CLINICAL PAPER

Incidence of Cellulitis in Lower Extremity Burns

6-Year Analysis
Joseph N. Batac, MD, Roger L. Simpson, MD, Catherine J. Sinnott, MD,
Michael P. Catanzaro, MD, and Laurence T. Glickman, MD

admitted Nassau University Medical Center Burn Center from January

Introduction: Patients with burn wounds of the lower extremities are at increased
2010 to January 2016. All patients with burns of the lower extremity
risk of developing cellulitis. The probability of developing burn-associated cellu-
of any etiology were included in this study. Patients who were evaluated
litis is presumed to be correlated with a medical history of diabetes, the etiology
and followed as an outpatient or pediatric patients under the age of
of the burn, delay in hospitalization of the patient during their initial presentation,
12 years were not included in this study. Patients were initially evaluated
and depth of the burn itself. This study aims to identify factors that place patients
either from the emergency department, from the burn clinic or after
at increased risk for developing lower extremity burn wound cellulitis.
transfer from an outside institution. Disposition after initial evaluation
Materials and Methods: A retrospective chart review was performed of all
was either admission to the burn unit or follow-up as an outpatient.
Nassau University Medical Center Burn Center admissions from January 2010
Extracted data were then analyzed as potential risk factors for de-
to January 2016. All patients admitted with burns of any etiology isolated to
velopment of lower extremity–associated burn cellulitis. Data on the
the lower extremity were included in this study. Patients who were evaluated
following characteristics were collected: demographics, burn etiology,
and followed as an outpatient were not included in this study. Pediatric patients
percent total body surface area (TBSA) involved, presence of medical
less than or equal to 12 years of age were excluded from this study.
comorbidities, disposition of the patient after initial evaluation, pres-
Results: Of the 218 admissions for lower extremity burns during the 6-year study
ence of cellulitis on presentation, and depth of burn. Patients were iden-
period, 34% of patients developed cellulitis. Risk factors for developing lower ex-
tified as having burn-associated cellulitis if it was recorded either on
tremity burn wound cellulitis included being male, greater depth of burn, and
initial presentation or during their hospital course. The diagnosis of
burn-to-admission delay. This was true in both univariate and multivariate analy-
burn wound cellulitis was based on clinical examination and the pres-
sis. total body surface area was a risk factor on univariate analysis but was not
ence of advancing erythema, induration, warmth, and tenderness of
found to be an independent risk factor on multivariate analysis. No difference
the tissues surrounding the burn wound.14
was observed in the development of cellulitis in patients discharged on oral anti-
Statistical analysis was performed using version 22 IBM SPSS
biotics compared with those not given antibiotics.
Statistics software. Significance was set at a P value of less than .05.
Conclusions: Burn wound cellulitis is the second most common complication
Univariate analyses were performed with independent sample t tests,
observed in burns. Identification of patients at risk for developing cellulitis is im-
χ2 tests, and Fisher exact test (for outpatient antibiotic analysis) when
portant. Admitting these patients at increased risk and excising and grafting the
appropriate. Adjusted odds ratios were calculated using a full model of bi-
burned area is a reasonable solution in preventing this costly complication.
nary logistic regression; variables with N < 10 were excluded from the
Key Words: lower extremity burn-associated cellulitis, burns regression. Variables that were statistically significant (P < 0.05) at the
(Ann Plast Surg 2018;00: 00–00)
univariate level were reassessed in a multiple logistic regression model.

