In Search of Risk Factors for Recurrent Erysipelas and Cellulitis of the Lower Limb: A Cross-Sectional Study of Epidemiological Characteristics of Patients Hospitalized due to Skin and Soft-Tissue Infections

Abstract

Background. Erysipelas and cellulitis are common, acute, bacterial infections of the skin and subcutaneous tissue. The incidence of these infections is growing, and the recurrence rate is high. Effective antibiotic prophylaxis is available, but insufficient data exist on the risks factors for recurrent infection. Purpose. To compare comorbidities and laboratory findings in patients with single-episode and recurrent erysipelas/cellulitis in order to identify risk factors for recurrent erysipelas/cellulitis. Methods. A cross-sectional study, which included patients hospitalized in the Department of Infectious and Tropical Diseases and Hepatology of the Medical University of Warsaw due to erysipelas and cellulitis during 3 consecutive years (July 2016–June 2019). Results. The study included 163 patients, of which 98 had a first episode of erysipelas/cellulitis and 65 had a recurrence. The recurrent infection was significantly associated with a history of lymphedema (12.3% in the recurrent group vs. 2.0% in the first-episode group, p=0.015), a higher BMI (35.4 vs. 31.2, respectively, p=0.002), chronic obstructive pulmonary disease (10.8% vs. 2.0%, p=0.030), and a shorter history of symptoms prior to hospitalization (6.0 days vs. 11.8 days, p=0.004). Patients with the first episode of infection were more likely to have had minor local trauma directly preceding the symptoms of infection (20.4% in the first-episode group vs. 1.5% in the recurrent group, p=0.001). Conclusions. Patients with lymphedema and obesity should be viewed at high risk of developing recurrence of erysipelas and thus should be considered as candidates for antibiotic prophylaxis and other prevention methods. Minor local trauma directly preceding the skin infection does not by itself confer a higher risk for erysipelas recurrence. More research is needed to assess the association of recurrent skin and soft-tissue infection to preceding minor local trauma, individual components of the metabolic syndrome, and COPD.

Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?

“…Risk factors for single episodes are associated with trauma, wounds or environmental exposure that are unlikely to recur. 18 , 30 Risk factors which are not modifiable or managed appropriately are more frequently associated with recurrent cellulitis.…”

“… 11 , 16 One study found a higher recurrence of cellulitis in the tibial region as compared to the femoral region or the foot. 11 Other risk factors that were identified include peripheral vascular disease, 13 , 17 chronic kidney disease, 17 chronic obstructive pulmonary disease, 13 , 30 and liver disease. 13 Social factors associated with the other established risk factors are also important, particularly homelessness which can be linked to poor skin and general health care.…”

Pathogenese, Klinik und Therapie des Erysipels

“…Hinsichtlich anderer Erkrankungen wie Diabetes mellitus, peripherer arterieller Verschlusskrankheit, Malignomen und chronisch-obstruktive Lungenerkrankung sind die Studienergebnisse kontroversiell hinsichtlich ihrer Eigenschaft als Risikofaktoren, die die Entstehung eines Erysipels möglicherweise begünstigen. Kontroversen bestehen ebenso hinsichtlich einer Adipositas als Risikofaktor [12,[23][24][25][26][27][28][29].…”

Liposuction and Controlled Compression Therapy Reduce the Erysipelas Incidence in Primary and Secondary Lymphedema

“…Another study by Inghammar et al 24 has shown that lymphedema is the greatest risk factor for erysipelas recurrence, which is in accordance with results from more recent research. 25 It has also been shown that late-stage lymphedema correlates with a higher incidence of erysipelas 26 and that lymphedema is a risk factor for developing bacteremia in the presence of cellulitis. 27 In a study by Deng et al, 20 patients with LEL had an increased OR of 2.53 (95% CI: 1.77–3.62) for developing skin infections compared with patients with upper extremity lymphedema (UEL).…”