Cellulitis: Difference between revisions

(Created page with "==Background== *Acute non-purulent spreading infection of the subcutanous tissue, causing overlying skin inflammation *Most often caused by strep, staph, MRSA *H.flu is most c...")
 
 
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==Background==
==Background==
*Acute non-purulent spreading infection of the subcutanous tissue, causing overlying skin inflammation
{{Skin anatomy background images}}
*Most often caused by strep, staph, MRSA
*Acute spreading infection of the dermis and subcutanous tissue, causing overlying skin inflammation<ref name="Gunderson">Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012 Feb;64(2):148-55.</ref>
*H.flu is most common cause in the orbit.
*Most often caused by streptococcus or staphylococcus (including [[MRSA]])


==Diagnosis==
===Risk factors<ref>Quirke M et al. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017 Aug;177(2):382-394.</ref>===
*Often accompanied by fever, chills, malaise, HA, vomiting
*Previous cellulitis
*Rash
*Wound or current leg ulcers
**Local redness, heat, swelling
*Excoriating skin diseases
**Warm tender indistinct margins. Pyrexia may signify systemic spread
*[[Lymphedema]]
*Venous insufficiency
*Obesity
*[[Tinea pedis]]


==Treatment==
==Clinical Features==
*Simple erysipelas
[[File:Cellulitis Of The Leg.jpg|thumb|Cellulitis of the leg]]
**Penicillin G (300K U/d IM for <30 kg, 600K to 1 million U/d IM for >30 kg)
*[[Rash]]
*Bullous erysipelas
**Local erythema, warmth, swelling
**Clindamycin OR trimethoprim-sulfamethoxazole
**Tender indistinct margins
*Can be accompanied by fever, chills, malaise, headache, nausea/vomiting


==Source==
==Differential Diagnosis==
*Tintinalli
{{SSTI DDX}}
{{Hand Infection DDX}}
{{Foot infection}}
{{Erythematous rash DDX}}


[[Category:Peds]]
==Evaluation==
[[Category:Derm]]
*Generally clinical diagnosis, may be assisted by ultrasound (above)
*[[Ultrasound: Soft tissue|Ultrasound]] can aid in diagnosis - may see "cobblestoning" of subcutaneous fat due to accumulation of fluid in these tissues. Also helpful to evaluate for [[abscess]].
 
==Management==
===[[Antibiotics]]===
{{Cellulitis antibiotics}}
 
===Predictors of Treatment Failure<ref>Peterson D. et al. Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis. Acad Emerg Med. 2014 May;21(5):526-31.</ref>===
*Fever (T>38°C) at triage (odds ratio [OR] 4.3)
*Chronic leg ulcers (OR 2.5)
*Chronic edema or lymphedema (OR 2.5)
*Prior cellulitis in the same area (OR 2.1)
*Cellulitis at a wound site (OR 1.9)
 
==Disposition==
*Admit for:
**Sepsis
**Significant hand, face, or genitalia infection
**Failure of outpatient treatment
**Significant comorbidity (e.g. immunocompromized, poorly controlled diabetes)
 
==See Also==
*[[Orbital cellulitis]]
*[[Hand cellulitis]]
*[[Periorbital cellulitis]]
*[[Erysipelas]]
*[[Facial cellulitis]]
*[[Erythematous rash]]
 
==References==
<references/>
 
[[Category:Dermatology]]
[[Category:ID]]

Latest revision as of 16:18, 11 December 2024

Background

Normal dermal anatomy.
  • Acute spreading infection of the dermis and subcutanous tissue, causing overlying skin inflammation[1]
  • Most often caused by streptococcus or staphylococcus (including MRSA)

Risk factors[2]

  • Previous cellulitis
  • Wound or current leg ulcers
  • Excoriating skin diseases
  • Lymphedema
  • Venous insufficiency
  • Obesity
  • Tinea pedis

Clinical Features

Cellulitis of the leg
  • Rash
    • Local erythema, warmth, swelling
    • Tender indistinct margins
  • Can be accompanied by fever, chills, malaise, headache, nausea/vomiting

Differential Diagnosis

Skin and Soft Tissue Infection

Look-A-Likes

Hand and finger infections

Look-Alikes

Foot infection

Look A-Likes

Erythematous rash

Evaluation

  • Generally clinical diagnosis, may be assisted by ultrasound (above)
  • Ultrasound can aid in diagnosis - may see "cobblestoning" of subcutaneous fat due to accumulation of fluid in these tissues. Also helpful to evaluate for abscess.

Management

Antibiotics

Tailor antibiotics by regional antibiogram[3]

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS[4]

  • 5 day treatment duration, unless symptoms do not improve within that timeframe[4]
    • Cephalexin 500mg PO q6hrs OR
      • Add TMP/SMX DS 1 tab PO BID[5] if MRSA is suspected
      • Most cases of non-purulent cellulitis are caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.[6]
    • Clindamycin 450mg PO TID covers both Strep and Staph
    • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis due to high rates of Strep resistance[7]

Inpatient

Saltwater related cellulitis

coverage extended for Vibrio vulnificus

Freshwater related cellulitis

coverage extended for Aeromonas sp

Predictors of Treatment Failure[8]

  • Fever (T>38°C) at triage (odds ratio [OR] 4.3)
  • Chronic leg ulcers (OR 2.5)
  • Chronic edema or lymphedema (OR 2.5)
  • Prior cellulitis in the same area (OR 2.1)
  • Cellulitis at a wound site (OR 1.9)

Disposition

  • Admit for:
    • Sepsis
    • Significant hand, face, or genitalia infection
    • Failure of outpatient treatment
    • Significant comorbidity (e.g. immunocompromized, poorly controlled diabetes)

See Also

References

  1. ↑ Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012 Feb;64(2):148-55.
  2. ↑ Quirke M et al. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017 Aug;177(2):382-394.
  3. ↑ Stevens D, et al. 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. 2014;59(2):e10-e52
  4. ↑ 4.0 4.1 Stevens D, et al. 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. 2014;59(2):e10-e52
  5. ↑ Cadena J, et al. Dose of trimethoprim-sulfamethoxazole to treat skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus. Antimicrobial agents and chemotherapy 55.12 (2011): 5430-5432.
  6. ↑ Pallin D, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 56.12 (2013): 1754-1762
  7. ↑ Traub, W and Leonhard, B. Comparative susceptibility of clinical group A, B, C, F, and G beta-hemolytic streptococcal isolates to 24 antimicrobial drugs. Chemotherapy 43.1 (1997):10-20.
  8. ↑ Peterson D. et al. Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis. Acad Emerg Med. 2014 May;21(5):526-31.
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