed as outpatients. This finding suggests that a significant proportion of cellulitis patients currently admitted to hospitals might be safely managed in outpatient settings, potentially leading to substantial cost savings and improved patient satisfaction.

However, it’s crucial to approach this information with caution and consider individual patient factors when making admission decisions. The development of cellulitis-specific risk stratification tools, similar to those used for pneumonia, could greatly aid clinicians in determining the most appropriate treatment setting for each patient.

As healthcare systems continue to evolve and seek ways to improve efficiency and patient outcomes, the management of common conditions like cellulitis presents an opportunity for optimization. By carefully balancing the risks and benefits of inpatient versus outpatient care, healthcare providers can work towards more targeted, cost-effective, and patient-centered approaches to cellulitis treatment.

Future research should focus on prospectively validating outpatient management strategies for cellulitis, developing robust risk assessment tools, and evaluating the long-term outcomes and cost-effectiveness of different treatment approaches. Additionally, exploring patient perspectives and preferences regarding cellulitis management could provide valuable insights for improving care delivery and satisfaction.

Ultimately, the goal is to ensure that patients with cellulitis receive the most appropriate level of care in the most suitable setting, balancing medical needs with resource utilization and patient preferences. As our understanding of cellulitis management continues to evolve, healthcare systems can work towards more efficient, evidence-based practices that benefit both patients and healthcare providers alike.

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

J Gen Intern Med. 2018 Sep; 33(9): 1553–1560.

, MD,^1,², MD,^1,² and , MD^2,³

Craig G. Gunderson

¹Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, West Haven, CT USA

²Veterans Affairs Connecticut Healthcare System, West Haven, CT USA

Benjamin M. Cherry

¹Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, West Haven, CT USA

²Veterans Affairs Connecticut Healthcare System, West Haven, CT USA

Ann Fisher

²Veterans Affairs Connecticut Healthcare System, West Haven, CT USA

³Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT USA

¹Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, West Haven, CT USA

²Veterans Affairs Connecticut Healthcare System, West Haven, CT USA

³Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT USA

Corresponding author.

Received 2018 Apr 26; Revised 2018 May 29; Accepted 2018 Jun 19.

Abstract

Background

Cellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code “other cellulitis and abscess” accounts for 1.4% of all admissions and $5.5 billion in annual costs. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis and to ascertain if the rate is comparable to the rate for low risk patients with community acquired pneumonia that are currently recommended for outpatient management.

Methods

A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random effects model. Heterogeneity was estimated using the I² statistic.

Results

Eighteen studies met inclusion criteria. The overall worldwide mortality rate was 1.1% (95% confidence interval (CI), 0.7–1.8). For studies from the USA, the rate was 0.5% (95% CI 0.3–0.9). The actual cause of death was generally poorly described, and only one third of deaths appeared to be due to infection.

Discussion

The estimated mortality rate for patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that are recommended for outpatient management by the Pneumonia Severity Index and CURB65 prediction models and strongly endorsed by major infectious disease societies. Outpatient management of these patients could result in large cost savings and may be much preferred by patients.

Electronic supplementary material

The online version of this article (10.1007/s11606-018-4546-z) contains supplementary material, which is available to authorized users.

KEY WORDS: Cellulitis, Mortality, Epidemiology, Hospitalization

INTRODUCTION

Cellulitis is a common cause of hospitalization. In the USA, for example, the International Classification of Diseases (ICD) code “other cellulitis and abscess” accounts for approximately 1.4% of all admissions and $5.5 billion in annual costs.^¹ The Infectious Diseases Society of America (IDSA) recommends that all patients with cellulitis and systemic signs of infection be considered for parenteral antibiotics, which for most patients requires hospitalization. The IDSA also recommends hospitalization for patients with altered mental status, hemodynamic instability, concern for deep infection, and poor adherence, who are severely immunocompromised, or who fail outpatient treatment. ^² Despite these recommendations, there is scant research to guide physicians about when to admit patients with cellulitis. It has been argued that the vast majority of patients with cellulitis could be managed as outpatients.^³ In the case of community-acquired pneumonia, several validated risk stratification tools exist that identify patients with low mortality for outpatient management.^{⁴, ⁵} We undertook a systematic review and meta-analysis of the literature of hospitalized patients with cellulitis to estimate the overall mortality of these patients and to assess whether the rate is low enough to potentially support alternatives to hospitalization.

METHODS

Data Sources and Search Strategy

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement for reporting systematic reviews was used for our study.^⁶ We searched for observational studies that reported the rate of mortality for hospitalized patients with cellulitis or erysipelas. We searched Medline, Embase, and the Cochrane Library from database inception through February 22, 2017. The search was limited to English language and adults. For Medline, we used the following search strategy: “Soft Tissue Infections/complications,” “Soft Tissue Infections/epidemiology,” “Soft Tissue Infections/mortality,” “Skin Diseases, Bacterial/complications,” “Skin Diseases, Bacterial/epidemiology,” “Skin Diseases, Bacterial/mortality,” “Cellulitis/epidemiology,” “Cellulitis/mortality,” “Erysipelas/diagnosis,” “Erysipelas/epidemiology,” or “Erysipelas/mortality.”

Study Selection

All observational studies of consecutive patients hospitalized with cellulitis or erysipelas were included. Studies of mixed cohorts of patients with skin and soft tissue infections (SSTI) that primarily included patients with cellulitis or erysipelas were also included but studies primarily of other types of SSTI such as abscess, diabetic foot, or complicated skin and soft tissue infection were excluded. Studies limited to patients treated with only one specific antimicrobial were not included as were studies limited to SSTI with specific comorbidities or limited to a specific pathogen. Studies with other selection criteria such as only culture-positive infections or only severe infections were also excluded. One author screened all titles and abstracts for full-text review which two authors (CG and AF) then independently reviewed for ultimate inclusion. Disagreement was resolved by consensus.

Data Extraction and Quality Assessment

A standardized data extraction form was used to document study characteristics such as study methodology, patient descriptions, type of SSTI included, method used for data acquisition, definition of mortality used, rate of overall mortality, and attributable mortality if included. Two authors (CG and BC) independently assessed study quality using a modified Newcastle-Ottawa Quality Assessment Scale (NOS) for Cohort Studies (see Supplementary File ¹). ^⁷ Differences in assessments were resolved by consensus. The original NOS included eight elements but three of these are not relevant to the types of included studies so only five elements were assessed. Representativeness was judged as good if the study was prospectively performed and patients with cellulitis were individually identified or if the study was retrospective and used record linkage with codes that only included cellulitis. Retrospective chart reviews were judged to have fair representativeness as were studies that used record linkage with non-cellulitis codes or poor if they included multiple non-cellulitis-related codes. Ascertainment was judged favorably if the study was prospectively conducted or if it used a national database for record linkage.

Data Synthesis and Analysis

The mortality rate for hospitalized patients with cellulitis for each study was recorded and the 95% confidence interval (CI) was calculated. Mortality rates from individual studies were pooled using a random effects model to calculate an overall mortality rate. Between-study heterogeneity was estimated using the I² statistic. Pre-specified subgroup analysis was performed based on study methodology (retrospective chart reviews vs. prospective studies vs. retrospective record linkage), study quality based on the NOS, and types of included infections (cellulitis only or mixed cohorts and whether necrotizing soft tissue infections were excluded). Meta-regression using these same variables was done to explore heterogeneity. Sensitivity analysis was done to assess the robustness of the overall pooled estimate after removal of individual studies. Statistical significance was assumed for p values less than 0.05. Statistical analysis was performed using Comprehensive Meta-Analysis, version 3 (Biostat, Englewood, NJ) and Stata/SE, version 14.2 (StataCorp, College Station, TX).

RESULTS

The initial electronic search found 2467 manuscripts (Fig. ). Two thousand three hundred and fifty-five manuscripts were excluded based on title and abstract review, leaving 112 for full-text review. Of these, 13 met criteria for study inclusion. An additional five studies were found by review of the references from the included studies. The main reasons that studies were excluded after full-text review were that they included outpatients, did not report mortality, or did not enroll consecutive hospitalized patients but instead used selection criteria such as only enrolling culture-positive infections, severe infections, or patients treated with specific antibiotics.

