Review of Cellulitis Treatment Recommendations - LECOM

Review of Cellulitis Treatment Recommendations

Tuesday, 02 June 2015

Cellulitis is defined as an infection of the skin and soft tissue beneath the skin. The infection is usually due to bacteria that are commonly present on the skin or inner surface of the nose or mouth of otherwise normal and healthy people, most commonly staphylococci or streptococci. Cellulitis develops when there is a break in the skin such as a wound or injury, which may be minor or even go unnoticed. This break allows bacteria to pass through the outer layer of the skin and multiply, causing infection and swelling.  Many cases of cellulitis are mild and heal completely with antibiotic treatment. However, some can be severe and lead to generalized infection. Thus, it is imperative to seek medical care promptly if the infection is associated with fever, rapid spreading and other signs of progression, or other medical conditions such as diabetes are present.1

Certain conditions increase the risk for developing cellulitis (Table 1), but it can occur in patients without known risk factors.1 The onset of cellulitis may be gradual or sudden. The most common symptom of cellulitis is pain or tenderness. Other cellulitis symptoms include swelling, warmth, redness in a distinct area of skin, and red streaking with associated lymphadenopathy along the lymphatic pathways. Symptoms commonly worsen and the redness may expand over the course of hours or days. Itching is not a typical symptom of cellulitis. The skin is usually smooth and shiny rather than raised and bumpy. Occasionally in cases of cellulitis, blisters or small pimples form on the skin. The most common areas of the body for cellulitis to develop include the legs and the arms.1

Table 1: Risk factors for developing cellulitis
Recent injury to the skin (a wound, abrasion, cut, shaving, or injection drug use)
The presence of a fungal or viral skin infection such as athlete’s foot or chicken pox
Accumulation of fluid (edema) due to poor circulation, heart failure, liver disease or past surgery to remove lymph nodes
Chronic skin conditions such as eczema
Obesity
Prior radiation therapy
Weakened immune system from conditions such as diabetes, leukemia, HIV/AIDS or medications such as corticosteroids or TNF-α inhibitor

Blood cultures and cutaneous aspirates, biopsies, or swabs are not routinely recommended except in patients with malignancy undergoing chemotherapy, neutropenia, severe immunodeficiency, immersion injuries, and animal bites.

Appropriate treatment of cellulitis involves selecting antibiotic therapy based on a patient’s symptoms and risk factors (Table 2).  Patients that do not have systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability can generally be treated on an outpatient basis. Poorly adherent or severely immuno-compromised patients and those that have deep or necrotizing infections should be hospitalized and treated with IV antibiotics. In conjunction with antibiotic therapy, antiinflammatory treatment with systemic corticosteroids or ibuprofen  has demonstrated more rapid clinical resolution of cellulitis and may be considered in non-diabetic adults as long as deeper infections are not present (i.e., necrotizing fasciitis). The duration of antibiotic therapy for uncomplicated cellulitis is usually 5 days but may be longer if the infection is slow to resolve. It is recommended that the affected area be elevated during treatment. It is also important to treat underlying contributing conditions such as tinea pedis, venous eczema, etc.

Table 2: Selection of antibiotic therapy2
Without systemic signs of infection (typical, uncomplicated, mild non-purulent cellulitis)  Should receive an antibiotic active against streptococci 1. monotherapy of  oral beta-lactams (penicillin, amoxicillin, amoxicillin clavulanate, dicloxacillin, cephalexin)

2. oral clindamycin monotherapy
With systemic signs of infection (moderate non-purulent)  · Intravenous antibiotics indicated

· Consider an antibiotic with methicillin-susceptible S. aureus (MSSA) coverage

 1. penicillin (no MSSA coverage)

2. nafcillin, oxacillin, dicloxacillin

3. cefazolin, cephalexin

4. clindamycin

5. doxycycline, minocycline

6. sulfamethoxazole/trimethoprim
Cellulitis associated with:

· Penetrating trauma

· Evidence of MRSA (methicillin-resistant S. aureus) including nasal colonization

· Intravenous drug use

· Purulent discharge

· SIRS

 Antibiotic selection should provide coverage of MRSA and streptococci Intravenous route
vancomycin, daptomycin, linezolid, tedizolid or telavancinOral Route 
clindamycin (monotherapy)sulfamethoxazole/trimethoprim + beta-lactam
doxycycline + beta lactam
Severely immunocompromised patients Broad-spectrum antibiotics should be considered 1. vancomycin + piperacillin/tazobactam

2. vancomycin + imipenem or meropenem
Recurrent cellulitis · Identification and treatment of underlying conditions such as edema, obesity, venous insufficiency, etc.

· Antibiotic prophylaxis: consider in patients who have had 3-4 episodes of cellulitis per year despite management of predisposing factors. Long-term prophylaxis considered if underlying conditions are chronic/persistent

 Oral penicillin or erythromycin twice daily for 4-52 weeks

Intramuscular benzathine penicillin every 2-4 weeks (preferred if patient has no identifiable predisposing factors)
  1. Baddour LM. Patient information: Skin and soft tissue infection (cellulitis) (Beyond the Basics). In UpToDate [Internet]. Wellesley (MA): UpToDate, Inc; c2015 [updated 2014 Jun 24; cited 2015 Jan 30]. Available from: www.uptodateonline.com
  2. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 20014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. July 15, 2014 2014:59(2):e10-e52.
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