Clinical Profile of Cellulitis and Erysipelas in the Tertiary Referral Hospital of West Java, Indonesia

Clinical Profile of Cellulitis and Erysipelas in the Tertiary Referral Hospital of West Java, Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Profile of Cellulitis and Erysipelas in the Tertiary Referral Hospital of West Java, Indonesia Hendra Gunawan, Reti Hindritiani, Hartati Purbo Dharmadji, Oki Suwarsa, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4250982/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Cellulitis and erysipelas belong to a group of diseases that are considered global health burdens. Epidemiological data on these diseases in Indonesia is still limited. Purposes: This study aimed to identify the clinical profile of cellulitis and erysipelas in the tertiary referral hospital in West Java, Indonesia. Method This was a retrospective, descriptive study using a cross-sectional design. Data were obtained from outpatient and inpatient records of cellulitis and erysipelas patients in the tertiary referral hospital in West Java, Indonesia, in a three-year period during January 2020–December 2022. Result The results of the study showed that cellulitis was most common in women within the 45–64-year age group with normoweight nutritional status, while erysipelas mostly occurred in men within the > 65-year age group without a certain nutritional status predominance. In general, the risk factor for cellulitis was skin barrier disruption, while that for erysipelas was metabolic disorders. Fever was present in less than half of cases with cellulitis and erysipelas, and the lower extremities were the most often affected. The most frequent portal of entry in cellulitis was scratched skin, whereas erysipelas had no particular predominance. Additional skin lesions, such as bullae and/or erosions and suppuration, were found in some cases of these diseases and usually showed Gram-positive cocci with leukocytosis. Normal saline dressing was given to all cases, and some of them were treated with additional wound dressings and 2% mupirocin cream. Clindamycin was the most commonly administered oral antibiotic, while ceftriaxone was administered parenterally. Conclusion The clinical profile of cellulitis and erysipelas in the tertiary referral hospital in West Java, Indonesia, is consistent with findings from other previous studies. Additionally, clindamycin is the most commonly used oral antibiotic for the treatment of cellulitis and erysipelas. cellulitis clinical profile erysipelas INTRODUCTION Cellulitis is an infection that occurs in the deep dermis, subcutaneous tissue, and deep lymphatic system. 1 Skin manifestations of cellulitis appear plaque-like with indistinct edges. 2 Erysipelas is a clinical variant of cellulitis that occurs in the superficial dermis, along with the superficial lymphatic system. Skin manifestations of erysipelas appear as bright red, inflamed, demarcated, firm, and elevated lesions. 1,2 The most common etiologies of cellulitis and erysipelas are Streptococcus pyogenes ( S. pyogenes ) and Staphylococcus aureus ( S. aureus ). 2 Cellulitis is the most common skin and soft tissue infection that requires hospitalization. Over 14 million cases of cellulitis are reported to occur in the US each year. It is responsible for 650,000 hospital admissions and over 3.7 billion dollars in ambulatory care expenses annually. 3 Therefore, cellulitis is included in the group of diseases that are considered global health burdens. 1,3 Erysipelas is a common disease, but the epidemiological sources are still limited and sourced from hospital-based research. Therefore, these sources do not describe the actual epidemiology of erysipelas in the field, as the management of erysipelas can usually be done completely in the primary health care setting. 4 Epidemiological data on cellulitis and erysipelas in Indonesia is still limited. The diagnosis of cellulitis and erysipelas is generally established based on the clinical features, while additional tests such as microbiological examinations usually give questionable or negative results. 1,2 This condition leads to misdiagnosis in more than 30% of cases. A late diagnosis of cellulitis and erysipelas will impede the initiation of therapy, thereby increasing the risk of complications, including potentially threatening sepsis. 2,5 In addition, late diagnosis also leads to high medical costs. 6 Based on the above background, a study describing cellulitis and erysipelas should be conducted to improve the quality of cellulitis and erysipelas management. So far, there have been a lack of studies describing cellulitis and erysipelas in Indonesia. The author was therefore interested in conducting a retrospective study of this cellulitis and erysipelas at the tertiary referral hospital in West Java, Indonesia. METHODS This study was a cross-sectional descriptive-retrospective study. Data were taken from the outpatient and inpatient medical records of cellulitis and erysipelas patients who seek treatment at the tertiary referral hospital in West Java, Indonesia, for a period of three years, starting January 1, 2020 and ending December 31, 2022. This hospital is a referral tertiary hospital in West Java Province, Indonesia. The investigated data included gender, age, nutritional status, risk factors, body temperature, portal of entry, location of skin disorders, accompanying skin lesions, symptoms of sepsis, white blood cell count, Gram staining examination, skin lesion cultures, blood cultures, topical treatment, systemic antibiotics, and surgical intervention. RESULTS During the study period, there were 24 cases of cellulitis and 9 cases of erysipelas at the tertiary referral hospital in West Java, Indonesia. Most cellulitis patients were women (62.5%), with the most prevalent age group being 45–64 years (33.3%). Most cellulitis patients had a normoweight nutritional status (50%). Most of the erysipelas patients were male (55.5%), with the most prevalent age group being above 65 years (33.4%). Most erysipelas patients had underweight (33.4%) and normoweight nutritional status (33.3%). All cases of cellulitis and erysipelas within the study period were the first episodes. The most common risk factors for cellulitis (37.5%) were skin barrier disorders, whereas erysipelas (66.6%) were metabolic diseases. Kidney disease was present in more cases of cellulitis (29.2%) than erysipelas (22.2%). Lymphovascular system disorders occurred in three (12.5%) cellulitis cases and one (11.1%) erysipelas case; the most common cause was deep vein thrombosis (8.3%) in cellulitis cases. Malignancy and connective tissue disease, 8.4%, respectively, were risk factors for cellulitis but not for erysipelas. Conversely, iatrogenic wounds were a risk factor for erysipelas (22.2%) and not for cellulitis. The same clinical manifestations of cellulitis and erysipelas were swelling and increased body temperature (subfebrile and febrile). An increase in body temperature occured in 45.8% of cellulitis patients and 33.3% of erysipelas patients. The most common portal of entry in cellulitis were scratch marks (16.7%), whereas in erysipelas there was no dominant portal of entry. The lower extremities were predilection areas for cellulitis (66.7%) and erysipelas (44.5%). Bullae and/or erosions were the additional skin lesions developed in 29.2% of cellulitis cases and 33.4% of erysipelas cases; suppuration lesions were observed in 20.8% of cellulitis cases and 11.1% of erysipelas cases. A small proportion of cellulitis patients had sepsis (16.7%), and none of the erysipelas patients presented with sepsis. Microscopic examination by Gram stain was performed in 12 (50%) cellulitis patients and four (44.4%) erysipelas patients. Bacteria were found in specimens from 11 (45.8%) cellulitis patients and two (22.2%) erysipelas patients, with Gram-positive cocci as the most prevalent bacteria both in cellulitis (45.8%) and erysipelas (22.2%). In this study, there was only one positive culture (4.2%) of a specimen obtained from an erosion of a cellulitis case that yielded the growth of Klebsiella pneumoniae . An increased white blood count was found in nine (37.4%) cellulitis patients and four (44.5%) erysipelas patients. A blood culture examination was only performed in two (8.3%) cases of cellulitis and one (11.1%) case of erysipelas with negative results. All of the erysipelas and cellulitis patients received normal saline dressing. Wound dressings were done on four (16.7%) cellulitis patients with Cutimed Sorbact ® as the most common wound dressing. Meanwhile, only one (11.1%) erysipelas patient was treated with the application of a wound dressing. About half of cellulitis (50%) and erysipelas (44.4%) cases, which developed additional skin lesions, received topical antibiotic therapy. All cellulitis and erysipelas patients received systemic antibiotic therapy. Clindamycin was the most commonly prescribed oral antibiotic in 13 (54.2%) cellulitis patients and three (33.4%) erysipelas patients. Intravenous antibiotics were given to 13 (54.2%) cellulitis patients and five (55.5%) erysipelas patients, with ceftriaxone as the most commonly prescribed intravenous antibiotic for cellulitis (29.2%), followed by meropenem (22.2%) and ampicillin-sulbactam (22.2%) for erysipelas. Surgical intervention with a drainage incision was only performed in one case of cellulitis (4.2%) and one case of erysipelas (11.1%). A summary of the demographic and clinical profiles of study subjects is shown in Table 1. Table 1 Summary of Demographic and Clinical Profile of Study Subjects Cellulitis Erysipelas Sex Female 15/24 Male 5/9 Age Age 45-64 and >65 >65 Nutritional status Normoweight Underweight and normoweight Risk factor Impaired skin barrier Metabolic disorder Body temperature Elevated in 11/24 patients Elevated in 3/9 patients Portal of entry Skin breaks due to scratching No particular predominance Location Lower extremities Lower extremities Additional lesion Bullae and or erosion in 7/24 patients, suppuration in 5/24 patients Bullae and or erosion in 3/9 patients, suppuration in 1/9 patients Sepsis 4/24 None Leukocyte count Done in 16/24 patient, elevated in 9 patients Done in 5/9 patient, elevated in 4 patients Blood culture Done in 2/24 patient, no microbial growth Done in 1/9 patient, no microbial growth Management Normal saline dressing was given to all cases. Some of the patients who developed additional skin lesions were treated with additional wound dressings or 2% mupirocin cream. Clindamycin was the most commonly administered oral antibiotic, while parenterally was ceftriaxone. DISCUSSION The gender prevalence of cellulitis in this study was in contrast with other study, as Cannon et al., 7 reported a higher incidence of cellulitis in men (58%), and Collazos et al. 5 reported no gender predominance in cellulitis cases. During the three-year period in this current study, the number of erysipelas patients increased every year. In general, no gender prevalence of erysipelas was found. This result favours other previous studies by Blackberg et al. 8 and Kozlowska et al. 9 An explanation regarding the relationship between the incidence of cellulitis and erysipelas 10 and gender was also not known. 8,9 Cellulitis and erysipelas in this study mostly affected older adults above 45 years of age. The finding favours other previous study by Simonsen et al. 11 and Bartholomeeusen et al. 4 In older age, there is often a decline in the function of the skin barrier, the immune system, and the quality of blood vessels and lymphatic channels. Therefore, cellulitis and erysipelas are more common in the elderly. 12 Most cellulitis and erysipelas cases in this study were found on normoweight group of patients, while a study by Harpsoe et al. 13 reported that obesity increased the risk of cellulitis and erysipelas by five times. The high number of cases in normoweight individuals in this current study may be due to various factors other than nutritional status. All cases of cellulitis and erysipelas in this study were first episodes, in contrast with a study by Collazos et al. 5 reported that 25.7% of cases of cellulitis were recurrent. In general, the risk factors for cellulitis and erysipelas are divided into systemic disorders, immune system disorders, circulatory system disorders, and skin barrier integrity disorders. 2 In this study, skin barrier disruption that become the entry point for pathogenic microorganisms 2,12 was found in 37.5% of cellulitis cases, which was the most prevalent risk factor, whereas in erysipelas it was found in 33.3% of cases. Metabolic disease was found in 66.6% of erysipelas cases of this study, that became the most prevalent risk factor for erysipelas, whereas in cellulitis it was found in 25% of cases. The metabolic diseases found in this study were diabetes mellitus (8.3% in cellulitis cases and 44.4% in erysipelas cases) that promotes disturbances in the neutrophil chemotaxis, circulatory system, skin barrier integrity; 12 defects in the lymphovascular system (12.5% in cellulitis cases and 11.1% in erysipelas cases) that reduced tissue perfusion and hypoxia, resulting in a slow inflammatory response, less effective elimination of pathogens, and leads to inhibition of neutrophil recruitment and macrophages to the source of infection; 1,2,12 kidney disease (29.2% cases of cellulitis and 22.2% cases of erysipelas) that underlies impaired skin barrier function such as xerosis cutis (50–90%) and pruritus (12–90%), 14 causing uremia that impairs the innate and adaptive immune systems; 15 hypoalbuminemia (16.7% cases of cellulitis and 44.4% cases of erysipelas) that decreases oncotic pressure, resulting in edema at the skin and connective tissue, facilitating bacterial growth. 1 A total of 8.3% of cellulitis cases in this study were accompanied by malignancy, i.e., cervical carcinoma (4.2%) and myelodysplasia syndrome (4.2%). In the study by Cannon et al., 7 malignancy was reported in 4.3% of cellulitis patients, and the study by Concheiro et al. 16 also reported malignancy in 11.5% of cellulitis and erysipelas cases. Malignancy increases the susceptibility to cellulitis and erysipelas by 1.9 times due to the immunodeficiency state. 7 In this study, 8.3% of cellulitis cases were accompanied by systemic lupus erythematosus (SLE). Cellulitis is one of the most common infections in SLE that impairs in the chemotaxis and phagocytic activity of neutrophils and macrophages. 17 Iatrogenic wounds caused by intravenous administration were reported as a risk factor in 22.2% of erysipelas cases in this study. This procedure creates a disrupted skin barrier that is vulnerable and becomes a gateway for microorganisms and cellulitis-causing pathogens. 2,12 From the results of this study, it was known that an increase in body temperature occurs in 45.8% of cellulitis cases and 33.3% of erysipelas cases, similar to the study by Rositawati and Sawitri. 18 Most of the portals of entry in cellulitis cases in this study were scratching (16.7%), whereas in erysipelas there was no predominant portal of entry found. A study by Rositawati and Sawitri also reported scratch marks as the portal of entry in 20.7% of cellulitis cases and 35.7% of erysipelas cases. 