Study flow diagram of literature search. Figure 1 contains poor quality of text inside the artwork. Please do not re-use the file that we have rejected or attempt to increase its resolution and re-save. It is originally poor; therefore, increasing the resolution will not solve the quality problem. We suggest that you provide us the original format. We prefer replacement figures containing vector/editable objects rather than embedded images. Preferred file formats are eps, ai, tiff, and pdf.Will attach original Figure 1 in PDF format, which i believe is acceptable. thx.

Table outlines the characteristics of the 18 included studies. Twelve of the studies were relatively small, occurred at a single hospital or institution, and used individual chart review for data acquisition. Seven of these 12 studies were conducted retrospectively and five prospectively. The remaining six studies used electronic coding for patient enrollment without chart review. Five of the six used ICD coding, and one was unspecified. In terms of types of infection included, the chart reviews and prospective studies purported to include only cellulitis and/or erysipelas, whereas the studies using coding included a more varied patient population; two included only cellulitis or erysipelas; two included a mix of infections including cellulitis, abscess, surgical site infection, ulcer-associated infections, and necrotizing infections; one included cellulitis, abscess, and surgical site infections; and one did not specify what types of infections were included. Of the 18 studies, eight were from Europe, four were from the USA, two were from China or Taiwan, two were from Australia-New Zealand, and one each from Israel and Canada.

Table 1

Characteristics of Included Studies

Author	Year	Country	Setting	Data acquisition	SSTI types included	Mortality, N (%)
Jorup-Ronstrom^⁸	1986	Sweden	Single hospital	Prospective	Cellulitis	1/233 0.4%
Eriksson^⁹	1997	Sweden	Single hospital	Prospective	Cellulitis	2/229 0. 9%
Cox^¹⁰	1998	England	Two hospitals	Retrospective chart review	Cellulitis	0/92
Perl^¹¹	1999	Israel	Single hospital	Retrospective chart review	Cellulitis	0/757
Carratala^¹²	2003	Spain	Single hospital	Hospital EMR with chart review	Cellulitis, ulcer, NSTI	8/332 2. 4%*
Lazzarini^¹³	2005	Italy	Single hospital	Retrospective chart review	Cellulitis	0/200
Morpeth^¹⁴	2005	New Zealand	Single hospital	Prospective	Cellulitis	0/51
Goettsch^¹⁵	2006	Netherlands	National	Primary ICD-9 code	Cellulitis	65/3473 1. 9%
Edelsberg^¹⁶	2008	USA	National	Primary ICD-9 codes	Cellulitis, abscess, SSI, ulcer, other	365/47,219 0.8%
Figtree^¹⁷	2010	Australia	Single hospital	Primary ICD-10 codes with chart review	Cellulitis, ulcer	10/395 2.5%
Jenkins^¹⁸	2010	USA	Single hospital	Primary ICD-9 codes with chart review	Cellulitis, abscess, NSTI	0/322
Shen^¹⁹	2010	Taiwan	National	Primary ICD-9 codes	Cellulitis, abscess, DFI, SSI, NSTI, ulcer, other	306/11,390 2. 7%
Lipsky^²⁰	2012	USA	National	Prospective	Cellulitis, abscess, DFI, SSI	4/1033 0.4%
Marwick^²¹	2012	Scotland	Single hospital	Prospective	Cellulitis, NSTI	2/79 2.5% 30 days
Perello-Alzamora^²²	2012	Spain	Single hospital	Retrospective chart review	Cellulitis, Ulcer	2/70 2. 9%
Baiber-genova^²³	2014	Canada	National	Primary ICD-10 Code	Cellulitis	654/65,454 1.0%
Kaye^¹	2015	USA	National	Primary ICD-9 codes	Cellulitis, abscess, SSI	22,140/4,891,187 0.45%
Li^²⁴	2016	China	Four hospitals	Data collected from the EMR corresponding to cSSTI	Cellulitis, abscess, SSI, NSTI, ulcer	14/575 2. 4%

Table describes the study quality assessment based on the modified NOS. Study quality was assessed based on five elements, each of which could earn one point if certain standards were met. Studies that scored favorably in all five elements received five points, which was achieved by seven studies. Ten studies scored four points and one three points. The main reason studies lost points were for retrospective chart reviews with poor ascertainment and for studies that used poorly representative coding.

Table 2

Author	Representativeness	Ascertainment	Outcome assessment	Follow-up duration	Adequacy of follow-up	NOS
Jorup-Ronstrom^⁸	Good*	Prospective*	Independent assessment*	Yes*	Yes*	5/5
Eriksson^⁹	Good*	Prospective*	Independent assessment*	Yes*	Yes*	5/5
Cox^¹⁰	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Perl^¹¹	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Carratala^¹²	Fair*	CR	Independent assessment*	72 h and 30 days	Yes*	3/5
Lazzarini^¹³	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Morpeth^¹⁴	Fair*	Prospective*	Independent assessment*	Yes*	Yes*	5/5
Goettsch^¹⁵	Fair*	Coding*	Record linkage*	Yes*	Yes*	5/5
Edelsberg^¹⁶	Poor	Coding*	Record linkage*	Yes*	Yes*	4/5
Figtree^¹⁷	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Jenkins^¹⁸	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Shen^¹⁹	Poor	Coding*	Record linkage*	Yes*	Yes*	4/5
Lipsky^²⁰	Good*	Prospective*	Independent assessment*	Yes*	Yes*	5/5
Marwick^²¹	Good*	Prospective*	Independent assessment*	30 days	Yes*	4/5
Perello-Alzamora^²²	Fair*	CR	Independent assessment*	Yes*	Yes*	4/5
Baibergenova^²³	Good*	Coding*	Record linkage*	Yes*	Yes*	5/5
Kaye^¹	Fair*	Coding*	Record linkage*	Yes*	Yes*	5/5
Li^²⁴	Poor	Coding*	Record linkage*	Yes*	Yes*	4/5

Figure presents the pooled and individual study mortality rates for hospitalized patients with cellulitis using random effects meta-analysis. The overall pooled rate was 1.1% (95% CI, 0.7–1.8). Individual studies ranged from 0 deaths to 2.9% mortality. The pooled result for important subgroups is listed in Table . The pooled rate for studies that used chart review was 1.2% (95% CI, 0.6–2.8) whereas the rate for studies that used record linkage was 1.3% (95% CI, 0.7–2.4). The pooled result for studies that purported to include only patients with cellulitis was 1.1% (95% CI, 0.7–1.8) whereas for studies with mixed cohorts, the rate was 1.3% (95% CI, 0.7–2.5). The only subgroup with a statistically significant different rate of mortality when compared to the remaining studies was of studies from the USA for which the pooled rate was 0.5% (95% CI, 0.3–0.9). Overall, there was statistically significant evidence for heterogeneity (I² = 98%, p < 0.001). We explored the heterogeneity by subgroup analysis but most subgroups also had high heterogeneity with the exception of the three studies of leg cellulitis only (I² = 0%, p = 0. 61) and the five prospective studies (I² = 22%, p = 0.28). On meta-regression, 93% of the heterogeneity was explained by the covariates of NOS of five (R² = 0.35) and studies from the USA (R² = 0.58). Sensitivity analysis removing individual studies or subgroups did not have an effect on the overall pooled result or on heterogeneity.

Forest plot of individual study and pooled mortality rates.

