Cellulitis and Abscess Pathway

Cellulitis and Abscess: ED Phase v 1.
1
Executive Summary
Explanation of Evidence Ratings
PHASE I (E.D.)
Test Your Knowledge
Summary of Version Changes

Inclusion Criteria
Suspected skin/soft tissue
infection in children > 44 weeks CGA
Exclusion Criteria
Hospital-acquired, surgical site &
device-associated infections
Presumed necrotizing fasciitis
Orbital/periorbital cellulitis
Immunodeficiency
Pressure ulcers
Solitary dental abscess
!
Labs
if systemic illness
or necrotizing
fasciitis suspected
!
Consider tetanus
immunization status
as necessary
If referral call from PMD,

request perimeter line be
drawn and make patient
NPO.
Provider Assessment
Determine if special
situation present.
Concern for:
Deep extremity infection (e.g., tenosynovitis, septic
arthritis, osteomyelitis)
Deep puncture wound of hand/fingers/feet
Yes
Order labs, then

Involve Orthopedics
Yes
Involve General
Surgery
Yes
Involve ENT
No
Concern for:
Peri-anal abscess (within 1cm of anal verge)
Breast abscess
Perineal abscess
Pilonidal cyst
Large or complex abscess
No
Concern for:
Neck abscess
No
Concern for:
Yes
Facial cellulitis of dental origin
Involve Dental; See

antibiotic table
No
Yes
Go to Simple Cellulitis / Abscess Phase
For questions concerning this pathway,

contact: [email protected]
2013 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer
Determine with consultant

if suitable for pathway
No
Off
Pathway
Last Updated: 08/15/2013

Valid until:08/15/2016
Cellulitis and Abscess: ED simple cellulitis / abscess v.1

Executive Summary
PHASE I (E.D.)
Test Your Knowledge
Inclusion Criteria
Exclusion Criteria

Immunodeficiency
Pressure ulcers
Solitary dental abscess
Labs
if systemic illness
or necrotizing
fasciitis suspected
Alter antibiotic
selection if >48h
of prior antibiotics given
Simple cellulitis / abscess
Perform bedside ultrasound

unless clearly fluctuant or
draining
Non-purulent
Purulent
Fluctuant or
abscess 1cm on ultrasound:
Sedation / pain control
I&D and culture wound
No routine labs
Determine Disposition
Inpatient Admit Criteria

(any one of the following)
Low Risk Criteria

Simple abscess
Adequate I&D
Age 1 year
No fever
Well-appearing
No significant
comorbidities
Follow up assured
Systemic illness
Not tolerating PO
Treatment failure on >48h of
appropriate antibiotics
Rapidly progressive lesion
Pain control / wound care
All < 2 mo; consider if <6 mo
Inadequate F/U
Discharged
patients
Purulent Definition
Actively draining pus
History of drainage
Abscess present
Admitted patients
!
Non-purulent
Medical Treatment
Oral cephalexin
Clindamycin if failed
outpatient treatment,
cephalosporin allergic or if
MRSA risks
Purulent
Antibiotic
selection by
condition
Medical Treatment
Non-purulent
Medical Treatment
No systemic antibiotics
after I&D if low risk
Oral clinda if not low risk
TMP/SMX (or doxycycline
if >8 years) if presumed
clindamycin-resistant
MRSA
IV cefazolin
Clindamycin if failed
outpatient treatment,
cephalosporin allergic or if
MRSA risks
Consider vancomycin if
systemic toxicity
Purulent
Medical Treatment
IV clindamycin
Vancomycin if presumed
clindamycin-resistant
MRSA
systemic toxicity, failed
outpatient clindamycin
Discharge
Instructions
7-10 days total
treatment
PMD f/u within
24-48 hours
Go to Inpatient Phase


