Assessment and Management of Cellulitis by Dr. Astrid Arellano
Assessment and
Management of Cellulitis
Dr Astrid Arellano
MBBS FRACP
Infectious Diseases Physician
Adult
Infectious Diseases
Physician
•
University of Adelaide Graduate,
Advanced training in Perth, WA
both in microbiology and infectious
diseases
•
Private Practice based in Subiaco
•
Inpatient care at SJOG Subiaco
Hospital
•
Public Health Physician at WA TB
Control Program
•
Lecturer and Clinical Tutor at Notre
Dame University
1/1 Sheen Street
Subiaco WA 6008
PH: 6478 9963
FAX: 9389 6531
M: 0421514653
Cellulitis
Definition
“Non-necrotising
inflammation of the skin
and subcutaneous
tissues, usually caused
by bacterial infection”
Pathophysiology
•
Acute inflammation with heat, swelling, redness and pain.
•
Microscopically: inflammatory infiltrate, predominant neutrophils and fat necrosis
•
Erysipelas is superficial (only dermis), cellulitis involves subcutaneous tissues
Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/
Fig. 1 Eysipelas: low power H&E, inflammation
Fig. 2 Eysipelas: high power H&E,
dense inflammatory infiltrate
Fig. 3 High power H&E,
inflammation and fat necrosis
Cellulitis
Clinical Presentation
C
l
a
s
s
i
c
•
Erythema
•
Pain
•
Swelling
•
Warmth
S
i
g
n
s
s
u
g
g
e
s
t
i
v
e
o
f
s
e
v
e
r
e
i
n
f
e
c
t
i
o
n
:
•
Malaise, chills, fever, and toxicity
•
Lymphangitic spread (red lines streaking away
from the area of infection)
•
Circumferential cellulitis
•
Pain disproportionate to examination findings
Cellulitis mimics
•
Contact dermatitis
•
Septic bursitis
•
Gout
•
Acute and chronic
lipodermatosclerosis (venous
insufficiency)
•
Lymphoedema
•
BILATERAL cellulitis is rare
Fig. 1 Chronic lymphoedema changes
Fig. 2 Venous insufficiency changes
Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/
Cellulitis RED FLAGS
•
V
i
o
l
a
c
e
o
u
s
b
u
l
l
a
e
•
C
u
t
a
n
e
o
u
s
h
e
m
o
r
r
h
a
g
e
•
S
k
i
n
s
l
o
u
g
h
i
n
g
•
R
a
p
i
d
p
r
o
g
r
e
s
s
i
o
n
•
G
a
s
i
n
t
h
e
t
i
s
s
u
e
•
S
y
s
t
e
m
i
c
c
o
m
p
r
o
m
i
s
e
:
h
y
p
o
t
e
n
s
i
o
n
,
t
a
c
h
y
c
a
r
d
i
a
Necrotizing fasciitis
Life threatening emergency: skin, fat and muscle necrosis, polymicrobial,
rapidly progressive with shock, extensive tissue loss and death
Pathogens
E
r
y
s
i
p
e
l
a
s
:
s
k
i
n
r
a
i
s
e
d
a
b
o
v
e
s
u
r
r
o
u
n
d
i
n
g
n
o
r
m
a
l
s
k
i
n
,
c
l
e
a
r
d
e
m
a
r
c
a
t
i
o
n
.
•
Streptococcus pyogenes
•
Common in infants, young children, older adults.
•
“Butterfly”
pattern of facial skin, and affecting lower limbs.
C
e
l
l
u
l
i
t
i
s
:
I
n
v
o
l
v
e
s
d
e
e
p
e
r
t
i
s
s
u
e
s
•
Children: periorbital
•
Adults: lower legs
•
Rapidly spreading:
Streptococcus pyogenes
or other
Streptococci e.g. group B, C, or G
•
Trauma, ulceration:
Staphylococcus aureus (
cMRSA,
40% of
S.aureus
)
O
t
h
e
r
o
r
g
a
n
i
s
m
s
:
•
Water related:
Aeromonas spp., Vibrio spp.
•
Immunocompromised: polymicrobial including Gram
negatives, fungi and mycobacteria
Predisposing factors
•
Damage to skin e.g. trauma, ulcers.