Table 3

Subgroup	Heterogeneity (I²)	Mortality rate and 95% CI
Overall pooled estimate	99%	1.1% (0.7–1.8)
Studies using chart review	55%	1. 2% (0.6–2.8)
Studies using record linkage	99%	1.3% (0.7–2.4)
Cellulitis only cohorts	74%	1.1% (0.7–1.8)
Mixed cohorts	99%	1.3% (0.7–2.5)
Leg cellulitis only cohorts	0%	1.8% (1.5–2.3)
Prospective studies only	22%	0.8% (0.4–1.6)
Studies that include NSTI (n = 3)	52%	1.9% (0.7–5.2)
Studies that exclude NSTI (n = 6)	99%	1. 0% (0.6–1.5)
Studies with NOS ≥ 4	99%	1.1% (0.7–1.7)
Studies with NOS ≥ 5	99%	0.8% (0.4–1.4)
U.S. studies only	97%	0.5% (0.3–0.9)*

Only five of the 18 studies included information about the actual cause of death. In these five studies, a total of 27 patients died including ten who were reported to have died directly from their infection (37%). Seven of these ten infectious deaths were from a single study.^¹² Of the remaining 17 patients who died, two died from heart failure,^²⁵ one from respiratory failure,^¹² and 14 were not specified other than that they did not die from infection.^²⁴

DISCUSSION

In total, we found 18 studies of consecutive patients hospitalized for cellulitis or associated infections. The estimated pooled mortality rate worldwide for these patients using random effects meta-analysis was 1.1%. For studies from the USA, the rate was 0.5%. Although poorly described, only about one third of this mortality appeared to be attributable to cellulitis. The overall rate is comparable to common thresholds to recommend outpatient management for community-acquired pneumonia. For example, a systematic review of 31 studies that assessed the mortality rate of class 1–2 patients as defined by the PSI found that the pooled mortality rate for these low-risk patients was 0.75%.^²⁶ The same systematic review found that the pooled mortality rate from 17 studies of the CURB65 score for patients with 0–1 risk factors was 2.0%. The IDSA and the British Thoracic Society (BTS) both recommend use of these prediction tools to identify patients for outpatient management. In the case of cellulitis, there are no well-described clinical models to predict mortality in hospitalized patients. The most widely known system classifies patients into four groups based on systemic signs of infection and comorbidity, but the actual mortality for the different groups has not been well defined.^²⁷ Our findings show that the pooled mortality rate of patients currently being hospitalized for cellulitis is comparable to the mortality rate of patients with community-acquired pneumonia that is strongly recommended for outpatient management by the IDSA and BTS.

Talan et al. reported that in 85% of cases, the reason emergency room physicians hospitalize patients with SSTI is to administer intravenous antibiotics.^³ The main significance of our study is to support the potential use of alternatives to hospitalization for these patients. The use of outpatient parenteral antimicrobial therapy (OPAT) for example has been shown to be a safe alternative to hospitalization and to be preferred by patients.^{²⁸, ²⁹} Another alternative is to briefly admit patients with cellulitis for observation. It has been estimated that the use of observation admission in the USA for low acuity conditions such as cellulitis could save individual patients $1500, individual hospitals $4.5 million, and the country $3.1 billion.^³⁰ Lastly, several antibiotics are now available for SSTI that have long half-lives allowing once-weekly outpatient administration.^³¹–³³

Another significance of the low pooled mortality rate for cellulitis relates to antibiotic stewardship. Current guidelines recommend relatively narrow spectrum antibiotics for most patients with cellulitis, targeting the most common organisms which are β-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus.^² Studies over the past decade, however, have shown that most patients in the USA when hospitalized with cellulitis are receiving combinations of broad-spectrum antibiotics, including frequent coverage of MRSA and resistant Gram-negative organisms as well as anaerobes.^{¹⁸, ²⁰, ³⁴} This practice likely reflects uncertainty about the true microbiology of these infections which are frequently unculturable and also promotion of broad-spectrum antibiotics for severe infections such as septic shock.^³⁵ Studies showing that inappropriate antibiotics are associated with higher mortality originate largely from studies of patients with bacteremia with severe illness hospitalized in the ICU.^³⁶ One systematic review for example found the pooled mortality rate for ICU patients with septic shock to be 46%.^³⁷ As shown by our study, the estimated mortality rate for hospitalized patients with SSTI is a magnitude lower and supports an initial narrow approach to empiric antibiotics.

Our review has several limitations. First, there was significant statistical heterogeneity for mortality between studies. This likely reflects both methodologic and clinical differences between studies. In particular, most of the studies purported to include only patients with cellulitis or erysipelas, but most of these were retrospective studies in which it may be difficult to distinguish cellulitis from other SSTI including abscess, bursitis, and ulcer-associated infections. It has also been pointed out that the terms cellulitis and erysipelas have been used differently by different authors so studies of these infections may in fact report heterogeneous SSTI.^³⁸ We also included studies of hospitalized patients that used coding without individual chart review to identify patients. Several of these studies included ICD codes other than cellulitis and erysipelas, including for different types of SSTI such as abscess, surgical site infection, and diabetic foot infections. To try to understand the heterogeneity of the included studies, we did subgroup analysis and meta-regression and found that most of the heterogeneity was due to the lower rates of mortality found in studies that had low risk of bias as measured by the NOS or originated from the USA. Ultimately, because of the heterogeneity of included studies and the limits in reporting for most of the studies, we used random effects meta-analysis to estimate the pooled mortality rate and we emphasize that different populations of patients with cellulitis likely have somewhat different rates of mortality.

Another potential weakness of our study is that only three of the included studies specifically included necrotizing soft tissue infections (NSTI) and most of the studies did not specify whether NSTI were included. The pooled mortality rate for the three studies that included NSTI was 1.9% and it is possible that to the extent that studies excluded NSTI that much of the attributable mortality rate for cellulitis was removed. Ideally, to answer our research question, studies would have included NSTI and reported the frequency and outcomes of these infections both separately and included with full cohort.

Lastly, our study does not by itself show that patients that are currently being hospitalized with cellulitis would have the same low rate of mortality if managed as outpatients. In addition to intravenous antibiotics, hospitalized patients also undergo monitoring and supportive care. After the PSI was derived, for example, three separate randomized controlled studies were conducted which confirmed that low-risk patients had in fact good outcomes when treated as outpatients.^{³⁹–⁴¹} Ideally, a randomized trial would be the next step to demonstrate that patients currently being hospitalized with cellulitis did equally well when managed as outpatients.

In summary, the estimated rate of mortality for patients hospitalized with cellulitis worldwide is approximately 1% and for patients in the USA, 0.5%. Attributable mortality is even lower. This rate is similar to the mortality rate of low-risk patients with community-acquired pneumonia that is currently strongly recommended for outpatient management by major infectious disease societies. If confirmed by a randomized controlled trial, outpatient management of patients currently being hospitalized for cellulitis could result in large cost savings to patients and payers and may be much preferred by patients.

Electronic Supplementary Material

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Compliance with Ethical Standards

Conflict of Interest

The authors have no conflicts to disclose.

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What you Need to know, When to go to the ER

Cellulitis: What you Need to know and When to Visit the ER

Cellulitis is a skin disease. Cellulitis Emergency happens when bacteria manages to get under the skin and spread to the tissues beneath, cellulitis can develop. The bacteria responsible are Streptococcus or Staphylococcus.

In most cases, Cellulitis Emergency is not a serious, life-threatening condition and as a bacterial skin infection, is easily treated with antibiotics. Cellulitis Emergency does, however, need treating, since if you leave it to its own devices it will probably get worse.

If you suspect a Cellulitis Emergency you should go and see your doctor as soon as possible to avoid potential complications. Keep an eye on the suspected area from day to day, and if you notice any worsening or spreading of the signs or symptoms, seek medical care.

What Does Cellulitis Emergency Look like?

The first thing you may notice is redness and inflammation at the site of the infection. This may swell, feel warmer to the touch and surrounding areas, and become painfully tender. The skin may crack or split and leak fluid or pus and you may notice red streaks extending from the area.

As well as these physical symptoms you may have a general feeling of illness or malaise. In more severe instances you may also experience fevers, chills, and sweats.

What Causes Cellulitis?

Anyone can be at risk from cellulitis emergency, and it can affect almost any part of the body, especially where the skin is damaged or broken.

Broken or damaged skin can come from skin conditions such as eczema, acne, psoriasis or scabies as well as from general cuts and grazes.
Insect bites puncture the skin and can put you at risk.
Cellulitis can sometimes result from surgical wounds.
Foreign objects becoming embedded in or under the skin (such as glass, metal or ceramics) can lead to cellulitis.

Cellulitis Diagnosis

Cellulitis Emergency Diagnosis is normally a simple matter for your doctor, based on a physical exam and your medical history.

Occasionally the doctor may request some blood work if he or she suspects infection has passed into the bloodstream, or to check your white blood cell count. If a foreign object is suspected, the doctor may also order an x-ray. In some instances, fluid may be taken from the affected area then sent to the lab for testing.

