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Starship Children’s Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS
• Definition • Resistant Organisms
• The Cellulitis / Abscess Clinical Pathway • Personal Hygiene
• Admission Guidelines • Education
• Infection Control • Other discharge information
• Assessment • Referral to Community District Nursing
• Teams & Referrals Service
• Investigations • Referral to Community Services
• Treatment Flow Chart
• Antibiotics

Definition
Cellulitis is a diffuse inflammation of the soft tissue or connective tissue due to infection.
A child with cellulitis will have a red, warm and tender area of skin.

There may be associated fever, chills and sweats, regional lymph node involvement and proximal
red streaking. Cellulitis may lead to ulceration and abscess.

An abscess is a cavity containing pus with or without surrounding cellulitis.

The Cellulitis / Abscess Clinical Pathway


Most children who present to the Starship with cellulitis &/or abscess will be managed according to
the “Cellulitis/Abscess Clinical Pathway”. There are Pathway forms for recording outcomes and
variances which are available in CED and on the wards.

The following children should not be managed according to the Pathway:


• Neonates age <4 weeks
• Children who are immunocompromised
• Dental abscess / cellulitis
• Underlying osteomyelitis or septic arthritis
• Children with orbital cellulitis (see below).

Periorbital cellulitis is swelling and erythema in the soft tissues around the eye. These children
can be managed on the pathway.

Children with orbital cellulitis have clinical evidence of exophthalmos, pain on eye movement, or
limitation of eye movement OR radiographic evidence of subperiosteal or orbital abscess. Urgent
ophthalmology review is mandatory for these patients and they should NOT be managed according
to the pathway.

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 1 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Admission Guidelines
Admit ALL children who:
• are toxic,
• have peri-orbital cellulitis,
• have not responded to oral antibiotics within 48hrs,
• have families unable to cope with the illness at home,
• require IV antibiotic therapy.
Admit MOST children who:
• are systemically unwell,
• have another serious systemic illness (e.g.diabetes),
• have facial cellulitis / abscess,
• are young infants,
• have failed a trial of appropriate oral antibiotics (not tolerated or compliance problems).

Consider a trial of a different antibiotic if the child is stable and there was intolerance or an
inappropriate antibiotic used in the first instance. It is also worth checking the dose of the antibiotic
prescribed to see that it was adequate.

Other Considerations For Admission

There are certain issues that will influence the decision made whether to discharge or admit a
child. These may not reflect the state of illness but some of the following should be considered:

• Social e.g. issues of compliance, coping skills, anxiety etc.


• Transport and phone access.
• Lack of community services in areas, for example no district nurses.

Infection Control
The mode of transmission is through direct contact with a person who has a purulent lesion.
Hands are the main vehicle for transmitting infection. Washing and drying your hands is the most
important means in preventing the spread of infection.

Methicillin Resistant Staph Aureus (M.R.S.A.)


If a patient is found to be positive for MRSA from a wound swab, or is known to be MRSA positive
from previous swabs, they should be placed into contact isolation.

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 2 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Assessment
Abscess
If the child has a fluctuant lump, the child is to be referred to the surgical team for consultation/
incision and drainage.

If in doubt of the diagnosis, an ultrasound should be considered.

Cellulitis
Remember to ask about:

• Underlying skin disorders (e.g. eczema)


• Insect bites
• Significant water exposure (e.g. traumatic lesion / cut sustained while in a pond, stream)
• Immunisations (H.influenzae is an important causative organism in unimmunised children)
• Personal or family history of previous skin sepsis (remember MRSA)
• Overseas travel
• Past history and family history of cellulitis and other skin sepsis.

Remember to examine for lymphadenopathy.

In periorbital cellulitis always examine for signs of orbital involvement (exophthalmos, pain on eye
movement, or limitation of eye movement) & meningitis.

Examine regularly for developing fluctuance.

Teams & Referrals


All patients with orbital or suspected orbital cellulitis should have an ophthalmology and ENT
consult at the time of admission. Patients with periorbital cellulitis should have an ENT consult.

All patients with cellulitis should be examined at least daily to check for abscess development. If
fluctuance develops referral should be made to the appropriate surgical team (depending on the
location of the infection).

Location Abscess ± Cellulitis Cellulitis alone Note


Trunk Surgical General Paediatrics
Limbs Orthopaedics Orthopaedics Refer cellulitis occurring as a
complication of another
illness (e.g. eczema or
chickenpox) to the general
paediatric team.
Head & Neck Surgical / ENT General Paediatrics The ENT service would like
to be notified of all patients
admitted with periorbital
cellulitis.

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 3 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Investigations
Investigations are not routinely required in most children with cellulitis/abscess.
Blood Culture
Rarely indicated as of little diagnostic value even in the presence of systemic symptoms. Many
children will have been on antibiotics prior to presentation. Consider blood cultures if:

• Temperature >38.5º
• Not on oral antibiotics at time of presentation
• Underlying skin lesions such as varicella or eczema
• +/- facial cellulitis

Full Blood Count.


Not indicated as of little diagnostic value. A raised white count is not useful to confirm or refute the
clinical diagnosis and does not relate to prognosis.

Wound/Pus Swabs
Not routine. May be done if you are considering a resistant organism e.g. MRSA (however often
results are not available until after the patient is discharged).

A swab for AFB (acid fast bacilli) should be taken where nontuberculous mycobacteria is
suspected.

X-Rays
Not routine. Performed only after discussion with the Orthopaedic team.