•
Tinea infection
•
Fissured dermatitis
•
Lymphoedema
•
History of DVT
•
Vascular surgery
•
Radiotherapy
•
Insect bites/scabies
Diagnosis
Clinical, no investigations required if:
•
Limited skin involvement
•
Minimal pain
•
No systemic signs of illness (eg,
fever, altered mental status,
tachycardia, hypotension)
•
No risk factors for serious illness
(eg, extremes of age, co-
morbidities immunocompromise)
Systemic signs=
Investigations
•
FBP, CRP, U+E
•
Blood cultures: Moderate to severe disease (cellulitis complicating
lymphoedema)
•
Orbital Cellulitis (fat and eye muscles) and periorbital (eyelid) cellulitis
•
Patients with malignancy or chemotherapy
•
Neutropenia or severe cell-mediated immunodeficiency
•
Animal bites
Hospital Admission
•
Patients who have extensive
cellulitis, especially if:
•
Patients with systemic signs
(high fever, chills, rigours,
hypotension, tachycardia)
•
Immunocompromised
•
Diabetics
•
Chronic renal failure patients
•
Orbital cellulitis (involvement of
fat and orbit muscles) +/-
periorbital cellulitis
Treatment
•
M
i
l
d
:
S
t
r
e
p
t
o
c
o
c
c
u
s
p
y
o
g
e
n
e
s
,
S
t
a
p
h
y
l
o
c
o
c
c
u
s
a
u
r
e
u
s
,
u
s
e
:
•
Flucloxacillin 500mg (child 12.5mg/kg up to 500mg) QID
orally for 5-10 days
•
Non-immediate penicillin allergy: Cephalexin 500mg (child
12.5mg/kg up to 500mg) QID orally for 5-10 days
•
Immediate penicillin allergy: Clindamycin 450mg (child
10mg/kg up to 450mg) TDS orally for 5-10 days
•
S
e
v
e
r
e
:
N
o
t
i
m
p
r
o
v
i
n
g
a
f
t
e
r
4
8
h
o
r
s
y
s
t
e
m
i
c
s
y
m
p
t
o
m
s
Treatment
•
S
e
v
e
r
e
c
e
l
l
u
l
i
t
i
s
m
a
n
a
g
e
m
e
n
t
:
•
S
t
r
e
p
t
o
c
o
c
c
u
s
p
y
o
g
e
n
e
s
,
S
t
a
p
h
y
l
o
c
o
c
c
u
s
a
u
r
e
u
s
,
u
s
e
:
•
Flucloxacillin 2g (child 50mg/kg up to 2g) IV QID
•
Non-immediate penicillin allergy: Cefazolin 2g (child
50mg/kg up to 2g) IV TDS
•
Immediate penicillin allergy: Vancomycin* or Clindamycin
600mg (child 15mg/kg up tp 600mg) IV TDS
***Ceftriaxone/broad spectrum antibiotics not required***
Therapeutic Guidelines Antibiotic, version 15, 2014
Hospital in the Home
•
Administration of IV antibiotics in outpatient setting where
IVABs are required for >1 week
•
Once stable and select patients (independent, no
significant co-morbidities), supported home environment,
able to attend clinic reviews and blood testing.
•
Antibiotic regimen: once daily dosing or infusion
•
Requires log term IV line: PICC line
•
Convenient for young/working individuals
•
Nursing Service: Access via AMU, direct admit for adults
•
SJOG Subiaco Hospital, ID Physicians and Health
Choices Nurses
Cellulitis Take Home Messages
•
Cellulitis is an infection of the
skin and subcutaneous
tissues, most common
organisms involved are
S.pyogenes
and
S.aureus
•
RED FLAGS: systemic
symptoms, rapid progression,
gas in tissues, bullae,
immunocompromised patient,
orbital involvement
•
“Bilateral cellulitis” is rare,
more likely venous
insufficiency changes
•
Direct and fast admission to AMU at
SJOG Subiaco Hospital for IVABs
and HITH without ED waiting times,
expert management and rapid return
to work for patients
Dr. Astrid Arellano, an Adult Infectious Diseases Physician based in Subiaco, discusses the definition, pathophysiology, clinical presentation, and red flags of cellulitis. Learn about the mimics of cellulitis and the critical condition of necrotizing fasciitis.