18 Scratching triggers inflammation and causes mechanical damage to the skin barrier. 2 In this study, the lower extremity was the most common predilection, both in cellulitis (66.7%) and erysipelas (44.4%). Similar results were obtained in studies by Rositawati and Sawitri, 18 Collazos et al., 5 and Concheiro et al. 16 Fissures and maceration are likely to occur between the toes. Humid conditions in these areas support the growth of pathogenic microorganisms. 19 There were accompanying skin lesions of bullae and/or erosions in 29.2% of cellulitis cases and 33.4% of erysipelas cases in recent study. Inflammation triggered by bacterial superantigens can cause severe intraepidemal spongiosis, resulting in bullae formation. 20 S. aureus is one of the main etiologies of cellulitis and erysipelas produce exfoliating toxins that also induce bullae formation. 21 Suppuration as the body's defence mechanism to limit the spread of S. aureus infection to the surrounding tissue 22 occurred in 20.8% of cellulitis cases and 11.1% of erysipelas cases in this study. A study by Concheiro et al. 16 reported that abscess formation was the most common skin lesion accompanying cellulitis and erysipelas (7.4%). An increase in the number of white blood cells was found in 37.4% of cases of cellulitis and 44.4% of cases of erysipelas in this study, in accordance with several other studies that reported increased white blood count in 34–50% of patients with cellulitis and erysipelas. 24 Sepsis is a serious complication of cellulitis and erysipelas. 19 In this study, a small portion of cellulitis cases (16.7%) had sepsis, and no erysipelas patients developed sepsis. This result was similar with a study by Collazos et al., 5 which reported that 10.7% of cellulitis cases developed sepsis. Culture of skin lesion specimens was performed in one (4.2%) case of cellulitis in this study with Klebsiella pneumoniae growth. The organism is an opportunistic pathogen in individuals with immunocompromised condition, commonly results in cellulitis due to a spread from other organs. 23 Blood cultures were performed in 8.3% of cellulitis cases that yielded no growth. Only 7% of blood culture results were positive, compared with 37.9% of skin lesion cultures in a study by Kielhofner et al. 24 Hence, culture examination is not recommended routinely for cellulitis and erysipelas, unless for severe cases and individuals who have failed with oral systemic antibiotics or have a fever, a heart rate greater than 90 x/minute, a respiratory rate greater than 24 x/minute, a leukocyte count greater than 12,000 or less than 400 cells/µL, are experiencing clinical signs of infection in the tissue such as the appearance of bullae, skin sloughing, hypotension, or organ dysfunction, immunocompromised individuals, elderly individuals with acute onset of disease, or have experienced skin trauma due to animal bites. 25 All patients with cellulitis (100%) and erysipelas (100%) in this study received normal saline dressing to reduce edema and pain. 26 Application of wound dressing was given to 16.7% of cellulitis patients and 11.1% of erysipelas patients with bullae and/or erosions. The most common wound dressing used in this study was Cutimed Sorbact®. In this study, topical mupirocin cream 2% were given in some cases of cellulitis (50%) and erysipelas (44.4%) with bullae, erosion, and suppuration lesions. Systemic antibiotic therapy was administered to all cases of cellulitis and erysipelas in this study, in accordance with the international guidelines for the management of cellulitis and erysipelas. 19 In this study, oral antibiotics were given as initial therapy in 70.8% of cellulitis cases and 44.4% of erysipelas cases, whereas intravenous antibiotics were given as initial therapy in 29.2% of cellulitis cases and 55.5% of erysipelas cases. Intravenous antibiotic initiation was administered for moderate and severe cases of cellulitis and erysipelas as recommended by the Infectious Diseases Society of America (IDSA). 19 Recommended first-line antibiotics for mild and nonpurulent cellulitis with methicillin-sensitive S. aureus (MSSA) etiology are cephalexin or oral dicloxacillin. 2 However, these antibiotics are difficult to obtain in Indonesia, thus oral clindamycin was chosen as a substitute for this antibiotic. Clindamycin is an alternative antibiotic recommended for mild and moderate nonpurulent cellulitis and mild purulent cellulitis with MSSA etiology, as well as the main antibiotic recommended for mild and moderate purulent cellulitis with MRSA etiology. 2,19 Frequently administered intravenous antibiotics in this study were ceftriaxone (24,2% cases of cellulitis and erysipelas), ampicillin-sulbactam (18,2% cases of cellulitis and erysipelas), and meropenem (12% cases of cellulitis and erysipelas). Ceftriaxone is the first-line intravenous antibiotic recommended for moderate nonpurulent cellulitis. 2 Meropenem is also recommended as an empiric antibiotic in severe cellulitis and erysipelas. Ampicillin-sulbactam is commonly administered in combination with other antibiotics to broaden the antimicrobial spectrum for MRSA and Gram-negative rods. 19 There were 20.8% of cellulitis cases and 33.3% of erysipelas cases in this study that developed a poor therapeutic response leading to a change in therapy from the initial regimen. The condition can be caused by resistance microorganisms, other diseases that mimic cellulitis, or underlying conditions such as immunodeficiency. 1 Cellulitis and erysipelas in immunodeficiency individuals often caused by atypical microorganisms that are resistant to first-line therapeutic regimens. 27 Surgery was performed on a small proportion of cellulitis cases (4.2%) and erysipelas (11.1%) in recent study, in accordance with the study by Collazos et al. 5 Incision was performed in cases with abscess formation, as it is the main intervention for abscesses. 28 The limitation of this study is due to incomplete data in the medical record. This study provides an overview of the clinical profile of patients with cellulitis and erysipelas in West Java, as the data is still lacking. An analytical study regarding the relationship between the various factors that have been observed in this study and the incidence of cellulitis or erysipelas needs to be carried out in the future. CONCLUSION The clinical profile of cellulitis and erysipelas in this study is consistent with findings from other previous studies. Additionally, clindamycin is the most commonly used oral antibiotic for the treatment of cellulitis and erysipelas. This study provides a review of the current situation of cellulitis and erysipelas in West Java, Indonesia regarding the clinical profile and treatment, which may help improve the future management of these diseases. Declarations FUNDING The authors received no specific funding for this work. Open access funding provided by University of Padjadjaran. CONFLICT OF INTEREST The author reports no conflicts of interest in this work. ETHICS APPROVAL AND CONSENT TO PARTICIPATE This study had obtained ethical clearance from the Research Ethics Committee of Padjadjaran University No. DP.04.03/D.XIV.6.5/41/2024. The authors certify that have obtained all appropriate patient consent forms. AVAILABILITY OF DATA AND MATERIAL Data supporting this study’s findings are available from the corresponding author upon reasonable request. CONSENT FOR PUBLICATION The authors certify that have obtained all appropriate patient consent forms. AUTHORS’ CONTRIBUTION Hendra Gunawan: HG. Stephanie Widjaja: SW. HG and SW wrote the main manuscript text and prepare Table 1. HG is the supervisor of SW. ACKNOWLEDGEMENT The authors would like to thank the staff of Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia. References Raff AB, Kroshinsky D. Cellulitis: A review. Jama. 2016;316(3):325-37. Pearson DR, Margolis DJ. Cellulitis and erysipelas. Dalam: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, et al., penyunting. Fitzpatrick’s dermatology. New York: McGraw Hill Education; 2019. hlm. 2758-69. Brown BD, Hood Watson KL. Cellulitis. Statpearls. 