Clinical Characteristics and Outcomes of Patients With Cellulitis Requiring Intensive Care

Abstract

IMPORTANCECellulitis is a commonly occurring skin and soft tissue infection and one of the most frequently seen dermatological diseases in the intensive care unit (ICU). However, clinical characteristics of patients with cellulitis requiring intensive care treatment are poorly defined. Necrotizing fasciitis is often confused for cellulitis at initial presentation and is considered to be more severe and thus has previously been described in more detail.OBJECTIVE To describe the clinical presentation and outcomes of patients with ICU-necessitating cellulitis and to compare them with patients with necrotizing fasciitis. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study includes all ICU admissions from 2 tertiary hospitals in the Netherlands. Of 2562 sepsis admissions, 101 had possible, probable, or definite cellulitis or soft tissue infections. Retrospective review identified severe cellulitis was the reason for ICU admission in 23 patients, necrotizing fasciitis in 31 patients, and other diagnoses in 47 patients. MAIN OUTCOMES AND MEASURES Patient and disease characteristics, cultured pathogens, lengths of stay, and short-term and long-term mortality. RESULTS Overall, 54 patients with cellulitis (n = 23; mean [SD] age, 57.2 [17.7] years) or necrotizing fasciitis (n = 31; mean [SD] age, 54.3 [13.5]) were included in this study. Patients with cellulitis were found to be less severely ill than patients with necrotizing fasciitis. This is reflected in rates of shock (7 [30.4%] vs 19 [61.3%]; P = .03), need for mechanical ventilation (12 [52.2%] vs 19 [93.5%]; P = .003) and slightly lower mean Sequential Organ Failure Assessment scores (8 vs 10; P = .046). Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation IV scores did not differ significantly (82 [75-98] vs 76 [70-96]; P = .16). Patients with cellulitis had more chronic comorbidities than patients with necrotizing fasciitis (20 [87.0%] vs 17 [54.8%]; P = .02), especially cardiovascular insufficiencies (10 [43.5%] vs 4 [12.9%]; P = .02) and immunodeficiencies (9 [39.1%] vs 3 [9.7%]; P = .02). Among patients with cellulitis and patients with patients with necrotizing fasciitis, Staphylococcus aureus (10 [43.5%] vs 4 [12.9%]; P = .02), Streptococcus pyogenes (2 [8.7%] vs 19 [61.3%]; P < .001) and Escherichia coli (4 [17.4%] vs 5 [16.2%]; P = .90) were the most frequently observed pathogens. Median (IQR) length of ICU stay was shorter for patients with cellulitis vs patients with necrotizing fasciitis (3 [2-5] vs 5 [3][4][5][6][7][8][9][10][11]; P = .01), while median (IQR) hospital length of stay did not differ significantly (22 [10.25-32] vs 36 [14.25-40]; P = .16); and the in-hospital mortality rate (26.1% vs 22.6%, P > .99) and 90-day mortality rate (30.4% vs 22.6%; P = .54) were similar.CONCLUSIONS AND RELEVANCE Patients with cellulitis patients are seldom admitted to the ICU. However, while these patients are less critically ill on admission than patients with necrotizing fasciitis, they have more chronic comorbidities an...

Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort

“…The study includes both cases with cellulitis and NSTI, clinical entities that are often hard to discern in the early phase [6], reflecting the diagnostic challenges seen in every-day handling of non-purulent SSTIs. Cellulitis constituted the majority of cases, and almost half of the patients belonged to severity classes I or II, suggesting that many patients are admitted for reasons other than systemic toxicity.…”

“…A major problem in the management of nonpurulent SSTIs is frequent over-treatment with use of broad-spectrum antibiotics, even in mild cases, partly reflecting difficulties in establishing the microbial aetiology [5]. Cases of moderate severity are also prone to over-treatment, as they may be hard to discern from early phases of necrotising soft tissue infections (NSTIs) [6]. Concerningly, at the severe end of the disease spectrum under-treatment is not uncommon [7,8].…”

Necrotizing skin and soft-tissue infections in the intensive care unit

“…Necrotizing skin and soft-tissue infections are rare, with a population incidence of 4 per 100 000 per year [19e23], and account for a small proportion of ICU admissions, estimated at 0.2% in the UK [24] or 1.2% of all critically ill patients admitted with sepsis in the Netherlands [25]. However, because of the severity of illness, underlying co-morbidities and intensity of postoperative wound care, ICU admission is frequently required [22,23,26e31].…”

“…Co-morbidities associated with NSTI include diabetes mellitus in 22%e59% [22,23,26,27,29e31,33,35e37,39,42] and obesity in 17%e31% [26,30,35e37,41,42]. Other risk factors include cardiovascular disease (9%e45%) or peripheral vascular disease (3%e19%) [22,23,26,30,31,33,36,39,41,42], intravenous drug use (2%e80%) [27,33,36,39], immunosuppression (4%e30%) [23,25,30,35,36,42] and chronic alcohol abuse (6%e27%) [30,33] (Table 1). Of note, up to onequarter of patients with NSTI have no obvious predisposing factor [30,36,37,39].…”

“…2), and crepitus (20%) as the most frequently encountered signs [78]. Fever was present in 40% of patients and hypotension in 21%, although the frequency of associated organ failures varies widely between studies, depending on the case mix, rising to 90% when only patients admitted to the ICU were included [25]. Because none of the previously mentioned signs provided a sufficient sensitivity when considered separately, approaches combining several clinical findings have been proposed and achieved better diagnostic yields than did each individual finding [80].…”