Cellulitis and Abscess: Inpatient Phase v.1

Executive Summary
PHASE II (INPATIENT)
Test Your Knowledge

Inclusion Criteria
INPATIENT Exclusion Criteria

Peri-anal or pilonidal abscesses
Pts admitted to surgical service
Immunodeficiency
Deep structure infections
Pressure ulcers
!
Labs
if systemic illness
or necrotizing
fasciitis suspected
Daily re-evaluation
Clinical exam
Culture data
Improving
!
Antibiotic
selection by condition
Not Improving
Tailor antibiotics if culture results are

available
If rapid progression at any time or no
improvement on empiric antibiotics at
48 hours, consider empiric change in
antibiotics
If no improvement on adequate
antibiotics, image (U/S preferred) to
rule out abscess formation
If fluctuance develops or abscess 1
cm on imaging, consult gen. surgery
Consult ID as necessary
Tailor antibiotics if culture results are

available
Use narrowest-spectrum agent
possible
Discharge Criteria
(Meets all)
Lesion(s) show signs of
improvement
Tolerating PO
Pain controlled
Afebrile >24 hours
F/U assured within 48 hours

Discharge
Instructions
7-10 days total
treatment
PMD f/u within
48 hours

Cellulitis and Abscess: Antibiotic Table

Executive Summary
Test Your Knowledge
Cellulitis and Abscess Antibiotic Table

Condition
Non-purulent cellulitis
Cefazolin
IV choice
IV Alternatives
Purulent SSTI/ abscess
Clindamycin
Vancomycin if presumed
clindamycin resistant MRSA;
rapidly progressive lesion;
Clindamycin if cephalosporin
hemodynamic instability; illallergic
appearing; failed oral
clindamycin as outpatient;
abscess in an area difficult to
rapidly progressive lesion;
drain completely such as
hemodynamic instability; illface/hand/genitals
appearing
Bite wounds
Ampicillin/sulbactam
Facial cellulitis of
dental origin
Penicillin OR
Cefoxitin (transition to
clindamycin AND
Clindamycin if penicillin allergic
ciprofloxacin at discharge)
if penicillin allergic
Call ID if linezolid desired

No antibiotics if low risk
criteria* met and abscess
adequately drained
Cephalexin
PO choice
Amoxicillin/clavulanate
Penicillin OR
Clindamycin otherwise
TMP/SMX if presumed
clindamycin resistant MRSA
PO Alternatives
Doxycycline if age >8 years

Clindamycin if cephalosporin and prior clindamycin and
allergic
TMP/SMX resistant MRSA OR
presumed clindamycin
resistance and sulfa allergy

and penicillin allergy
Clindamycin AND
Clindamycin if penicillin allergic
ciprofloxacin for penicillin
allergic patients
Call ID for other scenarios
*Low risk criteria: Age 1 year; no fever; well-appearing; adequate I&D; no significant comorbidities
Low Risk Criteria*

Simple abscess
Adequate I&D
Age 1 year
No fever
Well-appearing
No significant comorbidities
Follow up assured
Alternate antibiotic choices

If fresh or saltwater contact, or other
special circumstance, discuss with ID
* For use in determining the need for PO
antibiotics for purulent infection post I&D,

outpatient treatment (see above)
Return Initial ED phase
Return to ED Simple
Cellulitis / Abscess Phase
Return to Inpatient Phase


Initial ED phase
ED simple cellulitis/
abscess
Inpatient Phase
Bibliography
Literature SearchSearch Methods, Soft Tissue Infections Cellulitis, Clinical
Standard Work
Studies were identified by searching electronic databases using search strategies developed and
executed by a medical librarian, Susan Klawansky. Searches were performed in November 2012
in the following databases on the Ovid platform: Medline and Cochrane Database of Systematic
Reviews; elsewhere: Embase, Clinical Evidence, National Guideline Clearinghouse and TRIP.
Retrieval was limited to 2004 to current, humans, and English language. In Medline and Embase,
appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along
with text words, and the search strategy was adapted for other databases as appropriate.
Concepts searched were soft tissue infections, cellulitis and many other related conditions, some
of which are skin abscess, bites and stings, impetigo, carbuncle, infectious skin diseases and
penetrating wounds. All retrieval was further limited to certain publication types representing
high order evidence.
Susan Klawansky, MLS, AHIP
April 9, 2013
Identification
383 records identified through
database searching
13 additional records identified

through other sources
Screening
396 records after duplicates removed
396 records screened
340 records excluded
55 full-text articles assessed for eligibility
11 full-text articles excluded,