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Influence of underlying disease process on the utility of cellulitis needle aspirates. Arch Intern Med. 1988;148(11):2451-2. Bailey E, Kroshinsky D. Cellulitis: Diagnosis and management. Dermatol Ther. 2011;24(2):229-39. Singh R, Sreenivasa P. Comparison between dressing of cellulitis with normal saline and magnesium sulphate. International Surgery Journal. 2018;5. Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: Part i. Lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):163.e1-12; quiz 75-6. Breen JO. Skin and soft tissue infections in immunocompetent patients. Am Fam Physician. 2010;81(7):893-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4250982","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":291119480,"identity":"1417723f-24c7-4e61-9a7d-c144cd370ce4","order_by":0,"name":"Hendra Gunawan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBACAziLvbHhwIcKhCAPwwFCWngOHzw44wxJWiTSkg9ztiEL4tBizsB+Tbqg5rC8OUOOwWHGeYfzzNkPb2D4UcMgw4dDi2UDT5n0jGOHDXc2nDE4XLjtcLFlT1oBY88xBh5JXA47wJMmzcN2m3HDwR6DwzO3HU7ccCDHgIG3gYHHAK+Wf7ftNxzmMTjMOweo5fwbA8a/eLWwH5PmbbuduOEYW8Jh3gaglhs5Bsx4bTnMw2zN2/c/ecMZ5gMHZxxLT9w541nBYZljErj9crz94W2eb2m2G+4/bP7wocY6cTt/8saHb2ps7HGFGAMzjwGqAIgLVCyBQz0IsD/A1DIKRsEoGAWjABkAABFBaA9+GQGFAAAAAElFTkSuQmCC","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Hendra","middleName":"","lastName":"Gunawan","suffix":""},{"id":291119481,"identity":"d549aac3-2deb-4c6a-8bc0-4b35acd2f45a","order_by":1,"name":"Reti Hindritiani","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Reti","middleName":"","lastName":"Hindritiani","suffix":""},{"id":291119482,"identity":"8729a35a-df07-495a-854e-68f2e07575fa","order_by":2,"name":"Hartati Purbo Dharmadji","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Hartati","middleName":"Purbo","lastName":"Dharmadji","suffix":""},{"id":291119483,"identity":"854862bd-d4ad-4de2-aca7-a6ba2c75bf8a","order_by":3,"name":"Oki Suwarsa","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Oki","middleName":"","lastName":"Suwarsa","suffix":""},{"id":291119484,"identity":"1f632cd9-9b76-4872-8485-cbf5ba5fecb3","order_by":4,"name":"Stephanie Widjaja","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Widjaja","suffix":""}],"badges":[],"createdAt":"2024-04-11 07:56:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4250982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4250982/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63543392,"identity":"541b6cc1-5c2f-4a46-b576-911419c9130a","added_by":"auto","created_at":"2024-08-29 10:46:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":315488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4250982/v1/f27debd9-a02d-46b5-96a9-23f307a74b2d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eClinical Profile of Cellulitis and Erysipelas in the Tertiary Referral Hospital of West Java, Indonesia\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCellulitis is an infection that occurs in the deep dermis, subcutaneous tissue, and deep lymphatic system.\u003csup\u003e1\u003c/sup\u003e Skin manifestations of cellulitis appear plaque-like with indistinct edges.\u003csup\u003e2\u003c/sup\u003e Erysipelas is a clinical variant of cellulitis that occurs in the superficial dermis, along with the superficial lymphatic system. Skin manifestations of erysipelas appear as bright red, inflamed, demarcated, firm, and elevated lesions.\u003csup\u003e1,2\u003c/sup\u003e The most common etiologies of cellulitis and erysipelas are \u003cem\u003eStreptococcus pyogenes\u003c/em\u003e (\u003cem\u003eS. pyogenes\u003c/em\u003e) and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (\u003cem\u003eS. aureus\u003c/em\u003e).\u003csup\u003e2\u003c/sup\u003e Cellulitis is the most common skin and soft tissue infection that requires hospitalization. Over 14\u0026nbsp;million cases of cellulitis are reported to occur in the US each year. It is responsible for 650,000 hospital admissions and over 3.7\u0026nbsp;billion dollars in ambulatory care expenses annually.\u003csup\u003e3\u003c/sup\u003e Therefore, cellulitis is included in the group of diseases that are considered global health burdens.\u003csup\u003e1,3\u003c/sup\u003e Erysipelas is a common disease, but the epidemiological sources are still limited and sourced from hospital-based research. Therefore, these sources do not describe the actual epidemiology of erysipelas in the field, as the management of erysipelas can usually be done completely in the primary health care setting.\u003csup\u003e4\u003c/sup\u003e Epidemiological data on cellulitis and erysipelas in Indonesia is still limited.\u003c/p\u003e \u003cp\u003eThe diagnosis of cellulitis and erysipelas is generally established based on the clinical features, while additional tests such as microbiological examinations usually give questionable or negative results.\u003csup\u003e1,2\u003c/sup\u003e This condition leads to misdiagnosis in more than 30% of cases. A late diagnosis of cellulitis and erysipelas will impede the initiation of therapy, thereby increasing the risk of complications, including potentially threatening sepsis.\u003csup\u003e2,5\u003c/sup\u003e In addition, late diagnosis also leads to high medical costs.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBased on the above background, a study describing cellulitis and erysipelas should be conducted to improve the quality of cellulitis and erysipelas management. So far, there have been a lack of studies describing cellulitis and erysipelas in Indonesia. The author was therefore interested in conducting a retrospective study of this cellulitis and erysipelas at the tertiary referral hospital in West Java, Indonesia.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study was a cross-sectional descriptive-retrospective study. Data were taken from the outpatient and inpatient medical records of cellulitis and erysipelas patients who seek treatment at the tertiary referral hospital in West Java, Indonesia, for a period of three years, starting January 1, 2020 and ending December 31, 2022. This hospital is a referral tertiary hospital in West Java Province, Indonesia. The investigated data included gender, age, nutritional status, risk factors, body temperature, portal of entry, location of skin disorders, accompanying skin lesions, symptoms of sepsis, white blood cell count, Gram staining examination, skin lesion cultures, blood cultures, topical treatment, systemic antibiotics, and surgical intervention.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDuring the study period, there were 24 cases of cellulitis and 9 cases of erysipelas at the tertiary referral hospital in West Java, Indonesia. Most cellulitis patients were women (62.5%), with the most prevalent age group being 45\u0026ndash;64 years (33.3%). Most cellulitis patients had a normoweight nutritional status (50%). Most of the erysipelas patients were male (55.5%), with the most prevalent age group being above 65 years (33.4%). Most erysipelas patients had underweight (33.4%) and normoweight nutritional status (33.3%). All cases of cellulitis and erysipelas within the study period were the first episodes.