Diagnosis of cellulitis in the immunocompromised hostdownloads.hindawi.com/journals/cjidmm/1990/649417.pdf · BRIEF REPORT Diagnosis of cellulitis in the immunocompromised host CHARLES

BRIEF REPORT

Diagnosis of cellulitis in the immunocompromised host

CHARLES F CAREY, LAWRENCE DALL, MD

ABSTRACT: A prospective study of diagnostic techniques in cellulitis was performed on 28 patients with malignancy. Twenty-two (78%) of the fine needle aspiration cultures and 10 (35%) of the blood cultures were positive in this immunocomprornised population. The incidence of positive fine needle aspiration cultures (P<0.005) or bacteremia (P<0.0005) was significantly higher than results obtained in an immunocompetent population with cellulitis at the same institution. Staphylococci or streptococci were recovered in 59% of posi-

SKIN AND SOFT TISSUE INFECTIONS ACCOUNT FOR 22

to 33% of infections in immunocompromised patients (1). Cellulitis is a diffuse infection of the skin and underlying subcutaneous tissue that presents clinically with local erythema, warmth, edema, tenderness and occasional systemic symptoms (malaise. fever and chills). Staphylococcus aureus and grou p A streptococci are the usual pathogens involved in cellulitis (2,3). However, in the immunocompromised host there is an increased risk of infection with aerobic Gramnegative bacilli and fungi (2). Kielhofner et al (4) reported an increased sen sitivity of fine needle aspiration in the diagnosis of the etiologic agent causing cellulitis in the immunocompromised

Section of Infectious Diseases. Truman Medical Center. University of Missouri-Kansas City School of Medicine. Kansas City. Missouri. USA

Correspondence and reprints: Dr L Dall. University of Missouri-Kansas City School of Medicine. 2411 Holmes. Kansas City. MO 64108. USA. Telephone (816) 235-1960

Received for publication June 8. 1990. Accepted August 14. 1990

CAN J INFECT DIS VOL 1 No 4 WINTER 1990

tive cultures, while aerobic Gram-negative bacilli grew in 33%. This study indicates that in the immunocomprornised population with cellulitis, fine needle aspiration and b lood cultures should be obtained , and the antibiotic regimen should cover Gram-positive cocci and Gram-negative bacilli pending the results of cultures. Can J Infect Dis 1990;1(4):133-135

Key Words: Bacteremia, Cellu litis, Fine needle aspiration, Malignancy, Neutropenia

host, especially the diabetic. To further delineate the role of fine needle aspiration in the immunocompromised host, the authors performed a prospective study of patients with malignancies admitted to hospital with acute cellulitis.

PATIENTS AND METHODS Patients with a previous diagnosis of malignan

cy admitted to Truman Medical Center over a period of 28 months with a diagnosis of acute cellulitis were included in the study after informed consent was obtained. Cellulitis was diagnosed by the clinical find ings described above. Patients were excluded from the study if the cellulitis was associated with ulcerative lesions , abscesses, underlying osteomyelitis, or concurrent antibiotic therapy.

Fine needle aspiration of the leading edge of the cellulitis was performed according to the procedure described by Uman and Kunin in 1974 (5). The skin was disinfected with povidone-iodine and alcohol, and a sterile 21 or 22 gauge needle inserted without local anesthetic at the leading edge

133

CAREY AND D ALL

TABLE 1 Sensitivity of culture techniques for cellulitis in immunecompromised patients

Underlying disease Needle aspirate culture Blood culture

Number Positive (%) Positive (%)

Lymphoreticular 17 14 (82%) 6 (35%) malignancy

Solid tumour 11 8 (73%) 4 (36%)

Total 28 22 (78%) 10 (35%)

