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Dermatology
Cellulitis

Background

CellulitisCellulitis is defined as acute spreading inflammation involving the soft tissue, excluding muscle, characterised by recent onset soft-tissue erythema, warmth, swelling and tenderness, considered to be of infective origin, and acquired in the community (Nova Scotia Adult Cellulitis Guidelines 2000).

 

 

Assessment

  1. Definition
      • An acute skin and soft tissue infection characterised by localised pain, swelling, tenderness, erythema and warmth. If there is no increased warmth it is unlikely to be cellulitis.
      • The patient often feels quite unwell with a fever and chills.
      • It is often but not always preceded by a skin problem such as trauma, a cut, a puncture wound, an insect bite, ulceration, tinea pedis, onychomycosis or dermatitis .
      • The skin may blister. The borders are likely to be indistinct, unlike in erysipelas in which the borders are sharply demarcated and raised.
      • After successful treatment, the skin may flake or peel off as it heals.
    • Causes
      • The most common infecting organisms are Streptococcus pyogenes (two thirds) and Staphylococcus aureus (one third). Approximately 10% of Staphylococcus aureus may be beta-lactam resistant (MRSA).
    • Lymphangitis is a red line originating from the cellulitis and leading to tender swollen lymph glands draining the affected area (eg in the groin with a leg cellulitis). It is caused by infection within the lymph vessels. 
    • Bilateral cellulitisNote: Bilateral cellulitis is uncommon. Consider alternative diagnosis such as CHF, venous insufficiency and dependent oedema.

       

       

    • Note: Where a collection is noted, drainage is a priority.

     

    Grade 1 Grade 2 Grade 3 Grade 4

    Symptoms

    Signs           

    Medically stable

    No systemic toxicity

    No uncontrolled comorbidities

    Systemically ill or systemically well with co-morbidity such as:

    peripheral vascular disease

    chronic venous insufficiency

    morbid obesity

    which may complicate or delay resolution of their infection

    Significant systemic upset:

    Tachycardia 100-130

    Tachypnoea 20-24 Hypotension-relative

     

     

    Significant systemic upset:

    Tachycardia > 130

    Tachypnoea > 24

    Hypotension-symptomatic/unstable

     

    Unstable comorbidities that may interfere with a response to therapy

    Limb threatening infection due to vascular compromise

    Severe life-threatening infections such as necrotizing fasciitis

    Treatment

    Treat PO antibiotics as per Grade I table

    Treat PO antibiotics as per Grade II table

    Treat PO antibiotics as per Grade III table.

    If adherence is a major concern, or patient is unable to take probenecid, please refer to hospital.

    Admit

    • (Adapted from the Clinical Resource Efficiency Support Team (CREST) guidelines on the management of cellulitis in adults 2005).

Management

  1. Absolute Exclusions:

    Absolute Exclusions Recommended Action

    Age<15

    refer to the childhood skin sepsis pathway

    Periorbital cellulitis -note this is graded 4

    refer ophthalmology (TGA) / surgical (WHK) or Paediatrics in children

    Orbital cellulitis (characterised by painful movement of the eye).

    refer ophthalmology / surgical (WHK) or Paediatrics in children

    Underlying fracture

    refer orthopaedic

    Septic arthritis

    refer orthopaedic

    Suspected compartment syndrome

    refer orthopaedic

    Suspected necrotising fasciitis - consider if pain is out of proportion to appearance, there is significant pain on muscle movement, patient is unwell out of proportion to appearance or if 'cellulitic' area is growing rapidly. 

    refer general surgery

    Exceeds Grade III criteria

    refer medical


    Relative Exclusions:

    Relative Exclusions

    Recommended Action

    Infection in butcher, hunter or fisherman 

    d/w ID physician

    Fresh water injuries

    d/w ID physician

    Immunosuppressive therapy

    d/w ID physician

    >40mg oral steroids for >2 weeks

    d/w ID physician

    Current chemotherapy

    d/w oncologist

    Asplenia

    d/w medical team

    Cellulitis in the same limb as a prosthesis

    d/w orthopaedics

    Collection requiring drainage that cannot be managed in primary care

    d/w surgical team

    Foreign body that cannot be managed in a timely manner in primary care

    d/w surgical team

  2. Grade 1 Investigations and Treatment
      • Consider the following investigations:
        • HbA1c
        • Renal function:
          • eGFR > 30ml/min/1.73m2 – treat with probenecid if no other contraindication
          • eGFR < 30ml/min/1.73m2 – no probenecid
          • eGFR < 10ml/min/1.73m2 – discuss with ID consultant
        • Consider FBC/CRP for monitoring
    • No Penicillin allergy

      Not MRSA

      Not Human or animal bite

      * Flucloxacillin 1g PO BD + Probenecid 500mg PO BD for 7 days

       

      Can’t take probenecid?

      * Flucloxacillin 1g PO QID for 7 days

      Non-anaphylactic Penicillin allergy 

      Not MRSA

      Not Human or animal bite

      * Cephalexin 1g PO BD + Probenecid 500mg PO BD for 7 days

       

      Can’t take probenecid?

      * Cephalexin 1g PO QID for 7 days

      Anaphylaxis to Penicillin

      Not MRSA

      Not Human or animal bite

      * Clindamycin 450mg PO QID for 7 days

      Human or animal bite

      Augmentin 625mg PO TDS for 7 days

      Discuss with ID consultant if allergic to penicillin

      MRSA

      Treat as per sensitivities:

      * Co-trimoxazole 960mg PO BD for 7 days

       or

      * Clindamycin 450mg PO QID for 7 days

  3. Grade 2 Investigations and Treatment
      • Consider the following investigations:
        • HbA1c
        • Renal function:
          • eGFR > 30ml/min/1.73m2 – treat with probenecid if no other contraindication
          • eGFR < 30ml/min/1.73m2 – no probenecid
          • eGFR < 10ml/min/1.73m2 – discuss with ID consultant
        • Consider FBC/CRP for monitoring
    • No penicillin allergy

      Not MRSA

      Not human or animal bite

       

      * Flucloxacillin 1g PO BD + Probenecid 500mg PO BD for 7 days

       

      Can’t take probenecid?

      * Flucloxacillin 1g PO QID for 7 days

      Non-anaphylactic penicillin allergy

      Not MRSA

      Not human or animal bite

      * Cephalexin 1g PO BD + Probenecid 500mg PO BD for 7 days

       

      Can’t take probenecid?

      * Cephalexin 1g PO QID for 7 days

      Anaphylaxis to penicillin

      Not MRSA

      Not human or animal bite

      * Clindamycin 450mg PO QID for 7 days

      Human or animal bite

      Augmentin 625mg PO TDS for 7 days

       

      Discuss with ID consultant if allergic to penicillin

      MRSA

      Treat as per sensitivities:

      * Co-trimoxazole 960mg PO BD for 7 days

       or

      * Clindamycin 450mg PO QID for 7 days

  4. Grade 3 Investigations and Treatment
      • HbA1c
      • Renal function:
        • eGFR > 30ml/min/1.73m2 – treat with probenecid if no other contraindication
        • eGFR < 30ml/min/1.73m2 – no probenecid
        • eGFR < 10ml/min/1.73m2 – discuss with ID consultant
      • Consider FBC/CRP for monitoring
    • Notes

      The oral dosing  for grade 3 is therapeutically equivalent to IV.

      If adherence is a major concern, or the patient is unable to take probenecid, please refer to hospital

      No penicillin allergy

      Not MRSA

      Not human or animal bite

      * Flucloxacillin 1g PO TDS + Probenecid 500mg PO TDS for 7 days

       

      If the patient is >120kg:

      * Flucloxacillin 1g PO QID + Probenecid 500mg PO QID for 7 days

      Non-anaphylactic penicillin allergy

      Not MRSA

      Not human or animal bite

      * Cephalexin 1g PO TDS + Probenecid 500mg PO TDS for 7 days

       

      If the patient is >120kg:

      * Cephalexin 1g PO QID + Probenecid 500mg PO QID for 7 days

      Anaphylaxis to penicillin

      Not MRSA

      Not human or animal bite

      * Clindamycin 450mg PO QID for 7 days

      Human or animal bite

      Refer to hospital for IV antibiotics

      MRSA

      Treat as per sensitivities:

