Cellulitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2] Synonyms and keywords:

Causes

Life Threatening Causes

No known life-threatening causes are included.

Common Causes

The cellulitis is bacterial in origin caused by invasion of bacteria through the skin barrier. The common causes are:

• Streptococcus pyogenes
• Staphylococcus aureus
• Haemophilus influenza type B
• Clostridium
• Streptococcus pneumoniae
• Neisseria meningitidis

Diagnosis

Shown below is an algorithm summarizing the diagnosis of cellulitis according to the Infectious Diseases Society of America guidelines.

Patients presents with clinical symptoms suggestive of cellulitis, i.e. erythema edema warmth swollen regional lymph nodes involvement of one limb.

Perform compression Doppler ultrasound of the limb and D-dimers level

Positive

Negative

likely Deep vein thrombosis (DVT)

DVT unlikely. High clinical suspicion for cellulitis

Assess levels of inflammatory markers

Raised ESR, CRP and leukocytosis

Does patient have any signs of rapidly progressive or systemic infection? Body temperature>101.5 degrees Fahrenheit, chills, headache, and fatigue Signs of sepsis. i.e. hypotension and heart rate>100bpm Patient develops rapidly progressive symptoms like bullae, vesicles, petechia, crepitus Patient has low immunity (i.e. infants and elderly patients)

Perform the following tests: Debridement of wound with culture of the specimen Blood culture Radiographic tests to evaluate deep tissue infection

Treatment

Shown below is an algorithm summarizing the treatment of cellulitis.

Is the cellulitis having a purulent discharge?

Yes

No

Are there any of the following clinical signs? Systemic toxicity (fever, hypotension, and tachycardia) Presence of an indwelling device (pacemaker, vascular graft) Patient is on extremes of age Major comorbid conditions

Yes

No

Incise and drain any discrete abscess. Delay oral antibiotic therapy Monitor patient for spontaneous resolution. If respone is inadequate then initiate oral antibiotic therapy

Initiate intravenous antibiotic therapy. The coverage of the micro-organisms is determined by: Oral or peri-rectal ulcers Pressure ulcer with draining abscess Necrosis of overlying skin

Initiate oral antibiotic therapy. The coverage of the micro-organisms is determined by: Oral or peri-rectal ulcers Pressure ulcer with draining abscess Necrosis of overlying skin

Yes

No

Yes

No

Initiate antibiotics that cover both MRSA and gram negative rods. To cover MRSA: Vancomycin or Daptomycin Plus one of the following to cover for gram negative rods Ampicillin-Sulbactam Piperacillin-Tazobactam Ceftriaxone plus metronidazole Levofloxacin plus metronidazole

Infection most likely due to MRSA. Initiate Vancomycin or Daptomycin

* Incision and drainage of discrete abscesses Send drained specimen for culture and susceptibility Start wide coverage empirical antibiotic covering MRSA, gram-negative bacilli, anaerobes, and gram-positive organisms. Regimens includes: Trimethoprim-Sulfamethoxazole plus amoxicillin-clavulanate Doxycycline plus levofloxacin plus metronidazole Minocycline plus amoxicillin-clavulanate

Assess patient's risk for infective endocarditis

Yes

No

Initiate empirical antibiotics coverage for MRSA and beta-hemolytic streptococci. Regimens include Trimethoprim-sulfamethoxazole or Doxycycline plus amoxicillin or Minocycline plus amoxicillin. Incise and drain the abscess an hour after administration of the first dose of oral antibiotic. Send the specimen for culture and sensitivity and start antibiotic accordingly after the results.

Incise and drain the discrete abscess Send the specimen for culture and sensitivity Initiate empirical antibiotics for MRSA. Regimens include Trimethoprim-sulfamethoxazole or Doxycycline or Minocycline

Do's

• Supportive care including elevation of the limb and adequate moisturizing of the site of the cellulitis should be done. The elevation of the limb promotes venous and lymphatic drainage from the site. Moisturize the affected site with emollients and moisturizers. It will hydrate the skin and prevent breakouts.
• Physicians should prescribe antibiotics to the patients according to body weight. Obese or lymphedema patients can be given a lower dose than their body weight. This results in inadequate response and failure of the treatment.
• The duration of antibiotic treatment is variable and depends upon the clinical improvement of the cellulitis. Mostly, there is significant improvement within a day or two after the initiation of the antibiotics. The patient is given treatment for five days. The antibiotic course is given for two weeks in patients with systematic symptoms, low immunity, and rapidly progressive cellulitis.

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Don'ts

• The content in this section is in bullet points.