Cellulitis Clinical Presentation
- Author: Thomas E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD more...
A directed history is vital to the proper care of a patient with cellulitis. The patient may or may not relate an episode of trauma that preceded symptoms; when cellulitis develops, it is usually several days after the inciting trauma. Rapid progression or significant pain is a concerning sign that may indicate a severe problem, such as necrotizing fasciitis, which should be managed promptly.
If the patient recalls an episode of trauma, the clinician should ask about circumstances surrounding the incident that may elicit clues to a particular etiology. For example, exposure to standing or brackish water could mean that Aeromonas or Vibrio is the cause of infection; or a cut that occurred while butchering may be an important clue to consider Erysipelothrix rhusiopathiae. Identifying the specific inciting cause helps the clinician identify the most likely pathogen, choose appropriate antibiotic therapy, and offer appropriate immunization, such as tetanus toxoid (Td or Tdap), if indicated.
The patient should also be questioned about the presence of other skin disorders, including various types of dermatitis and especially any preceding fungal infection, which may serve as a portal of entry for bacterial pathogens.
The past medical history should focus on the presence of comorbid conditions that may increase the risk for cellulitis, with the most common ones being diabetes mellitus, human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), chronic kidney disease, and chronic liver disease.
The surgical history may include a recent procedure that resulted in wound infection. For example, severe bacterial cellulitis may occur as a postsurgical complication following hip replacement or liposuction. Alternatively, a remote surgical history involving lymph node dissection (eg, following either radical mastectomy or conservative breast surgery) may predispose to cellulitis, even years after the surgery, because of lymphatic occlusion.[57, 58, 59, 60] Impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass. In addition, the presence of foreign bodies, including indwelling IV catheters, external orthopedic pins, and other surgical devices, may predispose to infection.
The physical examination should first focus on the area of concern. Nonpurulent cellulitis is associated with 4 cardinal signs of infection: erythema, pain, swelling, and warmth. Several physical examination findings may help the clinician identify the most likely pathogen and assess the severity of the infection, thereby facilitating appropriate treatment. Those findings include the following:
The involved site(s)is/are red, hot, swollen, and tender
Unlike erysipelas, the borders are not elevated or sharply demarcated
The involved site is the leg, which is the most common site [46, 61]
Regional lymphadenopathy is present
Malaise, chills, fever, and toxicity are present
Skin infection without underlying drainage, penetrating trauma, eschar, or abscess is most likely caused by streptococci; on the other hand, S aureus, often community-acquired methicillin-resistant S aureus (CA-MRSA), is the most likely pathogen when these factors are present 
Perianal cellulitis is usually observed in children with perianal fissures; it is characterized by perianal erythema and pruritus, purulent secretions, painful defecation, and blood in the stools 
Lymphangitic spread (red lines streaking away from the area of infection), crepitus, and hemodynamic instability are indications of severe infection, requiring more aggressive treatment
Circumferential cellulitis or pain that is disproportional to examination findings should prompt consideration of severe soft-tissue infection
The IDSA indicates that the following are also signs/symptoms of potentially severe deep soft-tissue infection (Note: these frequently appear later in the course of necrotizing infections), which necessitate emergent surgical evaluation :
Gas in the tissue
Busch BA, Ahern MT, Topinka M, Jenkins JJ 2nd, Weiser MA. Eschar with cellulitis as a clinical predictor in community-acquired MRSA skin abscess. J Emerg Med. Jul 8 2008.
[Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. 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. 2014 Jul 15. 59(2):e10-52. [Medline].
Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY. Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis. Apr 2000. 19(4):294-7.
Swartz MN. Clinical practice. Cellulitis. N Engl J Med. Feb 26 2004. 350(9):904-12.
Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. Apr 2006. 13(4):384-8.
Chao HC, Lin SJ, Huang YC, Lin TY. Sonographic evaluation of cellulitis in children. J Ultrasound Med. Nov 2000. 19(11):743-9.
Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol. Mar 1998. 170(3):615-20.
Gabillot-Carré M, Roujeau JC. Acute bacterial skin infections and cellulitis. Curr Opin Infect Dis. 2007 Apr. 20(2):118-23. [Medline].
Stevenson A, Hider P, Than M. The utility of blood cultures in the management of non-facial cellulitis appears to be low. N Z Med J. Mar 11 2005. 118(1211):U1351.
Sachs MK. The optimum use of needle aspiration in the bacteriologic diagnosis of cellulitis in adults. Arch Intern Med. Sep 1990. 150(9):1907-12.
Zahar JR, Goveia J, Lesprit P, Brun-Buisson C. Severe soft tissue infections of the extremities in patients admitted to an intensive care unit. Clin Microbiol Infect. Jan 2005. 11(1):79-82.
Edlich RF, Cross CL, Dahlstrom JJ, Long WB 3rd. Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis. J Emerg Med. Dec 10 2008.
Kremer M, Zuckerman R, Avraham Z, Raz R. Long-term antimicrobial therapy in the prevention of recurrent soft-tissue infections. J Infect. Jan 1991. 22(1):37-40.
Seaton RA, Bell E, Gourlay Y, Semple L. Nurse-led management of uncomplicated cellulitis in the community: evaluation of a protocol incorporating intravenous ceftriaxone. J Antimicrob Chemother. May 2005. 55(5):764-7.
Lipsky BA. New developments in diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev. May-Jun 2008. 24 Suppl 1:S66-71.
Roujeau JC, Sigurgeirsson B, Korting HC, Kerl H, Paul C. Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study. Dermatology. 2004. 209(4):301-7.
Björnsdóttir S, Gottfredsson M, Thórisdóttir AS, Gunnarsson GB, Ríkardsdóttir H, Kristjánsson M, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. Nov 15 2005. 41(10):1416-22.
Roberts S, Chambers S. Diagnosis and management of Staphylococcus aureus infections of the skin and soft tissue. Intern Med J. Dec 2005. 35 Suppl 2:S97-105.
Kroshinsky D, Grossman ME, Fox LP. Approach to the patient with presumed cellulitis. Semin Cutan Med Surg. Sep 2007. 26(3):168-78.
Lin JN, Chang LL, Lai CH, Lin HH, Chen YH. Clinical and molecular characteristics of invasive and noninvasive skin and soft tissue infections caused by group A Streptococcus. J Clin Microbiol. 2011 Oct. 49(10):3632-7. [Medline]. [Full Text].
Miller LS, Cho JS. Immunity against Staphylococcus aureus cutaneous infections. Nat Rev Immunol. 2011. 11:505-18. [Medline].
Baddour LM, Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass surgery. Ann Intern Med. Oct 1982. 97(4):493-6.
Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis. Association with venous and lymphatic compromise. Am J Med. Aug 1985. 79(2):155-9.
Kalliola S, Vuopio-Varkila J, Takala AK, Eskola J. Neonatal group B streptococcal disease in Finland: a ten-year nationwide study. Pediatr Infect Dis J. Sep 1999. 18(9):806-10.
Cieslak TJ, Rajnik M, Roscelli JD. Immunization against Haemophilus influenzae type B fails to prevent orbital and facial cellulitis: results of a 25-year study among military children. Mil Med. Oct 2008. 173(10):941-4.
Parada JP, Maslow JN. Clinical syndromes associated with adult pneumococcal cellulitis. Scand J Infect Dis. 2000. 32(2):133-6.
Chin PW, Koh CK, Wong KT. Cutaneous tuberculosis mimicking cellulitis in an immunosuppressed patient. Singapore Med J. Jan 1999. 40(1):44-5.
Elkayam O, Gat A, Lidgi M, Segal R, Yaron M, Caspi D. Atypical cutaneous findings in a patient with systemic lupus erythematosus. Lupus. 2003. 12(5):413-7.
