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Brief Report
March 15, 2017

Clinical Characteristics and Outcomes of Patients With Cellulitis Requiring Intensive Care

Author Affiliations
  • 1Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 3Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 4Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
  • 5Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 6Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
JAMA Dermatol. Published online March 15, 2017. doi:10.1001/jamadermatol.2017.0159
Key Points

Question  How do the clinical presentation and outcomes of patients with cellulitis who require intensive care compare with those of patients with necrotizing fasciitis?

Findings  In this cohort study of 2562 sepsis admissions to intensive care units at 2 tertiary hospitals in the Netherlands, 23 patients admitted for cellulitis and 31 patients admitted for necrotizing fasciitis were included in this study. Fewer patients with cellulitis had shock and fewer needed mechanical ventilation, but patients with cellulitis had more chronic comorbidities; in-hospital and 90-day mortality were similar.

Meaning  Physicians should be aware that patients admitted to the intensive care unit for cellulitis and necrotizing fasciitis have similar mortality risks, despite differences in initial presentation.

Abstract

Importance  Cellulitis is a commonly occurring skin and soft tissue infection and one of the most frequently seen dermatological diseases in the intensive care unit (ICU). However, clinical characteristics of patients with cellulitis requiring intensive care treatment are poorly defined. Necrotizing fasciitis is often confused for cellulitis at initial presentation and is considered to be more severe and thus has previously been described in more detail.

Objective  To describe the clinical presentation and outcomes of patients with ICU-necessitating cellulitis and to compare them with patients with necrotizing fasciitis.

Design, Setting, and Participants  This prospective cohort study includes all ICU admissions from 2 tertiary hospitals in the Netherlands. Of 2562 sepsis admissions, 101 had possible, probable, or definite cellulitis or soft tissue infections. Retrospective review identified severe cellulitis was the reason for ICU admission in 23 patients, necrotizing fasciitis in 31 patients, and other diagnoses in 47 patients.

Main Outcomes and Measures  Patient and disease characteristics, cultured pathogens, lengths of stay, and short-term and long-term mortality.

Results  Overall, 54 patients with cellulitis (n = 23; mean [SD] age, 57.2 [17.7] years) or necrotizing fasciitis (n = 31; mean [SD] age, 54.3 [13.5]) were included in this study. Patients with cellulitis were found to be less severely ill than patients with necrotizing fasciitis. This is reflected in rates of shock (7 [30.4%] vs 19 [61.3%]; P = .03), need for mechanical ventilation (12 [52.2%] vs 19 [93.5%]; P = .003) and slightly lower mean Sequential Organ Failure Assessment scores (8 vs 10; P = 0.046). Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation IV scores did not differ significantly (82 [75-98] vs 76 [70-96]; P = .16). Patients with cellulitis had more chronic comorbidities than patients with necrotizing fasciitis (20 [87.0%] vs 17 [54.8%]; P = .02), especially cardiovascular insufficiencies (10 [43.5%] vs 4 [12.9%]; P = .02) and immunodeficiencies (9 [39.1%] vs 3 [9.7%]; P = .02). Among patients with cellulitis and patients with patients with necrotizing fasciitis, Staphylococcus aureus (10 [43.5%] vs 4 [12.9%]; P = .02), Streptococcus pyogenes (2 [8.7%] vs 19 [61.3%]; P < .001) and Escherichia coli (4 [17.4%] vs 5 [16.2%]; P = .90) were the most frequently observed pathogens. Median (IQR) length of ICU stay was shorter for patients with cellulitis vs patients with necrotizing fasciitis (3 [2-5] vs 5 [3-11]; P = .01), while median (IQR) hospital length of stay did not differ significantly (22 [10.25-32] vs 36 [14.25-40]; P = .16); and the in-hospital mortality rate (26.1% vs 22.6%, P > .99) and 90-day mortality rate (30.4% vs 22.6%; P = .54) were similar.

Conclusions and Relevance  Patients with cellulitis patients are seldom admitted to the ICU. However, while these patients are less critically ill on admission than patients with necrotizing fasciitis, they have more chronic comorbidities and most notably similar short-term and long-term mortality.

Trial Registration  clinicaltrials.gov Identifier: NCT01905033.

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