TABLE 2 Organisms isolated from patients with acute cellulitis

Organism Needle aspirate Blood

Staphylococcus aureus Group A streptococci Escherichia coli

Acinetobacter calcoaceticus Klebsiella oxytoca Pasturella multocidia

Pseudomonas aeruginosa Group B streptococci Clostridium perfringens

culture culture

9 4

3

5 2 1

0 0 0 1

0

of the infection and aspirated. If no material was recovered in the syringe, 1.0 mL of nonbacteriostatic saline solution was injected into the subcutaneous tissue and aspirated. The recovered material was inoculated onto the following media: tryptic soy blood agar, colistin-nalidixic acid agar, MacConkey agar, chocolate agar, and a liquid thioglycolate medium. In addition, aerobic and anaerobic blood cultures were obtained.

Experimental data were analyzed by Student's t test.

RESULTS 1Wen ty-eight patients were enrolled in the

s tudy. There were 13 male and 15 female patients between the ages of 18 and 82 years with a mean age of 46. The sites of infection included : upper extremity 18 (64%); lower extremity eigh t (28%); and one each (3.5%) of breast (lung cancer) and perineum (ovarian cancer). Eight of the 28 patients had neutrophil counts less than 1000/mm2

.

1Wenty-two (78%) of the fine needle aspiration cultures were positive. Blood cultures were positive in 10 patients (35%), including six of eight n eutropenic patients (Table 1) . The organisms isolated in the blood cultures were identical to the bacteria recovered from fine needle aspiration cultures in all cases (kappa=l). Staphylococcus aureus or group A streptococci were recovered in 13 cultures (59%) (Table 2) . No fungi were recovered .

134

TABLE 3 Comparison of acute cellulitis studies in adults

Study Ref. Fine needle aspirate Blood culture results (%) Positive (%) Positive

Goldgeier ( 11) 5% 1/20 10% 2/20

Epperly (12) 9% 9/1 03 3% 3/87

Hook ( 13) 10% 5/50 4% 2/50

Newe ll ( 14) 10% 3/30 4% 1/26

Lutomski (9) 24% 6/25 16% 4/25

Sigurdsson ' ( 15) 31% 22/72 0% 0/72

Li les ( 16) 33% 8/24 5% 1/21

Kielhofner ( 4) 38% 33/87 7% 6/87

Lee' (17) 52% 12/23 Not reported

Musher ( 8) 64% 14/22 O"'o 0/33 Hot ( 18) 84% 64/76 2% 1/66 'Aspiration biopsy described by Robinson (21). 1 Wound cultures -methods not reported

DISCUSSION This study focused on cellulitis in the im

munocompromised host. The high rate of positive cultures in pa tients with impaired immunity is probably secondary to increased numbers of infectious pathogens at the site of infection. Immunosuppression in patients with malignancies is secondary to effects of the neoplasm itself and the treatmen t modalities used in oncology. These defects consist of a decreased number of granulocytes, qualitative abnormalities in neutrophils, abnormal immunoglobulins, impaired cellmediated immunity, and an impaired skin barrier (1 ,6 ,7).

The results also showed a high ra te of bacteremia with the causative organism of the cellulitis. Others have reported positive blood culture ra tes in cellulitis of from 0 to 16% (8,9) . Interestingly, bacteremia in the present study was remarkably high (38.5%) even compared to patients with cellulitis with granulocyte counts less than 100/mm3 secondary to malignancy (19%) (10).

The value of fine needle aspiration is still debated, with sensitivities ranging from 5 to 64% in patients with a wide spectrum of underlying diseases (Table 3) (8, 11) . Epperly (12), who performed the only study exclusively on patients without underlying disease, reported nine of 103 patients (8 . 7%) with cellulitis having positive aspiration cultures, which all grew staphylococcal or streptococcal species. Kielhofner 's study (4) pointed out the value of fine needle aspiration in immunocompromised hosts, especially diabetics . In a comparison of pa tients with cellulitis with no underlying disease a t the authors' institution u s ing the same methods , there was a significant increase in positive fine needle aspiration cultures (P<0.005) and ba cteremia (P<0.0005) in patients

CAN J INFECT D IS VOL 1 No 4 WINTER 1990

with malignancies, and an increase incidence of aerobic Gram-negative infection (P<0.05).