      * Co-trimoxazole 960mg PO BD for 7 days

      or

      * Clindamycin 450mg PO QID for 7 days

  5. Grade 4 and Exclusions: Refer to appropriate hospital service
    • Using the switchboard GP line (priority service) and acute e-Referral (if available) acute referrals should be sent to the appropriate team as per the

       

      Cellulitis / Gangrene

      Cellulitis over a joint without evidence/suspicion of osteomyelitis or septic arthritis

       

      General Surgery

      Cellulitis over a joint with evidence/suspicion of osteomyelitis or septic arthritis

      Orthopaedics

      Associated with wound (no joint / osteomyelitis involvement)

      General Surgery

      Diabetic foot ulcer with cellulitis 

      General Surgery (or General Medicine as an alternative)

      Suspected necrotising fasciitis

      General Surgery. as an emergency

      Infection requiring surgical debridement or amputation

      General Surgery

      Facial or odontogenic:

      Adults

      Children

      Whakatane (Adults)

       

      General Medicine

      Paediatrics

      General Surgery

      Periorbital

      Orbital

      General Medicine

      Ophthalmology 

      Perineum involved

      General Surgery or Urology (if suspected Fourniers gangrene)

      All others

      General Medicine

  6. Elevation
    • Elevation of the limb is a critical part of the management of cellulitis and must be emphasized to the patient. It is probably the main reason people who are hospitalised do better than people in the community.
    • Elevation will:
      • Assist with pain control.
      • Improve the success of the treatment.
      • Help prevent deterioration and a hospital stay.
      • Help prevent the need for intravenous antibiotics if on oral therapy.
      • Minimise duration of IV antibiotic use.
      • Elevate the leg above the heart.
      • This requires the patient to remain in bed/on the couch with the leg rested on pillows to elevate the limb (see picture below).
      • They should mobilise every hour for a short period to get food/drink or use the toilet.
      • They should remain off work.
    • EXCEPTION: Patient with known peripheral vascular disease. The benefit of limb elevation should be weighed up against the vascular compromise that this may create.
    • Ideal position

      • Elevate the arm above the heart.
      • They should utilise a high arm sling while mobile.
      • While sitting/sleeping they should fashion an elevated platform to rest the arm on utilising pillows/cushions.
      • They should remain off work.
    • Patient information on Importance of Elevation 
  7.  Review
    • Grade 1 can be reviewed PRN. Grade 2 and 3 should be reviewed within 48 hours of treatment initiation, and then PRN. Treatment failure: review diagnosis and/or refer to hospital.
    • Determine appropriate review period dependent on appearance of affected limb.
    • Monitor for complications and inform the patient of what to look out for:
    • Local signs of increasing tissue infection:
      • Pain
      • Swelling
      • Ulceration
    • System signs:
      • Unresolving/worsening fever
      • Tachycardia
      • Hypotension
      • General unwellness
    • Watch out for adverse reactions to antibiotics including:
      • Clostridium difficile if diarrhoea occurs with cephazolin or clindamycin treatment, as this is a broad-spectrum antibiotic. If concerned a stool culture for Clostridium difficile and a stool assay for Clostridium difficile toxin are diagnostically helpful. 
    • Duration/Monitoring
      • Note appearances may worsen before they improve; this is to be expected and systemic signs should therefore be taken into consideration before assuming spread of cellulitis is an indication of lack of response to the antibiotics. The area can increase due to toxin release and move proximally even with limb elevation.
      • The limb is not required to look normal prior to stopping the antibiotics. 
      • While 5-7 days of antibiotics is sufficient for most cases, occasionally courses of up to 14 days may be necessary.
      • Resolution may include blistering of the skin; as these blisters de-roof the exposed tissue may weep and be red in appearance - this is a normal response. Alternatively the skin may exfoliate revealing new, red skin underneath.
    • If the patient is on warfarin note any potential interactions and test/adjust dose accordingly.
  8. Management for Recurrent Cellulitis:
    • Consider and treat:
      • Diabetes
      • Fungal infections (tinea pedis)
      • Lymphoedema - consider compression
      • Obesity
      • Alcoholism
    • Those with recurrent cellulitis should:
      • Avoid trauma by wearing long sleeves/pants when doing activities such as gardening.
      • Keep skin clean and well moisturised with nails well-tended.

Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.