P atients with lower extremity burns are at risk for developing celluli-
tis.1 The wound healing potential of lower extremity burn wounds
can be deceptive and often presents a therapeutic challenge. Patients with
lower extremity burn wounds may benefit from immediate hospitaliza-
tion instead of outpatient management to prevent this complication. The
probability of developing burn-associated cellulitis is likely multifactorial
and presumed to be correlated with a medical history of diabetes,2–13 the
etiology of the burn, delay in hospitalization of the patient during their ini-
tial presentation, and depth of the burn itself. This study proposes to an-
alyze which factors are most influential in developing burn-associated
cellulitis of the lower extremity. In addition, after identifying the most in-
fluential factors, we will make recommendations in regards to preventing
the occurrence of burn-associated lower extremity cellulitis.
PATIENTS AND METHODS
All patient data were obtained via retrospective chart review of
medical records of patients with isolated burns of the lower extremity
Received December 14, 2017, and accepted for publication, after revision December 22,
2017.
From the Nassau University Medical Center Burn Center, East Meadow, NY.
Conflicts of interest and sources of funding: none declared.
Reprints: Joseph Batac, MD, Nassau University Medical Center, East Meadow, NY.
E-mail: jbatac@lipsg.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/18/0000–0000
DOI: 10.1097/SAP.0000000000001361
RESULTS
Patient Characteristics
A total of 218 patients were admitted for lower extremity burns
during the 6-year study period. Demographic and clinical characteris-
tics of the patient population are as listed in Table 1. The patients had
a mean ± SD age of 43.39 ± 1.47 years with a mean ± SD percent TBSA
burned of 6.24 ± 0.45 percent. Males represented 55.5% of the patients.
Additional comorbidities were also examined. Diabetics com-
prised 15.1% of patients, 22.5% of patients had hypertension, and patients
who were active or former smokers comprised approximately 11.9%. Be-
cause of insufficient sample size for specific individual comorbidities,
some were grouped by organ system. For example, patients with asthma
or chronic obstructive pulmonary disease were grouped under pulmonary
disease and comprised of 3.6% of the entire patient population.
In regards to burn etiology, the most common etiology was due
to a scald caused either by hot water or grease in 62.4% of patients
followed by flame burn in 25.7%. Seventy-six percent of patients had
third-degree burns, and 83% of patients required surgery. Patients
who were initially evaluated, sent home, and subsequently admitted
after a second evaluation were reviewed. The number of days from
evaluation and subsequent admission will be referred to as burn-to-
admission delay. This mean ± SD number of days in burn-to-
admission delay was 3.2 ± 0.4 days with the mean ± SD hospital
length of stay of 11.1 ± 1.7 days.

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Batac et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018

TABLE 1. Demographic, Clinical, and Burn Characteristics of Lower Extremity Burns

Categorical: N (%) Continuous: Mean (±SEM) Total Patients (N = 218)*,** No Cellulitis (N = 142) Cellulitis (N = 76) P (Univariable Analysis)
Age, y: 43.39 (±1.47) 42.0 (±1.94) 46.0 (±2.10) 0.164
Sex, male: 121 (55.5) 67 (47.2) 54 (71.1) 0.001
Race: 0.180
White 113 (51.8) 69 (48.6) 44 (57.9)
Asian 16 (7.3) 10 (7) 6 (7.9)
Hispanic 36 (16.5) 21 (14.8) 15 (19.7)
Black 44 (20.2) 35 (24.6) 9 (11.8)
Other 9 (4.1) 7 (4.9) 2 (2.6)
Burn etiology: 0.574
Scald 136 (62.4) 83 (58.5) 53 (69.7)
Flame 56 (25.7) 39 (27.5) 17 (22.4)
Contact 13 (6.0) 10 (7.0) 3 (3.9)
Chemical 6 (2.8) 3 (2.1) 3 (3.9)
Electrical 3 (1.4) 3 (2.1) 0 (0)
Other/mixed 4 (1.8) 4 (2.8) 0 (0)
Comorbidity
Diabetic* 33 (15.1) 21 (14.7) 12 (15.7) 0.922
HTN* 49 (22.4) 33 (23.2) 16 (21.0) 0.455
HLD* 19 (8.7) 13 (9.1) 6 (7.8) 0.599
Psychiatric illness* 13 (5.9) 7 (4.9) 6 (7.8) 0.485
Pulmonary disease*† 8 (3.6) 7 (4.9) 1 (1.3) 0.141
Cardiac disease*‡ 14 (6.4) 7 (4.9) 7 (9.2) 0.300
Neurodegenerative*§ 5 (2.2) 3 (2.1) 2 (2.6) 0.892
HIV 2 (0.9) 2 (1.4) 0 (0.0) 0.275
Other 59 (27.0) 38 (26.7) 21 (27.6) 0.772
Smoker:** 26 (11.9) 12 (9.1)* 14 (18.4)* 0.076
TBSA (%): 6.24 (±0.45) 6.93 (±0.61) 4.95 (±0.58) 0.019
Third-degree burn: 167 (76.6) 98 (69.0) 69 (90.8) 0.000
Required surgery: 182 (83.5) 114 (80.3) 68 (89.5) 0.082
Discharged from ER: 68 (31.1) 41 (28.8) 27 (35.5) 0.297
Burn-to-admission delay, d: 3.20 (±0.45) 2.29 (±0.54) 4.91 (±0.80) 0.006
Length of stay, d: 11.13 (±1.72) 9.73 (±0.83) 13.75 (±4.69) 0.265
*Twenty-four subjects younger than 18 years at time of burn were excluded from comorbidity and smoking analyses. Percentages reflected accordingly.
**Sixteen subjects had unknown smoking histories and were excluded from smoking analysis. Percentages reflected accordingly.
†Includes asthma/COPD.
‡Includes CAD/CHF/dysrhythmia.
§Includes PD/dementia.
CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ER, emergency room; HIV, human immunodeficiency
virus; HLD, hyperlipidemia; HTN, hypertension.