\u003c/p\u003e\n\u003cp\u003eThe most common risk factors for cellulitis (37.5%) were skin barrier disorders, whereas erysipelas (66.6%) were metabolic diseases. Kidney disease was present in more cases of cellulitis (29.2%) than erysipelas (22.2%). Lymphovascular system disorders occurred in three (12.5%) cellulitis cases and one (11.1%) erysipelas case; the most common cause was deep vein thrombosis (8.3%) in cellulitis cases. Malignancy and connective tissue disease, 8.4%, respectively, were risk factors for cellulitis but not for erysipelas. Conversely, iatrogenic wounds were a risk factor for erysipelas (22.2%) and not for cellulitis.\u003c/p\u003e\n\u003cp\u003eThe same clinical manifestations of cellulitis and erysipelas were swelling and increased body temperature (subfebrile and febrile). An increase in body temperature occured in 45.8% of cellulitis patients and 33.3% of erysipelas patients. The most common portal of entry in cellulitis were scratch marks (16.7%), whereas in erysipelas there was no dominant portal of entry. The lower extremities were predilection areas for cellulitis (66.7%) and erysipelas (44.5%). Bullae and/or erosions were the additional skin lesions developed in 29.2% of cellulitis cases and 33.4% of erysipelas cases; suppuration lesions were observed in 20.8% of cellulitis cases and 11.1% of erysipelas cases. A small proportion of cellulitis patients had sepsis (16.7%), and none of the erysipelas patients presented with sepsis.\u003c/p\u003e\n\u003cp\u003eMicroscopic examination by Gram stain was performed in 12 (50%) cellulitis patients and four (44.4%) erysipelas patients. Bacteria were found in specimens from 11 (45.8%) cellulitis patients and two (22.2%) erysipelas patients, with Gram-positive cocci as the most prevalent bacteria both in cellulitis (45.8%) and erysipelas (22.2%). In this study, there was only one positive culture (4.2%) of a specimen obtained from an erosion of a cellulitis case that yielded the growth of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e. An increased white blood count was found in nine (37.4%) cellulitis patients and four (44.5%) erysipelas patients. A blood culture examination was only performed in two (8.3%) cases of cellulitis and one (11.1%) case of erysipelas with negative results.\u003c/p\u003e\n\u003cp\u003eAll of the erysipelas and cellulitis patients received normal saline dressing. Wound dressings were done on four (16.7%) cellulitis patients with Cutimed Sorbact\u003csup\u003e\u0026reg;\u003c/sup\u003e as the most common wound dressing. Meanwhile, only one (11.1%) erysipelas patient was treated with the application of a wound dressing. About half of cellulitis (50%) and erysipelas (44.4%) cases, which developed additional skin lesions, received topical antibiotic therapy. All cellulitis and erysipelas patients received systemic antibiotic therapy. Clindamycin was the most commonly prescribed oral antibiotic in 13 (54.2%) cellulitis patients and three (33.4%) erysipelas patients. Intravenous antibiotics were given to 13 (54.2%) cellulitis patients and five (55.5%) erysipelas patients, with ceftriaxone as the most commonly prescribed intravenous antibiotic for cellulitis (29.2%), followed by meropenem (22.2%) and ampicillin-sulbactam (22.2%) for erysipelas. Surgical intervention with a drainage incision was only performed in one case of cellulitis (4.2%) and one case of erysipelas (11.1%). A summary of the demographic and clinical profiles of study subjects is shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eSummary of Demographic and Clinical Profile of Study Subjects\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eCellulitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eErysipelas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eFemale 15/24\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eMale 5/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eAge 45-64 and \u0026gt;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eNutritional status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eNormoweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eUnderweight and normoweight\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eRisk factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eImpaired skin barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eMetabolic disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eBody temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eElevated in 11/24 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eElevated in 3/9 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003ePortal of entry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eSkin breaks due to scratching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eNo particular predominance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eLower extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eLower extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eAdditional lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eBullae and or erosion in 7/24 patients, suppuration in 5/24 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eBullae and or erosion in 3/9 patients, suppuration in 1/9 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e4/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eLeukocyte count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eDone in 16/24 patient, elevated in 9 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eDone in 5/9 patient, elevated in 4 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eBlood culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.26455906821963%\" valign=\"top\"\u003e\n \u003cp\u003eDone in 2/24 patient, no microbial growth\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.93344425956739%\" valign=\"top\"\u003e\n \u003cp\u003eDone in 1/9 patient, no microbial growth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eManagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.19800332778702%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNormal saline\u0026nbsp;dressing\u0026nbsp;was given to all cases.\u003c/li\u003e\n \u003cli\u003eSome of the patients who developed additional skin lesions were treated with additional wound dressings or 2% mupirocin cream.\u003c/li\u003e\n \u003cli\u003eClindamycin was the most commonly administered oral antibiotic, while parenterally was ceftriaxone.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe gender prevalence of cellulitis in this study was in contrast with other study, as Cannon et al.,\u003csup\u003e7\u003c/sup\u003e reported a higher incidence of cellulitis in men (58%), and Collazos et al.\u003csup\u003e5\u003c/sup\u003e reported no gender predominance in cellulitis cases. During the three-year period in this current study, the number of erysipelas patients increased every year. In general, no gender prevalence of erysipelas was found. This result favours other previous studies by Blackberg et al.\u003csup\u003e8\u003c/sup\u003e and Kozlowska et al.\u003csup\u003e9\u003c/sup\u003e An explanation regarding the relationship between the incidence of cellulitis and erysipelas\u003csup\u003e10\u003c/sup\u003e and gender was also not known.