Hsu PY, Yang YH, Hsiao CH, Lee PI, Chiang BL. Mycobacterium kansasii infection presenting as cellulitis in a patient with systemic lupus erythematosus. J Formos Med Assoc. Aug 2002. 101(8):581-4.
Bassetti S, Battegay M. Staphylococcus aureus infections in injection drug users: risk factors and prevention strategies. Infection. Jun 2004. 32(3):163-9.
Sierra JM, Sanchez F, Castro P, et al. Group A streptococcal infections in injection drug users in Barcelona, Spain: epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003. Medicine (Baltimore). May 2006. 85(3):139-46.
Horowitz Y, Sperber AD, Almog Y. Gram-negative cellulitis complicating cirrhosis. Mayo Clin Proc. Feb 2004. 79(2):247-50.
Sebeny PJ, Riddle MS, Petersen K. Acinetobacter baumannii skin and soft-tissue infection associated with war trauma. Clin Infect Dis. Aug 15 2008. 47(4):444-9.
Semel JD, Goldin H. Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples. Clin Infect Dis. Nov 1996. 23(5):1162-4.
Vugia DJ, Peterson CL, Meyers HB, et al. Invasive group A streptococcal infections in children with varicella in Southern California. Pediatr Infect Dis J. Feb 1996. 15(2):146-50.
Waldhausen JH, Holterman MJ, Sawin RS. Surgical implications of necrotizing fasciitis in children with chickenpox. J Pediatr Surg. Aug 1996. 31(8):1138-41.
Lowy FD. Staphylococcus aureus infections. N Engl J Med. Aug 20 1998. 339(8):520-32.
Barrett FF, McGehee RF Jr, Finland M. Methicillin-resistant Staphylococcus aureus at Boston City Hospital. Bacteriologic and epidemiologic observations. N Engl J Med. Aug 29 1968. 279(9):441-8.
Four Pediatric Deaths from Community-Acquired Methicillin-Resistant Staphylococcus aureus -- Minnesota and North Dakota, 1997-1999. CDC. August 20, 1999. 707-10. [Full Text].
Furuya EY, Cook HA, Lee MH, Miller M, Larson E, Hyman S. Community-associated methicillin-resistant Staphylococcus aureus prevalence: how common is it? A methodological comparison of prevalence ascertainment. Am J Infect Control. Aug 2007. 35(6):359-66. [Medline].
Brook I. Microbiology and management of human and animal bite wound infections. Prim Care. Mar 2003. 30(1):25-39.
Dendle C, Looke D. Review article: Animal bites: an update for management with a focus on infections. Emerg Med Australas. Dec 2008. 20(6):458-67.
Noonburg GE. Management of extremity trauma and related infections occurring in the aquatic environment. J Am Acad Orthop Surg. Jul-Aug 2005. 13(4):243-53.
Dechet AM, Yu PA, Koram N, Painter J. Nonfoodborne Vibrio infections: an important cause of morbidity and mortality in the United States, 1997-2006. Clin Infect Dis. Apr 1 2008. 46(7):970-6.
McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota. Mayo Clin Proc. Jul 2007. 82(7):817-21.
Ellis Simonsen SM, van Orman ER, Hatch BE, et al. Cellulitis incidence in a defined population. Epidemiol Infect. Apr 2006. 134(2):293-9. [Medline].
Lamagni TL, Darenberg J, Luca-Harari B, et al. Epidemiology of severe Streptococcus pyogenes disease in Europe. J Clin Microbiol. Jul 2008. 46(7):2359-67. [Medline].
Lederman ER, Weld LH, Elyazar IR, et al. Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network. Int J Infect Dis. Nov 2008. 12(6):593-602.
Givner LB, Mason EO Jr, Barson WJ, et al. Pneumococcal facial cellulitis in children. Pediatrics. Nov 2000. 106(5):E61.
