A Review of Acute Bacterial Dermo-hypodermatitis: Diabetes Mellitus Does Not Influence its Frequency or Prognosis
Introduction: Acute bacterial dermo-hypodermatitis (DHAB) is an acute infection of the dermis and hypodermis that most often affects the lower limbs. Although diabetes mellitus has been identified as a risk factor for its development, recent studies have questioned this relationship. The aim of the present study was to compare clinical characteristics of inpatients with DHAB associated or not with diabetes mellitus.
Material & Methods: Prospective study of patients hospitalized at the Dermatology Department of the Coimbra Hospital and University Center with the diagnosis of DHAB between January and June 2018. The following parameters were evaluated: 1) demographic / biometric data - gender, age; body mass index; 2) clinical and evolutionary aspects - location of infection, interval between initial symptoms and diagnosis, history of a previous episode; previous diagnosis of diabetes mellitus; 3) laboratory abnormalities - leukocytosis, C-reactive protein (CRP), microorganism screening (blood, abscess pus, wound exudate, blister content); 3) therapy - duration of antibiotic therapy, need for second line therapy, length of hospitalization; 4) local (abscess, necrosis) or systemic complications (bacteremia, drug rash, deterioration of underlying disease and death). Data were analyzed with the SPSS software, mainly looking for the influence of diabetes mellitus on the different parameters evaluated. Statistical significance was set at p <0.05.
Results: We included 102 patients, 55 female (53.9%) and 47 male (46.1%), with a mean age of 68.6 ± 13.9 years. The lower limb was the most affected site (73.5%), followed by the upper limb (20.6%) and face (5.9%). In average there were 3.1 ± 2.5 days between initial symptoms and hospitalization. Twenty-four patients had a diagnosis of diabetes mellitus (23.5%), six under insulin treatment (25%). No statistically significant difference was found between the diabetic and non-diabetic group for gender, age, infection location, time from initial symptoms to hospitalization, neither in circulating leukocyte or CRP values. Microorganism screening (blood, abscess pus, wound exudate, blister content) was positive in 2/8 diabetics (25%) and 15/39 non-diabetics (38.5%) (p=0.138), with the same type of microorganism isolated in both groups. Initial antibiotic therapy - cefoxitin plus clindamycin in 64.7% - was replaced in one non-diabetic and 10 diabetic patients (p=0.451) and the total duration of antibiotic treatment and hospitalization between groups was similar. Local complications occurred in 3 diabetics (12.5%) and 15 non-diabetics (19.2%), and systemic complications in 4 diabetics (16.7%) and 12 non-diabetics (15.4%), p=0.553 and p=1.000, respectively.
Conclusion: The present study shows that diabetes mellitus in hospitalized patients diagnosed with DHAB is not associated with a worse prognosis, namely in which concerns need for second line antibiotic therapy, longer hospitalization or local/systemic complications.
Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996;334:240-245. doi:10.1056/NEJM199601253340407
Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350:904-912. doi:10.1056/NEJMcp031807
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-52. doi:10.1093/cid/ciu444
Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. Cochrane database Syst Rev. 2010;CD004299. doi:10.1002/14651858.CD004299.pub2
Grosshans E. [Erysipelas. Clinicopathological classification and terminology]. Ann Dermatol Venereol. 2001;128:307-311. PMID: 11319356
Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas--risk factors and clinical presentation. BMC Infect Dis. 2014;14:270. doi:10.1186/1471-2334-14-270
Christensen KLY, Holman RC, Steiner CA, Sejvar JJ, Stoll BJ, Schonberger LB. Infectious Disease Hospitalizations in the United States. Clin Infect Dis. 2009;49:1025-1035. doi:10.1086/605562
Blackberg A, Trell K, Rasmussen M. Erysipelas, a large retrospective study of aetiology and clinical presentation. BMC Infect Dis. 2015;15:402. doi:10.1186/s12879-015-1134-2
