EMed

Cellulitis

Background

Cellulitis is an acute, spreading, pyogenic inflammation of the lower dermis and subcutaneous tissue.

  • Incidence rising
  • Majority - S. pyogenes or Staph aureus
  • MRSA and VLE versions emerging
  • Dx is clinical
  • Classified using Dundee criteria

Risk factors

  • Venous insufficiency
  • Lymphoedema (also a complication)
  • Peripheral vascular disease
  • Diabetes mellitus
  • Obesity
  • Tinea pedis
  • Local ulcers, trauma, insect bites

Diagnosis

  • Clinical
  • Usually lower limb
  • Acute, tender, erythematous, swollen area
  • ± ill-distinct margin (subcut. rather than skin infection)
  • ± blisters
  • ± ulcers
  • ± oedema
  • Classically ascending lymphangitis
  • Regional adenitis
  • Fever, Malaise
  • Beware sepsis (See SIRS)

Differential Dx

Treatment recommendations for cellulitis based on organisms

Stasis dermatitis Absence of pain or fever; circumferential; bilateral
Acute arthritis Involvement of joint; pain on movement
Pyoderma gangrenosum IBD Hx, Local ulceration
Hypersensitivity/drug reaction Hx exposure, pruritus, not toxic, little pain
DVT Low (if any) fever, few skin changes
Necrotising fasciitis Severe pain, swelling and fever; rapid progression; pain out of proportion; systemic toxicity; skin crepitus; necrosis; ecchymosis

Investigations

  • Check blood glucose (or BM) in all
  • WCC / CRP / d-dimers are not helpful
  • U&E / Creat in all
  • Blood cultures only if significant systemic upset including pyrexia (>38°C).
  • Swab (C&S) open wounds.
  • Imaging if suspected DVT or abscess/ostemyelitis.
  • MRI if suspicion of necrotising facsiitis.

Treatment

  • Analgesia
  • Treat the patient, not the test
  • Rest, elevation, analgesia ± VTE thromboprophylaxis
  • Mark the area
  • IV or PO antibiotics
  • Beware SIRS
  • Beware possibility MRSA or VLE in susceptible patients
  • Admit CDU if IV antibiotics required and no SIRS
  • Out patient IV antibiotics only after discharge from CDU

Atypical Scenarios

Clinical presentation Organism Antibiotic (more on nchd.ie
Typical cellulitis Streptococcus pyogenes Clindamycin or Amoxicillin or Flucloxacillin
Typical cellulitis—pus forming Staphylococcus aureus Clindamycin or Flucloxacillin
Penicillin allergy NA Clindamycin or Clarithromycin
Cat or dog bite Pasteurella multocida Co-amoxiclav; if allergic to penicillin: doxycycline and metronidazole
Freshwater exposure Aeromonas hydrophila Ciprofloxacillin
Salt-water exposure Vibrio vulnificus Doxycycline
Necrotising fasciitis Clostridium perfringens Benzylpenicillin, ciprofloxacillin, and clindamycin
Butchers and fish handlers Erysipelothrix Ciprofloxacillin

Dundee classification of severity

Patients should be stratified into four classes of severity (class IV most severe) based

  1. Sepsis
  2. Co-morbidity
  3. Standardized early warning score (SEWS).

SIRS = ≥2 of: <4 WCC >12, <36° Temp >.388C, HR > 90, RR >20

Further details to follow - but class 3 (significant co-morbidities or SIRS features are not suitable for CDU).

CDU (CUH) patients

For CDU patients please start either:

  1. Cefazolin 2g q24h iv plus probenicid 1g po q24h if CIT suitable.
    or
  2. Flucloxacilin (± penicillin) (more on nchd.ie).

Cefazolin / Probenicid

More details on home IV antibiotics for cellulitis.

If the patient is unable to tolerate the once daily regimen due to GI upset, then prescribe Cefazolin 2g twice daily iv without the probenacid.

Check dosing (with pharmacist) in renal impairment.

For penicillin allergic (OPAT/CIT only) patients, please contact micro. for advice on vancomycin dosing and monitoring.

Probenecid contra-indicated with:

  • Methotrexate
  • Sodium phenylbutyrate
  • Ketorolac
  • Pyrazinamide
  • High dose aspirin
  • Dapsone
  • Heparin
  • Fosfomycin

More details on home IV antibiotics for cellulitis.

Content by Dr Íomhar O' Sullivan 10/08/2012. Last review Dr ÍOS 13/05/19.