Risk factors for bacteremia in patients with limb cellulitis

  • G. Peralta
  • E. Padrón
  • M. P. Roiz
  • I. De Benito
  • J. C. Garrido
  • F. Talledo
  • M. J. Rodríguez-Lera
  • L. Ansorena
  • M. B. Sánchez
Article

Abstract

The aim of this study was to identify the risk factors for bacteremia in patients with limb cellulitis. Using the administrative and microbiology laboratory databases of a community teaching hospital, a review was conducted of all cases of community-acquired limb cellulitis that occurred during the period 1997–2004 and in which blood cultures had been performed. A comparison of demographical, clinical, and analytical data of patients with bacteremia versus patients without bacteremia was performed by univariate and multivariate analyses. Of 2,678 patients with cellulitis who presented to the hospital’s emergency department, 308 were diagnosed with limb cellulitis and had blood cultures. Of these, 57 (18.5%) had bacteremia. In 24 of the 57 (42.1%) patients with bacteremia, the microorganism isolated in blood cultures was non-group-A β-hemolytic Streptococcus, and in another 14 (24.6%), the microorganism identified was a gram-negative bacterium. Staphylococcus aureus was determined as the cause of bacteremia in just 6 (10.5%) patients and group A Streptococcus in 2 (3.5%). By logistic regression analysis, the following factors were associated with bacteremia: absence of previous antibiotic treatment (OR 5.3, 95% CI 1.4–20.3), presence of two or more comorbid factors simultaneously (OR 4.3, 95% CI 1.6–11.7), length of illness <2 days OR 2.44, 95% CI 1.07–5.56), and proximal limb involvement (OR 6, 95% CI 3.03–12.04). Patients with limb cellulitis who exhibit any of these characteristics are at increased risk of bacteremia. In such patients, it is imperative that blood cultures be performed.

Notes

Acknowledgment

We thank Luis Martínez (University Hospital “Marqués de Valdecilla”) for critical reading of the manuscript.