\u003csup\u003e8,9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCellulitis and erysipelas in this study mostly affected older adults above 45 years of age. The finding favours other previous study by Simonsen et al.\u003csup\u003e11\u003c/sup\u003e and Bartholomeeusen et al.\u003csup\u003e4\u003c/sup\u003e In older age, there is often a decline in the function of the skin barrier, the immune system, and the quality of blood vessels and lymphatic channels. Therefore, cellulitis and erysipelas are more common in the elderly.\u003csup\u003e12\u003c/sup\u003e Most cellulitis and erysipelas cases in this study were found on normoweight group of patients, while a study by Harpsoe et al.\u003csup\u003e13\u003c/sup\u003e reported that obesity increased the risk of cellulitis and erysipelas by five times. The high number of cases in normoweight individuals in this current study may be due to various factors other than nutritional status. All cases of cellulitis and erysipelas in this study were first episodes, in contrast with a study by Collazos et al.\u003csup\u003e5\u003c/sup\u003e reported that 25.7% of cases of cellulitis were recurrent.\u003c/p\u003e \u003cp\u003eIn general, the risk factors for cellulitis and erysipelas are divided into systemic disorders, immune system disorders, circulatory system disorders, and skin barrier integrity disorders.\u003csup\u003e2\u003c/sup\u003e In this study, skin barrier disruption that become the entry point for pathogenic microorganisms\u003csup\u003e2,12\u003c/sup\u003e was found in 37.5% of cellulitis cases, which was the most prevalent risk factor, whereas in erysipelas it was found in 33.3% of cases. Metabolic disease was found in 66.6% of erysipelas cases of this study, that became the most prevalent risk factor for erysipelas, whereas in cellulitis it was found in 25% of cases.\u003c/p\u003e \u003cp\u003eThe metabolic diseases found in this study were diabetes mellitus (8.3% in cellulitis cases and 44.4% in erysipelas cases) that promotes disturbances in the neutrophil chemotaxis, circulatory system, skin barrier integrity;\u003csup\u003e12\u003c/sup\u003e defects in the lymphovascular system (12.5% in cellulitis cases and 11.1% in erysipelas cases) that reduced tissue perfusion and hypoxia, resulting in a slow inflammatory response, less effective elimination of pathogens, and leads to inhibition of neutrophil recruitment and macrophages to the source of infection;\u003csup\u003e1,2,12\u003c/sup\u003e kidney disease (29.2% cases of cellulitis and 22.2% cases of erysipelas) that underlies impaired skin barrier function such as xerosis cutis (50\u0026ndash;90%) and pruritus (12\u0026ndash;90%),\u003csup\u003e14\u003c/sup\u003e causing uremia that impairs the innate and adaptive immune systems;\u003csup\u003e15\u003c/sup\u003e hypoalbuminemia (16.7% cases of cellulitis and 44.4% cases of erysipelas) that decreases oncotic pressure, resulting in edema at the skin and connective tissue, facilitating bacterial growth.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA total of 8.3% of cellulitis cases in this study were accompanied by malignancy, i.e., cervical carcinoma (4.2%) and myelodysplasia syndrome (4.2%). In the study by Cannon et al.,\u003csup\u003e7\u003c/sup\u003e malignancy was reported in 4.3% of cellulitis patients, and the study by Concheiro et al.\u003csup\u003e16\u003c/sup\u003e also reported malignancy in 11.5% of cellulitis and erysipelas cases. Malignancy increases the susceptibility to cellulitis and erysipelas by 1.9 times due to the immunodeficiency state.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, 8.3% of cellulitis cases were accompanied by systemic lupus erythematosus (SLE). Cellulitis is one of the most common infections in SLE that impairs in the chemotaxis and phagocytic activity of neutrophils and macrophages.\u003csup\u003e17\u003c/sup\u003e Iatrogenic wounds caused by intravenous administration were reported as a risk factor in 22.2% of erysipelas cases in this study. This procedure creates a disrupted skin barrier that is vulnerable and becomes a gateway for microorganisms and cellulitis-causing pathogens.\u003csup\u003e2,12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrom the results of this study, it was known that an increase in body temperature occurs in 45.8% of cellulitis cases and 33.3% of erysipelas cases, similar to the study by Rositawati and Sawitri.\u003csup\u003e18\u003c/sup\u003e Most of the portals of entry in cellulitis cases in this study were scratching (16.7%), whereas in erysipelas there was no predominant portal of entry found. A study by Rositawati and Sawitri also reported scratch marks as the portal of entry in 20.7% of cellulitis cases and 35.7% of erysipelas cases.\u003csup\u003e18\u003c/sup\u003e Scratching triggers inflammation and causes mechanical damage to the skin barrier.\u003csup\u003e2\u003c/sup\u003e In this study, the lower extremity was the most common predilection, both in cellulitis (66.7%) and erysipelas (44.4%). Similar results were obtained in studies by Rositawati and Sawitri,\u003csup\u003e18\u003c/sup\u003e Collazos et al.,\u003csup\u003e5\u003c/sup\u003e and Concheiro et al.\u003csup\u003e16\u003c/sup\u003e Fissures and maceration are likely to occur between the toes. Humid conditions in these areas support the growth of pathogenic microorganisms.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere were accompanying skin lesions of bullae and/or erosions in 29.2% of cellulitis cases and 33.4% of erysipelas cases in recent study. Inflammation triggered by bacterial superantigens can cause severe intraepidemal spongiosis, resulting in bullae formation.\u003csup\u003e20\u003c/sup\u003e \u003cem\u003eS. aureus\u003c/em\u003e is one of the main etiologies of cellulitis and erysipelas produce exfoliating toxins that also induce bullae formation.\u003csup\u003e21\u003c/sup\u003e Suppuration as the body's defence mechanism to limit the spread of \u003cem\u003eS. aureus\u003c/em\u003e infection to the surrounding tissue\u003csup\u003e22\u003c/sup\u003e occurred in 20.8% of cellulitis cases and 11.1% of erysipelas cases in this study. A study by Concheiro et al.\u003csup\u003e16\u003c/sup\u003e reported that abscess formation was the most common skin lesion accompanying cellulitis and erysipelas (7.4%).\u003c/p\u003e \u003cp\u003eAn increase in the number of white blood cells was found in 37.4% of cases of cellulitis and 44.4% of cases of erysipelas in this study, in accordance with several other studies that reported increased white blood count in 34\u0026ndash;50% of patients with cellulitis and erysipelas.\u003csup\u003e24\u003c/sup\u003e Sepsis is a serious complication of cellulitis and erysipelas.\u003csup\u003e19\u003c/sup\u003e In this study, a small portion of cellulitis cases (16.7%) had sepsis, and no erysipelas patients developed sepsis. This result was similar with a study by Collazos et al.,\u003csup\u003e5\u003c/sup\u003e which reported that 10.7% of cellulitis cases developed sepsis.\u003c/p\u003e \u003cp\u003eCulture of skin lesion specimens was performed in one (4.2%) case of cellulitis in this study with \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e growth. The organism is an opportunistic pathogen in individuals with immunocompromised condition, commonly results in cellulitis due to a spread from other organs.\u003csup\u003e23\u003c/sup\u003e Blood cultures were performed in 8.3% of cellulitis cases that yielded no growth. Only 7% of blood culture results were positive, compared with 37.9% of skin lesion cultures in a study by Kielhofner et al.