Kokx NP, Comstock JA, Facklam RR. Streptococcal perianal disease in children. Pediatrics. Nov 1987. 80(5):659-63.
Lipsky BA, Weigelt JA, Gupta V, Killian A, Peng MM. Skin, soft tissue, bone, and joint infections in hospitalized patients: epidemiology and microbiological, clinical, and economic outcomes. Infect Control Hosp Epidemiol. Nov 2007. 28(11):1290-8. [Medline].
Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. Jul 28 2008. 168(14):1585-91. [Medline].
Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med. Aug 22 1996. 335(8):547-54. [Medline].
Bisno AL, Cockerill FR 3rd, Bermudez CT. The initial outpatient-physician encounter in group A streptococcal necrotizing fasciitis. Clin Infect Dis. Aug 2000. 31(2):607-8. [Medline].
Francis JS, Doherty MC, Lopatin U, Johnston CP, Sinha G, Ross T. Severe community-onset pneumonia in healthy adults caused by methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine leukocidin genes. Clin Infect Dis. Jan 1 2005. 40(1):100-7. [Medline].
Durupt F, Dalle S, Ronger S, Thomas L. Does erysipelas-like rash after hip replacement exist?. Dermatology. 2006. 212(3):216-20.
Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. Nov 1992. 93(5):543-8.
Masmoudi A, Maaloul I, Turki H, et al. Erysipelas after breast cancer treatment (26 cases). Dermatol Online J. Dec 1 2005. 11(3):12.
Zippel D, Siegelmann-Danieli N, Ayalon S, Kaufman B, Pfeffer R, Zvi Papa M. Delayed breast cellulitis following breast conserving operation. Eur J Surg Oncol. May 2003. 29(4):327-30.
El Saghir NS, Otrock ZK, Bizri AR, Uwaydah MM, Oghlakian GO. Erysipelas of the upper extremity following locoregional therapy for breast cancer. Breast. Oct 2005. 14(5):347-51.
Lazzarini L, Conti E, Tositti G, de Lalla F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. Dec 2005. 51(5):383-9.
Spear RM, Rothbaum RJ, Keating JP, Blaufuss MC, Rosenblum JL. Perianal streptococcal cellulitis. J Pediatr. Oct 1985. 107(4):557-9.
Markham RB, Polk BF. Seal finger. Rev Infect Dis. May-Jun 1979. 1(3):567-9.
Crum NF, Higginbottom PA, Fehl FC, Graham BS. Sweet's syndrome masquerading as facial cellulitis. Cutis. Jun 2003. 71(6):469-72.
Jenkins TC, Knepper BC, Sabel AL, Sarcone EE, Long JA, Haukoos JS, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011 Jun 27. 171(12):1072-9. [Medline].
Perl B, Gottehrer NP, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. Dec 1999. 29(6):1483-8.
Liu C, Bayer A, Cosgrove SE, et al. 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. [Medline].
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012. 54(12):3132-3172. [Full Text].
Brown T. Recurrent Cellulitis: Penicillin Effective for Prevention. Medscape Medical News, May 1, 2013. Available at http://www.medscape.com/viewarticle/803476. Accessed: May 8, 2013.
Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013 May 2. 368(18):1695-703. [Medline].
Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, McDougal LK, Carey RB, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. Aug 17 2006. 355(7):666-74.
Cenizal MJ, Skiest D, Luber S, Bedimo R, Davis P, Fox P, et al. Prospective randomized trial of empiric therapy with trimethoprim-sulfamethoxazole or doxycycline for outpatient skin and soft tissue infections in an area of high prevalence of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. Jul 2007. 51(7):2628-30.
Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. Jul 26 2007. 357(4):380-90.
Stryjewski ME, Chambers HF. Skin and soft-tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. Clin Infect Dis. Jun 1 2008. 46 Suppl 5:S368-77.