See also: Psoriasis : Challenges, Causes, Symptoms, Diagnosis and Treatment

Cellulitis Treatment

Cellulitis Emergency is normally treated with antibiotics you can take orally for a week to ten days. If antibiotics are prescribed for you, make sure you take the entire course of treatment even if the infection seems to be getting better after a few days. Occasionally stronger antibiotics may be needed and these are generally given in hospital intravenously (although sometimes this can be administered at home).

During your recovery at home, you should get plenty of rest so the body can concentrate on fighting the infection. If you can keep the area of infection raised, this will help ease swelling, improve drainage and reduce any pain. Over-the-counter pain relievers may also help reduce inflammation or fevers.

Preventing Cellulitis Emergency

Sensible precautions against accidental injuries are the first guard against cellulitis. For instance, taking care when using knives or other sharp instruments, and not going barefoot in hazardous areas such as on the beach or in the forest.Cellulitis is also easily spread from skin to skin contact or by touching infected surfaces.

Simple precautions can help reduce the chances of infection spreading:

Daily showering or bathing.
Frequent hand washing.
Keeping wounds covered.
Not sharing towels with others.
Regularly changing and washing bed linen.

When Cellulitis Becomes an Emergency

There are some instances when cellulitis needs urgent emergency room treatment. If you notice any of the following symptoms, please treat them seriously and get urgent medical care:

Certain pre-existing medical conditions can also increase the seriousness of cellulitis, so if you have any of the following you should also seek urgent medical care:

Diabetes
Liver conditions such as cirrhosis or hepatitis
Kidney disease
Circulatory problems or varicose veins
Eczema or psoriasis
Any medical problems that can be made worse by other infections
Impaired immune systems

In addition, certain areas of the body are more sensitive than others, for instance in or around the eyes. Children with facial cellulitis can sometimes develop brain or eye infections. These are potentially dangerous so should always be treated as an emergency.

Often, skin conditions don’t appear to be an emergency initially, but in the long term, they can become problematic. As with any health concern, prompt treatment results in faster healing and fewer complications. It is far better to seek medical advice as soon as you suspect infection rather than waiting to see what happens.

Cellulitis | Journal of Hospital Medicine

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. the healthcare cost and utilization project (hcup) states there were approximately 340,000 hospital discharges in 2002 with a diagnosis related group (drg) for cellulitis. patients with cellulitis with complications and co‐morbidities had a mean length‐of‐stay of 5.3 days with an in‐hospital mortality of 0.8%. the mean charges for these patients were $13,000. the figures were slightly improved for uncomplicated cellulitis, as the mean length‐of‐stay dropped to 3.6 days and total charges decreased to $8,000 per patient. hospitalists can provide leadership to standardize care delivery, improve discharge planning, and promptly identify and address severe cases of cellulitis that require further intervention.

KNOWLEDGE

Hospitalists should be able to:

Describe the clinical presentation of cellulitis and compare routine and complicated cellulitis.
Differentiate cellulitis from chronic venous stasis and other conditions that may mimic cellulitis and discuss the accuracy of signs/symptoms in patients admitted with cellulitis.
Describe the indicated tests required to evaluate cellulitis.
Relate cellulitis with certain host exposures (including pseudomonas with hot tub exposure, streptococci and venous harvest site cellulitis, and aeromonas with fresh or brackish water).
Identify patients with co‐morbidities (such as the immunocompromised patient, and those with chronic venous and lymphatic problems) and extremes of age (the elderly and the very young) who are at increased risk for a complicated course of cellulitis.
Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.
Explain indications for inpatient admission.
Describe the prognostic indicators, including patient co‐morbidities, for complicated and uncomplicated cellulitis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

Elicit a focused history to identify precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.
Accurately identify and document cellulitis borders and signs of complications, which may include crepitis and abscess.
Determine and interpret an appropriate and cost‐effective initial diagnostic evaluation of cellulitis including laboratory and radiological studies.
Initiate empiric antibiotic treatment of cellulitis based on host exposures, predisposing underlying systemic illness, history and physical examination, presumptive bacterial pathogens, and evidence based recommendations.
Treat co‐existing fungal infection, edema, and other conditions that may exacerbate cellulitis.
Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.
Determine appropriate timing for transition from intravenous to oral therapy.
Assess patients with cellulitis in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

Communicate with patients and families to explain the history and prognosis of cellulitis.
Communicate with patients and families to explain goals of care plan, discharge instructions, and management after release from hospital.
Communicate with patients and families to explain tests and procedures and their indications, and obtain informed consent.
Recognize the need for early specialty consultation in cases with complications, misdiagnosis, or lack of response to therapy.
Initiate prevention measures for recurrent cellulites, prior to discharge.
Employ a multidisciplinary approach to the care of patients with cellulitis that begins at admission and continues through discharge.
Communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.
Consider cost effectiveness (including formulary availability), and ease of conversion to outpatient treatment when choosing among therapeutic options.
Employ multidisciplinary teams to facilitate discharge planning.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cellulitis.

SYSTEM ORGANIZATIONS AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease physicians, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with cellulitis.

Cellulitis | University Hospitals

What is cellulitis?

Cellulitis is a deep infection of the skin caused by bacteria. It
often affects the arms and legs. It can also develop around the eyes, mouth, and anus,
or on the belly (abdomen). Normal skin can be affected by cellulitis. But it often
happens after some type of injury causes a skin break, including trauma or surgery.
Once
the skin breaks, bacteria can enter and cause infection.

What causes cellulitis?

Cellulitis is often caused when
bacteria enter a wound or area where there is no skin. The most common bacteria that
cause cellulitis include:

Group A ß – hemolytic streptococcus (Strep)
Streptococcus pneumoniae (Strep)
Staphylococcus aureus (Staph)

Staph and strep bacteria are
commonly found on the skin and mucous membranes of the mouth and nose in healthy people.
The infection happens when there is a break in the skin that lets the bacteria
enter. Other causes may include human or animal bites, or injuries that happen in
water.

What are the symptoms of cellulitis?

Symptoms can be different for each
person. Common symptoms include:

Skin redness
Skin swelling
Soreness
Warm skin
Pain
Bruising
Blisters
Fever
Headache
Chills
Weakness
Red streaks from the original site of the cellulitis

Some cases of cellulitis are an
emergency. Always talk with your healthcare provider right away if you notice any
of the
following symptoms:

A very large area of red, inflamed skin
Fever
If the area affected is causing numbness, tingling, or other changes in a hand, arm,
leg, or foot
If the skin appears black
If the area that is red and swollen is
around your eye or behind the ear
If you have diabetes or have a weak
immune system and get cellulitis

Many of these symptoms can be
caused by other skin conditions. Always talk with your healthcare provider for a
diagnosis.

How is cellulitis diagnosed?

Diagnosis is often based on a health history and physical exam. Blood
and skin samples may be taken to confirm the diagnosis and the type of bacteria
present.

A bacterial culture can sometimes identify the organism causing the
condition. This helps guide treatment with the correct antibiotic.

How is cellulitis treated?

Your healthcare provider will
consider your age, overall health, and severity of the condition when finding the
best
treatment for you.

Getting treated right away can help prevent the spread of cellulitis. Treatment may
include:

Antibiotics, which can be given by
mouth (oral), shot (injection), or by IV (intravenously)
Keeping the area clean and applying
dressings as instructed
Surgery
If your arm or leg is affected,
raising (elevating) the arm or leg may help
Rest
Time to heal
Pain medicine as needed

Based on the physical exam,
your healthcare provider may treat you in the hospital, depending on the severity
of the
cellulitis. In the hospital, you may get antibiotics and fluids through an IV.

What are possible complications of cellulitis?

In most cases, cellulitis is easily treated with no complications.
But in some cases complications can be very serious. These can include extensive tissue
damage and tissue death (gangrene). The infection can also spread to the blood, bones,
lymph system, heart, or nervous system. These infections can lead to removing the
affected arm or leg (amputation), shock, or even death.

Can cellulitis be prevented?

To prevent cellulitis:

Use good personal hygiene.
Wash hands often.
Apply lotion to dry, cracked skin.
Use gloves when cuts and scrapes may happen.
Never go barefoot, always wear
protective footwear.