\u003csup\u003e24\u003c/sup\u003e Hence, culture examination is not recommended routinely for cellulitis and erysipelas, unless for severe cases and individuals who have failed with oral systemic antibiotics or have a fever, a heart rate greater than 90 x/minute, a respiratory rate greater than 24 x/minute, a leukocyte count greater than 12,000 or less than 400 cells/\u0026micro;L, are experiencing clinical signs of infection in the tissue such as the appearance of bullae, skin sloughing, hypotension, or organ dysfunction, immunocompromised individuals, elderly individuals with acute onset of disease, or have experienced skin trauma due to animal bites.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAll patients with cellulitis (100%) and erysipelas (100%) in this study received normal saline dressing to reduce edema and pain.\u003csup\u003e26\u003c/sup\u003e Application of wound dressing was given to 16.7% of cellulitis patients and 11.1% of erysipelas patients with bullae and/or erosions. The most common wound dressing used in this study was Cutimed Sorbact\u0026reg;. In this study, topical mupirocin cream 2% were given in some cases of cellulitis (50%) and erysipelas (44.4%) with bullae, erosion, and suppuration lesions.\u003c/p\u003e \u003cp\u003eSystemic antibiotic therapy was administered to all cases of cellulitis and erysipelas in this study, in accordance with the international guidelines for the management of cellulitis and erysipelas.\u003csup\u003e19\u003c/sup\u003e In this study, oral antibiotics were given as initial therapy in 70.8% of cellulitis cases and 44.4% of erysipelas cases, whereas intravenous antibiotics were given as initial therapy in 29.2% of cellulitis cases and 55.5% of erysipelas cases. Intravenous antibiotic initiation was administered for moderate and severe cases of cellulitis and erysipelas as recommended by the Infectious Diseases Society of America (IDSA).\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRecommended first-line antibiotics for mild and nonpurulent cellulitis with methicillin-sensitive \u003cem\u003eS. aureus\u003c/em\u003e (MSSA) etiology are cephalexin or oral dicloxacillin.\u003csup\u003e2\u003c/sup\u003e However, these antibiotics are difficult to obtain in Indonesia, thus oral clindamycin was chosen as a substitute for this antibiotic. Clindamycin is an alternative antibiotic recommended for mild and moderate nonpurulent cellulitis and mild purulent cellulitis with MSSA etiology, as well as the main antibiotic recommended for mild and moderate purulent cellulitis with MRSA etiology.\u003csup\u003e2,19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrequently administered intravenous antibiotics in this study were ceftriaxone (24,2% cases of cellulitis and erysipelas), ampicillin-sulbactam (18,2% cases of cellulitis and erysipelas), and meropenem (12% cases of cellulitis and erysipelas). Ceftriaxone is the first-line intravenous antibiotic recommended for moderate nonpurulent cellulitis.\u003csup\u003e2\u003c/sup\u003e Meropenem is also recommended as an empiric antibiotic in severe cellulitis and erysipelas. Ampicillin-sulbactam is commonly administered in combination with other antibiotics to broaden the antimicrobial spectrum for MRSA and Gram-negative rods.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere were 20.8% of cellulitis cases and 33.3% of erysipelas cases in this study that developed a poor therapeutic response leading to a change in therapy from the initial regimen. The condition can be caused by resistance microorganisms, other diseases that mimic cellulitis, or underlying conditions such as immunodeficiency.\u003csup\u003e1\u003c/sup\u003e Cellulitis and erysipelas in immunodeficiency individuals often caused by atypical microorganisms that are resistant to first-line therapeutic regimens.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSurgery was performed on a small proportion of cellulitis cases (4.2%) and erysipelas (11.1%) in recent study, in accordance with the study by Collazos et al.\u003csup\u003e5\u003c/sup\u003e Incision was performed in cases with abscess formation, as it is the main intervention for abscesses.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe limitation of this study is due to incomplete data in the medical record. This study provides an overview of the clinical profile of patients with cellulitis and erysipelas in West Java, as the data is still lacking. An analytical study regarding the relationship between the various factors that have been observed in this study and the incidence of cellulitis or erysipelas needs to be carried out in the future.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe clinical profile of cellulitis and erysipelas in this study is consistent with findings from other previous studies. Additionally, clindamycin is the most commonly used oral antibiotic for the treatment of cellulitis and erysipelas. This study provides a review of the current situation of cellulitis and erysipelas in West Java, Indonesia regarding the clinical profile and treatment, which may help improve the future management of these diseases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work. Open access funding provided by University of Padjadjaran.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author reports no conflicts of interest in this work.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study had obtained ethical clearance from the Research Ethics Committee of Padjadjaran University No. DP.04.03/D.XIV.6.5/41/2024. The authors certify that have obtained all appropriate patient consent forms.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIAL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting this study\u0026rsquo;s findings are available from the corresponding author upon reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that have obtained all appropriate patient consent forms. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS\u0026rsquo; CONTRIBUTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHendra Gunawan: HG. Stephanie Widjaja: SW. HG and SW wrote the main manuscript text and prepare Table 1. HG is the supervisor of SW.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the staff of Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran \u0026ndash; Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRaff AB, Kroshinsky D. Cellulitis: A review. Jama. 2016;316(3):325-37.\u003c/li\u003e\n\u003cli\u003ePearson DR, Margolis DJ. Cellulitis and erysipelas. Dalam: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, et al., penyunting. Fitzpatrick\u0026rsquo;s dermatology. New York: McGraw Hill Education; 2019. hlm. 2758-69.\u003c/li\u003e\n\u003cli\u003eBrown BD, Hood Watson KL. Cellulitis. Statpearls. Treasure Island (FL): StatPearls Publishing; 2023.\u003c/li\u003e\n\u003cli\u003eBartholomeeusen S, Vandenbroucke J, Truyers C, Buntinx F. Epidemiology and comorbidity of erysipelas in primary care. Dermatology. 2007;215(2):118-22.\u003c/li\u003e\n\u003cli\u003eCollazos J, de la Fuente B, Garc\u0026iacute;a A, G\u0026oacute;mez H, Men\u0026eacute;ndez C, Enr\u0026iacute;quez H, dkk. Cellulitis in adult patients: A large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment. PLoS One. 2018;13(9):e0204036.\u003c/li\u003e\n\u003cli\u003eRaff AB, Weng QY, Cohen JM, Gunasekera N, Okhovat J-P, Vedak P, dkk. A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study. Journal of the American Academy of Dermatology. 2017;76(4):618-25.e2.