The Diagnosis and Management of Cellulitis

Journal Club:
DIAGNOSIS AND
MANAGEMENT OF
CELLULITIS
CONTENTS
• INTRODUCTION
• CAUSATIVE ORGANISMS
• HISTORY TAKING
• CLINICAL PRESENTATION
• CELLULITIS MIMICS
• TREATMENT
• PROPHYLAXIS
• REFERENCE ARTICLE
• KEY POINTS
INTRODUCTION
DEFINITION OF CELLULITIS:
• Cellulitis is defined as an acute infection of the skin involving the
dermis and subcutaneous tissues.
• Erysipelas refer to a more superficial cellulitis of the face or
extremities with lymphatic involvement, classically due to
streptococcal infection.
CAUSATIVE ORGANISMS
• Culture negative cellulitis: Group A streptococcal infection
• Skin infection with pus: S aureus
• Animal bites: Pasteurella and Capnocytophaga
• Skin break + salt or fresh water: Vibrio
vulnificus and Aeromonas species respectively
HISTORY TAKING
• Pattern, speed of progression
• Age, comorbidities (diabetes, chronic kidney disease, hepatic disease, vascular

disease, immunosuppression)
• Recent antimicrobial treatment

• Possible site of inoculation – trauma, fungal infections
• History of previous cellulitis
• Travel history
ATYPICAL ORGANISMS:
1. profound immunosuppression
2. animal or human bites
3. sea or freshwater exposure
4. exposure to animals, fish, or reptiles
5. intravenous drug use
CLINICAL PRESENTATION
SYMPTOMS:
• Portal of entry: ulcers, trauma, eczema, cutaneous mycosis
• Groin pain
SIGNS:
• Rubor, dolor, tumor, calor
• bullae, necrotic tissue
• NECROTIZING FASCIITIS: rapidly spreading erythema, fulminant
sepsis, pain out of proportion to the clinical signs
MANAGEMENT
• Cultures of blood, aspirates or biopsies in:
a) Systemic features of sepsis
b) Immunosuppressed
c) Immersion injuries
d) Animal bites
CELLULITIS MIMICS
1. Eczema
2. Lymphoedema
3. Lipodermatosclerosis
• The above receive unnecessary hospital admission and antibiotics.

Dundee classification – markers of sepsis
The presence of infection, with 2/ more of:
1. White blood cell count < 4 or > 12/mm3
2. Temperature <36°C or >38°C
3. Heart rate > 90 beats/min
4. Respiratory rate > 20 breaths/min
Eron/CREST(Clinical Resource Efficiency Modified ‘Dundee’ classification
Support Team) classification
No sepsis, no comorbidities and
CLASS I No or well-controlled comorbidities, systemically well SEWS (Standardized Early Warning
Score) <4
Systemically unwell with no uncontrolled Documentation of one or more

comorbidities (eg: obesity, peripheral vascular significant comorbidities (eg obesity,
CLASS II disease or venous insufficiency) or systemically well peripheral vascular disease or
with poorly controlled comorbidities, which may venous insufficiency), no sepsis,
delay their recovery SEWS <4
Marked systemic inflammatory response (altered

mental status, tachypnoea, tachycardia, hypotension
etc.) or may have very poorly controlled
CLASS III comorbidities which may affect their response to
Sepsis but SEWS <4
treatment or have a limb-threatening infection due to
vascular compromise
Septic shock or life threatening presentations such as

CLASS IV necrotizing fasciitis requiring urgent critical care and Sepsis and SEWS ≥4
surgical input
SUSPECTED SEPSIS: NICE (National Institute for Health and Care
Excellence)
HIGH RISK CRITERIA:
1) Objective evidence of new altered mental state
2) RR: ≥25 breaths per minute/ new need for oxygen (≥40% FiO2) to maintain
saturation ≥92% (or ≥88% in known chronic obstructive pulmonary disease)
3) HR: ≥130 bpm

