Cellulitis resident survival guide: Difference between revisions

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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Cellulitis Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Dos|Dos]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Cellulitis resident survival guide#Don'ts|Don'ts]]
|}
__NOTOC__
__NOTOC__


{{WikiDoc CMG}}; {{AE}}
{{WikiDoc CMG}}; {{AE}} {{MSJ}}
{{SK}}
 
{{SK}}: Bacterial skin infection, Local skin infection.
<br >To read the [[cellulitis]] microchapter [[cellulitis|click here]].
==Overview==
==Overview==
[[Cellulitis]] is the [[inflammation]] of deeper layers of the [[skin]] including the [[dermis]] and [[subcutaneous tissue]]. It is mostly due to a [[bacteria|bacterial]] [[infection]]. The [[bacteria]] usually invades the deeper layers after breaching the [[skin]] barrier. Common [[bacteria]] such as [[streptococcus pyogenes]], [[staphylococcus aureus]], [[haemophilus influenzae|haemophilus influenza type B]], [[clostridium]], [[streptococcus pneumoniae]] and [[neisseria meningitidis]] usually involve the lower [[Limb (anatomy)|limbs]]. It presents clinically with [[medical sign|signs]] of [[inflammation]] such as [[erythema|redness]], [[edema|swelling]], warmth and [[pain]]. [[Risk factors]] for [[cellulitis]] include a weakened [[immune system]], [[diabetes]], [[lymphedema|lymphatic obstruction]], and [[varicose veins]]. It is recommended to first rule out [[deep vein thrombosis]] ([[Deep vein thrombosis|DVT]]) with [[Medical ultrasonography|compression doppler ultrasound]] of the [[Limb (anatomy)|limbs]] and [[D-dimer|d-dimer level]]. Elevated levels of [[erythrocyte sedimentation rate]] ([[erythrocyte sedimentation rate|ESR]]), [[C-reactive protein]] ([[C-reactive protein|CRP]]) and [[leukocytosis]] could be detected. It is required to check systemic [[medical sign|signs]] of [[infection]]. It is treated conservatively with [[mouth|oral]] [[antibiotic|antibiotics]] in uncomplicated cases. [[Route of administration|Parenteral]] [[antibiotic|antibiotics]] are administered in [[patients]] with systematic [[symptoms]] and progressive lesions. [[Incision and drainage]] are done if discrete [[abscess|abscesses]] are present.


==Causes==
==Causes==
===Life Threatening Causes===
===Life-Threatening Causes===
No known life-threatening causes are included.
No known life-threatening causes are included.


===Common Causes===
===Common Causes===
The cellulitis is bacterial in origin caused by invasion of bacteria through the skin barrier. The common causes are:  
The [[cellulitis]] is [[bactery|bacterial]] in origin and caused by the invasion of [[bacteria]] through the [[skin]] barrier. The common causes are listed below.<ref name="pmid27434444">{{cite journal| author=Raff AB, Kroshinsky D| title=Cellulitis: A Review. | journal=JAMA | year= 2016 | volume= 316 | issue= 3 | pages= 325-37 | pmid=27434444 | doi=10.1001/jama.2016.8825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27434444  }} </ref><ref name="pmid8922818">{{cite journal| author=Semel JD, Goldin H| title=Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples. | journal=Clin Infect Dis | year= 1996 | volume= 23 | issue= 5 | pages= 1162-4 | pmid=8922818 | doi=10.1093/clinids/23.5.1162 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8922818  }} </ref><ref name="pmid14985488">{{cite journal| author=Swartz MN| title=Clinical practice. Cellulitis. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 9 | pages= 904-12 | pmid=14985488 | doi=10.1056/NEJMcp031807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14985488  }} </ref>:  