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Assessment and Management of Cellulitis Dr Astrid Arellano MBBS FRACP Infectious Diseases Physician
Adult Infectious Diseases Physician University of Adelaide Graduate, Advanced training in Perth, WA both in microbiology and infectious diseases Private Practice based in Subiaco Inpatient care at SJOG Subiaco Hospital Public Health Physician at WA TB Control Program Lecturer and Clinical Tutor at Notre Dame University 1/1 Sheen Street Subiaco WA 6008 PH: 6478 9963 FAX: 9389 6531 M: 0421514653
Cellulitis Definition Non-necrotising inflammation of the skin and subcutaneous tissues, usually caused by bacterial infection
Pathophysiology Acute inflammation with heat, swelling, redness and pain. Microscopically: inflammatory infiltrate, predominant neutrophils and fat necrosis Erysipelas is superficial (only dermis), cellulitis involves subcutaneous tissues Fig. 2 Eysipelas: high power H&E, dense inflammatory infiltrate Fig. 3 High power H&E, inflammation and fat necrosis Fig. 1 Eysipelas: low power H&E, inflammation Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/
Cellulitis Clinical Presentation Classic Erythema Pain Swelling Warmth Signs suggestive of severe infection: Malaise, chills, fever, and toxicity Lymphangitic spread (red lines streaking away from the area of infection) Circumferential cellulitis Pain disproportionate to examination findings
Cellulitis mimics Contact dermatitis Septic bursitis Gout Fig. 1 Chronic lymphoedema changes Acute and chronic lipodermatosclerosis (venous insufficiency) Lymphoedema BILATERAL cellulitis is rare Fig. 2 Venous insufficiency changes Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/
Cellulitis RED FLAGS Violaceous bullae Cutaneous hemorrhage Skin sloughing Rapid progression Gas in the tissue Systemic compromise: hypotension, tachycardia
Necrotizing fasciitis Life threatening emergency: skin, fat and muscle necrosis, polymicrobial, rapidly progressive with shock, extensive tissue loss and death
Pathogens Erysipelas: skin raised above surrounding normal skin, clear demarcation. Streptococcus pyogenes Common in infants, young children, older adults. Butterfly pattern of facial skin, and affecting lower limbs. Cellulitis: Involves deeper tissues Children: periorbital Adults: lower legs Rapidly spreading: Streptococcus pyogenes or other Streptococci e.g. group B, C, or G Trauma, ulceration: Staphylococcus aureus (cMRSA, 40% of S.aureus) Other organisms: Water related: Aeromonas spp., Vibrio spp. Immunocompromised: polymicrobial including Gram negatives, fungi and mycobacteria
Predisposing factors Damage to skin e.g. trauma, ulcers. Tinea infection Fissured dermatitis Lymphoedema History of DVT Vascular surgery Radiotherapy Insect bites/scabies
Diagnosis Clinical, no investigations required if: Limited skin involvement Minimal pain No systemic signs of illness (eg, fever, altered mental status, tachycardia, hypotension) No risk factors for serious illness (eg, extremes of age, co- morbidities immunocompromise)
Systemic signs= Investigations FBP, CRP, U+E Blood cultures: Moderate to severe disease (cellulitis complicating lymphoedema) Orbital Cellulitis (fat and eye muscles) and periorbital (eyelid) cellulitis Patients with malignancy or chemotherapy Neutropenia or severe cell-mediated immunodeficiency Animal bites
Hospital Admission Patients who have extensive cellulitis, especially if: Patients with systemic signs (high fever, chills, rigours, hypotension, tachycardia) Immunocompromised Diabetics Chronic renal failure patients Orbital cellulitis (involvement of fat and orbit muscles) +/- periorbital cellulitis
Treatment Mild: Streptococcus pyogenes, Staphylococcus aureus, use: Flucloxacillin 500mg (child 12.5mg/kg up to 500mg) QID orally for 5-10 days Non-immediate penicillin allergy: Cephalexin 500mg (child 12.5mg/kg up to 500mg) QID orally for 5-10 days Immediate penicillin allergy: Clindamycin 450mg (child 10mg/kg up to 450mg) TDS orally for 5-10 days Severe: Not improving after 48h or systemic symptoms
Treatment Severe cellulitis management: Streptococcus pyogenes, Staphylococcus aureus, use: Flucloxacillin 2g (child 50mg/kg up to 2g) IV QID Non-immediate penicillin allergy: Cefazolin 2g (child 50mg/kg up to 2g) IV TDS Immediate penicillin allergy: Vancomycin* or Clindamycin 600mg (child 15mg/kg up tp 600mg) IV TDS ***Ceftriaxone/broad spectrum antibiotics not required*** Therapeutic Guidelines Antibiotic, version 15, 2014
Hospital in the Home Administration of IV antibiotics in outpatient setting where IVABs are required for >1 week Once stable and select patients (independent, no significant co-morbidities), supported home environment, able to attend clinic reviews and blood testing. Antibiotic regimen: once daily dosing or infusion Requires log term IV line: PICC line Convenient for young/working individuals Nursing Service: Access via AMU, direct admit for adults SJOG Subiaco Hospital, ID Physicians and Health Choices Nurses
Cellulitis Take Home Messages Cellulitis is an infection of the skin and subcutaneous tissues, most common organisms involved are S.pyogenes and S.aureus RED FLAGS: systemic symptoms, rapid progression, gas in tissues, bullae, immunocompromised patient, orbital involvement Direct and fast admission to AMU at SJOG Subiaco Hospital for IVABs and HITH without ED waiting times, expert management and rapid return to work for patients Bilateral cellulitis is rare, more likely venous insufficiency changes