Risk Factors for Development of Cellulitis
Patients were analyzed for potential risk factors for the develop-
ment of lower extremity–associated burn cellulitis. Thirty-five percent
of our patients with lower extremity burns developed cellulitis. Of
the patients who developed cellulitis, 16% were diabetic and 18% were
smokers. Mean TBSA was 4.95%, and 90.8% were third degree in
depth. Mean burn-to-admission delay was 4.91 days.
On univariate analysis, male sex, TBSA, third-degree burns, and
burn-to-admission delay were statistically significant factors associated
with the development of lower extremity burn cellulitis (Table 2). Patients
who were male had a 2.7-fold increased risk for developing cellulitis.
Patients who had third-degree burns had a 4.4-fold risk for developing
cellulitis. Patients with a burn-to-admission delay were stratified into
categories of whether or not discharge on oral antibiotics prevented
development of cellulitis. Eighty-eight percent of patients who developed
cellulitis were not discharged on oral antibiotics; however, on univariate
analysis, this was not statistically significant. Interestingly, comorbidities
such as diabetes or hypertension did not show a statistically significant
increase in development of cellulitis when present.
Male sex, TBSA, third-degree burn, and burn-to-admission de-
lay were further evaluated in multiple logistic regression analysis. Male
sex and third-degree burn emerged as strong predictors for development
of lower extremity cellulitis. Burn-to-admission delay was a slight
predictor for development of cellulitis, whereas TBSA was no longer
predictive (Table 3).
DISCUSSION
Burn wound cellulitis is the second leading complication reported
in burns and is the most common complication in patients who are not
mechanically ventilated.1,15 Some studies have shown that burn wound

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Incidence of Cellulitis in Lower Extremity Burns

