Journal of General Internal Medicine

, Volume 33, Issue 9, pp 1553–1560 | Cite as

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
Review Paper



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.


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.


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.


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.


Cellulitis Mortality Epidemiology Hospitalization 


Compliance with Ethical Standards

Conflict of Interest

The authors have no conflicts to disclose.

Supplementary material

11606_2018_4546_MOESM1_ESM.docx (14 kb)
ESM 1 (DOCX 13.9 kb)


  1. 1.
    Kaye KS, Patel DA, Stephens JM, Khachatryan A, Patel A, Johnson K. Rising United States Hospital Admissions for Acute Bacterial Skin and Skin Structure Infections: Recent Trends and Economic Impact. PLoS One 2015; 10(11): e0143276.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    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. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2014; 59(2): 147–59.CrossRefGoogle Scholar
  3. 3.
    Talan DA, Salhi BA, Moran GJ, et al. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. West J Emerg Med 2015; 16(1): 89–97.CrossRefPubMedGoogle Scholar
  4. 4.
    Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336(4): 243–50.CrossRefPubMedGoogle Scholar
  5. 5.
    Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58(5): 377–82.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283(15): 2008–12.CrossRefPubMedGoogle Scholar
  7. 7.
    Wells GE, Shea, B, O’Connell D, Peterson, J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Accessed June 6, 2017.
  8. 8.
    Jorup-Ronstrom C. Epidemiological, bacteriological and complicating features of erysipelas. Scand J Infect Dis 1986; 18(6): 519–24.CrossRefPubMedGoogle Scholar
  9. 9.
    Eriksson B, Jorup-Ronstrom C, Karkkonen K, Sjoblom AC, Holm SE. Erysipelas: clinical and bacteriologic spectrum and serological aspects. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 1996; 23(5): 1091–8.CrossRefGoogle Scholar
  10. 10.
    Cox NH, Colver GB, Paterson WD. Management and morbidity of cellulitis of the leg. Journal of the Royal Society of Medicine 1998; 91(12): 634–7.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Perl B, Gottehrer NP, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 1999; 29(6): 1483–8.CrossRefGoogle Scholar
  12. 12.
    Carratala J, Roson B, Fernandez-Sabe N, et al. Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology 2003; 22(3): 151–7.Google Scholar
  13. 13.
    Lazzarini L, Conti E, Tositti G, de Lalla F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. The Journal of infection 2005; 51(5): 383–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Morpeth SC, Chambers ST, Gallagher K, Frampton C, Pithie AD. Lower limb cellulitis: features associated with length of hospital stay. The Journal of infection 2006; 52(1): 23–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Goettsch WG, Bouwes Bavinck JN, Herings RM. Burden of illness of bacterial cellulitis and erysipelas of the leg in the Netherlands. J Eur Acad Dermatol Venereol 2006; 20(7): 834–9.PubMedGoogle Scholar
  16. 16.
    Edelsberg J, Berger A, Weber DJ, Mallick R, Kuznik A, Oster G. Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections. Infect Control Hosp Epidemiol 2008; 29(2): 160–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Figtree M, Konecny P, Jennings Z, Goh C, Krilis SA, Miyakis S. Risk stratification and outcome of cellulitis admitted to hospital. The Journal of infection 2010; 60(6): 431–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Jenkins TC, Sabel AL, Sarcone EE, Price CS, Mehler PS, Burman WJ. Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2010; 51(8): 895–903.CrossRefGoogle Scholar
  19. 19.
    Shen HN, Lu CL. Skin and soft tissue infections in hospitalized and critically ill patients: a nationwide population-based study. BMC infectious diseases 2010; 10: 151.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Lipsky BA, Moran GJ, Napolitano LM, Vo L, Nicholson S, Kim M. A prospective, multicenter, observational study of complicated skin and soft tissue infections in hospitalized patients: clinical characteristics, medical treatment, and outcomes. BMC infectious diseases 2012; 12: 227.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Marwick C, Rae N, Irvine N, Davey P. Prospective study of severity assessment and management of acute medical admissions with skin and soft tissue infection. The Journal of antimicrobial chemotherapy 2012; 67(4): 1016–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Perello-Alzamora MR, Santos-Duran JC, Sanchez-Barba M, Canueto J, Marcos M, Unamuno P. Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology 2012; 31(9): 2147–52.CrossRefGoogle Scholar