If skin breaks happen, keep the area clean and use an over-the-counter antibiotic
ointment. Watch for signs of infection. If you have diabetes, visually check your
feet for signs of skin breaks or infection. Also, don’t cut out warts or calluses,
and don’t cut toenails too short.

When should I call my healthcare provider?

Call your healthcare provider right away if a wound starts to swell,
turn red, feel warm, or get painful. Also call if the redness or warmth starts to
spread
from the wound.

Key points about cellulitis

Cellulitis is a deep bacterial infection of the skin.
It often causes redness, swelling, and
soreness.
Good hygiene, protective footwear, and
skin care can help prevent cellulitis.
Watch any breaks in the skin for signs of infection.
Untreated cellulitis can lead to amputation, shock, and even death.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells
you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments,
or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also
know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that
visit.
Know how you can contact your provider if you have questions.

A SYSTEMATIC REVIEW AND META-ANALYSIS – Abstracts

Craig Gunderson, MD FHM¹, Benjamin Cherry, MD², Ann Fisher, MD³, ¹Yale Medical School, Department of Internal Medicine and VA Connecticut Healthcare System, West Haven, CT; ²Yale Medical School, Department of Internal Medicine and VA Connecticut Healthcare System; ³Yale Medical School, Department of Internal Medicine, Section of Infectious Diseases, VA Connecticut Healthcare System

Abstract Number: 351

Background: Cellulitis is a common cause of hospitalization. In the United States there are approximately 650,000 hospitalizations for cellulitis yearly, accounting for 1% of all admissions and approximately $10 billion. Most patients when hospitalized are treated with combinations of antibiotics with broad-spectrum Gram-positive, Gram-negative and anaerobic coverage. The Infectious Disease Society of America recommends hospitalization for patients for cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. The purpose of this study is to determine the mortality rate of patients hospitalized with cellulitis to determine if the rate is low enough to support a relatively narrow approach to empiric antibiotics and to support potential outpatient management of many of these patients.

Methods: A systematic literature search was conducted for studies of consecutive patients hospitalized with cellulitis or erysipelas that reported inpatient mortality. We searched Medline, Embase and the Cochrane Library from database inception through February 22, 2017. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale. The mortality rates from the included studies were pooled using a random-effects model. Heterogeneity was estimated using the I² statistic.

Results: Eighteen studies met inclusion criteria. The overall pooled mortality rate was 1.1% (95% CI, 0.7-1.8). Subgroup analysis found little difference in mortality with the exception of studies with the lowest risk of bias for which the pooled rate was 0.6% (95% CI, 0.3-1.1) and with studies from the United States for which the rate was 0.5% (95% CI 0.3-0.9). The actual cause of death was generally poorly described, and only approximately 1/3rd of deaths appeared to be due to infection.

Conclusions: The overall mortality rate for patients hospitalized with cellulitis is 1.1% and for patients in the United States the rate was 0.5%. This rate compares to mortality rates of low risk conditions that are often managed as outpatients or in observation units. Although poorly described, only about one third of this mortality appeared to be attributable to cellulitis. Overall, our results appear to support a narrow approach to empiric antibiotics and also potentially support alternatives to hospitalization such as observation admission or outpatient parenteral antimicrobial therapy.

IMAGE 1: Forest Plot of Individual Study and Pooled Mortality Rates

To cite this abstract:

Gunderson, C; Cherry, B; Fisher, A.

MORTALITY OF HOSPITALIZED PATIENTS WITH CELLULITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla..

Abstract 351

https://shmabstracts.org/abstract/mortality-of-hospitalized-patients-with-cellulitis-a-systematic-review-and-meta-analysis/.

October 18th 2021.

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Epidemiology, treatment, and prevention of community-acquired methicillin-resistant Staphylococcus aureus infections. Mayo Clin Proc.
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Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol.
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2012;166(1):169–178.

Sex differences in hospitalized adult patients with cellulitis: A prospective, multicenter study

https://doi.org/10.1016/j.ijid.2021.01.044Get rights and content

Highlights

•: Adult female patients with cellulitis were substantially older than adult male patients.
•: Female patients had higher rates of edema/lymphedema as an underlying condition than male patients.
•: Female patients were more likely to have had prior episodes of cellulitis than male patients.
•: Male patients with cellulitis were more likely to have positive pus cultures than female patients.
•: The location of cellulitis involvement differed between the sexes.

Abstract

Objectives

Sex differences in adult cellulitis, a frequent cause of hospitalization, have not been analyzed. These differences were investigated in a large cellulitis series.

Methods

This was a prospective observational study of 606 Spanish hospitalized cellulitis patients. Different comorbidities, clinical, diagnostic, and treatment data were compared between the sexes. Multiple logistic regression modeling was performed to determine the variables independently associated with sex.

Results

Overall 606 adult cellulitis patients were enrolled; 314 (51.8%) were male and 292 (48.2%) were female. Females were older (mean age 68.8 vs 58.9 years, p < 0.0001), less likely to have prior wounds (p = 0.02), and more likely to have venous insufficiency (p = 0.0002) and edema/lymphedema (p = 0.0003) than males. The location of the infection differed between the sexes (p = 0.02). Males were more likely to have positive pus cultures (p = 0.0008), the causing agent identified (p = 0.04), and higher rates of Staphylococcus aureus infection (p = 0.04) and received longer antibiotic treatment (p = 0.03). Factors independently associated with female sex in the multivariate analysis were older age (p < 0.0001), prior cellulitis (p = 0.01), presence of edema/lymphedema as the predisposing factor (p = 0.004), negative versus positive pus culture (p = 0.0002), and location of cellulitis other than in the lower extremities (p = 0.035).

Conclusions

Differences between male and female patients with cellulitis were age, recurrence, presence of edema/lymphedema, positivity of pus culture, and topography of the infection.

Keywords

Cellulitis

Sex

Predisposing factors

Microbiology

Treatment

Staphylococcus aureus

Citing articles

90,000 Interventions to prevent recurrence of cellulite and erysipelas

Relevance

Both cellulite and erysipelas are bacterial skin infections that most commonly affect the legs. Erysipelas affects the upper layers of the skin, while cellulite spreads to deeper layers. However, it is often quite difficult to draw a clear line between them, so in this review we will consider both diseases using a single term “cellulite”. About half of people suffering from cellulite are faced with the problem of its recurrence.Despite the prevalence of this condition, there is currently no confirmed, high-quality evidence-based information on effective ways to prevent recurrence of the disease.

Review question

What is the most effective treatment for preventing cellulite recurrence compared to no treatment, placebo, other intervention, or the same intervention in a different regimen in patients over 16 years of age, and what are the side effects?

Research characteristics

We searched databases and registers up to June 2016.We found 6 trials involving 573 people, with an average age of 50 to 70 years. The participants included patients of both sexes, but there were about 2 times more women than men. Five trials compared antibiotic use (four with penicillin, one with erythromycin) versus placebo or no treatment, and another compared selenium with saline. The duration of treatment was from 6 to 18 months.

Studies were carried out in the UK, Sweden, Tunisia, Israel and Austria.They were mostly hospital-based, and two of the studies were multicenter. Participants in all trials had a history of a small number (1 to 4) of cellulite episodes. In trials that looked at antibiotic prophylaxis, participants had leg cellulite, and in a trial that looked at selenium, participants had hand cellulite.

Highlights

Prevention of repeated episodes of cellulite was the main outcome. Other outcomes include the number of cellulite recurrences, time between recurrences, hospitalizations, quality of life, development of antibiotic resistance, adverse reactions, and mortality.

Summarizing the results of all five antibiotic trials, we found moderate-quality evidence that antibiotic treatment (particularly with penicillin) is an effective and safe way to prevent leg cellulite recurrence, compared with no treatment or placebo.

The analysis showed that, compared with no treatment or placebo, antibiotics reduced the risk of relapses by 69%, decreased their number by more than 50%, and significantly reduced the time to recurrences (moderate quality evidence).However, we found low-quality evidence that the effect of antibiotics on these outcomes declined after discontinuation of treatment. In addition, it was noted that the beneficial effect of antibiotic use was consistent in patients who had at least two episodes of cellulite in the previous three years.

