CELLULITIS

CELLULITIS

Definitions:
An acute, diffuse inflammation of the skin and subcutaneous structures characterized by hyperaemia, edema, and leukocytic infiltration. An acute, diffuse, and suppurative inflammation of loose connective tissue, particularly the deep subcutaneous tissues, and sometimes muscle, which is most commonly seen as a result of infection of a wound, ulcer, or other skin lesions. An acute, spreading infection of the deep tissues of the skin and muscle that causes the skin to become warm and tender and may also cause fever, chills, swollen lymph nodes, and blisters.

Risk Factors: Trauma, Injury Underlying skin lesion-furuncle, skin ulcer Neoplasms Extremity Stasis or Edema Diabetes Mellitus Immunocompromised Causes:

Most common Staphylococal Group A Stretococcus

 Symptoms: Inflamed skin wound develops rapidly days after injury Local tenderness Pain Very red, hot, swollen and painful Associated symptoms Malaise, fever, chills. Signs: Erythema , warmth, edema, erythematous plaque usually tender-to-painful to touch without sharply demarcated border May cover small to large area of skin Fever, lympadenopathy frequent

Diagnosis
Diagnosis is based upon clinical manifestations. Cultures of blood, needle aspirations, or punch biopsies arent useful in mild infection. Cultures should be performed in patients with systemic toxicity, extensive skin involvement, underlying comorbidities (ie diabetes), animal bite, or recurrent cellulitis. Radiographic exam can be useful in excluding occult abscess and osteomyelitis.

Microbiology
Most common pathogens are beta-hemolytic Strep and Staph aureus, including MRSA. Gram-negative aerobic bacilli are identified in a minority of cases.

Treatment
Antibiotic selection for treatment depends on whether presentation consists of purulent or nonpurulent cellulitis (per 2011 ID Society of Americal guidelines).

Treatment: Purulent cellulitis

Patients with purulent cellulitis (purulent drainage or exudate, in the absence of a drainable abscess) should be managed with empiric therapy for infection due to MRSA.

Treatment: MRSA
Options for empiric oral therapy for MRSA: 1) Clindamycin 300 to 450 mg PO TID 2) Bactrim 1-2 DS tab PO BID 3) Doxycycline 100 mg PO BID 4) Linezolid 600 mg PO BID Depends on clinical response but a time course of 5-10 days is usually appropriate.

Treatment: Nonpurulent Cellulitis

For nonpurulent cellulitis, cover for betahemolytic Strep and MSSA. MRSA coverage is warranted for patients fail initial therapy, signs of systemic illness, recurrent infection in the setting of underlying predisposing conditions, and previous episode of MRSA infection. Empiric MRSA coverage should be used in patients with risk factors for MRSA and in communities with high prevalence of MRSA.

Treatment: Nonpurulent
Options for Nonpurulent cellulitis (excluding MRSA) 1) Dicloxacillin 500 mg PO every 6 hours 2) Cephalexin 500 mg PO every 6 hours 3) Clindamycin 300 to 450 mg PO every 6-8 hours Depends on clinical response but a time course of 5 to 10 days is usually appropriate.

Treatment: MRSA and Nonpurulent

Options for empiric oral therapy for betahemolytic Strep and MRSA: 1) Clindamycin 300 to 450 mg PO TID 2) Amoxicillin 500 mg PO TID + Bactrim 1 to 2 DS tabs PO BID 3) Amoxicillin 500 mg orally TID + Doxycycline 100 mg orally twice daily 4) Linezolid 600 mg orally BID A time course of 5 to 10 days is usually appropriate.

Treatment Requiring Hospitalization

Parenteral therapy should be considered for patients with extensive soft tissue involvement, fever or other signs of systemic illness, or patients with diabetes or other immunodeficiency.

 Prevention of Recurrent: Prevention of Recurrent Reduce peripheral edema (support stockings) Good skin hygiene Prophylactic antibiotics: Efficacy Not useful if underlying predisposing condition No Penicillin Allergy Penicillin G 1.2 MU IM q4 weeks Penicillin V 250 mg PO bid Penicillin Allergic Erythromycin 500 mg PO qd Azithromycin 250 mg PO qd Clarithromycin 500 mg PO qd

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