* [[Streptococcus pyogenes]]
*[[Streptococcus pyogenes]]
* [[Staphylococcus aureus]]
*[[Staphylococcus aureus]]
* [[Haemophilus influenzae|Haemophilus influenza type B]]
*[[Haemophilus influenzae|Haemophilus influenza type B]]
* [[Clostridium]]
*[[Clostridium]]
* [[Streptococcus pneumoniae]]
*[[Streptococcus pneumoniae]]
* [[Neisseria meningitidis]]
*[[Neisseria meningitidis]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[cellulitis]].
Shown below is an algorithm summarizing the [[diagnosis]] of [[cellulitis]] according to the Infectious Diseases Society of America guidelines.<ref name="pmid3947189">{{cite journal| author=Hook EW, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M| title=Microbiologic evaluation of cutaneous cellulitis in adults. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 2 | pages= 295-7 | pmid=3947189 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3947189  }} </ref><ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL | display-authors=etal| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref><ref name="pmid8564693">{{cite journal| author=Beltran J| title=MR imaging of soft-tissue infection. | journal=Magn Reson Imaging Clin N Am | year= 1995 | volume= 3 | issue= 4 | pages= 743-51 | pmid=8564693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8564693  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01= <div style="float: center; text-align: left;"> Patients presents with clinical symptoms suggestive of cellulitis, i.e.
{{familytree | | | | A01 | | | A01= <div style="float: center; text-align: left;"> [[patient|Patients]] present with the following [[symptoms]]:
* erythema
*[[Erythema]]
* edema
*[[Edema]]
* warmth
*Warmth
* swollen regional lymph nodes
*Swollen regional [[lymph node|lymph nodes]]
* involvement of one limb. }}
*Involvement of one [[limb]] }}
{{familytree | | | | |!| | | | }}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= Perform compression Doppler ultrasound of the limb and D-dimers level}}
{{familytree | | | | B01 | | | B01= Perform [[Medical ultrasonography|compression doppler ultrasound]] of the [[limb]] and [[D-dimer|D-dimer level]] }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= Positive| C02= Negative }}
{{familytree | | C01 | | C02 | C01= Positive| C02= Negative }}
{{familytree | | |!| | | |!| | }}
{{familytree | | |!| | | |!| | }}
{{familytree | | D01 | | D02 | D01= likely Deep venous thrombosis (DVT)| D02= DVT unlikely. High clinical suspicion for cellulitis }}
{{familytree | | D01 | | D02 | D01= [[Deep vein thrombosis]] ([[deep vein thrombosis|DVT]]) is likely.| D02= [[Deep vein thrombosis|DVT]] unlikely. High clinical suspicion for [[cellulitis]] }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | E01 | E01= Assess levels of inflammatory markers }}
{{familytree | | | | | | E01 | E01= Assess levels of [[inflammation|inflammatory markers]] }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | F01 | F01= Raised ESR, CRP and leukocytosis }}
{{familytree | | | | | | F01 | F01= Raised [[erythrocyte sedimentation rate]] ([[erythrocyte sedimentation rate|ESR]]), [[C-reactive protein]] ([[C-reactive protein|CRP]]) and [[leukocytosis]] }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | G01 | G01= <div style="float: center; text-align: left;">Does patient have any signs of rapidly progressive or systemic infection?
{{familytree | | | | | | G01 | G01= <div style="float: center; text-align: left;">Does the [[patient]] have any of the following [[Medical sign|sign]]s of systemic or rapidly progressive [[infection]]?
* Body temperature>101.5 degrees Fahrenheit, chills, headache, and fatigue
*Body temperature >101.5 degrees Fahrenheit, [[rigor|chills]], [[headache]], and [[fatigue]]
* Signs of sepsis. i.e. hypotension and heart rate>100bpm
*[[medical sign|Signs]] of [[sepsis]] such as [[hypotension]] and [[heart rate]] > 100bpm
* Patient develops rapidly progressive symptoms like bullae, vesicles, petechiae, crepitus  
*[[Patient]] develops rapidly progressive [[symptom|symptoms]] like bullae, [[vesicle|vesicles]], [[petechia]] and [[crepitus]]
* Patient has low immunity (i.e. infants and elderly patients) }}
*[[Patient]] with low [[immunity]] (such as [[infancy|infants]] and elderly [[patients]]) }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | |!| | }}
{{familytree | | | | | | H01 | H01= <div style="float: center; text-align: left;">Perform the following tests:
{{familytree | | | | | | H01 | H01= <div style="float: center; text-align: left;">Perform the following tests:
* Debridement of wound with culture of the specimen   
*Debridement of the [[wound]] with the [[culture]] of the specimen   
* Blood culture
*[[Blood culture]]
* Radiographic tests to evaluate deep tissue infection }}
*[[radiology|Radiographic]] tests to evaluate [[Skin and soft-tissue infections|deep tissue infection]] }}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
Shown below is an algorithm summarizing the [[treatment]] of [[cellulitis]].<ref name="pmid17243049">{{cite journal| author=Miller LG, Quan C, Shay A, Mostafaie K, Bharadwa K, Tan N | display-authors=etal| title=A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection. | journal=Clin Infect Dis | year= 2007 | volume= 44 | issue= 4 | pages= 483-92 | pmid=17243049 | doi=10.1086/511041 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17243049  }} </ref><ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL | display-authors=etal| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref><ref name="pmid27434444">{{cite journal| author=Raff AB, Kroshinsky D| title=Cellulitis: A Review. | journal=JAMA | year= 2016 | volume= 316 | issue= 3 | pages= 325-37 | pmid=27434444 | doi=10.1001/jama.2016.8825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27434444  }} </ref><ref name="pmid9055782">{{cite journal| author=Bobrow BJ, Pollack CV, Gamble S, Seligson RA| title=Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults. | journal=Ann Emerg Med | year= 1997 | volume= 29 | issue= 3 | pages= 404-8 | pmid=9055782 | doi=10.1016/s0196-0644(97)70354-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9055782  }} </ref><ref name="pmid17989377">{{cite journal| author=Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M| title=Videos in clinical medicine. Abscess incision and drainage. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 19 | pages= e20 | pmid=17989377 | doi=10.1056/NEJMvcm071319 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17989377  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=cellulitis treatment Algorithm.}}