Low-quality evidence indicated that there was no significant difference in the incidence of side effects and hospitalization rates between patients who received antibiotics and those who did not take anything or received a placebo.The available data do not allow us to draw unambiguous conclusions about the length of hospitalization of patients.

The studies did not report any serious adverse effects. The most commonly reported side effects were diarrhea, nausea, rash (no severe skin lesions reported), and candidiasis. In 3 studies, antibiotics were discontinued due to unwanted effects. 3 people taking erythromycin developed complaints of abdominal pain and nausea, after which they were transferred to penicillin.In one study, 2 people stopped taking penicillin due to diarrhea and nausea. Also, about 10% of participants in another study refused injections of benzathine benzylpenicillin because of pain at the injection site.

None of the studies assessed quality of life and development of antibiotic resistance.

Confidence in evidence

The quality of the evidence for the effectiveness of antibiotics in preventing relapse, reducing the frequency and increasing the time between recurrences, compared with placebo or no treatment, was moderate and limited to a small number of participants and events.For the same reasons, the evidence for other outcomes is of low quality and the results are inaccurate.

Pressoprogram (lymphatic drainage pressotherapy)

One of the types of lymphatic drainage is pressotherapy, which allows you to effectively get rid of cellulite and other problems associated with a sedentary lifestyle. During pressotherapy, the lymphatic system of the body is influenced with the help of compressed air. Air exerts effective mechanical pressure on the skin and subcutaneous fat, which makes it possible to effectively remove various edema, remove cellulite and increase skin elasticity.

One of the types of lymphatic drainage is pressotherapy, which can effectively get rid of cellulite and other problems associated with a sedentary lifestyle. During pressotherapy, the lymphatic system of the body is influenced with the help of compressed air. Air exerts effective mechanical pressure on the skin and subcutaneous fat, which makes it possible to effectively remove various edema, remove cellulite and increase skin elasticity.

Lymphatic drainage is a type of hardware cosmetology . This procedure allows you to increase the outflow of lymph by using a low frequency current and alternating polarity. At the same time, the increased outflow of lymph allows you to remove various toxins and toxins from the body.

One of the types of lymphatic drainage is pressotherapy , which allows you to effectively get rid of cellulite and other problems associated with a sedentary lifestyle.

During pressotherapy , the lymphatic system of the body is influenced by compressed air. Air exerts effective mechanical pressure on the skin and subcutaneous fat, which makes it possible to effectively remove various edema, remove cellulite and increase skin elasticity. The procedure is carried out using a special apparatus Pressogram , which allows you to work with eight different parts of the body (including the buttocks, which are one of the most problematic areas).

During the procedure, nutrition and the level of protection of the human body improves, as well as its natural cleaning. The latter is connected with the fact that a similar lymphatic drainage massage ensures the removal of excess fluid, toxins, harmful substances from the body and helps to restore the normal water balance in the body.

Among the main indications for the appointment of pressotherapy, the following can be distinguished:

skin laxity;
the presence of edema of various origins;

90,075 obese;

90,075 cellulite;

heaviness in the legs;
rehabilitation period after surgery.

Note that lymphatic drainage on the device Pressogram has another additional effect, which is expressed in the complete comfort of the body during the procedure and a feeling of pleasant lightness in the legs at the end of the session.

The procedure of lymphatic drainage has practically no medical restrictions and is suitable even for those who are contraindicated for electrical muscle tissue stimulation.

The course of pressotherapy , as a rule, consists of 15 procedures, the duration of which is about half an hour.In this case, these procedures are carried out, depending on the specific situation, determined by the cosmetologist, every 2-3 days.

To sign up for the course of lymphatic drainage procedures in the cosmetology center of the Scandinavia clinic, as well as learn more about this and other cosmetology services, call: 600-78-77 .

What is cellulite – Healthcare Institution “Grodno University Clinic”

Under the common and not entirely correct term cellulite, doctors mean gynoid lipodystrophy, which means a malnutrition of adipose tissue.

Fat cells are present in the thickness of the skin of every person, so the disease can develop at any age, but by an amazing whim of nature, only women who have reached puberty are susceptible to it.

Fat storage or degeneration

Recent medical research has proven that

Cellulite is a lingering disease, serious enough not to pay attention to its presence and not take steps to eliminate it, slowly developing, nevertheless – quite amenable, albeit long-term, but successful treatment.

The most important, among many, reason for the development of such an unpleasant phenomenon as cellulite is the characteristic structure of the skin in women – it is thinner and more elastic than men, which allows the skin to stretch when the fetus is carried.

Collagen fibers, passing through its thickness, are located in the risk zones in the form of honeycomb cells, while in other places they are simply intertwined, like in a cloth.

Disturbance of metabolism in lipid tissue provokes tension of connective structures, creating an obstacle to the removal of water and fat from the depot.

Fat cells, larger than in men, surrounded by fibrous formations, during the development of the disease, are confined in a confined space, which prevents the normal outflow of fluid from the tissue.

Puffiness almost always accompanies cellulite – this is the water that is unable to leave the intercellular space. Along with it, decay products cease to be removed from the cells, which leads to a violation of their internal composition and sticking together in bunches.

Precisely such clusters, hardened and located in “cocoons” of coarsened fibers that have lost their elasticity, appear through the epidermis, giving the skin surface a characteristic appearance.

Who has cellulite

People with “orange peel” skin are wondering if everyone has cellulite? Experts in this field argue that this problem is quite common, and affects almost 90% of women.

There is no definite answer to the question of how many years cellulite appears. This can happen both during puberty and during menopause.

Some women experience orange peel during pregnancy or after childbirth.Therefore, the statement that cellulite appears during periodic hormonal surges is considered the most correct.

But there is another reason for this problem – weight play. Experts are unanimous in the opinion that those women develop cellulite, who have a sharp change in weight.

Living in a “lose weight – get better” regime can lead to an ugly “orange peel” in problem areas. Girls, learn more about how to maintain a normal body weight, and the likelihood of cellulite will be significantly reduced.

Recently, the problem of adolescent cellulite has appeared. In addition to puberty, its causes are a passive lifestyle, unhealthy diet and the presence of bad habits, so girls who smoke and drink alcohol are at risk of developing this disease.

In addition to cellulite in adolescence, bad habits, lack of physical activity and poor nutrition can provoke it in adults.

It is widely believed that overweight women have cellulite much more often than thin women.But this is not the case. The appearance of the “orange peel” does not depend on the complexion of its owner. Quite often there are overweight women with smooth, firm skin and thin girls with cellulite on the abdomen, buttocks and thighs.

Causes of cellulite

There can be many of them:

Sedentary lifestyle, sedentary work;
Improper nutrition, frequent diets;
Chronic stress, fatigue and depression;
Hormonal disruption in the body and an increase in estrogen in the blood;
Disorders of the endocrine system, in particular the thyroid gland;
Low blood protein;
Influence of heredity;
Bad habits.

All of the above negatively affects the processes of our body, and in combination, this is guaranteed to lead to cellulite.

USE OF ULTRASONIC THERAPY IN THE TREATMENT OF CELLULITE

Ultrasound therapy as a defibrosing method in recent years has been widely used to treat cellulite at any stage in combination with an anti-cellulite diet, lipolytic, vasoactive and lymphatic drainage effects.

Cellulite (lipodystrophy) is a term denoting the degenerative-dystrophic nature of processes occurring in tissues, a certain (transient or permanent) skin condition associated with a violation of the structure of connective tissue fibers and adipocytes of subcutaneous fat.Clinically, cellulite is an aesthetic, cosmetic drawback, expressed in a specific change in the skin, which is visually defined as the “orange peel” effect, in unevenness, roughness of the skin, a decrease in its turgor, in most cases accompanied by excess fat deposits. Cellulite develops in stages over a period of time. It tends to progress quickly, and therefore it is very important, for effective treatment, to identify it at the earliest stages.

In the first stage, there is a simple “softening” of the affected areas caused by stagnation of the interstitial fluid between the cells (“soft” cellulite).