did not answer clinical question
did not meet quality threshold
Elgibility
Included
44 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
To Bibliography, Pg 1
Initial ED phase
abscess
Inpatient Phase
Bibliography
1)
Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas.
Cochrane Database of Systematic Reviews 2010 (6). DOI:10.1002/14651858.CD004299.pub2.
2)
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP,
Murray BE, Rybak MJ, Talan DA, Chambers HF. Clinical practice guidelines by the Infectious Diseases
Society of America for the treatment of methicillin-resistant staphylococcus aureus infections in adults and
children. Clin Infect Dis 2011 Feb;52:1-38.
3)
JL Robinson, MI Salvadori; Canadian Paediatric Society Infectious Diseases and Immunization
Committee, Management of community associated methicillin-resistant Staphylococcus aureus skin
abscesses in children. Paediatr Child Health 2011; 16(2):115-6
4)
May A et al. Treatment of complicated skin and soft tissues infections, Surgical Infection Society
Guidelines. Surgical Infections 2009 Vol 10, Number 5, 467-501
5)
Paydar, K Z, Hansen, SL, Charlebois, ED, Harris, HW, Young, DL. Inappropriate antibiotic use in soft
tissue infections. Archives of Surgery 2006; 141(9), 850-856.
6)
Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R. Empiric antimicrobial therapy for pediatric skin and
soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. Pediatrics 2009; 123(6),
e959-966.
7)
Duong et al, Randomized Controlled Trial of Antibiotics in the Management of CommunityAcquired Skin Abscesses in the Pediatric Patient. Ann Emerg Med 2010;55(5):401-7.
8)
Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue
infections. Clin Infect Dis 2005;41:1373-406.
9)
Williams DJ et al. Comparative effectiveness of antibiotic treatment strategies for pediatric skin
and soft-tissue infections. Pediatrics 2011;128(3) e1-e9.
10)
Chen AE et al. Randomized Controlled Trial of Cephalexin Versus Clindamycin for Uncomplicated
Pediatric Skin Infections. Pediatrics 2011;127(3);e573.
11)
Squire et al. ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft
Tissue Infections. Acad Emerg Med 2005 Vol. 12, No. 7, 601-606
12)
Tayal, VS, Hasan, N, Norton, HJ et al, The effect of soft-tissue ultrasound on the management of
cellulitis in the emergency department. Acad Emerg Med 2006, 13, 4, 384-388.
Initial ED phase
abscess
Inpatient Phase
Executive Summary
Objective
To improve the quality and safety of care for uncomplicated community acquired soft tissue infections in children
older than 30 days of life, specifically:
Reduce use of broader spectrum, inappropriate, or more toxic antibiotics for cellulitis and abscess
Reduce the use of systemic antibiotics for children with simple abscess who meet low risk criteria
Decrease unnecessary laboratory testing
Increase the use of laboratory testing that will allow for targeted antimicrobial therapy
Decrease unnecessary hospital days
Recommendations
1.
Use bedside ultrasound where available to improve the accuracy in diagnosis of subcutaneous abscesses.
2.
Obtain wound cultures when possible.
3.
Do NOT obtain routine blood testing (CBC, CRP, blood culture) for most children with cellulitis or abscess.
4.
No incision and drainage is needed for abscesses <1 cm on bedside ultrasound; these patients may be
discharged home on antibiotics alone.
5.
Do NOT prescribe oral antibiotics for simple abscesses that have been incised and drained completely, if
the patient is >1 year of age, afebrile, well-appearing, with no significant comorbidities and adequate follow up
assured.
6.
Prescribe oral clindamycin for outpatient treatment of abscesses that could not have an adequate I&D, or
do not meet low-risk criteria.
7.
Prescribe cephalexin for outpatient treatment of simple cellulitis without an abscess, drainage, history of
drainage, or failure of outpatient antibiotic course (>48 h on appropriate antibiotics).
8.
Prescribe oral clindamycin for outpatient treatment of purulent cellulitis or cellulitis that has not responded
to anti-MSSA therapy (beta lactam, >48 hours).
9.
Prescribe cefazolin for inpatient treatment of simple cellulitis without an abscess, drainage, history of
drainage, or failure of outpatient antibiotic course (>48 h on appropriate antibiotic).
10.
Prescribe IV clindamycin for inpatient treatment of purulent cellulitis or cellulitis that has not responded to
anti-MSSA therapy (beta lactam, >48 hours) .
11.
Prescribe IV vancomycin for inpatient treatment of cellulitis in patients who are systemically ill (fever >38,
tachycardia, vomiting) or have failed antibiotic therapy that covers MRSA .
12.
Obtain general surgery, orthopedics, ENT, or dental consultation for the appropriate special clinical
scenarios.
Implementation Items
Created three care algorithms (two for the Emergency Department, and one for inpatients) as well as an
antibiotic table to address common clinical scenarios
Developed a Learning Center training module for the management of community acquired cellulitis and
abscess
Developed a multi-phase PowerPlan, with ED, inpatient, and discharge phases