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree | | | | | | | | | | A01 | | | | |A01=<div style="float: center; text-align= left; width: 20em; height: 3em"> Does the [[cellulitis]] present with [[pus|purulent discharge]]? }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | | | | |,|-|-|^|-|-|.|}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | | | | | B01 | | | | B02 | | |B01= Yes |B02= No }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | | | | | |!| | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | | | | | | | C01 | | | | C02 | |C01=<div style="float: center; text-align: left; width: 20em; height: 15em"> Are there any of the following present?
{{familytree | |,|-|^|.| | | | | | | | |!| }}
*Systemic toxicity ([[fever]], [[hypotension]], and [[tachycardia]])
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
*Presence of an indwelling device ([[artificial pacemaker|pacemaker]], vascular graft)
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
*[[Patient]] is on extremes of age
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
*Major comorbid conditions |C02=<div style="float: center; text-align: left; width: 15em; height: 15em"> Incise and drain any discrete [[abscess]]:
{{familytree | | | | | | | | | | |!| | | | |!| }}
*Delay [[mouth|oral]] [[antibiotic]] [[therapy]]
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
*Monitor [[patient]] for spontaneous resolution.
*If response is inadequate then initiate [[mouth|oral]] [[antibiotic]] [[therapy]] }}
{{familytree | | | | |,|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | D01 | | | | | | D02 | | |D01= Yes |D02= No }}
{{familytree | | | | |!| | | | | | | |!| | | | | | }}
{{familytree | | | | E01 | | | | | | E02 | | | | | |E01=<div style="float: center; text-align: left; width: 15em; height: 15em"> Initiate [[Intravenous therapy|intravenous]] [[antibiotic]] [[therapy]]. The coverage of the [[microorganisms]] is determined by:
*[[mouth|Oral]] or peri-[[rectal]] [[ulcer|ulcers]]
*Pressure [[ulcer]] with draining [[abscess]]
*[[Necrosis]] of overlying [[skin]] |E02=<div style="float: center; text-align: left; width: 15em; height: 15em"> Initiate [[mouth|Oral]] [[antibiotic]] [[therapy]].
The coverage of the [[microorganisms]] is determined by:
*[[mouth|Oral]] or peri-[[rectal]] [[ulcers]]
*[[bed sore|Pressure ulcer]] with [[abscess|draining abscess]]
*[[Necrosis]] of [[skin|overlying skin]] }}
{{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | }}
{{familytree | | F01 | | F02 | | F03 | | F04 | |F01= Yes |F02= No |F03=Yes |F04= No }}
{{familytree | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | G01 | | G02 | | G03 | | G04 | |G01=<div style="float: center; text-align: left; height: 20em; width: 18em"> Initiate [[Antibiotic|antibiotics]] that cover both [[Methicillin-resistant staphylococcus aureus|MRSA]] and [[Gram-negative bacteria|gram negative rods]].
To cover [[Methicillin-resistant staphylococcus aureus|MRSA]]:
*[[Vancomycin]] or
*[[Daptomycin]]
Plus one of the following to cover for [[Gram-negative bacteria|gram negative rods]]:
*[[Ampicillin-Sulbactam]]
*[[Piperacillin-Tazobactam]]
*[[Ceftriaxone]] plus [[metronidazole]]
*[[Levofloxacin]] plus [[metronidazole]] | G02=<div style="float: center; text-align: left;"> [[Infection]] most likely due to [[Methicillin-resistant staphylococcus aureus|MRSA]]. Initiate
*[[Vancomycin]] or
*[[Daptomycin]] |G03=<div style="float: center; text-align: left;">
*Incision and drainage of discrete [[abscesses]].
*Send drained specimen for culture and susceptibility.
*Start wide coverage [[antibiotic|empirical antibiotic]] covering [[Methicillin-resistant staphylococcus aureus|MRSA]], [[Gram-negative bacteria|gram negative rods]], [[Anaerobic organism|anaerobes]], and [[Gram-positive bacteria|gram-positive organisms]].
Regimens include:
*[[Trimethoprim-Sulfamethoxazole]] plus [[amoxicillin-clavulanate]]
*[[Doxycycline]] plus [[levofloxacin]] plus [[metronidazole]]
*[[Minocycline]] plus [[amoxicillin-clavulanate]] |G04= Assess [[patient]]'s risk for [[Endocarditis|infective endocarditis]] }}
{{familytree | | | | | | | | |,|-|-|-|-|-|^|.| | }}
{{familytree | | | | | | | | H01 | | | | | H02 | |H01= Yes| H02= No }}
{{familytree | | | | | | | | |!| | | | | | |!| | | }}
{{familytree | | | | | | | | I01 | | | | | I02 | |I01= <div style="float: center; text-align: left;">
*Initiate [[antibiotic|empirical antibiotics]] coverage for [[Methicillin-resistant staphylococcus aureus|MRSA]] and [[Streptococcus|beta-hemolytic streptococci]]. Regimens include [[trimethoprim-sulfamethoxazole]] or [[doxycycline]] plus [[amoxicillin]] or [[minocycline]] plus [[amoxicillin]].
*Incise and drain the [[abscess]] an hour after administration of the first dose of [[antibiotic|oral antibiotic]].
*Send the specimen for culture and [[sensitivity]] and start [[antibiotic]] accordingly after the results. |I02= <div style="float: center; text-align: left; height: 20em; width: 12em">
*Incise and drain the discrete [[abscess]]
*Send the specimen for [[culture]] and [[sensitivity]]
*Initiate [[antibiotic|empirical antibiotics]] for [[Methicillin-resistant staphylococcus aureus|MRSA]]. Regimens include [[trimethoprim-sulfamethoxazole]] or [[doxycycline]] or [[minocycline]] }}
{{familytree/end}}
{{familytree/end}}


