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Clinical Characteristics and Outcomes of Patients With Cellulitis Requiring Intensive Care
Duncan R Cranendonk1, Lonneke A van Vught2, Maryse A Wiewel2
1Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands3Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Insights
Patients with cellulitis admitted to the intensive care unit (ICU) are less severely ill than those with necrotizing fasciitis. Despite fewer critical illnesses, cellulitis patients exhibit more comorbidities and similar mortality rates, highlighting the need for careful management.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Dermatology
Background:
- Cellulitis is a common skin infection, frequently seen in intensive care units (ICUs).
- Clinical features and outcomes of ICU-admitted cellulitis patients are not well-defined.
- Necrotizing fasciitis is often misdiagnosed as cellulitis and is more severe.
Purpose of the Study:
- To characterize the clinical presentation and outcomes of patients with cellulitis requiring ICU admission.
- To compare these patients with those diagnosed with necrotizing fasciitis.
Main Methods:
- A prospective cohort study was conducted across two tertiary hospitals in the Netherlands.
- Included 23 patients with severe cellulitis, 31 with necrotizing fasciitis, and 47 with other diagnoses from 2562 sepsis admissions.
- Data collected included patient demographics, disease characteristics, pathogens, ICU and hospital length of stay, and mortality.
Main Results:
- Cellulitis patients were less severely ill (lower shock rates, less mechanical ventilation) than necrotizing fasciitis patients.
- Cellulitis patients had more chronic comorbidities, particularly cardiovascular and immunodeficiency issues.
- Despite differences in severity and pathogens (Staphylococcus aureus more common in cellulitis, Streptococcus pyogenes in necrotizing fasciitis), mortality rates were similar.
Conclusions:
- While less critically ill upon ICU admission, patients with cellulitis present with more comorbidities compared to necrotizing fasciitis.
- Short-term and long-term mortality rates for cellulitis and necrotizing fasciitis in the ICU setting are comparable.
- Further research into the management of ICU-admitted cellulitis is warranted given the similar outcomes despite differing severity.
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 = .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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