Patients' Understanding of Cellulitis and Views on Preventing Recurrent Episodes: Mixed Methods Study

1. Patients’ understandings about cellulitis and views about how best to prevent recurrent episodes: mixed methods study in primary and secondary care E Teasdale, A Lalonde, I Muller, J Chalmers, P Smart, J Hooper, M El-Gohary, KS Thomas and M Santer University of Southampton and University of Nottingham, UK British Journal of Dermatology. DOI: 10.111/bjd.17455

2. Lead authors Dr Miriam Santer Dr Emma Teasdale

3. Introduction What’s already known? • Cellulitis is an acute, painful and potentially serious bacterial infection of the skin and underlying tissue, which causes considerable impact on quality of life. • Approximately a third of patients who have had cellulitis suffer recurrent episodes, and a number of different strategies for prevention have been proposed. • The only treatment shown to reduce the risk of recurrence is long-term low-dose antibiotics but these appear to be under-used in practice.

4. Objectives • To explore people’s views about cellulitis • To explore people’s willingness to adopt potential methods of preventing recurrent episodes, including • Long-term, low dose antibiotics • Enhanced foot hygiene • Applying emollients to feet daily • Compression garments • Lifestyle changes such as weight loss and exercise

5. Methods Participants • Adults (over 18 years) with a history of cellulitis - both first and recurrent episodes Recruited from: • 25 primary care sites (database searches and mail out) • 2 secondary care sites (opportunistic recruitment) • Community recruitment (newspaper advert)

6. Methods Data collection • Cross-sectional survey • Online or paper • Response rate: 240/1,418 (17%) • Semi-structured interviews • 30 face to face interviews • August 2016 to July 2017 • Audio-recorded and transcribed

7. Methods Data analysis • Inductive thematic analysis (Qualitative data) • Descriptive statistical analysis (Quantitative data) • A triangulation protocol was adopted to integrate the quantitative and qualitative data

8. Results • Participants had wide-ranging beliefs about the causes of cellulitis • Many participants said they had not been informed about the risk of recurrence

9. Survey findings (n=240)

10. Qualitative interview findings • Enhanced skin care and foot hygiene were seen as something familiar and easy to fit into established daily routines. • Compression garments were perceived to be impractical, uncomfortable and more associated with flights and recovery after operations than everyday use. • Participants were cautious of using long-term oral antibiotics due to perceived immunity and side effects.

11. Discussion • Many participants were surprised they had not been informed of the risk of recurrence • Although there is a lack of evidence for many prevention strategies, people with cellulitis are keen to know about the effectiveness of possibilities for preventative practices. • Enhanced skin care, foot hygiene and exercise may be acceptable prevention strategies, but further research is needed to explore uptake and effectiveness in practice.

12. ConclusionsWhat does this study add? • Quantitative and qualitative data showed that people who have had cellulitis are often unaware of risk of recurrence or potential strategies to prevent recurrence. • Enhanced foot hygiene, applying emollients daily and exercise appeared to be more acceptable prevention strategies than compression or long-term antibiotics. • People were cautious of using long-term oral antibiotics, particularly if they had only experienced one episode of cellulitis.

13. Several of the co-authors were members of the James Lind Alliance priority setting partnership on cellulitis, findings of which were also published in the BJD.

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