==Do's==
==Dos==


*The content in this section is in bullet points.
*Supportive care including elevation of the [[limb]] and adequate moisturizing of the [[cellulitis]] site should be done. The elevation of the [[limb]] promotes [[vein|venous]] and [[Lymphatic system|lymphatic drainage]] from the site. Moisturize the affected site with [[emollients]] and [[emollient|moisturizers]]. It will [[hydrate]] the [[skin]] and prevent breakouts.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL | display-authors=etal| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>
*[[Physicians]] should prescribe [[antibiotics]] for [[patients]] according to their body [[weight]]. [[obesity|Obese]] or [[lymphedema]] [[patients]] can be given a lower [[dose]] than their body [[weight]], which results in inadequate response and failure of the [[treatment]].<ref name="pmid22445732">{{cite journal| author=Halilovic J, Heintz BH, Brown J| title=Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. | journal=J Infect | year= 2012 | volume= 65 | issue= 2 | pages= 128-34 | pmid=22445732 | doi=10.1016/j.jinf.2012.03.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22445732  }} </ref>
*The duration of [[antibiotic]] [[treatment]] is variable and depends upon the clinical improvement of the [[cellulitis]]. Mostly, there is significant improvement within a day or two after the initiation of the [[antibiotic|antibiotics]]. The [[patient]] should receive the [[treatment]] for five days. The [[antibiotic]] course is given for two weeks in [[patient|patients]] with systematic [[symptoms]], low [[immunity]], and rapidly progressive [[cellulitis]].<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL | display-authors=etal| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref><ref name="pmid15302637">{{cite journal| author=Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC| title=Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. | journal=Arch Intern Med | year= 2004 | volume= 164 | issue= 15 | pages= 1669-74 | pmid=15302637 | doi=10.1001/archinte.164.15.1669 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15302637  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=15739992 Review in: ACP J Club. 2005 Mar-Apr;142(2):45] </ref>