References

  1. 1.
    Swartz MN (2004) Cellulitis. N Engl J Med 35:904–912CrossRefGoogle Scholar
  2. 2.
    Morris A (2004) Cellulitis and erysipelas. Clin Evid 11:2133–2139PubMedGoogle Scholar
  3. 3.
    Perl B, Gottehrer NP, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM (1999) Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis 29:1483–1488CrossRefPubMedGoogle Scholar
  4. 4.
    Sadow KB, Chamberlain JM (1998) Blood cultures in the evaluation of children with cellulitis. Pediatrics 101:E4CrossRefPubMedGoogle Scholar
  5. 5.
    Kielhofner MA, Brown B, Dall L (1988) Influence of underlying disease process on the utility of cellulitis needle aspirates. Arch Intern Med 148:2451–2452CrossRefPubMedGoogle Scholar
  6. 6.
    Sachs MK (1990) The optimum use of needle aspiration in the bacteriologic diagnosis of cellulitis in adults. Arch Intern Med 150:1907–1912CrossRefPubMedGoogle Scholar
  7. 7.
    Hook EW III, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M (1986) Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med 146:295–297CrossRefPubMedGoogle Scholar
  8. 8.
    Howe PM, Eduardo Fajardo J, Orcutt MA (1987) Etiologic diagnosis of cellulitis: comparison of aspirates obtained from the leading edge and the point of maximal inflammation. Pediatr Infect Dis J 6:685–686CrossRefPubMedGoogle Scholar
  9. 9.
    Mills AM, Chen EH (2005) Are blood cultures necessary in adults with cellulitis? Ann Emerg Med 45:548–549CrossRefPubMedGoogle Scholar
  10. 10.
    Newell PM, Norden CW (1988) Value of needle aspiration in bacteriologic diagnosis of cellulitis in adults. J Clin Microbiol 26:401–414PubMedGoogle Scholar
  11. 11.
    Ginsberg MB (1981) Cellulitis: analysis of 101 cases and review of the literature. South Med J 74:530–533PubMedGoogle Scholar
  12. 12.
    Ho PW, Pien FD, Hamburg D (1979) Value of cultures in patients with acute cellulitis. South Med J 72:1402–1403PubMedGoogle Scholar
  13. 13.
    Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000) Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis 19:294–297CrossRefPubMedGoogle Scholar
  14. 14.
    Corredoira JM, Ariza J, Pallares R, Carratala J, Viladrich PF, Rufi G, Verdaguer R, Gudiol F (1994) Gram-negative bacillary cellulitis in patients with hepatic cirrhosis. Eur J Clin Microbiol Infect Dis 13:19–24CrossRefPubMedGoogle Scholar
  15. 15.
    Horowitz Y, Sperber AD, Almog Y (2004) Gram-negative cellulitis complicating cirrhosis. Mayo Clin Proc 79:247–250PubMedCrossRefGoogle Scholar
  16. 16.
    Manfredi R, Calza L, Chiodo F (2002) Epidemiology and microbiology of cellulitis and bacterial soft tissue infection during HIV disease: a 10-year survey. J Cutan Pathol 29:168–172CrossRefPubMedGoogle Scholar
  17. 17.
    Zahar JR, Goveia J, Lesprit P, Brun-Buisson C (2005) Severe soft tissue infections of the extremities in patients admitted to an intensive care unit. Clin Microbiol Infect 11:79–82CrossRefPubMedGoogle Scholar
  18. 18.
    Sharkawy A, Low DE, Saginur R, Gregson D, Schwartz B, Jessamine P, Green K, McGeer A; Ontario Group A Streptococcal Study Group (2002) Severe group A streptococcal soft-tissue infections in Ontario: 1992–1996. Clin Infect Dis 34:454–460CrossRefPubMedGoogle Scholar
  19. 19.
    Björnsdóttir S, Gottfredsson M, Thórisdóttir AS, Gunnarsson GB, Ríkardsdóttir H, Kristjánsson M, Hilmarsdóttir I (2005) Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis 41:1416–1422CrossRefPubMedGoogle Scholar
  20. 20.
    Vartivarian SE, Papadakis KA, Palacios JA, Manning JT Jr, Anaissie EJ (1994) Mucocutaneous and soft tissue infections caused by Xanthomonas maltophilia. A new spectrum. Ann Intern Med 121:969–973PubMedGoogle Scholar
  21. 21.
    Schwartz GR, Wright SW (1996) Changing bacteriology of periorbital cellulitis. Ann Emerg Med 28:617–620CrossRefPubMedGoogle Scholar
  22. 22.
    Gellady AM, Shulman ST, Aycub EM (1978) Periorbital and orbital cellulitis in children. Pediatrics 61:272–277PubMedGoogle Scholar
  23. 23.
    Smith TF, O’Day D, Wright PF (1978) Clinical implications of preseptal (periorbital) cellulitis in childhood. Pediatrics 62:1006–1009PubMedGoogle Scholar
  24. 24.
    Givner LB, Mason EO Jr, Barson WJ, Tan TQ, Wald ER, Schutze GE, Kim KS, Bradley JS, Yogev R, Kaplan SL (2000) Pneumococcal facial cellulitis in children. Pediatrics 106:E61CrossRefPubMedGoogle Scholar
  25. 25.
    Halperin SA (1990) Haemophilus influenzae type B and its role in diseases of the head and neck. J Otolaryngol 19:169–174PubMedGoogle Scholar
  26. 26.
    Bisharat N, Agmon V, Finkelstein R, Raz R, Ben-Dror G, Lerner L, Soboh S, Colodner R, Cameron DN, Wykstra DL, Swerdlow DL, Farmer JJ 3rd (1999) Clinical, epidemiological, and microbiological features of Vibrio vulnificus biogroup 3 causing outbreaks of wound infection and bacteraemia in Israel. Israel Vibrio Study Group. Lancet 354:1421–1424CrossRefPubMedGoogle Scholar
  27. 27.
    Kimura AC, Pien FD (1993) Head and neck cellulitis in hospitalized adults. Am J Otolaryngol 14:343–349CrossRefPubMedGoogle Scholar
  28. 28.
    Brook I, Frazier EH (1995) Clinical features and aerobic and anaerobic microbiological characteristics of cellulitis. Arch Surg 130:786–792PubMedGoogle Scholar
