Background

Assessment

1. Definition
   • Clinical Features
     • 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 cellulitis

     Note: Bilateral cellulitis is uncommon. Consider alternative diagnosis such as CHF, venous insufficiency and dependent oedema.

      

      

2. Decide Classification
   • 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. Exclusions from Community Management

   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
   • Grade 1 Laboratory Investigations
     • 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
   • Grade 1 Oral Treatment

     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
   • Grade 1 and 2 Laboratory Investigations
     • 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
   • Grade 2 Oral Treatment

     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
   • Grade 3 Laboratory 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
   • Grade 3 Treatment Options

     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 hospital standard operating procedures (SOP) guidelines

     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.
   • Those with lower limb cellulitis should
     • 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 image

     

   • Those with an upper limb cellulitis should
     • 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

• For Providers
  • Pathlab Antibiotic Susceptibility
  • Cellulitis Hospital Elevation Suggestions
  • Cellulitis CME talk by Kate Grimwade January 2021
  • EBOP Cellulitis Flowchart
• For Patients
  • Elevation Advice
  • What to look out for
  • EBOP Cellulitis Patient Advice
• Acknowledgements

  This pathway was developed in collaboration with the following:

  Position	Name
  Medical SMO	*Kate Grimwade
  WBOP GP	*Nick Hanna
  WBOPPHO	Sue Matthews
  Paeds SMO	Hugh Lees
  P&F Portfolio Manager	Richard Vipond
  Orthopaedic SMO	Richard Keddell
  BOPDHB Business Leader	Bronwyn Anstis
  Te Manu Toroa	Debbie Inglis
  Pathlab	Michael Addidle
  P&F BOPDHB	Philippa Jones
  EBOPPHA	Sandra Ball
  Project Administrator	Jacky Maaka
  Program Manager	Caroline Davy
  Project Manager	Wendy Carey
  GP Liaison	Chris Tofield

  *Pathway Lead

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.