Metrics Plan
Cellulitis Process Metrics
Antibiotic Change/Vancomycin Rate AIM : fewer than 10% of eligible population should change from
clindamycin or cefazolin to vancomycin.
ED Antibiotics for Home Rate AIM: reduce antibiotic prescription rate to 15% among patients undergoing I&D
for abscess who are discharged from the ED
PDCA Plan
Quarterly Review of Metrics, Literature Review, E-Feedback, and Audit Reports will inform Improvement efforts
Revision History
Date Approved:
August, 2013
Initial ED phase
Inpatient Phase
Next Review Date:
August, 2016
abscess
Executive Summary
Initial ED phase
abscess
Inpatient Phase
Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
Cellulitis and Abscess: Test your knowledge!

1. When evaluating a patient for SSTI, blood cultures
should be drawn:
a)
From all patients with suspected SSTI
b)
From patients with cellulitis only
c)
From patients with abscess only
d)
From patients with systemic toxicity or suspected necrotizing

fasciitis.
2. Abscesses that have been adequately drained may be

discharged home without antibiotics if
a)
>1 year old
b)
Well appearing
c)
Reliable followup within 2 days
d)
All of the above
Initial ED phase
abscess
Inpatient Phase
Test Your Knowledge 2

Answer Key
Self-Assessment

3. A patient has an uncomplicated non-suppurative
cellulitis. The patient should be discharged home with:
a)
Cephalexin
b)
Trimethoprim-Sulfamethoxazole
c)
Clindamycin
d)
No antibiotics.
4. A patient presents to the ED for evaluation of a

suspected pilonidal abscess. You should consult:
a)
Plastic surgery
b)
General surgery
c)
Orthopedic surgery
d)
All of the above
Initial ED phase
abscess
Inpatient Phase

Answer Key
Self-Assessment

5. A patient is admitted after an I&D of a buttock abscess
with significant surrounding cellulitis. You would treat
initially start treatment with:
a)
Vancomycin
b)
Clindamycin
c)
Cefazolin
d)
Trimethoprim-sulfamethoxazole
e)
Cephalexin
Initial ED phase
abscess
Inpatient Phase
Test Your Knowledge
Answer Key
Cellulitis and Abscess: Answer Key!

Answers:
1. d
2. d
3. a
4. b
5. b
Initial ED phase
abscess
Inpatient Phase
Test Your Knowledge
Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in
the following manner:
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Quality of Evidence:
High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394
To Bibliography
Initial ED phase
abscess
Inpatient Phase

Version 1 (08/15/2013): Go live
Version 1.1 (11/6/2013): Clarified which patients should receive Orthopedic consultation in the
ED; recommended laboratory studies to be performed prior to Orthopedic consultation; excluded
patients with solitary dental abscess from the ED phase
Initial ED phase
Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Childrens Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
Initial ED phase
Background
Many patients present to their health care providers, urgent care clinics,
or the emergency department for evaluation and treatment of soft
tissue infections. Some have a simple cellulitis that is often easily
treated with antibiotics, while others have more complicated infections
that require extensive incision and drainage or hospitalization. In
addition to Streptococcus pyogenes and methicillin-sensitive
Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus
aureus (MRSA) has also become a real consideration in these types of
infections.
This pathways intent is to standardize to the extent possible the
diagnosis and management of such soft tissue infections at Seattle
Childrens.
Initial ED phase
abscess
Inpatient Phase
Introduction Cellulitis and Abscess