4) SBP ≤90 mmHg or ≥40 mmHg below normal
5) Not passed urine in previous 18 hours; catheterized patients: passed < 0.5 mL/kg
urine/hour
6) Mottled/ ashen appearance
7) Cyanosis of skin/ lips/ tongue
8) Non-blanching rash of skin
TREATMENT
• Abscesses, furuncles or carbuncles: Incision and Drainage
• Dundee class I: Oral antimicrobial therapy
• Dundee class II: Initial intravenous therapy, then oral antibiotics
• Dundee class III and IV: Intravenous agents
• Necrotizing infection: Urgent surgical debridement
• Mild to moderate cellulitis: Agent against streptococci
• Penetrating trauma/ purulent infection: add anti-staphylococcal
cover
• Venous thromboembolism: Low-molecular-weight heparin
No penicillin allergy Non-severe penicillin allergy Severe penicillin
allergy
Clarithromycin
Initial PO Flucloxacillin 500 mg – As for severe penicillin allergy or 500 mg bd PO or
therapy 1 g qds PO cephalexin 500 mg qds PO Doxycycline 100 mg
bd PO
Clindamycin 600 mg
Initial IV Flucloxacillin 1–2 g 6- Ceftriaxone 1–2 g OD – 1.2 g IV qds IV or
therapy hourly IV IV vancomycin
Broad spectrum antimicrobials in:
• Human/ animal bites
• Atypical sites: face, torso and upper limb
• Severe/ necrotising infections
Limb elevation
Treat comorbidities
Outpatient Parenteral Antimicrobial Therapy(OPAT):

• Moderate (Dundee grade II) cellulitis without necrotizing infection or
sepsis
• Early discharge
 Treatment success rates: ~90%
DURATION:
• 1–2 weeks
• Uncomplicated Skin and Soft Tissue Infections: switch to oral
antibiotics after 1–4 days of parenteral therapy
CREST CRITERIA FOR ORAL SWITCH:

1. Settling pyrexia
2. Stable comorbidities
3. Less intense erythema
4. Falling inflammatory markers
PROPHYLAXIS
• Address predisposing factors:
1)lower limb oedema
2)lymphoedema
3)dermatitis
4)tinea pedis
• 3-4 episodes of cellulitis/ year despite addressing predisposing
factors: prophylactic antimicrobial therapy so long as the factors
persist
• Phenoxymethylpenicillin prophylaxis in recurrent cellulitis- reduced
rate of recurrence
REFERENCE ARTICLE
• Sullivan T, de Barra E. Diagnosis and management of cellulitis. Clin

Med (Lond). 2018 Mar;18(2):160-163. doi: 10.7861/clinmedicine.18-
2-160. PMID: 29626022; PMCID: PMC6303460.
KEY POINTS
• Correct diagnosis is key. Consider non-infectious conditions.
• Narrow spectrum penicillins targeting streptococci and staphylococci =

mainstay of antimicrobial therapy
• Natural history of cellulitis: slow resolution. Fever and inflammation: first

72 hours of treatment. Management: limb elevation, narrow-spectrum
antimicrobial therapy, treatment of comorbid conditions.
• Outpatient parenteral antimicrobial therapy (OPAT) in patients requiring

intravenous therapy. Daily review and early switch to oral therapies is
optimal.
• Recurrent cellulitis: address risk factors, prophylaxis

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Journal Club:

• Age, comorbidities (diabetes, chronic kidney disease, hepatic disease, vascular

• Recent antimicrobial treatment

• The above receive unnecessary hospital admission and antibiotics.

Systemically unwell with no uncontrolled Documentation of one or more

Marked systemic inflammatory response (altered

Septic shock or life threatening presentations such as

3) HR: ≥130 bpm

Outpatient Parenteral Antimicrobial Therapy(OPAT):

CREST CRITERIA FOR ORAL SWITCH:

• Sullivan T, de Barra E. Diagnosis and management of cellulitis. Clin

• Narrow spectrum penicillins targeting streptococci and staphylococci =

• Natural history of cellulitis: slow resolution. Fever and inflammation: first

• Outpatient parenteral antimicrobial therapy (OPAT) in patients requiring

• Recurrent cellulitis: address risk factors, prophylaxis

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