Among Cellulitis of various regions, ascending cellulitis of the leg was a common medical emergency characterized by edema, fever, swelling and malaise. It is one among the multidisciplinary disorder.1-3 Common organisms leading to higher frequency of cellulitis include Streptococci, mixed infections in particular when cellulitis is localized or a penetrating injury.4-6 Most of the time bacteriological diagnosis is difficult due to no wound site present for culturing. Severity of streptococcal infections include streptococcal toxic shock syndrome, necrotizing fasciitis, other conditions which may progress due to poor therapy include infected venous eczema or lymphoedema, deep venous thrombosis, myositis or fasciitis, tibial compartment syndrome etc.7-11
Cellulitis is the inflammation of the skin and soft tissue caused due to bacterial infections majorly affecting the lower limbs. It is sometimes also called as Lymphangitis or Erysipelas.12-15 Associated risk factors for cellulitis include lymphoedema/ chronic edema, Diabetes, primary or secondary insect bites, blistering disorders like bullous pemphigoid, skin trauma/ ulcers, animal bites, bullous impetigo, skin rash-eczema, dry skin, obesity, kidney and liver disease etc.16-19
Initial appearance of the skin is generally glossy, tight, stretched. Tenderness and pain of the affected area is seen. Occassionally, swelling of the local lymph nodes is observed with other common symptoms like fever accompanied with or without chills, fatigue, sweating, muscle pains, malaise.20-24 Diagnosis made involve culture studies, blood test, imaging studies etc. Treatment carried out involved antibiotics, with steroids occasionally.
Some of the cases monitored were as below.
PROCEDURES AND METHODS
The study was carried out at the general medicine ward of Thiruvallur Government Hospital for a period of 3 months. A written consent was collected from all the patients who were included in the study. A close observation was done on cases of cellulitis and patients were selected based upon the following criteria. Inclusion criteria were those with predisposing conditions of cellulitis like diabetes, skin disorders, local injury etc. those who were willing to reveal their consent were selected. Exclusion criteria were localized cellulitis, bursitis or abscesses cases or those made with incorrect diagnosis (Figure 1,2,3).
Cellulitis in right leg with plagues.
Cellulitis in leg with edematous plagues.
Cellulitis with skin eruptions in Right thigh.
Predisposing causes of cellulitis in pictorial representation.
Antibiotic therapy observed on the patients.
About 90 patients were chosen for the study based on the criteria’s and data obtained were on demographic details, short-term morbidity, predisposing cause, antibiotic therapy, duration of admission, diagnosis, therapy after discharge. Previous episodes of attacks were documented in addition to any long term morbidity found in the patients.
RESULTS AND DISCUSSION
Out of the 90 patients (48 females and 42 males) with age of 50-75 years (median age 62.5 ± 3.5 years), most of them were observed with pyrexia, malaise, edema etc, at the time of admission. About some 25 patients were found to be apyrexial along with cellulitis. Among the various preceding causes found in cellulitis patients, those with infection due to Tinea pedis (13/90), a minor non-penetrating local injury (10/90) were found to be common (Table 1). Others had eczema of foot (9/90), diabetic foot ulcer (5/90) in which the condition worsen from the foot towards the upper knee. Leg ulceration (7/90) was also found to be common. Common concomitant diseases accompanied with the patients were cardiovascular diseases (45/90) while all others were found to be less in number (Table 4).
Preceding causes of cellulitis in the patients were as follows.
|Portals||No: of patients||% of patients|
|Diabetic foot ulcer||5||5.5%|
|Blisters of foot||2||2.2%|
|Local injury (minor, non-penetrating)||10||11.1%|
|Eczema of foot/ leg||9||10%|
|Tineapedis/ toe web maceration||13||14.4%|
Demographic details of patients.
|Factors||Case patients (n=90)|
Concomitant diseases of patients:
|62.5 ± 3.5 yrs|
Commonly found microorganism causing cellulitis in the patients.