This clinical standard work pathway is meant to guide the diagnosis
and management of patients with cellulitis and/or abscess.
Inclusion criteria: Suspected community-acquired skin and soft
tissue infection in a child > 44 weeks CGA
Exclusion criteria:
o
Hospital-acquired, surgical site and device-associated infections
Pressure ulcers
Immunodeficiency
Solitary dental abscesses
Note: For the inpatient phase, we additionally exclude peri-anal

abscesses, pilonidal abscesses, deep structure infections, and
patients admitted to surgical services. Initial ED management is
provided in the ED phase, however.
Initial ED phase
abscess
Inpatient Phase
Initial ED phase
abscess
Inpatient Phase
Microbiology
Nonpurulent cellulitis is usually due to group A
streptococci (although studies are limited due to the
difficulty culturing from these infections)
Purulent cellulitis may be caused by

MSSA, MRSA, or group A streptococci
(GAS).
Approximately 27% of S aureus isolates

from wounds are MRSA at Seattle
Childrens (2012-13 data)
S. pyogenes (GAS)
http://textbookofbacteriology.net/
Initial ED phase
abscess
Inpatient Phase
Risk factors for MRSA
History in the last 6 months of:

MRSA in the patient
MRSA in the family
Recurrent boils, pustules, spider bites, etc. that
required antibiotics, in patient or family
Initial ED phase
abscess
Inpatient Phase
Examining a soft tissue infection

Erythema, warmth, edema universally present
Induration or fluctuance (the latter diagnostic of fluid
collection) may be present
Signs of possible necrotizing infection:
Very rapid spread
Bluish discoloration, blistering, pain out of proportion or

beyond the edges of the lesion, skin anesthesia, rapid
progression, or gas in the tissue
These signs sometimes appear late in course
When first examining, draw a line (mark date/time) around

lesions borders, if not already present
Initial ED phase
abscess
Inpatient Phase
Diagnostic testing
Use bedside ultrasound where available to improve the accuracy in

diagnosis of subcutaneous abscesses (Squire , Tayal
)
Obtain wound cultures when possible; i.e., in patients who have

spontaneously draining lesions and in patients who undergo I&D
procedures (Liu , local consensus [LC])
Routine blood testing (CBC, CRP, blood culture) is not necessary for
most children with SSTI (Stevens , LC)
Obtain a CBC, CRP, and blood cultures in children with signs of

systemic toxicity, including ill-appearance, rapidly spreading lesions,
persistent fevers, and age <1yo (Liu , Stevens , LC)
Initial ED phase
Initial ED phase
abscess
abscess
Inpatient Phase
Inpatient Phase
Surgical consultation
Specific locations of cellulitis/abscess warrant subspecialist
consultation to evaluate for deeper and more serious/complicated
extension of infection.
Orthopedics: Infections over joints, infections of hand/fingers/feet
General surgery: Peri-anal abscess (within 1 cm of anal verge),

pilonidal abscess, perineal abscess, breast abscess
ENT: Neck abscess
Dental: Facial cellulitis of dental origin

(LC)
Note: Also consult General Surgery if an inpatient develops any

abscess requiring drainage (LC)
Initial ED phase
abscess
Inpatient Phase
Laboratory studies prior to Orthopedic consultation

Prior to consulting Orthopedics, obtain the following:
Blood work: Complete blood count with differential, C-reactive

protein, and erythrocyte sedimentation rate. Consider blood culture
for ill-appearing or febrile patients.
Radiographs: Obtain appropriate films of the affected area; typically

more than one view is required
(LC)
Note: The above studies will need to be ordered as needed from

outside the Cellulitis and Abscess PowerPlan.
Initial ED phase
abscess
Inpatient Phase
Incision and drainage (I&D)
No drainage is needed for abscesses <1 cm on bedside ultrasound;

these patients may be discharged home on antibiotics alone with
close PCP follow-up (Tayal , LC)
Larger abscesses require thorough I&D of purulent material with

adequate sedation and analgesia
Ketamine sedation is frequently needed in pediatric patients, though local

anesthesia will also provide some pain relief
Consider surgical consultation for very large or complicated abscesses that
may require extensive exploration or prolonged sedation time
All patients who have had an I&D procedure should have reliable
follow-up for re-evaluation with their PCP in 24 - 48 hours
Incision and drainage (continued)

