Abstract
Nonpurulent lower extremity cellulitis (NLEC) is a common clinical diagnosis, with
β-hemolytic streptococci and Staphylococcus aureus considered to be the most frequent causes. In 1999, the US Public Health Service
alerted clinicians to the presence of community-acquired methicillin-resistant S aureus (CA-MRSA) infections in 4 children in the upper Midwest. Since then, it has become
a well-recognized cause of skin and soft-tissue infections, in particular, skin abscess.
A previous population-based study of NLEC in Olmsted County, Minnesota, reported an
unadjusted incidence rate of 199 per 100,000 person-years in 1999, but it is unknown
whether CA-MRSA subsequently has affected NLEC incidence. We, therefore, sought to
determine the population-based incidence of NLEC since the emergence of CA-MRSA. Age-
and sex-adjusted incidence (per 100,000 persons) of NLEC was 176.6 (95% CI, 151.5-201.7).
Incidence differed significantly between sexes with age-adjusted sex-specific rates
of 133.3 (95% CI, 104.1-162.5) and 225.8 (95% CI, 183.5-268.0) in females and males,
respectively. Seasonal incidence differed, with rates of 224.6 (95% CI, 180.9-268.4)
in warmer months (May-September) compared with 142.3 (95% CI, 112.8-171.9) in colder
months (January-April and October-December). Despite emergence and nationwide spread
of CA-MRSA since 1999 in the United States, the incidence of NLEC in Olmsted County
was lower in 2013 than in 1999, particularly in females. This suggests that CA-MRSA
is not a significant cause of NLEC and that NLEC cases are seasonally distributed.
These findings may be important in formulation of empirical therapy for NLEC and in
patient education because many patients with NLEC are prone to recurrent bouts of
this infection.
Abbreviations and Acronyms:
CA-MRSA (community-acquired methicillin-resistant Staphylococcus aureus), ICD-9 (International Classification of Diseases, Ninth Revision), IQR (interquarile range), NLEC (nonpurulent lower extremity cellulitis), SSTI (skin/soft-tissue infection), REP (Rochester Epidemiology Project)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Mayo Clinic ProceedingsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Clinical practice. Cellulitis.N Engl J Med. 2004; 350: 904-912
- Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.Clin Infect Dis. 2014; 59: e10-e52
- Morbidity Statistics From General Practice: Fourth National Study 1991-1992.Office of National Statistics, HMSO, London, England1995
- Cellulitis incidence in a defined population.Epidemiol Infect. 2006; 134: 293-299
- Cellulitis among active duty servicemembers, US Armed Forces, 1998-2001.Med Surveill Monthly Rep (MSMR). 2002; 8: 6-9
- Bacterial skin infections, active component, U.S. Armed Forces, 2000-2012.Med Surveill Monthly Rep (MSMR). 2013; 20: 2-7
- Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota.Mayo Clin Proc. 2007; 82: 817-821
- Community-acquired methicillin-resistant Staphylococcus aureus endocarditis in the Detroit Medical Center.Ann Intern Med. 1982; 97: 330-338
- Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus—Minnesota and North Dakota, 1997-1999.MMWR Morb Mortal Wkly Rep. 1999; 48: 707-710
- Emergency department visit rates for abscess versus other skin infections during the emergence of community-associated methicillin-resistant Staphylococcus aureus, 1997-2007.Clin Infect Dis. 2012; 55: 103-105
- Methicillin-resistant Staphylococcus aureus disease in three communities.N Engl J Med. 2005; 352: 1436-1444
- Community-associated methicillin-resistant Staphylococcus aureus: trends in case and isolate characteristics from six years of prospective surveillance.Public Health Rep. 2009; 124: 427-435
- History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.Mayo Clin Proc. 2012; 87: 1202-1213
- Risk factors for acute cellulitis of the lower limb: a prospective case-control study.Clin Infect Dis. 2005; 41: 1416-1422
- Penicillin to prevent recurrent leg cellulitis.N Engl J Med. 2013; 368: 1695-1703
- Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester epidemiology project.Am J Epidemiol. 2011; 173: 1059-1068
- United States Census Bureau website.(Accessed March 30, 2017)
- Decreasing incidence of skin and soft tissue infections with a seasonal pattern at an academic medical center, 2006–2014.Open Forum Infect Dis. 2016; 3: ofw179
- Comparison of community- and health care–associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984
- Changes in prescriptive practices in skin and soft tissue infections associated with the increased occurrence of community acquired methicillin resistant Staphylococcus aureus.J Infect Public Health. 2013; 6: 423-430
- Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis.BMJ Open. 2017; 7: e013260
- Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis.J Antimicrob Chemother. 2015; 70: 2382-2388
- Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial.Clin Infect Dis. 2013; 56: 1754-1762
- Admissions to a U.K. teaching hospital with nonnecrotizing lower limb cellulitis show a marked seasonal variation.Br J Dermatol. 2007; 157: 1047-1048
- Influence of environmental temperature on the occurrence of non-necrotizing cellulitis of the leg.Br J Dermatol. 2004; 150: 155-156
- Ambient ozone and emergency department visits for cellulitis.Int J Environ Res Public Health. 2010; 7: 4078-4088
- Lower limb cellulitis and its mimics, part II: conditions that simulate lower limb cellulitis.J Am Acad Dermatol. 2012; 67 (quiz 185-186): 177e1-177e9
Article Info
Publication History
Published online: July 08, 2017
Footnotes
Grant Support: This publication was supported by the Mayo Foundation for Research and Education through the Division of Infectious Diseases, by the Rochester Epidemiology Project (grant number R01-AG034676; Principal Investigators: Walter A. Rocca, MD, MPH, and Jennifer L. St Sauver, PhD), and by grant UL1 TR000135 from the National Center for Advancing Translational Sciences . Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
These data were presented in part at IDWeek 2016 in New Orleans, LA; abstract selected for IDWeek 2016 Trainee Travel Grant.
Identification
Copyright
© 2017 Mayo Foundation for Medical Education and Research