CT Scan.
Children must have a CT scan (brain, orbits and sinuses) if there is clinical evidence of orbital
cellulitis. Note: children need not wait in CED until the CT scan has been undertaken but can be
transferred to the ward.

Lumbar Puncture
A lumbar puncture is usually indicated in patients with orbital cellulitis.
It is only considered in patients with peri-orbital cellulitis (or cellulitis involving other sites), if the
patient has any signs suggestive of meningitis (e.g. photophobia, meningism etc.)

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 4 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Treatment Flow Chart


Cellulitis

Consider Yes
Abscess
Surgical
Present?
Intervention

No

Penicillin
Allergic?

Yes
No

Site of
Cellulitis

Limbs or Neck, Face &


Torso Bites
(Dog & Human)

No IV IV IV
antibiotic antibiotic No antibiotic No
required? required? required?

Yes Yes Yes

IV IV IV
Flucloxacillin Amoxicillin + Erythromycin
Clavulanic acid

Oral
Flucloxacillin
capsules

Child unable to
take capsules

Yes
Oral Oral Oral
Amoxycillin + Amoxicillin + Erythromycin
Clavulanic acid Clavulanic acid tabs/suspension
suspension tabs/suspension

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 5 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Antibiotics
Choose the appropriate antibiotic according to site of cellulitis, etiology, presence or absence of
penicillin allergy, and ability of child to swallow tablets (see flow chart).

Duration of therapy: 7-10 days.

• Flucloxacillin.
Very effective against S.aureus and has adequate cover for S.pyogenes.

Use for IV therapy and oral therapy for children able to ingest capsules for torso and limb
cellulitis. As flucloxacillin is not palatable in the liquid form, amoxycillin and clavulanic acid may
be a more suitable alternative in a child requiring a syrup.

IV 100 mg/kg/day in four divided doses up to a max. 1000mg/dose.


PO 50 mg/kg/day in four divided doses up to a max. 500 mg/dose on an
empty stomach.

In severe infections a maximum of 2000mg/dose IV may be used

• Amoxycillin + Clavulanic Acid.


Has a much broader spectrum and is best reserved for puncture wounds, facial cellulitis,
animal and human bites, and oral therapy for those children unable to ingest capsules/tablets.

- IV 100 mg/kg/day* in three divided doses up to a max. 1000 mg/dose


- PO 40 mg/kg/day* in three divided doses up to a max. 500mg/dose with food.
* Doses expressed as amoxicillin component.

• Erythromycin.
The drug of choice when there is penicillin allergy.
If there is penicillin allergy (immediate allergic reaction, anaphylaxis or widespread urticaria) then refer to
paediatric immunology non acutely.

- IV 40mg/kg/day in four divided doses up to a max. 500mg/dose.


- PO 40 mg/kg/day in four divided doses up to a max. 500mg/dose with or
without food.

In severe infections a maximum of 1000mg/dose IV may be used

Resistant Organisms
If there is deterioration on the recommended Intravenous antibiotics or no improvement within 48
hours, consider resistant organisms (e.g. MRSA, resistant Streptococcus)

Discuss with General Paediatrics or Infectious Diseases team as necessary.

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 6 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Personal Hygiene
Parents should be reminded to;
• avoid sharing towels and bedding at home,
• wash linen and clothing regularly,
• maintain children’s short / clean fingernails to avoid skin breaks from scratching,
• examine their child’s skin and clean breaks in the skin,
• see their GP early if redness develops,
• encourage all family members to wash and dry hands properly,
• avoid sharing bath, swimming, and cleaning water when the child has an infected wound,
• restrict their child from swimming in unclean water when they have an open wound.

Education
• Parents / caregivers are to be given the ‘Skin Infections’ handout. This handout is to be
explained to parents/ caregivers.

Medications
Antibiotics
• Parents should be well informed regarding the use of the antibiotics prescribed.
• In particular they should be informed of the importance to complete the course given to the
child, and not to share the course of antibiotics among the family members.
• Parents should be aware of possible adverse effect.

Pain relief – Paracetemol


Caregivers should be informed of the appropriate dose of paracetemol to use for pain relief.

Insect Bites
Parents should;
• be educated to inspect child regularly, to identify insect bites early, so that bites can be treated
early,
• be informed that insect bites have the potential to lead to a more serious situation through
scratching,
• be advised to visit the G.P. early in the disease process.

Recurrent cellulitis/abscess

For children/families who have multiple episodes of skin infection:


• Reinforce personal hygiene measures,
• Encourage early presentation to the GP,
• Some families may find bathing with ½ tsp Janola / 5 litres water useful for reducing bacterial
loads,
• Family to consider discussion with GP regarding other possible decontamination strategies
(may include short/medium term antibiotics).

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 7 of 8
Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

CELLULITIS

Other discharge information


Parents should be advised to keep their child at home until the child has regained mobility, is pain
free, is afebrile and is systemically well.

Referral to Community District Nursing Service


The following are the considerations for a referral to Paediatric Homecare Starship, Waitemata
Homecare for Kids and South Auckland Home Health (adult district nursing);
• when the wound has a copious high exudate.
• when there is a drain in situ.
• When dressings are required.

Referral to Community Services


The following are other considerations for a referral to community services;
• when a G.P. is not identified,
• when there are transport difficulties,
• when social circumstances indicate a need,
• when the child has multiple skin infections,
• when there is a potential for cellulitis to develop into an abscess,

Author: Dr Alison Leversha Service: General Paediatrics


Editor: Dr Raewyn Gavin Date Issued: Reviewed April 2005
Cellulitis Page: 8 of 8