Correct incision and drainage technique is the cornerstone
of treating abscesses. If you perform I&D, the following
video is a good reminder of proper techniques:
http://www.nejm.org/doi/full/10.1056/NEJMvcm071319
Return to Home
Initial ED phase
abscess
Inpatient Phase
Incision and drainage (continued)

Correct incision and drainage technique is the cornerstone
of treating abscesses. If you perform I&D, the following
video is a good reminder of proper techniques:
http://www.nejm.org/doi/full/10.1056/NEJMvcm071319
Initial ED phase
abscess
Inpatient Phase
Antibiotics for abscess post I&D

No oral antibiotics are needed for simple abscesses that have been incised
and drained completely, (Duong , Chen , Paydar ,
and Hankin ) unless the patient has one of the following:
Severe or extensive disease
Rapid progression in presence of associated cellulitis
Signs and symptoms of systemic illness
Associated comorbidities or immunosuppression
Extremes of age (<1 year old)
Abscess in area difficult to drain (face, hand, and genitalia)
Associated septic phlebitis
Lack of response to I &D alone (Liu )
Initial ED phase
abscess
Inpatient Phase
Antibiotics for abscess (continued)
Prescribe oral clindamycin for outpatient treatment of

abscesses that could not have an adequate I&D, or
do not meet low-risk criteria as summarized below
(Liu )
Initial ED phase
abscess
Inpatient Phase
Antibiotics for nonpurulent cellulitis

Prescribe an oral beta lactam (cephalexin) for outpatient treatment of
simple cellulitis without an abscess, drainage, history of drainage, or
failure of outpatient antibiotic course (>48 h on appropriate antibiotics)
(Liu , Stevens , Elliott , and Williams )
Prescribe an IV beta lactam (cefazolin) for inpatient treatment of
simple cellulitis without an abscess, drainage, history of drainage, or
failure of outpatient antibiotic course (>48 h on appropriate antibiotic)
(Liu and Stevens )
Prescribe oral clindamycin for cellulitis that has not responded to antiMSSA therapy (beta lactam, >48 hours) (Liu , LC)
Consider IV vancomycin for inpatient treatment of cellulitis in patients
who are systemically ill (fever >38, tachycardia, vomiting) or have failed
an outpatient antibiotic course that covers MRSA (Liu )
Antibiotics for purulent cellulitis

Prescribe oral clindamycin for outpatient treatment of purulent
cellulitis or cellulitis that has not responded to anti-MSSA therapy (beta
lactam, >48 hours) (Liu , LC)
Prescribe IV clindamycin for inpatient treatment of purulent cellulitis or
cellulitis that has not responded to anti-MSSA therapy (beta lactam,
>48 hours) (Liu , LC)
Prescribe IV vancomycin for inpatient treatment of cellulitis in patients

who are systemically ill (fever >38, tachycardia, vomiting) or have failed
antibiotic therapy that covers MRSA (Liu )
Initial ED phase
abscess
Inpatient Phase
ED Cellulitis / Abscess pathway Antibiotic selection
Initial ED phase
abscess
Inpatient Phase
Empiric antibiotic selection

Non-purulent cellulitis
IV choice
Cefazolin
Purulent SSTI/ abscess

Clindamycin
Facial cellulitis of
dental origin
Bite wounds
Penicillin OR
Vancomycin if presumed clindamycin

resistant MRSA; rapidly progressive
lesion; hemodynamic instability; illCefoxitin (transition to
appearing; failed oral clindamycin as
clindamycin AND
Clindamycin if penicillin
Consider vancomycin if rapidly outpatient; abscess in an area difficult
ciprofloxacin at discharge) if allergic
to drain completely such as
progressive lesion;
penicillin allergic
hemodynamic instability; illface/hand/genitals
appearing
allergic
IV Alternatives
PO choice
Cephalexin
No antibiotics if low risk criteria met

and abscess adequately drained
Penicillin OR
Clindamycin otherwise
TMP/SMX if presumed clindamycin
resistant MRSA
PO Alternatives
allergic
Doxycycline if age >8 years and prior