At the second stage, the reticular connective fibers located around the adipocytes thicken and harden, making it difficult for blood and lymph to circulate at the capillary level. When pressed, traces remain on the skin – dents (the skin loses its elasticity). The “orange peel” effect is expressed in the first stages when the skin fold is captured.

At the third stage, liposclerosis develops. Micro-nodules are formed and, as a result, the symptom of “orange peel” (“hard” cellulite) appears.

At the fourth stage, the nodules become larger, they increase in size, are mobile, can be easily felt with the fingers and are often a source of pain when touched and pressed. The skin looks bumpy, cyanotic or pale due to microcirculation disorders. Skin temperature drops significantly, blood vessels break easily and poorly absorbable bruises form.

Ultrasonic vibrations loosen collagen and elastic fibers, increase the elasticity of connective tissue, reduce the viscosity of subcutaneous adipose tissue and improve microcirculation.

The procedure is as follows. After preliminary cleaning of the skin, a contact medium is applied to the problem areas. An anti-cellulite gel based on hyaluronic acid and mitofen antihypoxant is used (laboratory “COPHY”, St. Petersburg). The ultraphonophoresis procedure is carried out with smooth movements along the course of the venous blood and lymph flow to the lymph nodes.

1-2 stage of cellulite. Ultrasonic vibration frequency 0.88 MHz (0.88 MHz – IUT-0.88-4.04F), continuous mode, intensity 0.4-0.6 W / cm ², procedure time no more than 20 minutes, maximum exposure area not more than 600 cm ². The course is 10-15 procedures 2-3 times a week. A repeated course in 3-6 months.

3-4 stage of cellulite. Ultrasonic vibration frequency 0.88 MHz (IUT-0.88-4.04F), continuous mode, intensity 0.6-0.8-1.0 W / cm ², procedure time no more than 20 minutes, exposure area no more than 600 cm ².The course consisted of 15-20 daily procedures. A second course in 2-3 months.

After the course of treatment, there is an increase in muscle tone, an improvement in the turgor of the skin of the body, smoothing of the skin relief, a decrease in the volume in the buttocks and thighs during the impact on these zones by 2-3 cm.

To increase the effectiveness of treatment in combination with ultrasound therapy, pneumocompression therapy and water procedures can be used.

90,000 Interventions to prevent recurrence of erysipelas and cellulite – Dalal, A – 2017

Interventions to prevent recurrence of cellulite and erysipelas

Background

Both cellulite and erysipelas are bacterial skin infections that most commonly affect the legs.Erysipelas affects the upper layers of the skin, while cellulite spreads to deeper layers. However, it is often quite difficult to draw a clear line between them, so in this review we will consider both diseases using a single term “cellulite”. About half of people suffering from cellulite are faced with the problem of its recurrence. Despite the prevalence of this condition, there is currently no confirmed, high-quality evidence-based information on effective ways to prevent recurrence of the disease.

Review question

What is the most effective treatment for preventing cellulite recurrence compared to no treatment, placebo, other intervention, or the same intervention with a different regimen in patients over 16 years of age, and what are the side effects?

Study characteristics

We searched databases and registers up to June 2016. We found 6 trials involving 573 people, with an average age of 50 to 70 years.The participants included patients of both sexes, but there were about 2 times more women than men. Five trials compared antibiotic use (four with penicillin, one with erythromycin) versus placebo or no treatment, and another compared selenium with saline. The duration of treatment was from 6 to 18 months.

Research was carried out in Great Britain, Sweden, Tunisia, Israel and Austria. They were mostly hospital-based, and two of the studies were multicenter.Participants in all trials had a history of a small number (1 to 4) of cellulite episodes. In trials that looked at antibiotic prophylaxis, participants had leg cellulite, and in a trial that looked at selenium, participants had hand cellulite.

Main Findings

Prevention of recurrent episodes of cellulite was the main outcome. Other outcomes include the number of cellulite recurrences, time between recurrences, hospitalizations, quality of life, development of antibiotic resistance, adverse reactions, and mortality.

Summarizing the results of all five antibiotic trials, we found moderate-quality evidence that antibiotic treatment (particularly with penicillin) is an effective and safe way to prevent recurrence of leg cellulitis, compared with no treatment or placebo.

Analysis showed that, compared with no treatment or placebo, antibiotics reduced the risk of relapse by 69%, decreased the number by more than 50%, and significantly reduced the time to recurrence (moderate-quality evidence).However, we found low-quality evidence that the effect of antibiotics on these outcomes declined after discontinuation of treatment. In addition, it was noted that the beneficial effect of antibiotic use was consistent in patients who had at least two episodes of cellulite in the previous three years.

The studies did not report any serious adverse effects. The most commonly reported side effects were diarrhea, nausea, rash (no severe skin lesions reported), and candidiasis. In 3 studies, antibiotics were discontinued due to adverse effects. 3 people taking erythromycin developed complaints of abdominal pain and nausea, after which they were transferred to penicillin.In one study, 2 people stopped taking penicillin due to diarrhea and nausea. Also, about 10% of participants in another study refused injections of benzathine benzylpenicillin because of pain at the injection site.

None of the studies assessed quality of life and development of antibiotic resistance.

Confidence in Evidence

The quality of the evidence for antibiotic efficacy in preventing relapse, reducing recurrence, and increasing the time between recurrences versus placebo or no treatment was moderate and limited to a small number of participants and events.For the same reasons, the evidence for other outcomes is of low quality and the results are inaccurate.

Clinical Trial Uncomplicated Outpatient Cellulite – Clinical Trial Register

Executive Summary	Introduction: Despite several expert panel recommendations and cellulite treatment guidelines, there are currently no clinical decision rules to help clinicians make decisions. which emergency department patients should be treated with oral antibiotics and which patients should be treated with intravenous therapy at the first sign of uncomplicated cellulite.The objective of this prospective study is to identify potential patient-related risk factors in adult patients (& gt; 17 years old) presenting to the emergency department with skin or soft tissue concerns. tissue infections that are ineffective with initial antibiotic therapy for standard cellulite and require antibiotic changes or hospitalization. Methods. This study will be a prospective study conducted in two emergency departments.Patients will be excluded if they have been treated with antibiotics during the current bout of cellulite before going to the emergency room, patients hospitalized, and those patients with abscesses only. Hired Researchers (RAs) will conduct the questionnaire on an initial visit to the emergency department followed by a telephone call 2 weeks later. Treatment failure will be defined as: patients requiring follow-up hospitalization, initiation of intravenous antibiotics (for oral administration, antibiotics were initially prescribed), or substitution of oral antibiotics for baseline cellulitis. Results: This study will provide a detailed profile of patient risk factors associated with cellulite treatment failure. The results will be analyzed and used to formulate the Clinical Decision Rule for the effective treatment of cellulite admitted to the emergency department. Each of the predictor variables associated (p ≤ 0.1) with treatment failure in univariate analysis will be considered in a multivariate logistic regression model. In addition, treatment variability among clinicians regarding cellulite will be assessed and compared with treatment failure to provide evidence of successful treatment regimens. Conclusions: The results of this study can be used to create a clinical prediction rule to assist clinicians in effectively treating patients admitted to emergency departments with cellulite. Understanding which patient risk factors are ineffective in treatment will help clinicians determine which patients will benefit from intravenous rather than oral antibiotics.

Executive Summary

Introduction: Despite several expert panel recommendations and cellulite treatment guidelines, there are currently no clinical decision rules to help clinicians make decisions. which emergency department patients should be treated with oral antibiotics and which patients should be treated with intravenous therapy at the first sign of uncomplicated cellulite.The objective of this prospective study is to identify potential patient-related risk factors in adult patients (& gt; 17 years old) presenting to the emergency department with skin or soft tissue concerns. tissue infections that are ineffective with initial antibiotic therapy for standard cellulite and require antibiotic changes or hospitalization.

Methods. This study will be a prospective study conducted in two emergency departments.Patients will be excluded if they have been treated with antibiotics during the current bout of cellulite before going to the emergency room, patients hospitalized, and those patients with abscesses only. Hired Researchers (RAs) will conduct the questionnaire on an initial visit to the emergency department followed by a telephone call 2 weeks later. Treatment failure will be defined as: patients requiring follow-up hospitalization, initiation of intravenous antibiotics (for oral administration, antibiotics were initially prescribed), or substitution of oral antibiotics for baseline cellulitis.