  29. 29.
    Carratalá J, Roson B, Fernandez-Sabe N, Shaw E, del Rio O, Rivera A, Gudiol F (2003) Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. Eur J Clin Microbiol Infect Dis 22:151–157PubMedGoogle Scholar
  30. 30.
    Parada JP, Maslow JN (2000) Clinical syndromes associated with adult pneumococcal cellulitis. Scand J Infect Dis 32:133–136CrossRefPubMedGoogle Scholar
  31. 31.
    Goldgeier MH (1983) The microbial evaluation of acute cellulitis. Cutis 31:649–650PubMedGoogle Scholar
  32. 32.
    Fleisher G, Ludwig S (1980) Cellulitis: a prospective study. Ann Emerg Med 9:246–249CrossRefPubMedGoogle Scholar
  33. 33.
    Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ (1999) Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 340:85–92CrossRefPubMedGoogle Scholar
  34. 34.
    Jackson LA, Hilsdon R, Farley MM, Harrison LH, Reingold AL, Plikaytis BD, Wenger JD, Schuchat A (1995) Risk factors for group B streptococcal disease in adults. Ann Intern Med 123:415–420PubMedGoogle Scholar
  35. 35.
    Galpin JE, Chow AW, Bayer AS, Guze LB (1976) Sepsis associated with decubitus ulcers. Am J Med 61:346–350CrossRefPubMedGoogle Scholar
  36. 36.
    Lau SK, Woo PC, Tse H, Leung KW, Wong SS, Yuen KY (2003) Invasive Streptococcus iniae infections outside North America. J Clin Microbiol 41:1004–1009CrossRefPubMedGoogle Scholar
  37. 37.
    Lutomski DM, Trott AT, Runyon JM, Miyagawa CI, Staneck JL, Rivera JO (1988) Microbiology of adult cellulitis. J Fam Pract 26:45–48PubMedGoogle Scholar
  38. 38.
    Sylvetsky N, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM (2002) Bacteremia due to beta-hemolytic Streptococcus group G: increasing incidence and clinical characteristics of patients. Am J Med 112:622–626CrossRefPubMedGoogle Scholar
  39. 39.
    Berenguer J, Sampedro I, Cercenado E, Baraia J, Rodriguez-Creixems M, Bouza E (1992) Group-C beta-hemolytic streptococcal bacteremia. Diagn Microbiol Infect Dis 15:151–155CrossRefPubMedGoogle Scholar
  40. 40.
    Farley MM, Harvey RC, Stull T, Smith JD, Schuchat A, Wenger JD, Stephens DS (1993) A population-based assessment of invasive disease due to group B Streptococcus in nonpregnant adults. N Engl J Med 328:1807–1811CrossRefPubMedGoogle Scholar
  41. 41.
    Schugk J, Harjola VP, Sivonen A, Vuopio-Varkila J, Valtonen M (1997) A clinical study of beta-haemolytic groups A, B, C and G streptococcal bacteremia in adults over an 8-year period. Scand J Infect Dis 29:233–238PubMedCrossRefGoogle Scholar
  42. 42.
    Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, Harriman K, Harrison LH, Lynfield R, Farley MM; Active Bacterial Core Surveillance Program of the Emerging Infections Program Network (2005) Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 352:1436–1444CrossRefPubMedGoogle Scholar
  43. 43.
    Eady EA, Cove JH (2003) Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 16:103–124PubMedGoogle Scholar
  44. 44.
    Charlson ME, Pompei P, Ales KL, McKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal populations: development and validation. J Chronic Dis 40:373–378CrossRefPubMedGoogle Scholar
  45. 45.
    Bone RC, Sprung CL, Sibbald WJ (1992) Definitions for sepsis and organ failure. Crit Care Med 20:724–726PubMedCrossRefGoogle Scholar
  46. 46.
    Weinstein MP (1996) Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis 23:40–46PubMedGoogle Scholar
  47. 47.
    Bates DW, Goldman L, Lee TH (1991) Contaminant blood cultures and resource utilization—the true consequences of false-positive results. JAMA 265:365–369CrossRefPubMedGoogle Scholar
  48. 48.
    DiNubile MJ, Lipsky BA (2004) Complicated infections of skin and skin structures: when the infection is more than skin deep. J Antimicrob Chemother 5(Suppl 2):37–50Google Scholar
  49. 49.
    Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC (2005) Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 41:1373–1406CrossRefPubMedGoogle Scholar
  50. 50.
    Cockerill FR 3rd, Wilson JW, Vetter EA, Goodman KM, Torgerson CA, Harmsen WS, Schleck CD, Ilstrup DM, Washington JA 2nd, Wilson WR (2004) Optimal testing parameters for blood cultures. Clin Infect Dis 38:1724–1730CrossRefPubMedGoogle Scholar
  51. 51.
    Kobayashi I, Yamamoto M, Hasegawa M, Sato Y, Uchino U, Kaneko A (2004) Effect of delay of blood cultures on positive detection by automated blood culture system. Kansenshogaku Zasshi 78:959–966PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • G. Peralta
    • 1
  • E. Padrón
    • 1
  • M. P. Roiz
    • 2
  • I. De Benito
    • 2
  • J. C. Garrido
    • 3
  • F. Talledo
    • 1
  • M. J. Rodríguez-Lera
    • 4
  • L. Ansorena
    • 5
  • M. B. Sánchez
    • 6
  1. 1.Internal Medicine ServiceSierrallana HospitalTorrelavegaSpain
  2. 2.Microbiology ServiceSierrallana HospitalTorrelavegaSpain
  3. 3.Biochemistry ServiceSierrallana HospitalTorrelavegaSpain
  4. 4.Emergency ServiceSierrallana HospitalTorrelavegaSpain
  5. 5.Admission ServiceSierrallana HospitalTorrelavegaSpain
  6. 6.Clinical Pharmacology ServiceUniversity Hospital “Marqués de Valdecilla”SantanderSpain

Personalised recommendations