==Don'ts==
==Don'ts==


*The content in this section is in bullet points.
*Suppressive [[antibiotic]] [[therapy]] is administered to [[patients]] with three to four episodes of [[cellulitis]] per year with predisposing factors that can not be alleviated. Suppressive [[antibiotic]] [[therapy]] is directed against [[Streptococcus|beta-hemolytic streptococci]] and [[Staphylococcus|staphylococci]] [[infection]]. Suppressive [[antibiotic]] [[therapy]] is not beneficial in [[patient|patients]] with greater than three episodes of [[cellulitis]] in a year, chronic [[edema]], and [[obesity]].<ref name="pmid23635049">{{cite journal| author=Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR | display-authors=etal| title=Penicillin to prevent recurrent leg cellulitis. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 18 | pages= 1695-703 | pmid=23635049 | doi=10.1056/NEJMoa1206300 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23635049  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=24475469 Review in: J Fam Pract. 2014 Jan;63(1):E10-2] </ref>
*[[Physicians]] should not perform [[incision and drainage]] for discrete [[abcess|abscesses]] in [[patient|patients]] with high susceptibility of [[bacteria|bacterial]] [[endocarditis]] without prior administration of the [[antibiotic]]. 2 grams of [[mouth|oral]] [[amoxicillin]] should be given to the [[patient]] an hour before performing [[incision and drainage]] of the [[infection|infected]] site.<ref name="pmid28233191">{{cite journal| author=Thornhill MH, Dayer M, Lockhart PB, Prendergast B| title=Antibiotic Prophylaxis of Infective Endocarditis. | journal=Curr Infect Dis Rep | year= 2017 | volume= 19 | issue= 2 | pages= 9 | pmid=28233191 | doi=10.1007/s11908-017-0564-y | pmc=5323496 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28233191  }} </ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
[[Category:Disease]]
[[Category:Primary care]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Infectious disease]]
[[Category:Up-To-Date]]

Latest revision as of 21:31, 14 January 2021

Cellulitis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and keywords:: Bacterial skin infection, Local skin infection.
To read the cellulitis microchapter click here.

Overview

Cellulitis is the inflammation of deeper layers of the skin including the dermis and subcutaneous tissue. It is mostly due to a bacterial infection. The bacteria usually invades the deeper layers after breaching the skin barrier. Common bacteria such as streptococcus pyogenes, staphylococcus aureus, haemophilus influenza type B, clostridium, streptococcus pneumoniae and neisseria meningitidis usually involve the lower limbs. It presents clinically with signs of inflammation such as redness, swelling, warmth and pain. Risk factors for cellulitis include a weakened immune system, diabetes, lymphatic obstruction, and varicose veins. It is recommended to first rule out deep vein thrombosis (DVT) with compression doppler ultrasound of the limbs and d-dimer level. Elevated levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocytosis could be detected. It is required to check systemic signs of infection. It is treated conservatively with oral antibiotics in uncomplicated cases. Parenteral antibiotics are administered in patients with systematic symptoms and progressive lesions. Incision and drainage are done if discrete abscesses are present.

Causes

Life-Threatening Causes

No known life-threatening causes are included.

