Risk factors associated with local complications of erysipelas: a retrospective study of 152 cases

Erysipelas is a common skin infection. Hemorrhagic, bullous, abcessing and necrotic lesions are the major local complications. However, their occurrence factors are not clearly known. The aim of this study is to identify the risk factors associated with the occurrence of local complications of Erysipelas. Medical records from all patients hospitalized with local complications of erysipelas admitted to the Military Hospital of Rabat between 2005 and 2015, were retrospectively studied. Using an univariate and multivariate statistical study, the main characteristics were compared with those from patients with erysipelas without local complications. In total, 152 patients were analysed, of whom 72 had local disease complications. Using univariate analysis, the factors significantly associated with disease complications were found to be: age ≤ 50 years, female gender, heart disease, smoking, taking antibiotics or non-steroid anti-inflammatory drug before hospitalization, and accelerated sedimentation rate. However, in multivariate analysis, taking antibiotics before hospitalization (OR 5.15, 95% CI 1.28 to 20.72, P = 0.01) and accelerated sedimentation rate (OR 5, 15, 95% CI 1.00 to 1.06, P = 0.001) were the only independent factors associated with complicated erysipelas. Our study showed that prior antibiotics taking and higher sedimentation rate are independent risk factors for local complications of erysipelas. Patients with these characteristics should be carefully evaluated and monitored.


Introduction
Erysipelas is an infectious disease of the dermis and subcutaneous tissue commonly caused by streptococci [1]. It is a clinical form of acute cellulitis [2]. Clinically it is characterized by the acute onset of local signs of inflammation such as erythema, oedema, pain and heat. In its classic form it is accompanied by systemic signs such as fever, chills and malaise and sometimes nausea and vomiting [3,4].
An increase of inflammation biological parameters is frequent such as leukocytosis with predominance of neutrophils, and increased Creactive protein (CRP) [5]. Erysipelas can be serious but rarely fatal.
Erysipelas has a rapid and favorable response to antibacterial therapy [6,7]. Systemic complications are very rare: sepsis was reported in 2-5% of patients in large series [7,8]. Local complications are more frequent occurring in one third of patients hospitalized for erysipelas [9] and they are mainly abscess formation, necrosis, bubbles and hemorrhagic purpura.These complications are associated with a more severe condition [10,11].
In this study, we reviewed all cases of erysipelas recorded in our hospital within a period of 10 years with the aim of assessing possible risk factors for patients developing local complications.

Study protocol
The study was a retrospective analysis of clinical records in all Erysipelas was defined as a skin infection of sudden onset with a red indurated expanding plaque with a distinct border isolated or associated with one or more of the following: the identification of an infection door, a sensitive satellite lymphadenopathy or fever. All patients with local complications of erysipelason admission or during hospitalization including haemorrhagic, bullous, abscessing or necrotic lesions, who were admitted to the hospital during the same period, were included in the study.
Patient information was recorded, including gender, age, temperature, lesion site, lymph-node involvement, fever duration, days of hospitalization, number of relapses before complications, the initial response to antibiotic therapy and presence of coexisting diseases. Local factors such as presence of ulcers, local surgery, tineapedis, varicose veins, injury and lymphoedema were also recorded as were laboratory parameters, including white blood cell (WBC) count, erythrocyte sedimentation rate and C-reactive protein levels on admission and at discharge. In most cases, no bacteriological evidence was requested.
All cases were divided into two groups: those with uncomplicated and those with complicated erysipelas. The group of complicated erysipelas included all patients with bullous, abscessing, hemorrhagic or necrotizing forms. We compared the clinical and laboratory characteristics between the two groups.

Statistical analysis
The collected data were entered and analyzed by SPSS
The percentage of patients with local complications responding to an initial empirical antibiotic treatment given was slightly lower than patients without complications (96% vs. 95%, P = 0.89) ( Table 2).
Finally, in the multivariate analysis ( Reflecting the discomfort of patients and the socio economic impact.
In our practice, there was an extension of the duration of antibiotic therapy in complicated patients, which was demonstrated in previous studies [9,12]. Schrock JW et al. concluded in their study that patients with complicated erysipelas require antibiotic treatment intensification [13]. We did not find significant differences in obesitybetween the 2 groups in our series, in contrast to a previous study of Krasagakis et al. [9]. Obesity is a known risk factor for erysipelas [14,15]. It is considered as a severity marker indicating hospitalization [10].
Our study revealed statistically significant difference between the two groups regarding age > 50, female gender, smoking and cardiovascular history. These results are similar to those reported in some series in the litterature [9,12,16,17]. The standardization delay in laboratory parameters (ESR and WBC) for complicated forms has been shown in previous studies [9,17].
Our study is retrospective, which limited us to analyze this factor.
Although we found that an increased erythrocyte sedimentation rate at the admission is an independent risk factor for local complications. Lazzarini et al. suggest in their study that the sedimentation rate at admission could be a potential indirect marker of disease severity [17].
Page number not for citation purposes 4 Some authors have proposed criteria for hospitalization for patients with erysipelas [16,18]. Data from our study may contribute to these efforts in order to adapt the therapeutic approach and reduce the frequency of complications.

Conclusion
Erysipelas is a common skin infection which diagnosis is clinical.  Patients with these early indicators should be hospitalized for close monitoring and proper care.

Competing interests
The authors declare no competing interests.

Authors' contributions
All the authors have read and agreed to the final manuscript.