\u003c/li\u003e\n\u003cli\u003eCannon J, Rajakaruna G, Dyer J, Carapetis J, Manning L. Severe lower limb cellulitis: Defining the epidemiology and risk factors for primary episodes in a population-based case-control study. Clin Microbiol Infect. 2018;24(10):1089-94.\u003c/li\u003e\n\u003cli\u003eBl\u0026auml;ckberg A, Trell K, Rasmussen M. Erysipelas, a large retrospective study of aetiology and clinical presentation. BMC Infectious Diseases. 2015;15(1):402.\u003c/li\u003e\n\u003cli\u003eKozłowska D, Myśliwiec H, Kiluk P, Baran A, Milewska AJ, Flisiak I. Clinical and epidemiological assessment of patients hospitalized for primary and recurrent erysipelas. Przegl Epidemiol. 2016;70(4):575-84.\u003c/li\u003e\n\u003cli\u003eCollazos J, de la Fuente B, de la Fuente J, Garc\u0026iacute;a A, G\u0026oacute;mez H, Rivas-Carmenado M, dkk. Sex differences in hospitalized adult patients with cellulitis: A prospective, multicenter study. Int J Infect Dis. 2021;104:584-91.\u003c/li\u003e\n\u003cli\u003eEllis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, dkk. Cellulitis incidence in a defined population. Epidemiol Infect. 2006;134(2):293-9.\u003c/li\u003e\n\u003cli\u003eCranendonk DR, Lavrijsen APM, Prins JM, Wiersinga WJ. Cellulitis: Current insights into pathophysiology and clinical management. Neth J Med. 2017;75(9):366-78.\u003c/li\u003e\n\u003cli\u003eHarps\u0026oslash;e MC, Nielsen NM, Friis-M\u0026oslash;ller N, Andersson M, Wohlfahrt J, Linneberg A, dkk. Body mass index and risk of infections among women in the danish national birth cohort. Am J Epidemiol. 2016;183(11):1008-17.\u003c/li\u003e\n\u003cli\u003eVan de Velde-Kossmann KM. Skin examination: An important diagnostic tool in renal failure patients. Blood Purif. 2018;45(1-3):187-93.\u003c/li\u003e\n\u003cli\u003eKato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y, dkk. Aspects of immune dysfunction in end-stage renal disease. Clin J Am Soc Nephrol. 2008;3(5):1526-33.\u003c/li\u003e\n\u003cli\u003eConcheiro J, Loureiro M, Gonz\u0026aacute;lez-Vilas D, Garc\u0026iacute;a-Gav\u0026iacute;n J, S\u0026aacute;nchez-Aguilar D, Toribio J. Erysipelas and cellulitis: A retrospective study of 122 cases. Actas Dermo-Sifiliogr\u0026aacute;ficas (English Edition). 2009;100(10):888-94.\u003c/li\u003e\n\u003cli\u003eFessler BJ. Infectious diseases in systemic lupus erythematosus: Risk factors, management and prophylaxis. Best Pract Res Clin Rheumatol. 2002;16(2):281-91.\u003c/li\u003e\n\u003cli\u003eRositawati A, Sawitri S. A retrospective study: Erysipelas and cellulitis patients\u0026rsquo; profile. Berkala Ilmu Kesehatan Kulit Dan Kelamin. 2016;28:137-45.\u003c/li\u003e\n\u003cli\u003eStevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, dkk. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406.\u003c/li\u003e\n\u003cli\u003eGuberman D, Gilead LT, Zlotogorski A, Schamroth J. Bullous erysipelas: A retrospective study of 26 patients. J Am Acad Dermatol. 1999;41(5 Pt 1):733-7.\u003c/li\u003e\n\u003cli\u003eTravers JB. Gram-positive infections associated with toxin production. Dalam: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, et al., penyunting. Fitzpatrick\u0026rsquo;s dermatology. New York: McGraw Hill Education; 2019. hlm. 2756-69.\u003c/li\u003e\n\u003cli\u003ePitch\u0026eacute; PV, Saka B, Diatta AB, Faye O, Dian\u0026eacute; BF, Sangar\u0026eacute; A, dkk. Risk factors associated with abscess formation among patient with leg erysipelas (cellulitis) in sub-saharan africa: A multicenter study. BMC Dermatol. 2015;15:18.\u003c/li\u003e\n\u003cli\u003ePark HS, Lee UH, Choi JC, Chun DK. Klebsiella pneumoniae cellulitis in an immunocompetent man. J Am Acad Dermatol. 2004;51(5):836.\u003c/li\u003e\n\u003cli\u003eKielhofner MA, Brown B, Dall L. Influence of underlying disease process on the utility of cellulitis needle aspirates. Arch Intern Med. 1988;148(11):2451-2.\u003c/li\u003e\n\u003cli\u003eBailey E, Kroshinsky D. Cellulitis: Diagnosis and management. Dermatol Ther. 2011;24(2):229-39.\u003c/li\u003e\n\u003cli\u003eSingh R, Sreenivasa P. Comparison between dressing of cellulitis with normal saline and magnesium sulphate. International Surgery Journal. 2018;5.\u003c/li\u003e\n\u003cli\u003eHirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: Part i. Lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):163.e1-12; quiz 75-6.\u003c/li\u003e\n\u003cli\u003eBreen JO. Skin and soft tissue infections in immunocompetent patients. Am Fam Physician. 2010;81(7):893-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cellulitis, clinical profile, erysipelas","lastPublishedDoi":"10.21203/rs.3.rs-4250982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4250982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eCellulitis and erysipelas belong to a group of diseases that are considered global health burdens. Epidemiological data on these diseases in Indonesia is still limited.\u003c/p\u003e\u003ch2\u003ePurposes:\u003c/h2\u003e \u003cp\u003eThis study aimed to identify the clinical profile of cellulitis and erysipelas in the tertiary referral hospital in West Java, Indonesia.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis was a retrospective, descriptive study using a cross-sectional design. Data were obtained from outpatient and inpatient records of cellulitis and erysipelas patients in the tertiary referral hospital in West Java, Indonesia, in a three-year period during January 2020\u0026ndash;December 2022.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe results of the study showed that cellulitis was most common in women within the 45\u0026ndash;64-year age group with normoweight nutritional status, while erysipelas mostly occurred in men within the \u0026gt;\u0026thinsp;65-year age group without a certain nutritional status predominance. In general, the risk factor for cellulitis was skin barrier disruption, while that for erysipelas was metabolic disorders. Fever was present in less than half of cases with cellulitis and erysipelas, and the lower extremities were the most often affected. The most frequent portal of entry in cellulitis was scratched skin, whereas erysipelas had no particular predominance. Additional skin lesions, such as bullae and/or erosions and suppuration, were found in some cases of these diseases and usually showed Gram-positive cocci with leukocytosis. Normal saline dressing was given to all cases, and some of them were treated with additional wound dressings and 2% mupirocin cream. Clindamycin was the most commonly administered oral antibiotic, while ceftriaxone was administered parenterally.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe clinical profile of cellulitis and erysipelas in the tertiary referral hospital in West Java, Indonesia, is consistent with findings from other previous studies. Additionally, clindamycin is the most commonly used oral antibiotic for the treatment of cellulitis and erysipelas.\u003c/p\u003e","manuscriptTitle":"Clinical Profile of Cellulitis and Erysipelas in the Tertiary Referral Hospital of West Java, Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 11:04:43","doi":"10.21203/rs.3.rs-4250982/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dcb19b39-1578-4c44-a276-30ca43cfadc9","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-29T10:38:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-17 11:04:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4250982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4250982","identity":"rs-4250982","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}