Cellulitis resident survival guide

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Cellulitis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


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

Synonyms and keywords:

Overview

Cellulitis is inflammation of deeper layers of the skin including the dermis and subcutaneous tissue. It is mostly due to bacterial infection. The bacteria invade the deeper layers after breaching the skin barrier. It usually involves the lower limbs. It presents clinically with signs of inflammation, i.e., redness, swelling, warmth, pain. The risk factors for cellulitis include a weakened immune system, diabetes, lymphatic obstruction, and varicose veins. It is treated conservatively with oral antibiotics in uncomplicated cases. Parenteral antibiotics are administered in patients with systematic symptoms and progressive lesions. Incision and drainage are done if discrete abscesses are present.

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[1][2][3]:

Diagnosis

Shown below is an algorithm summarizing the diagnosis of cellulitis according to the Infectious Diseases Society of America guidelines.[4][5][6]

 
 
 
Patients presents with clinical symptoms suggestive of cellulitis, i.e.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 the wound with the culture of the specimen
  • Blood culture
  • Radiographic tests to evaluate deep tissue infection

Treatment

Shown below is an algorithm summarizing the treatment of cellulitis.[7][5][1][8][9]

 
 
 
 
 
 
 
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 include:
  • 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.[5]
    • 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.[10]
    • 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 patient with systematic symptoms, low immunity, and rapidly progressive cellulitis.[5][11]

    Don'ts

    • Suppressive antibiotic therapy is administered to patients with three to four episodes of cellulitis per year with predisposing factors that can not be alleviated. Suppressive antibiotic therapy is directed against beta-hemolytic streptococci and staphylococci infection. Suppressive antibiotic therapy is not beneficial in patients with greater than three episodes of cellulitis in a year, chronic edema, and obese patients.[12]
    • Physicians should not perform incision and drainage for discrete abscesses in patients with high susceptibility of bacterial endocarditis without prior administration of the antibiotic. 2 grams oral amoxicillin should be given to the patient an hour before performing incision and drainage of the infected site.[13]

    References

    1. ↑ 1.0 1.1 Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
    2. ↑ Semel JD, Goldin H (1996). "Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples". Clin Infect Dis. 23 (5): 1162–4. doi:10.1093/clinids/23.5.1162. PMID 8922818.
    3. ↑ Swartz MN (2004). "Clinical practice. Cellulitis". N Engl J Med. 350 (9): 904–12. doi:10.1056/NEJMcp031807. PMID 14985488.
    4. ↑ Hook EW, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M (1986). "Microbiologic evaluation of cutaneous cellulitis in adults". Arch Intern Med. 146 (2): 295–7. PMID 3947189.
    5. ↑ 5.0 5.1 5.2 5.3 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
    6. ↑ Beltran J (1995). "MR imaging of soft-tissue infection". Magn Reson Imaging Clin N Am. 3 (4): 743–51. PMID 8564693.
    7. ↑ Miller LG, Quan C, Shay A, Mostafaie K, Bharadwa K, Tan N; et al. (2007). "A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection". Clin Infect Dis. 44 (4): 483–92. doi:10.1086/511041. PMID 17243049.
    8. ↑ Bobrow BJ, Pollack CV, Gamble S, Seligson RA (1997). "Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults". Ann Emerg Med. 29 (3): 404–8. doi:10.1016/s0196-0644(97)70354-8. PMID 9055782.
    9. ↑ Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M (2007). "Videos in clinical medicine. Abscess incision and drainage". N Engl J Med. 357 (19): e20. doi:10.1056/NEJMvcm071319. PMID 17989377.
    10. ↑ Halilovic J, Heintz BH, Brown J (2012). "Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess". J Infect. 65 (2): 128–34. doi:10.1016/j.jinf.2012.03.013. PMID 22445732.
    11. ↑ Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC (2004). "Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis". Arch Intern Med. 164 (15): 1669–74. doi:10.1001/archinte.164.15.1669. PMID 15302637. Review in: ACP J Club. 2005 Mar-Apr;142(2):45
    12. ↑ Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR; et al. (2013). "Penicillin to prevent recurrent leg cellulitis". N Engl J Med. 368 (18): 1695–703. doi:10.1056/NEJMoa1206300. PMID 23635049. Review in: J Fam Pract. 2014 Jan;63(1):E10-2
    13. ↑ Thornhill MH, Dayer M, Lockhart PB, Prendergast B (2017). "Antibiotic Prophylaxis of Infective Endocarditis". Curr Infect Dis Rep. 19 (2): 9. doi:10.1007/s11908-017-0564-y. PMC 5323496. PMID 28233191.
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