|Microorganism||Commonly occurring body site||No of patients affected by the organism||% of patients|
|Staphylococcus aureus (found with other organisms too in same individual )||Usually occurring in any parts of the body||38||42.2%|
|β-hemolytic streptococci (group A, B, C, G)||Parts of the foot and inner thighs||36||40%|
|Dermatophytes (found with other organisms too in same individual)||Foot, toe webs, toe nails, sole of foot||55||61.1%|
|Gram negative bacilli||Toe webs||18||20%|
Risk factors associated with cellulitis in the patients group.
|Factors||No: of patients||% of patients|
|Obesity (BMI ≥ 30)|
BMI > 25 and < 30
|Persisting history of the following conditions|
Chronic leg edema
(S, aureus and β Hemolytic streptococci) in foot and toe
Toe nail dystrophy
Abnormalities of sole
Details on Risk factors associated with the sides of the limbs in the patients.
|Risk factors of the patients||Found in Ipsilateral limbs||Found in Contralateral limbs||Found in both limbs|
|History of patients:|
Chronic leg edema
|Current conditions along with cellulitis|
Abnormalities of the sole
Antibiotic therapy followed in the patients initially.
|With Benzylpenicillin||With Erythromycin||With Amoxicillin/ Ampicillin||With Metronidazole||With Gentamicin|
|Amoxicillin/ Clavulanic acid||3||0||0||0||0||0|
From the total number of patients selected for the study only about 38% (42 patients) had their wounds taken for culture examination. Among the performed culture test of the patient’s dermatophytes (55%), Staphylococcus aureus (38%) were more common (Figure 5). Single culture could also identify the presence of more than one organism where again dermatophytes and Staphylococcus aureus were common.25-29
Analysis of Causative organisms causing cellulitis.
Risk factors persisting in the patients were with recurrent episodes of cellulitis (25/90). They had an episodal attack of 1 to 2 times which were unpreventable due to antibiotic resistance in them.30-33 Resistance towards microorganisms like staphylococcus aureus and β-hemolytic streptococci (30/90) initiating from the foot or toe and their rising upwards were also a risk factor towards ascending limb cellulitis.
Dermatophytes (20/90) and leg ulcer (30/90) were also prominent etiological and risk factor in most of the patients examined upon.34,29 Lesions and dry skin due to excessive sunlight exposure and other conditions were found to be common. Diabetes, smoking, abnormalities of the sole, toenail dystrophy etc, were the other factors found towards contributing to present condition. Skin and vascular abnormalities condition like statis dermatitis (12), dry skin (6), varicose vein (18) etc, were also found in a good number as contributing conditions.
Common therapy was with Cephalosporin (23), Ciprofloxacin (29) etc. both natural and synthetic penicillins were also found to be given in a good number. Those allergic with Benzylpenicillin were preferred with erythromycins. Long term morbidities or frequent conditions could be treated with Benzylpenicillin based on literature studies.35-36
From the study it could be concluded that the main contributing etiological conditions towards cellulitis were streptococci, lymphoedema, infection due to tinea pedis, etc, which all when left untreated could lead to repeated episodes of cellulitis and morbidity of it. Benzylpenicillin and other penicillins would be suggested for long term use or prophylaxis for cellulitis due to its improving results when compared to other drugs. Culture examination and prescribing of required narrow line antibiotics would lay down to decreased resistance towards antibiotics unnecessarily.
The authors are thankful to the patients who have given consent for the present study and made this work successful
CONFLICT OF INTEREST
The authors declare no conflicts of interest concerning the content of this case report.
The study carried out upon cellulitis patients highlights the etiological causes, main causative organisms and therapy followed in them. Penicillin was found to be a good antibiotic for cellulitis patients, which even prevents recurrent attacks of cellulitis. Ascending cellulitis of the limbs was found to be in common, where diabetes condition was a prior etiological factor for most of the cases. Pharmacists role mainly involved in culturing of the wound section which is in most cases neglected, being a common factor for antibiotic resistance. Other points could be in counseling of the patients and making them take the precaution steps in advance.
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