Common Causes

The cellulitis is bacterial in origin and caused by the invasion of bacteria through the skin barrier. The common causes are listed below.[1][2][3]:

Diagnosis

Shown below is an algorithm summarizing the diagnosis of cellulitis according to the Infectious Diseases Society of America guidelines.[4][5][6]

 
 
 
Patients present with the following symptoms:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform compression doppler ultrasound of the limb and D-dimer level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
Deep vein thrombosis (DVT) is likely.
 
DVT unlikely. High clinical suspicion for cellulitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess levels of inflammatory markers
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Raised erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocytosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following signs of systemic or rapidly progressive infection?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform the following tests:

Treatment

Shown below is an algorithm summarizing the treatment of cellulitis.[7][5][1][8][9]

 
 
 
 
 
 
 
 
 
Does the cellulitis present with purulent discharge?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are there any of the following present?
 
 
 
Incise and drain any discrete abscess:
  • Delay oral antibiotic therapy
  • Monitor patient for spontaneous resolution.
  • If response is inadequate then initiate oral antibiotic therapy
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Initiate intravenous antibiotic therapy. The coverage of the microorganisms is determined by:
     
     
     
     
     
    Initiate Oral antibiotic therapy.

    The coverage of the microorganisms is determined by:

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    No
     
    Yes
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Infection most likely due to MRSA. Initiate
  • Vancomycin or
  • Daptomycin
  •  
  • Incision and drainage of discrete abscesses.
  • Send drained specimen for culture and susceptibility.
  • Start wide coverage empirical antibiotic covering MRSA, gram negative rods, anaerobes, and gram-positive organisms.
  • Regimens include:

     
    Assess patient's risk for infective endocarditis
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
  • Incise and drain the discrete abscess
  • Send the specimen for culture and sensitivity
  • Initiate empirical antibiotics for MRSA. Regimens include trimethoprim-sulfamethoxazole or doxycycline or minocycline
  •  

    Dos

    Don'ts

    References

    1. 1.0 1.1 Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
    2. Semel JD, Goldin H (1996). "Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples". Clin Infect Dis. 23 (5): 1162–4. doi:10.1093/clinids/23.5.1162. PMID 8922818.
    3. Swartz MN (2004). "Clinical practice. Cellulitis". N Engl J Med. 350 (9): 904–12. doi:10.1056/NEJMcp031807. PMID 14985488.
    4. Hook EW, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M (1986). "Microbiologic evaluation of cutaneous cellulitis in adults". Arch Intern Med. 146 (2): 295–7. PMID 3947189.
    5. 5.0 5.1 5.2 5.3 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
    6. Beltran J (1995). "MR imaging of soft-tissue infection". Magn Reson Imaging Clin N Am. 3 (4): 743–51. PMID 8564693.
    7. Miller LG, Quan C, Shay A, Mostafaie K, Bharadwa K, Tan N; et al. (2007). "A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection". Clin Infect Dis. 44 (4): 483–92. doi:10.1086/511041. PMID 17243049.
    8. Bobrow BJ, Pollack CV, Gamble S, Seligson RA (1997). "Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults". Ann Emerg Med. 29 (3): 404–8. doi:10.1016/s0196-0644(97)70354-8. PMID 9055782.
    9. Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M (2007). "Videos in clinical medicine. Abscess incision and drainage". N Engl J Med. 357 (19): e20. doi:10.1056/NEJMvcm071319. PMID 17989377.
    10. Halilovic J, Heintz BH, Brown J (2012). "Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess". J Infect. 65 (2): 128–34. doi:10.1016/j.jinf.2012.03.013. PMID 22445732.
    11. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC (2004). "Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis". Arch Intern Med. 164 (15): 1669–74. doi:10.1001/archinte.164.15.1669. PMID 15302637. Review in: ACP J Club. 2005 Mar-Apr;142(2):45
    12. Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR; et al. (2013). "Penicillin to prevent recurrent leg cellulitis". N Engl J Med. 368 (18): 1695–703. doi:10.1056/NEJMoa1206300. PMID 23635049. Review in: J Fam Pract. 2014 Jan;63(1):E10-2
    13. Thornhill MH, Dayer M, Lockhart PB, Prendergast B (2017). "Antibiotic Prophylaxis of Infective Endocarditis". Curr Infect Dis Rep. 19 (2): 9. doi:10.1007/s11908-017-0564-y. PMC 5323496. PMID 28233191.