eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Cellulitis: Follow-up

Author: Isaac P Humphrey, MD, Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Instructor of Internal Medicine, Wright State University Boonshoft School of Medicine
Coauthor(s): Eric S Halsey, MD, Chief, Department of Infectious Diseases, Wright-Patterson Air Force Base; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Assistant Professor of Medicine, Wright State University
Contributor Information and Disclosures

Updated: Sep 23, 2009

Follow-up

Further Inpatient Care

  • Patients with cellulitis admitted for intravenous therapy who show significant improvement may be discharged on an oral agent to complete a course until the inflammation resolves. Outlining the borders of the erythema on admission assists in evaluating response to therapy.
  • If a patient does not respond to the initial choice of antibiotic, the organism may be resistant to the drug. Also, entertain unusual organisms that may require combinations of antibiotics. Finally, consider an alternative diagnosis that might be commonly confused with cellulitis.27

Further Outpatient Care

  • All patients with cellulitis should be re-evaluated in a short interval, ideally 48-72 hours, to confirm that they are improving and that no concerning signs or symptoms have developed.

Inpatient & Outpatient Medications

  • Antibiotics to treat cellulitis should provide coverage against gram-positive bacteria such as S aureus and GABHS, as detailed above.
  • If cellulitis progresses or does not improve with oral therapy, start parenteral therapy with continued coverage of common pathogens. Also, consider addition of coverage for MRSA if not already present and consider unusual pathogens. An infectious disease specialist is particularly helpful in these cases.

Transfer

  • Transfer to a higher level of care is usually unnecessary for cellulitis. However, if necrotizing fasciitis is discovered, the patient may require a higher level of care depending on available surgical expertise.

Deterrence/Prevention

  • The most important element of prevention for skin and soft-tissue infections is to control underlying risk factors that predispose to cellulitis. Specific areas of concern are the presence of edema, tinea pedis, and diabetic ulcers.6,28,9 Aggressive control of these risk factors may decrease the likelihood of skin and soft-tissue infections.

Complications

  • Bacteremia with seeding of distant sites
  • Abscess
  • Superinfection
  • Lymphangitis
  • Thrombophlebitis
  • Gas-forming cellulitis
  • Toxin-mediated disease
  • Thrombophlebitis
  • Necrotizing fasciitis

Prognosis

  • Uncomplicated cellulitis carries an excellent prognosis. Most patients respond well to standard oral antibiotics. When outpatient therapy is unsuccessful and in patients who require admission initially, intravenous antibiotics are usually effective.

Patient Education

  • Cellulitis can come in many different forms. Certain common bacteria cause most cases of cellulitis.
  • Symptoms include redness, warmth, and tenderness.
  • Discerning the exact border of the infection is difficult because the edge gradually blends with surrounding skin.
  • Bacteria that enter damaged skin cause cellulitis. Damage occurs via injuries such as scrapes, bites, puncture wounds, or cuts. Some skin damage is too small to see with the eye.
  • In healthy people, cellulitis is rarely a serious illness. Most cases respond to oral antibiotics.
  • Schedule a follow-up appointment within 2-3 days for re-evaluation if treated as an outpatient.
  • Patients with severe cellulitis sometimes need a brief hospitalization to receive antibiotics intravenously. When the infection improves, patients usually return home on oral antibiotics.
  • Patients with advanced HIV infection/AIDS or who are receiving cancer chemotherapy often need hospitalization to treat cellulitis.
  • Long-term use of corticosteroids to reduce inflammation weakens the immune system. This group of patients often requires hospitalization.
  • Depending on the location of the affected area, the patient may want to decrease physical activity and elevate the extremity, if possible.
  • Patients may take over-the-counter pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) for pain if approved by their physician.
  • Patients should call their doctor's office immediately if they have any of the following symptoms:
    • Fever (>100.5°F), especially associated with chills
    • Cellulitis with a generalized feeling of aches and fatigue
    • A red streak from an area of cellulitis or a fast-spreading area of redness, which indicates that the infection may need a different antibiotic or an intravenous antibiotic
    • Significant pain not relieved by acetaminophen or ibuprofen
    • Inability to move an extremity or joint because of pain
  • If patients have diabetes, cancer, or immunosuppression, localized cellulitis may become serious.
  • For additional patient education resources, visit eMedicine's Diabetes Center. Also, see eMedicine's patient education article Cellulitis.

Miscellaneous

Medicolegal Pitfalls

  • One common pitfall is not admitting patients with lymphangitis or systemic symptoms who require parenteral therapy.
  • Use caution when considering outpatient treatment for immunocompromised individuals. Assess the severity and mechanism of immunocompromise when deciding if the patient is an appropriate candidate for outpatient therapy.
  • Carefully examine patients for crepitus and other signs of deeper infection. Any suspicion of a gas-producing infection requires surgical consultation and admission.
  • Document the patient's blood pressure and pulse. Hypotension and tachycardia in patients with cellulitis are signs of toxin-mediated disease or sepsis.
  • Obtain medication allergies prior to prescribing antibiotics.
  • Patients with cellulitis that inhibits range of motion of the joints usually require admission. Consider septic arthritis in addition to cellulitis.

Special Concerns

  • Rapidly progressing cellulitis may indicate a very virulent organism such as V vulnificus and those found in the oral flora of dogs and cats. Cellulitis developing within hours of surgery may be the result of Clostridium or GABHS infection.
  • Patients with nephrotic syndrome have immunodeficiency due to proteinuria (including the loss of immunoglobulins). This population is at high risk for Escherichia coli cellulitis and sepsis.
  • Consider unusual organisms, especially if the infection involves a postoperative incision or the skin is damaged in unusual environments, such as water.
 
Acknowledgments

Thanks to Dr. Sarah Hedrick, Dr. Karolyn Teufel, and Sara Humphrey for assistance with initial proofreading and editing. The authors and editors of eMedicine also gratefully acknowledge the contributions of previous author, Dennis Cunningham, MD, and previous coauthor, Robert Edelman, MD, to the development and writing of this article.



More on Cellulitis

Overview: Cellulitis
Differential Diagnoses & Workup: Cellulitis
Treatment & Medication: Cellulitis
Follow-up: Cellulitis
Multimedia: Cellulitis
References
[ CLOSE WINDOW ]

References

  1. 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].

  2. 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. [Medline].

  3. 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].

  4. 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].

  5. 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. [Medline].

  6. 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. [Medline].

  7. 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. [Medline].

  8. 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;[Medline].

  9. Lipsky BA. New developments in diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev. May-Jun 2008;24 Suppl 1:S66-71. [Medline].

  10. Brook I. Microbiology and management of human and animal bite wound infections. Prim Care. Mar 2003;30(1):25-39, v. [Medline].

  11. 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. [Medline].

  12. 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. [Medline].

  13. Aubry A, Chosidow O, Caumes E, Robert J, Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. Arch Intern Med. