الفهرس 
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Abstract
Cirrhotic patients are prone to infectious diseases due to their underlying immunocompromised status. Skin and soft tissue infection in cirrhotic patients may be underestimated due to the frequently swelling of skin or soft tissue from hypoalbuminemia. To date, studies on cellulitis in cirrhotic patients are lacking, especially from our region.
This study aimed to evaluate the prevalence, risk factors, infective organisms and outcome of cellulitis in patients with liver cirrhosis.
A total of 525 cirrhotic patients admitted to Al-Rajhi Liver Hospital, Assiut University Hospital, Egypt were included in the study between May 2017 and November 2017. Of them, 65(12.4%) patients had cellulitis. The remaining 460 patients with liver cirrhosis without cellulitis considered as control group.
All individuals were subjected to:
- Full medical history and physical examination
- Liver function tests: serum bilirubin, serum albumin, ALT, AST, and
prothrombin time and INR.
- Complete blood picture
- Blood urea and serum creatinine
- Random blood sugar
- Limb Doppler ultrasound to diagnose DVT.
- Microbiological studies: blood culture and skin culture (when it was available).
The following results were observed:
- The prevalence of cellulitis in cirrhotic patients was 12.4%.
- Regarding clinical characteristics we found that majority of patients (95.4%) had tenderness and (89.2%) had pain at the site of cellulitis, but about half of patients (52.3%) only had fever.
- Lower Limb edema, venous insufficiency, ascites and trauma, were found to be predisposing factors for developing cellulitis in cirrhotic patients or multiple risk factors of those may be present, also hyperbilirunbineamia and hypoalbumineamia were associated with developing cellulitis in cirrhotic patients.
- Most cases with cellulitis were Child C (61.5%) and higher MELD score but with no statistical significance.
- Diabetes, hepatitis B and C infection were not found to be significant risk factors of developing cellulitis in our study
- Cirrhotic patients with cellulitis had significantly prolonged hospital stay than those without [8 (2 - 25) days versus 6 (3 - 21) days, P = 0.011].
- We reported a somewhat higher frequency of Gram-negative than Gram-positive bacteria (51.7% versus 37.9%) with E. coli, and Klebsiella being the predominant. On the other hand, Staphylococcus spp. had the highest Gram-positive bacteria percentage (81.8%).
- It was the first time to report fungal infection in patients with cellulitis; Candida species (one case) and A. nigar (2 cases) in wound and blood cultures respectively.
- 81.5% of patients with cellulitis received empirical antibiotics (53/65) then 13 cases of them received adjusted antibiotic therapy (according to the results of blood and/or skin cultures). Cephalosporins was the commonest antibiotics used (31/53, 58.5%) where 93.5% of cases (29/31) were received cefotaxime.
- In-hospital mortality rate in cirrhotic patients with cellulitis was 27.7% Using Cox regression model, cellulitis is associated with in-hospital mortality in cirrhotic patients [P = 0.05 (odds ratio 0.502, 95% CI 0.249 - 1.01)].
- All non-survivors with positive cultures were of Gram negative cellulitis.
- Risk factors predicting in-hospital mortality of cirrhotic patients with cellulitis were prolonged hospital stay, higher MELD score, higher neutrophilic cell count, occurrence of complications, septic shock and recurrence of cellulitis.
Conclusion
Cellulitis is a common skin infection that is usually mild disease but it may be associated with significant