Cellulitis in Patients with Cirrhosis and Edema: An Under-Recognized Complication Currently More Common than Spontaneous Bacterial Peritonitis

Background: Cellulitis is often a recurring infection resulting in hospitalizations. In patients with cirrhosis, gram-negative bacilli may be causative. Methods: Retrospective chart review of patients admitted to a dedicated Liver Unit in a tertiary referral center. Risk factors, characteristics and antibiotic treatment of patients with cirrhosis and edema complicated by cellulitis were compared to similar patients without cellulitis. We compared the frequency of cellulitis to that of spontaneous bacterial peritonitis in the same cohort. Our study is the largest case series focusing on the factors which predispose patients with cirrhosis to cellulitis. Results: Of 145 consecutive patients who were admitted to this unit during 1 year’s time, 19.3% were diagnosed with cellulitis compared to 4.1% diagnosed with spontaneous bacterial peritonitis. Cellulitis recurred in 21.4% of our patients. Significant risk factors for cellulitis included history of trauma or break in the skin barrier, homelessness, body mass index on admission and subjective degree of ascites and edema. Hospital stay was four days longer in patients with cellulitis, although this finding was not statistically significant. The duration of intravenous antibiotic treatment was 11.9 days. Conclusions: The incidence and recurrence rates of cellulitis in patients with cirrhosis and edema are very high and appear to be higher than those of spontaneous bacterial peritonitis in the current era. The diagnosis of cellulitis remains a clinical one as laboratory values and body temperature may not reveal the diagnosis and wound cultures are not usually helpful. Optimal antibiotic treatment warrants further delineation as continued intravenous antibiotic treatment may prolong hospitalization. INTRODUCTION Although approximately 75% of all infections in patients with cirrhosis are caused by gram-negative organisms, it is commonly assumed that skin infections are most likely caused by gram-positive organisms [1, 2]. Staphylococcus aureus and Streptococcus pyogenes are responsible for the majority of cellulitis cases in patients without cirrhosis [1, 2]. Gram-negative infections are considered in perianal cellulitis, immunocompromised patients [3, 4] and patients with nephrotic syndrome [5]. There are several case studies [6-10] and one case series [11] of gram-negative cellulitis in patients with cirrhosis. Although penicillins are currently accepted as first-line treatment for group A Streptococcus cellulites [12], broader coverage should probably be considered in resistant cellulitis in patients with cirrhosis. Our study is *Address correspondence to this author at the Liver Service, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; E-mail: [email protected] the largest case series focusing on the factors that predispose patients with cirrhosis to cellulitis. METHODS A retrospective chart review from September 2000 through September 2001 was performed investigating cellulitis in a population of patients with ascites due to cirrhosis. Cellulitis was defined by the presence of erythema, warmth and swelling. The control population was identified through a chart review of all patients admitted to one team of our liver unit. The control population was defined by ascites due to cirrhosis and without a past medical history of cellulitis. We compared categorical variables between groups using a chi-square analysis. We used the Mann Whitney U test for continuous variables. A p-value less than 0.05 was considered to indicate statistical significance. This study was approved by the institutional review board of Rancho Los Amigos. Cellulitis in Patients with Cirrhosis and Edema The Open Gastroenterology Journal, 2008, Volume 2 25 RESULTS Sixty-one control patients were identified, but of these 3 had ascites secondary to etiology other than cirrhosis, 7 had cellulitis in the past, 3 had developed spontaneous bacteremia of unknown etiology and 16 charts could not be found. A chart review was performed on the remaining 32 charts. Etiology of Cirrhosis Our cellulitis and control population groups were similar with a non-significant difference found between age, gender, race and etiologies of cirrhosis which included alcohol, nonalcoholic steatohepatitis (NASH), hepatitis B and hepatitis C (Table 1). The population was predominantly male in both groups and alcohol appeared to be the most common etiology of cirrhosis. Sites of infection varied with the most common site being the lower extremity (Table 2). Table 1. Baseline Characteristics of Study Population Cellulitis Control p-Value