  23. 23.
    Baibergenova A, Drucker AM, Shear NH. Hospitalizations for cellulitis in Canada: a database study. Journal of cutaneous medicine and surgery 2014; 18(1): 33–7.PubMedGoogle Scholar
  24. 24.
    Li X, Chen Y, Gao W, Ouyang W, Wei J, Wen Z. Epidemiology and outcomes of complicated skin and soft tissue infections among inpatients in southern China from 2008 to 2013. PLoS ONE 2016; 11 (2) (no pagination) (e0149960).CrossRefGoogle Scholar
  25. 25.
    Eriksson B, Jorup-Ronstrom C, Karkkonen K, Sjoblom AC, Holm SE. Erysipelas: Clinical and bacteriologic spectrum and serological aspects. Clinical Infectious Diseases 1996; 23(5): 1091–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Chalmers JD, Singanayagam A, Akram AR, et al. Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis. Thorax 2010; 65(10): 878–83.CrossRefPubMedGoogle Scholar
  27. 27.
    Eron LJ, Lipsky BA, Low DE, et al. Managing skin and soft tissue infections: expert panel recommendations on key decision points. The Journal of antimicrobial chemotherapy 2003; 52 Suppl 1: i3–17.CrossRefPubMedGoogle Scholar
  28. 28.
    Corwin P, Toop L, McGeoch G, et al. Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital. BMJ 2005; 330(7483): 129.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Chapman AL. Outpatient parenteral antimicrobial therapy. BMJ 2013; 346: f1585.CrossRefPubMedGoogle Scholar
  30. 30.
    Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood) 2012; 31(10): 2314–23.CrossRefGoogle Scholar
  31. 31.
    Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med 2014; 370(23): 2169–79.CrossRefPubMedGoogle Scholar
  32. 32.
    Corey GR, Jiang H, Moeck G. Dalbavancin or oritavancin for skin infections. N Engl J Med 2014; 371(12): 1162–3.PubMedGoogle Scholar
  33. 33.
    Agarwal R, Bartsch SM, Kelly BJ, et al. Newer glycopeptide antibiotics for treatment of complicated skin and soft tissue infections: systematic review, network meta-analysis and cost analysis. Clin Microbiol Infect 2018; 24(4): 361–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Huttner B, Jones M, Huttner A, Rubin M, Samore MH. Antibiotic prescription practices for pneumonia, skin and soft tissue infections and urinary tract infections throughout the US Veterans Affairs system. The Journal of antimicrobial chemotherapy 2013; 68(10): 2393–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Gunderson CG. Overtreatment of nonpurulent cellulitis. J Hosp Med 2016; 11(8): 587–90.CrossRefPubMedGoogle Scholar
  36. 36.
    Paul M, Shani V, Muchtar E, Kariv G, Robenshtok E, Leibovici L. Systematic review and meta-analysis of the efficacy of appropriate empiric antibiotic therapy for sepsis. Antimicrob Agents Chemother 2010; 54(11): 4851–63.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 775–87.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Chambers HF . Cellulitis, by any other name. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2013; 56(12): 1763–4.CrossRefGoogle Scholar
  39. 39.
    Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA 2000; 283(6): 749–55.CrossRefPubMedGoogle Scholar
  40. 40.
    Carratala J, Fernandez-Sabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med 2005; 142(3): 165–72.CrossRefPubMedGoogle Scholar
  41. 41.
    Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized controlled trial. Ann Intern Med 2005; 143(12): 881–94.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Craig G. Gunderson
    • 1
    • 2
  • Benjamin M. Cherry
    • 1
    • 2
  • Ann Fisher
    • 2
    • 3
  1. 1.Department of Internal Medicine, Section of General Internal Medicine Yale University School of MedicineWest HavenUSA
  2. 2.Veterans Affairs Connecticut Healthcare SystemWest HavenUSA
  3. 3.Department of Internal Medicine, Section of Infectious DiseasesYale University School of MedicineNew HavenUSA

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