Results: This study will provide a detailed profile of patient risk factors associated with cellulite treatment failure. The results will be analyzed and used to formulate the Clinical Decision Rule for the effective treatment of cellulite admitted to the emergency department. Each of the predictor variables associated (p ≤ 0.1) with treatment failure in univariate analysis will be considered in a multivariate logistic regression model. In addition, treatment variability among clinicians regarding cellulite will be assessed and compared with treatment failure to provide evidence of successful treatment regimens.

Conclusions: The results of this study can be used to create a clinical prediction rule to assist clinicians in effectively treating patients admitted to emergency departments with cellulite. Understanding which patient risk factors are ineffective in treatment will help clinicians determine which patients will benefit from intravenous rather than oral antibiotics.

Cellulite treatment, radiolifting, piercing in Chelyabinsk

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Cellulite.

Cellulite is a change in adipose tissue, which is a part of the skin, inherent only in women, which is manifested by the appearance of a finely knobby surface of the skin (“orange peel”).

Statistics claim that more or less pronounced cellulite is present in 80% of women.

Changes happen imperceptibly. The small-knobby surface of the skin first occurs only when the skin is taken into a fold (I-II degree).Then this tuberosity appears without additional measures. In the end, cellulite can significantly disfigure the legs and thighs (III-IV degrees).

Cellulite occurs due to impaired blood circulation and lymph circulation.

Causes of cellulite:

Improper nutrition (a significant amount of animal fats in the diet and a small amount of vegetable fats, an abundance of carbohydrates, lack of vegetables, fruits and vitamins in the diet
Changes in hormonal levels.
Genetic predisposition.
Violations of the water-salt balance.
Prolonged wearing of tight clothing that interferes with blood circulation.
Decreased thyroid function.
Disruption of the pancreas, one of the variants of which is diabetes, leading to vascular damage.
Bad habits – smoking, alcohol.

Cellulite control methods:

The body of each person is individual, and only a doctor can determine exactly what caused cellulite and prescribe the correct treatment, therefore, before fighting the disease, a specialist consultation is necessary.

The approach to cellulite treatment should be comprehensive. This implies rational nutrition , adequate skin care , including gentle cleansing, exfoliation (exfoliation) and constant hydration, manual massage with elements of lymphatic drainage (or hardware techniques that improve lymphatic drainage), the use of hardware methods of body shaping – electrical stimulation , ultrasound, mesotherapy , etc.

To strengthen and consolidate the achieved effect, cold and warm wraps are used.

The doctor must select an individual complex of various procedures, taking into account the individual characteristics of each person.

Special attention should be paid to the hardware methods of fighting cellulite, as the most effective and less traumatic.

Taking into account the knowledge of the causes and mechanisms of the occurrence of cellulite, the specialists of our center have developed comprehensive programs to get rid of this ailment.

Prices

Dear patients!
Please note that the cost of a visit to a doctor does not always coincide with the indicated admission price.The final cost of admission may include the cost of additional services. The need for the provision of such services is determined by the doctor depending on the medical indications directly during the appointment.

Item

Cost

90,000 Indications for hospitalization for emergency care

Department of Otorhinolaryngology
1	Dysfunction of the tracheostomy Stenosis under the proper vocal apparatus after medical procedures (cicatricial stenosis of the larynx)	J95.0J95.5
2	Paralysis of the vocal folds and larynx (laryngoplegia, paralysis of the vocal apparatus itself) Polyp of the vocal fold and larynx Other diseases of the vocal folds (abscess, cellulitis, granuloma, leukokeratosis, leukoplakia	J38.0J38.1 J38.2 J38.3
3	Chr. sinusitis (maxillary, frontal, ethmoidal, sphenoidal, pansinusitis, others) Sinus polyps (ethmoidal, maxillary, sphenoidal)	J32J33.8
4	Benign neoplasms: – lips, tongue, floor of the mouth, other and unspecified parts of the mouth, pharynx of unspecified localization, palatine tonsil, other parts of the oropharynx, nasopharynx, laryngopharynx, pharynx of unspecified localization – parotid salivary gland, other large salivary glands, large salivary gland unspecified – nasal cavity, nasal cartilage, paranasal sinuses, middle ear – larynx	D10.0, D10.1, D10.2, D10.3, D10.4, D10.6, D10.9 D11.0, D11.7 D11.9 D14.0 D14.1
5	Hereditary hemorrhagic telangiectasia	I78.0
6	Otosclerosis involving the foramen ovale, non-obliterating; otosclerosis involving the oval window, obliterating; cochlear otosclerosis; other forms of otosclerosis; otosclerosis, unspecified	H80.0; H80.1; H80.2; H80.8; H 80.9
7	Adhesive middle ear disease	H74.1
8	Purulent and unspecified otitis media: chronic tubotympanic purulent otitis media; chronic epitympano-antral suppurative otitis media (chronic suppurative otitis media)	H66.1; H66.2
9	Chronic tubotympanic suppurative otitis media; chronic epitympano-antral suppurative otitis media	H66.1; H66.2
10	Displaced nasal septum (curvature of the nasal septum)	J34. Post navigation Wahls diet for ms. Wahls Protocol Diet for MS: Effectiveness, Foods, and Key Insights Ibs diverticulitis. Increased Risk for Irritable Bowel Syndrome After Acute Diverticulitis Leave a Reply Cancel reply Your email address will not be published. Required fields are marked * Comment * Name * Email * Website Search for: Categories About all Bends Eye Finger Home Stone Copyright All Rights Reserved 2020 Proudly powered by WordPress \| Theme: Polite Grid by Template Sell.

Cellulitis Hospitalization: Mortality Rates and Necessity of Inpatient Care

Understanding Cellulitis and Its Impact on Healthcare Systems

Methodology of the Systematic Review and Meta-analysis

Key Findings on Cellulitis Mortality Rates

Comparing Cellulitis and Community-Acquired Pneumonia Management

Potential Benefits of Outpatient Management for Cellulitis

Factors to Consider in Cellulitis Admission Decisions

Implications for Clinical Practice and Future Research

Clinical Practice Recommendations

Future Research Directions

Limitations of the Current Study

Conclusion and Future Perspectives

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

Craig G. Gunderson

Benjamin M. Cherry

Ann Fisher

Abstract

Background

Methods

Results

Discussion

Electronic supplementary material

INTRODUCTION

METHODS

Data Sources and Search Strategy

Study Selection

Data Extraction and Quality Assessment

Data Synthesis and Analysis

RESULTS

Table 1

Table 2

Table 3

DISCUSSION

Electronic Supplementary Material

Compliance with Ethical Standards

References

What you Need to know, When to go to the ER

Cellulitis: What you Need to know and When to Visit the ER

What Does Cellulitis Emergency Look like?

What Causes Cellulitis?

Cellulitis Diagnosis

Cellulitis Treatment

Preventing Cellulitis Emergency

When Cellulitis Becomes an Emergency

Cellulitis | Journal of Hospital Medicine

KNOWLEDGE

SKILLS

ATTITUDES

SYSTEM ORGANIZATIONS AND IMPROVEMENT

Cellulitis | University Hospitals

What is cellulitis?

What causes cellulitis?

What are the symptoms of cellulitis?

How is cellulitis diagnosed?

How is cellulitis treated?

What are possible complications of cellulitis?

Can cellulitis be prevented?

When should I call my healthcare provider?

Key points about cellulitis

Next steps

A SYSTEMATIC REVIEW AND META-ANALYSIS – Abstracts

<< Go back

Skin and Soft Tissue Infections

Sex differences in hospitalized adult patients with cellulitis: A prospective, multicenter study

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Keywords

Recommended articles

Citing articles

Pressoprogram (lymphatic drainage pressotherapy)

What is cellulite – Healthcare Institution “Grodno University Clinic”

Fat storage or degeneration

Causes of cellulite

USE OF ULTRASONIC THERAPY IN THE TREATMENT OF CELLULITE

Interventions to prevent recurrence of cellulite and erysipelas

Clinical Trial Uncomplicated Outpatient Cellulite – Clinical Trial Register