Davis SL, McKinnon PS, Hall LM, Delgado G Jr, Rose W, Wilson RF. Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes. Pharmacotherapy. Dec 2007. 27(12):1611-8.
Krige JE, Lindfield K, Friedrich L, Otradovec C, Martone WJ, Katz DE. Effectiveness and duration of daptomycin therapy in resolving clinical symptoms in the treatment of complicated skin and skin structure infections. Curr Med Res Opin. Sep 2007. 23(9):2147-56.
Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. Aug 9-23 2004. 164(15):1669-74.
Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul. 32(7):1535-41. [Medline].
King MD, Humphrey BJ, Wang YF, Kourbatova EV, Ray SM, Blumberg HM. Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections. Ann Intern Med. Mar 7 2006. 144(5):309-17.
Halilovic J, Heintz BH, Brown J. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. J Infect. 2012 Mar 21. [Epub ahead of print]. [Medline].
Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia. Clin Infect Dis. Jul 1999. 29(1):60-6; discussion 67-8.
Chuang YC, Yuan CY, Liu CY, Lan CK, Huang AH. Vibrio vulnificus infection in Taiwan: report of 28 cases and review of clinical manifestations and treatment. Clin Infect Dis. Aug 1992. 15(2):271-6.
Fernandez JM, Serrano M, De Arriba JJ, Sanchez MV, Escribano E, Ferreras P. Bacteremic cellulitis caused by Non-01, Non-0139 Vibrio cholerae: report of a case in a patient with hemochromatosis. Diagn Microbiol Infect Dis. May 2000. 37(1):77-80.
US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when linezolid (Zyvox®) is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm265305.htm. Accessed: July 27, 2011.
Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013 Dec. 126(12):1099-106. [Medline].
|Location||Likely Organisms||Other Organisms||Complication/ Discussion||Antibiotic Regimen -- Oral/ Outpatient||Indication for Hospitalization||Antibiotic Regimen -- Parenteral/ Hospitalized|
|Uncomplicated cellulitis||Group A streptococci much more likely than Staphylococcus aureus||Cephalexin or dicloxacillin
|Cefazolin or oxacillin
|Cellulitis, concern for methicillin-resistant S aureus is a concern||Group A streptococci and S aureus||[(Cephalexin or dicloxacillin or clindamycin) plus trimethoprim/ sulfamethoxazole]
|Dog bite||Pasteurella species (50% of wounds)
Aerobes --Moraxella and Neisseria
Anaerobes --Fusobacterium, Bacteroides, Porphyromonas, and Prevotella
|Capnocytophaga canimorsus may cause sepsis in patients with asplenia/hepatic disease.
Avoid first-generation cephalosporins/ erythromycin/ dicloxacillin.
High likelihood of infection –
Prophylactic antibiotics indicated for the following wounds: deep puncture, hands, requiring surgical repair, immunocompromised host, venous or lymphatic compromise, crush injury.
Requires close follow-up care within 24-48 h.
|Deep wounds or severe wounds;
infections not responding to oral antibiotics
|Third-generation cephalosporin (ceftriaxone [Rocephin]) plus metronidazole
beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or
fluoroquinolone plus metronidazole
|Human bite||Eikenella corrodens (gram-negative facultative anaerobe, 29% of wounds)
Aerobic gram-positive cocci, anaerobes
|Clenched fist lacerations over metacarpophalangeal joints should be considered human bites; anesthetize wounds and irrigate; reevaluate within 24-48 h.
Intercanine distance >3 cm is likely bite from adult; if wound to child, consider abuse.
(Clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)
|Third-generation cephalosporin (Rocephin) plus metronidazole
beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam)
fluoroquinolone plus metronidazole
|Cat bite||Pasteurella multocida and P septica (75% of wounds)||Staphylococci, streptococci, Bacteroides, Peptostreptococcus, Actinomyces, Fusobacterium, Porphyromonas, and Veillonella parvula||Avoid first-generation cephalosporins/ erythromycin/ dicloxacillin
High likelihood of infection -- Prophylactic antibiotics indicated for the following wounds: deep puncture, hands, requiring surgical repair, immunocompromised host, venous or lymphatic compromise.