Male sex was independently associated with the development of

TABLE 2. Crude and Adjusted Odds Ratios (Binary Logistic lower extremity burn wound cellulitis. This has been shown to be the
Regression) case in other studies regarding burn wound cellulitis in general.1 Most
patients in our data set were Caucasian with African Americans being
Crude Adjusted the second most common ethnicity. Other studies have observed a de-
OR (95% CI) P OR (95% CI) P creased association between the development of cellulitis of burn
wounds and African Americans1; however, we did not see a statistically
Age, y: — 0.164 1.0 (1.0–1.0) 0.684 significant difference on univariate analysis.
Sex, male: 0.7 (0.5–0.8) 0.001 3.1 (1.4–7.0) 0.006 In regards to comorbidities, diabetics are presumed to have an in-
Race: — 0.180 — — crease in development of wound infections in general; however, our
White 0.8 (0.7–1.1) — 1.5 (0.4–5.4) 0.532 study does not indicate an association between having diabetes and de-
Asian 0.9 (0.3–2.4) — n < 10 n < 10 velopment of lower extremity burn-associated cellulitis. Other studies
Hispanic 0.7 (0.4–1.4) — 1.1 (0.7–1.8) 0.790 did show an increased incidence of development of burn wound cellu-
Black 2.1 (1.1–4.1) — 0.9 (0.6–1.3) 0.685 litis in general. However, on multivariate regression, it does not show
Other 1.9 (0.4–8.8) — n < 10 n < 10 any statistical significance.
Depth of burn was a strong independent risk factor with an over-
Burn etiology: — 0.574 — 0.574
all odds risk of 5.8 in our study. This finding is reasonable because the
Scald 0.8 (0.7–1.0) — 2.1 (0.7–6.5) 0.208
necrotic eschar is prime environment for bacteria to thrive. In regards to
Flame 1.2 (0.7–2.0) — 1.2 (0.4–4.2) 0.763 TBSA, although on univariate analysis, it did appear to have a statisti-
Contact 1.7 (0.5–6.3) — n < 10 n < 10 cally significant impact on the risk for developing cellulitis it was not
Chemical 0.5 (0.1–2.6) — n < 10 n < 10 found to be an independent risk factor on multivariate analysis.
Electrical 1.0 (1.0–1.0) — n < 10 n < 10 Delay of burn admission was found to be an independent risk
Other/mixed 1.0 (0.9–1.0) — n < 10 n < 10 factor for the development of cellulitis. Patients with cellulitis had a
Diabetic* 1.0 (0.5–2.0) 0.922 1.0 (0.3–3.2) 0.956 mean ± SD burn-to-admission delay of 4.91 ± 0.80 days versus
HTN* 1.2 (0.7–2.1) 0.455 0.8 (0.3–2.2) 0.455 3.20 ± 0.45 days in patients without cellulitis. The increased risk may
HLD* 1.3 (0.5–3.2) 0.599 n < 10 n < 10 be due to the anatomic location of the wound in which the dependent
location of the limb predisposes to edema and increased infection.
Psychiatric illness* 0.7 (0.2–2.0) 0.485 n < 10 n < 10
Zachary et al16 showed that no patients with burns of the feet of any eti-
Pulmonary disease*1 4.1 (0.5–33.0) 0.141 n < 10 n < 10
ology admitted on the day of injury developed burn wound cellulitis, in
Cardiac disease*2 0.6 (0.2–1.6) 0.300 n < 10 n < 10 contrast to 26.5% (13/49) of those patients with delayed admission. Pa-
Neurodegenerative*3 0.9 (0.2–5.2) 0.892 n < 10 n < 10 tient noncompliance for leg elevation while at home may increase their
HIV 1.0 (1.0–1.0) 0.275 n < 10 n < 10 risk for developing cellulitis as compared with those who are admitted
Other 1.1 (0.7–1.7) 0.772 n < 10 n < 10 where strict leg elevation can be monitored.
Smoker:** 2.1 (0.9–4.9) 0.076 2.4 (0.9–6.7) 0.088 With respect to outcomes, our study showed that there was no
TBSA (%): — 0.019 1.0 (0.9–1.0) 0.578 difference in hospital length of stay or need for surgical intervention
Third-degree burn: 0.8 (0.7–0.9) 0.000 5.8 (1.2–28.3) 0.029 in patients with lower extremity burn wound cellulitis compared with
Required surgery: 0.9 (0.8–1.0) 0.082 0.4 (0.1–2.1) 0.305 patients without cellulitis. This is in contrast to another study that
showed an increased hospital length of stay and number of surgeries
Discharged from ER: 0.8 (0.5–1.2) 0.312 1.0 (0.4–2.4) 0.962
in patients with burn wound cellulitis compared with those without cel-
Burn-to-admission delay, d: — 0.006 1.2 (1.1–1.4) 0.002
lulitis in regional and national data.1 This difference may be explained
LOS, d: — 0.265 1.0 (1.0–1.1) 0.528 because this study examined burn wounds of all locations on the body,
Crude odds ratios were not calculated for continuous variables (age, TBSA, whereas our study examined only lower extremity burn wounds.
burn to admit time, LOS). We did not observe a significant decrease in the risk of develop-
Variables that included condition with n < 10 were excluded from binary ment of cellulitis in patients given oral antibiotics as outpatients. A lim-
logistic regression. itation of our study is the small number of patients who were discharged
OR, odds ratio; CI, confidence interval; HIV, human immunodeficiency virus; ER, with oral antibiotics. Nevertheless, it remains something to pursue for
emergency room; LOS, length of stay; HTN, hypertension, HLD, hyperlipidemia. further investigation.

cellulitis has been associated with increased length of hospital stay, an in-
creased likelihood of requiring surgery, and higher costs.1 Other studies
have tried to elucidate factors associated with developing burn wound
cellulitis; however, ours is the first to analyze factors associated with
the development of burn wound cellulitis isolated to the lower extremity.
CONCLUSIONS
Lower extremity burn wound cellulitis is a pervasive problem.
This study is the first to delineate risk factors for developing lower
extremity–associated burn wound cellulitis. Male sex, depth of burn,
and burn-to-admission delay are strong independent risk factors for

TABLE 3. Antibiotic Use in Patients Discharged From Emergency Room After Initial Presentation

Categorical: N (%) Total No. Patients Discharged after Initial Presentation (N = 59) No Cellulitis (n = 35) Cellulitis (n = 24) P
0.062
D/c'ed with home antibiotics 3 0 (0) 3 (12.5)
D/c'ed without home antibiotics 56 35 (100) 21 (87.5)
D/c'ed, Discontinued.

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Batac et al
developing cellulitis. Diabetes, other comorbidities, and TBSA do not
independently increase the risk for developing cellulitis. Further efforts
should be made to risk stratify patients in regards to the factors outlined
in this study to identify those who should be admitted and whose burns
should be excised in a timely manner.
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