JOURNAL READING

Diagnosis and
Management of Cellulitis
Presented By:
Muhammad Yusuf Makkaraeng A. M.

Supervisor:
dr. Hanny Tanasale, Sp.KK.

Departemen of Dermatovenerologi
Medical Faculty
Pattimura University
CMF
INFECTION
DISEASE
Clinical Medicine
2018Vol2,No2;160-3
Authors: Tadhg Sullivan and Eoghan de Barra
 ABSTRACT
Cellulitis is a frequently encountered
condition, but remains a challenging clinical
entity. Under and overtreatment with

itis
antimicrobials frequently occurs and mimics

nt o is and
llul
cloud the diagnosis. Typical presentation,

f Ce
microbiology and management approaches
are discussed.

s
Man Diagno
age
Content
Introduction
01 Definition, Burden of disease, and Miocrobiology

02 Clinical Presentation
03 Risk Factor
04 Management
05 Cellulitis mimics
06 Stratifying Risk
07 Treatment
08 Prophylaxis
Introduction
Cellulitis is simply defined as an acute infection of the skin involving the dermis and
subcutaneous tissues. Erysipelas classically refers to a more superficial cellulitis of the face
or extremities with lymphatic involvement, classically due to streptococcal infection. Diabetic
foot infections and wound infections are specific entities.

in .................. cellulitis was listed as a primary diagnosis for 114,190 completed consultant
episodes in secondary care and 75,838 inpatient admissions with a median length
2014-5 of stay of 3 days with a mean patient age of 63. Many more cases are treated in
primary care

• Streptococcus spp and Staphylococcus aureus → predominant cause of cellulitis

• >10% of cases → Positive blood cultures
• S aureus , group A streptococci and group G streptococci → the most common isolates
from wound cultures
• Serological studies suggest group A streptococcal infection → culture negative cellulitis.
• Skin infection with pus? strongly associated with S aureus.
• Animal bites : Pasteurella and Capnocytophaga
• Exposure of a skin break to salt or fresh water : Vibrio vulnificus and Aeromonas spp
respectively
 Clinical Presentation
Rubor (redness), dolor (pain), Reveal a portal of entry such as
tumor (swelling), calor (heat) ulcers, trauma, eczema or cutaneous
mycosis

Bilateral lower limb erythema in an afebrile

Localised erythema patient with normal inflammatory markers
→ reconsider the diagnosis of cellulitis
Cellulitis

Pain Systemic features and groin pain

Timing and evolution of the skin Skin breaks, bullae or areas of

findings necrotic tissue → severe cellulitis
Risk Factor
Venous Insufficiency

Obesity

Lymphedema

Tinea Pedis

Skin Breaks
Management
Not recommended but should be
considered in patient who have
systemic features of sepsis, who
are immunosuppressed or for
cases associated with immersion
Liver and Renal injuries or animal bites
Function

Culture of Blood,
Aspirate or Bio[sies
May be useful for
assessing end-organ dysfunction
in patients with sepsis and for
dosing of antimicrobials
 Cellulitis Mimics

30% of Alternate diagnoses : Misdiagnosed patients:

cellulitis patients are eczema, lymphoedema 85% did not require
misdiagnosed and hospital admission and
lipodermatosclerosis 92% received
unnecessary antibiotics.
Stratifying Risk
Dundee Classification
Eron Classification
to separate patients into distinct
groups based on the presence or
For grade severity of cellulitis
absence of defined systemic features
of sepsis, the presence or absence of
significant comorbidities and
their Standardised Early Warning
score (SEWS)

Standardised Early Warning

Score (SEWS) Skin and soft tissue
infections (SSTIs)
Standardised form of early warning
score, calculated from the patient’s Marwick et al found signification
routine clinical observations, with a overtreatment of skin and soft tissue
threshold score of 4 selected to infekction particularly in the lowest
indicate the most severely unwell severity group
patients (class IV) in whom a clinical
review was mandated at the site
where the study was undertaken
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Treatment
 Treatment

Purulent Skin and Soft Tissue Deep or Necrotising Infection

Infection Should have an urgent surgical
Such as abscesses, furuncles or consultation for consideration of surgical
carbuncles should have those inspection and debridement
collections incised and drained.
given to systemic antibiotics in patients
with systemic signs of infection