Requires close follow-up care within 24-48 h.
Penicillin allergic --
(Clindamycin or metronidazole) plus
(doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)
|Deep wounds or severe wounds; infections not responding to oral antibiotics||Third-generation cephalosporin (Rocephin) plus metronidazole
beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or
fluoroquinolone plus metronidazole
|Preseptal (periorbital) cellulitis||Haemophilus influenzae type b, Streptococcus pneumoniae, S aureus, other streptococcal species, and anaerobes||Nocardia brasiliensis, Bacillus anthracis, Pseudomonas aeruginosa, Neisseria gonorrhoeae, Proteus species, Pasteurella multocida, Mycobacterium tuberculosis||Largest study indicates that H influenzae type b and S pneumoniae not diminished in facial cellulitis as a result of immunizations||Amoxicillin-clavulanate, cefpodoxime, cefdinir||Age < 1 y/ more severe disease require intravenous antibiotic||Third-generation cephalosporin (Rocephin)|
|Lower extremity --
Complicating saphenous venectomy site after coronary bypass grafting
|No pathogen identifiable in most infections, but it is likely to be streptococcal (> staphylococcal)
Non-group A beta-hemolytic streptococci most likely organism; S aureus less common
|Recurrent episodes common; may be associated with rigors, extreme fatigue, myalgias, and hypotension; some associated with tinea pedis (toe web cultures may be useful in establishing probable pathogen)||Dicloxacillin or cephalexin.
Add trimethoprim/ sulfamethoxazole or tetracycline or clindamycin if concern for methicillin-resistant S aureus
|First-generation cephalosporin (cefazolin); clindamycin; vancomycin|
|Breast/arm - - (not mastitis)
Complicating breast cancer surgery/lymph node dissection
|No pathogen identifiable in most infections
Group A or Non-group A beta-hemolytic streptococci most likely organisms
|Dicloxacillin, cephalexin. Add trimethoprim/ sulfamethoxazole or tetracycline or clindamycin if concern for methicillin-resistant S aureus||Fever, recent chemotherapy, neutropenia||Multiple regimens, none clearly superior –Piperacillin/tazobactam or ceftazidime plus aminoglycoside;
ciprofloxacin plus beta-lactam
monotherapy with piperacillin/tazobactam or cefepime
|Aquatic environment --
Fresh water/ salt water/ brackish water/ swimming pools/ aquarium
|Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Vibrio species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and others||A hydrophila and Vibrio vulnificus may produce rapidly progressive soft-tissue infection and sepsis||Fluoroquinolone (eg, ciprofloxacin or levofloxacin)
Note: For M marinum infection, use clarithromycin plus either ethambutol or rifampin
|Third- or fourth-generation cephalosporin (eg, ceftazidime or cefepime) or fluoroquinolone (eg, ciprofloxacin or levofloxacin)|
|Clenched-fist injury||E corrodens (gram-negative anaerobe, 29 % of wounds); aerobic gram-positive cocci, anaerobes||Lacerations over metacarpophalangeal joints should be considered human bites; anesthetize wounds and irrigate; reevaluate within 24-48 h
Lacerations of extensor tendon
|Amoxicillin/ clavulanate; penicillin allergic:
(clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)
|Failure to respond to oral therapy marked by increasing pain and swelling or purulent drainage||Beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam)|
|Odontogenic facial cellulitis||Aerobic and facultative organisms: group A beta-hemolytic streptococci, Neisseria and Eikenella species
Anaerobes: Prevotella and Peptostreptococcus species
|Require extraction or root canal||Amoxicillin-clavulanate
|Beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or