The present results reaffirm fine needle aspiration as a sensitive and safe method for determining the etiology of cellulitis in this select patient population. Because of the higher incidence of aerobic Gram-negative bacilli and a significant tendency toward bacteremia, the authors recommend initial antibiotic coverage for both Gramnegative bacilli and Gram-positive cocci pending the results of cultures .

ACKNOWLEDGEMENTS: The authors greatly appreciate the secretartal skills of Jeri Hawkins in the preparation of this manuscript.

REFERENCES 1. Wolfson JS. Sober AJ, Rubin RH. Dermatologic

manifestations of infection in the compromised host. Annu Rev Med 1983;34:205- 17.

2. Sheagren JN. Treatment of skin and skin structure infections in the patient at risk. Am J Med 1984;76: 180-6.

3. Swartz MN. Cellulitis and superficial infections. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and Practices of Infectious Disease. New York: John Wiley Medical Publications. 1985:598-609 .

4. K.ielhofner MA. Brown B, Dall L. Influence of underlying disease process on the utility of cellulitis needle aspirates . Arch Intern Med 1988:148:2451-2.

5. Uman SJ, Kunin CM. Needle aspiration in the diagnosis of soft tissue infections. Arch Intern Med 1975; 135:959-61.

CAN J INFECT DIS VOL 1 No 4 WINTER 1990

Cellulitis in immunocompromised host

6 . Singer C. Infections in patients with neoplastic dis eases. In: Grieco MH. ed. Infections in the Abnormal Host. New York: Yorke Medical Books. 1980:546-84.

7 . Albano EA, Pizzo PA. Infectious complications in childhood acute leukemias. Pediatr Clin North Am 1988;35:873-90.

8. Musher OM. F'ainstein V. Young EJ. Treatment of cellulitis with ceforanide. Antimicrob Agents Chemother 1980; 17:254-47.

9. Lutomski OM, Trott AT, Runyon JM, Miyagawa CI. Staneck JL. Rivera , JO. Microbiology of adult cellulitis . J F'am Pract 1988;26:45-8.

10. Sickles EA, Greene WH, Wiemik PH. Clinical presentation of infection in granulocytopenic patients. Arch Intern Med 1975; 135:715-9.

11. Goldgeier MH. The microbial evaluation of acute cellulitis. Cutis 1983;31 :649-56.

12. Epperly TO. The value of needle aspiration in the management of cellulitis . J F'am Pract 1986;23:337-40.

13. Hook EW, Hooton TM, Horton CA, Coyle MB, Ramsey PG. Turck M. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med 1986:146:295-7 .

14. Newell PM, Norden CW. Value of needle aspiration in bacteriologic diagnoses of cellulitis in adults. J Clin Microbial 1988;26:401-4.

15. Sigurdsson AF', Gudmundsson S. The etiology of bacterial cellulitis as determined by fine -needle aspiration. Scand J Infect Dis 1989;21:537-42.

16. Liles OK, Dal1 LH. Needle aspiration for diagnosis of cellulitis. Cutis 1985;36:63-4.

17. Lee PC, Turnidge V, McDonald PJ. Fine needle aspiration biopsy in diagnosis of soft tissue infections. J Clin Microbial 1985;22:80-3.

18. Ho PW, Plen F'D, Hamburg D. Value of cultures in patients with acute cellulitis. South Med J 1979;72: 1402-3.

19. Robinson CR. New technique for fme needle aspiration biopsy. Hum Pathol 1984; 15:197.

135

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Documents

Diagnosis of cellulitis in the immunocompromised hostdownloads.hindawi.com/journals/cjidmm/1990/649417.pdf · BRIEF REPORT Diagnosis of cellulitis in the immunocompromised host CHARLES