Cellulitis

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Background

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

Clinical Features

  • 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

Foot infection

Look A-Likes

Evaluation

Work-up

Evaluation

  • Generally clinical diagnosis, may be assisted by ultrasound (above)

Management

Antibiotics

Tailor antibiotics by regional antibiogram[2]

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS[3]

  • 5 day treatment duration, unless symptoms do not improve within that timeframe[3]
    • Cephalexin 500mg PO q6hrs OR
      • Add TMP/SMX DS 1 tab PO BID[4] if MRSA is suspected
      • Most cases of non-purulent cellulitis are thought caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.[5]
    • Clindamycin 450mg PO TID
    • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis, due to high rates of Strep resistance[6]

Inpatient

Saltwater related cellulitis

coverage extended for Vibrio vulnificus

Freshwater related cellulitis

coverage extended for Aeromonas sp

Predictors of Treatment Failure[7]

  • 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. 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
  3. 3.0 3.1 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
  4. 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.
  5. 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
  6. 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.
  7. 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.