Figure 178-2 A. Cellults after puncture trauma, The forearm mation. B, Cellulitis arising at the site of a surgical deep-seated infection. Crepitus is a rare sign that sign fies a gas-forming pathogen (see Chapter 179). Cellulitis usually presents atthe site of an antecedent lesion, including acute and chronic ulcers, traumatic wounds (abrasions, lacerations, animal and human, bites), surgical procedure sites, dermatoses, or percuta- neous catheters. Less commonly, bacteremia {rom sys temic infections such as osteomyelitis and diverticular abscesses may cause SSTI Although erysipelas shares many clinical features with classical cellubitis (pain, tenderness, erythema, and edema), the plaque-like edema has a more sharply defined margin to normal tissue, and the erythema is classically bright red (Fig. 178-3). The surface findings are often described as penu id'orange (skin of an orange) in appearance. In the presence of antecedent edema or other anatomic abnormalities, the margin between normal and diseased soft tissue may be more obscure, much a in primary cellulitis, Seventy-five to 90% of cases involve the lower ‘extremities, while the face is affected in 25%-10% of cases.” Facial erysipelas begins unilaterally but may spread by contiguity over the nasal prominence to involve the face symmetrically (Eig. 178-4). There may not be an obvious portal of entry, and skipped areas ray confuse the nature of the process. The oropharynx is a common portal of entry, and throat culture may show GAS. Inflammatory edema can extend tothe lids, but orbital complications are rare Fever may precede local signs, and occasionally before distal extremity findings, patients complain of groin pain caused by swelling of femoral lymph nodes. Lymphangitis and abscess are not common, but the process may spread rapidly from the initial lesion Infrequently, bullae or epidermal sloughing may occur in the involved area.” tender; there is abscess yiococcus aureus. Note discharge of p Surgical wound infections are the most common adverse events in hospitalized patients undergoing surgery and are classified as incisional (superficial) or deep.” Incisional wound infections involve the skin, subcutaneous tissue, and /or muscle (see Fig. 178-28) Up to 80% of wound infections are incisional. A wound is considered to be infected if there is drainage of pur Tent material and evidence of inflammation. Incisional infections present with erythema, pain, tenderness, Figure 178-3 Exysipelas ythema ofthe lower extremity 2163