Non-purulent Skin and Soft Infections Associated with

Tissue Infection Human or Animal Bites
Generally require treatment with may require broader spectrum
systemic antimicrobials antimicrobial cover and should be
discussed with an infection specialist
Non Purulent Skin and
Soft Tissue Infection

Generally require treatment with systemic antimicrobials

Oral antimicrobial therapy

Is adequate for patient with no systematic sign of infection and no
comorbidities (Dundee class I), some Dundee class II patients may
be suitable for oral antibiotics or may require an initial period if
intravenous therapy either in hospital or via outpatient antimicrobial
therapy (OPAT)

Intravenous Agents
Intravenous agents should be used for those with evidence of
systemic infection (Dundee class III and IV) or those who do not
respond to initial oral therapy
Recommendation Antimicrobial Agents

 Depending on local practice and resistance rates

40% 80% 60% 50%  Moderate cellulitis active against streptococci

 History of penetrating trauma or with a purulent
infection → anti-staphylococcal cover is strongly
advised
 Guidance from UK CREST recommends an agent
with both anti-streptococcal and anti-
staphylococcal activity, such as flucloxacillin
 Thromboprophylaxis with low-molecular-weight
heparin should be considered in line with local and
national guidelines
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Severe Necroting Infections
 Should have initial broad spectrum antimicrobial cover to
include staphylococci, streptococci, Gram-negative
organisms and also an agent with activity against toxin
production in group A streptococci, such as clindamycin or
linezolid.
 Treatment with an agent active against methicillin-resistant
S aureus (MRSA) should be considered in patients with a
known history of, or risk factors for, MRSA colonisation as
well as in those with suspected necrotising fasciitis.
 Recent prospective trials in the USA have suggested that
empiric use of agents active against MRSA may not be
warranted in the treatment of non-purulent cellulitis
The Lillte Evidence to Support the Historical Practice

Adding Bencylpenicillin to Flucixacillin

In the treatment of cellulitis
In the randomised double-blinded trial comparing flucoxacillin and clindamycin
with flucoxacillin alone, there was no difference in clinical improvement or the
resumption of normal daily activities, but there was increased diarrhoea in the
clindamycin group.

Brunn et al: the early antimicrobial (during the first 3 days of therapy) did not
result in improved outcome and addresing non-antibiotic factor such as limb
elevation and treatment of comorbidities should be considered as an integrated
part of the clinical management of cellulitis
Parenteral Antimicrobial
therapy

Outpatient parenteral antimicrobial therapy has become an

increasingly important means of delivering ambulatory care.

in ........... Cellulitis was the most common primary infective

2015 diagnosis in UK OPAT

• Outpatient parenteral antimicrobial therapy may be considered as

initial management in suitable patients with moderate (Dundee
grade II) cellulitis without evidence of necrotising infection or
sepsis alternatively, it may be used to facilitate early discharge in
patients with improving parameters. Treatment success rates are
almost 90%
The Optimal Duration
of Antimicrobial Therapy
The optimal duration of antimicrobial
therapy in cellulitis remains unclear

o Most cases of uncomplicated cellulitis are traditionally treated with 1–2

weeks of antimicrobial therapy
o Evidence now exists to suggest that such prolonged courses may be
unnecessary, and that 5 days treatment may be sufficient in cases of
uncomplicated cellulitis
o Patients with uncomplicated SSTIs can be safely switched to oral
antibiotics after 1–4 days of parenteral therapy
o The CREST guidance suggests settling pyrexia, stable comorbidities,
less intense erythema and falling inflammatory markers as criteria for
an oral switch
o Any predisposing factors (eg tinea pedis, lymphoedema etc) should
be addressed to reduce the risk of recurrent cellulitis
Prophylaxis
Patients with a history of cellulitis, particularly of the lower limbs, have an estimated
recurrence rate of 8–20%

Patients with three to four episodes of cellulitis

per year despite addressing predisposing
factors could be considered for prophylactic
antimicrobial therapy so long as those factors
persist

A randomised controlled trial of

phenoxymethylpenicillin Emerg Med J
2005 ; 22 : 342 – 6. prophylaxis in patients with
a history of recurrent cellulitis showed a
reduced rate of recurrence in the treatment
group (hazard ratio [HR] 0.55, 95% confidence
interval [CI] 0.35–0.86, p=0.001)

The number needed to treat (NNT) was five

(95% CI 4–9)
Thank You