Goettsch WG, Bouwes Bavinck JN, Herings RMC. Burden of illness of bacterial cellulitis and erysipelas of the leg in the Netherlands. J Eur Acad Dermatol Venereol. 2006;20:834-839. doi:10.1111/j.1468-3083.2006.01657.x
Bartholomeeusen S, Vandenbroucke J, Truyers C, Buntinx F. Epidemiology and comorbidity of erysipelas in primary care. Dermatology. 2007;215:118-122. doi:10.1159/000104262
Nathwani D. The Management of Skin and Soft Tissue Infections: Outpatient Parenteral Antibiotic Therapy in the United Kingdom. Chemotherapy. 2001;47:17-23. doi:10.1159/000048564
Ostermann H, Blasi F, Medina J, Pascual E, McBride K, Garau J, et al. Resource use in patients hospitalized with complicated skin and soft tissue infections in Europe and analysis of vulnerable groups: the REACH study. J Med Econ. 2014;17:719-729. doi:10.3111/13696998.2014.940423
Bernard P, Bedane C, Mounier M, Denis F, Catanzano G, Bonnetblanc JM. Streptococcal cause of erysipelas and cellulitis in adults. A microbiologic study using a direct immunofluorescence technique. Arch Dermatol. 1989;125:779-782. PMID: 2658843
Caetano M, Amorin I. [Erysipelas]. Acta Med Port. 18:385-393. PMID: 16611543
Chira S, Miller LG. Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review. Epidemiol Infect. 2010;138:313-317. doi:10.1017/s0950268809990483
Raff AB, Kroshinsky D. Cellulitis: A Review. Jama. 2016;316:325-337. doi:10.1001/jama.2016.8825
Morris AD. Cellulitis and erysipelas. BMJ Clin Evid. 2008;2008. pii: 1708. PMID: 19450336
Dupuy A, Benchikhi H, Roujeau J-C, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ. 1999;318:1591-1594. doi:10.1136/bmj.318.7198.1591
Bjornsdottir S, Gottfredsson M, Thorisdottir AS, et al. Risk Factors for Acute Cellulitis of the Lower Limb: A Prospective Case-Control Study. Clin Infect Dis. 2005;41:1416-1422. doi:10.1086/497127
Koutkia P, Mylonakis E, Boyce J. Cellulitis: evaluation of possible predisposing factors in hospitalized patients. Diagn Microbiol Infect Dis. 1999;34:325-327. doi:10.1016/S0732-8893(99)00028-0
Kulthanan K, Rongrungruang Y, Siriporn A, et al. Clinical and microbiologic findings in cellulitis in Thai patients. J Med Assoc Thai. 1999;82:587-592. PMID: 10443081
Bonnetblanc JM, Bedane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4:157-163. doi:10.2165/00128071-200304030-00002
Kwak YG, Choi S-H, Kim T, et al. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother. 2017;49:301. doi:10.3947/ic.2017.49.4.301
Mokni M, Dupuy A, Denguezli M, et al. Risk Factors for Erysipelas of the Leg in Tunisia: A Multicenter Case-Control Study. Dermatology. 2006;212:108-112. doi:10.1159/000090649
Quirke M, Ayoub F, McCabe A, et al. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017;177:382-394. doi:10.1111/bjd.15186
Smolle J, Kahofer P, Pfaffentaler E, Kerl H. [Risk factors for local complications in erysipelas]. Hautarzt. 2000;51:14-18. doi:10.1007/s001050050004
Wojas-Pelc A, Alekseenko A, Jaworek AK. Erysipelas--course of disease, recurrence, complications; a 10 years retrospective study. Przegla̧d Epidemiol. 2007;61:457-464. PMID: 18069381
Krasagakis K, Valachis A, Maniatakis P, Kruger-Krasagakis S, Samonis G, Tosca AD. Analysis of epidemiology, clinical features and management of erysipelas. Int J Dermatol. 2010;49:1012-1017.
Kozłowska D, Myśliwiec H, Kiluk P, Baran A, Milewska AJ, Flisiak I. Clinical and epidemiological assessment of patients hospitalized for primary and recurrent erysipelas. Przegl Epidemiol. 70:575-584.
Lazzarini L, Conti E, Tositti G, de Lalla F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. 2005;51:383-389. doi:10.1016/j.jinf.2004.12.010
Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis. 2013;56:1754-1762. doi:10.1093/cid/cit122
Brindle R, Williams OM, Davies P, et al. Adjunctive clindamycin for cellulitis: A clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis. BMJ Open. 2017;7:e013260. doi: 10.1136/bmjopen-2016-013260.. doi:10.1136/bmjopen-2016-013260
Diabetes: Factos e Números – O Ano de 2015 − Relatório Anual do Observatório Nacional da Diabetes; 12/2016, Sociedade Portuguesa de Diabetologia
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