Clindamycin AND
clindamycin and TMP/SMX resistant
ciprofloxacin for penicillin
MRSA OR presumed clindamycin
allergic patients
resistance and sulfa allergy
Initial ED phase

and penicillin allergy
abscess
Clindamycin if penicillin
allergic
Call ID for other scenarios
Inpatient Phase
Admission criteria
Patients who should be admitted:
Are systemically ill (ill-appearance, persistent fevers, hemodynamic

instability etc.)
Are unable to tolerate oral therapy
Fail appropriate outpatient therapy (48 hours of treatment and not

showing signs of improvement)
Have rapidly progressive lesions
Need pain control or wound care
Consider if < 6 months of age
Adequate follow up not available

(LC)
Initial ED phase
abscess
Inpatient Phase
Inpatient pathway daily flow
Initial ED phase
abscess
Reevaluate lesion
daily or with
significant changes
Follow microbiology
cultures, and change
to the narrowest
spectrum antibiotic
once sensitivities are
available
Consult general
surgery if an abscess
develops that
necessitates
drainage
Inpatient Phase
Treatment failure
Treatment failure occurs if there is:
Significant or rapid expansion of cellulitis at any point in the

course of treatment (i.e. more than just one or two centimeters
beyond margins), or
Cellulitis is not showing improvement after 48 hours of effective
antibiotic treatment (LC)
The development of a new abscess within an area of previous

infection while on antibiotics does not in and of itself constitute
treatment failure
Note: Referring physicians will be asked to outline lesions with
permanent marker if possible before sending patients to the ED
and make the patient NPO; lesions will be outlined in ED triage if
not already done
Initial ED phase
abscess
Inpatient Phase
Switching to oral antibiotics
Conversion from an IV to oral antibiotic prior to discharge is

not necessary (LC)
If worries about palatability or concerns about administration
exist, a single oral antibiotic dose may be given prior to
discharge (LC)
Initial ED phase
abscess
Inpatient Phase
Discharge criteria
A patient is ready for discharge when:
Lesion(s) show signs of improvement
Tolerating PO
Pain well controlled
No fever > 24 hours
Follow up assured within 48 hours

(LC)
Patients should complete 7-10 total days of antibiotic treatment.
(LC, Liu ).
Antibiotic treatment can be extended by the PCP if the lesion is not
completely resolved at the end of this course.
Initial ED phase
abscess
Inpatient Phase

Cellulitis and Abscess Pathway

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Cellulitis and Abscess Pathway

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Cellulitis and Abscess: ED Phase v 1.

Explanation of Evidence Ratings

Summary of Version Changes

If referral call from PMD,

Order labs, then

Facial cellulitis of dental origin

Involve Dental; See

Go to Simple Cellulitis / Abscess Phase

For questions concerning this pathway,

Determine with consultant

Last Updated: 08/15/2013

Cellulitis and Abscess: ED simple cellulitis / abscess v.1

Explanation of Evidence Ratings

Summary of Version Changes

Hospital-acquired, surgical site &

Simple cellulitis / abscess

Perform bedside ultrasound

Inpatient Admit Criteria

Low Risk Criteria

For questions concerning this pathway,

Last Updated: 08/15/2013

Cellulitis and Abscess: Inpatient Phase v.1

Explanation of Evidence Ratings

Summary of Version Changes

INPATIENT Exclusion Criteria

Tailor antibiotics if culture results are

Tailor antibiotics if culture results are

For questions concerning this pathway,

Last Updated: 08/15/2013

Cellulitis and Abscess: Antibiotic Table

Explanation of Evidence Ratings

Test Your Knowledge

Summary of Version Changes

Cellulitis and Abscess Antibiotic Table

Purulent SSTI/ abscess

Call ID if linezolid desired

Doxycycline if age >8 years

Doxycycline if age >8 years

Call ID if linezolid desired

Low Risk Criteria*

Alternate antibiotic choices

* For use in determining the need for PO

antibiotics for purulent infection post I&D,

Return Initial ED phase

Return to Inpatient Phase

For questions concerning this pathway,

Last Updated: 08/15/2013

13 additional records identified

396 records screened

340 records excluded

55 full-text articles assessed for eligibility

11 full-text articles excluded,

Developed a multi-phase PowerPlan, with ED, inpatient, and discharge phases

Cellulitis and Abscess: Test your knowledge!

From all patients with suspected SSTI

From patients with cellulitis only

From patients with abscess only

From patients with systemic toxicity or suspected necrotizing

2. Abscesses that have been adequately drained may be

>1 year old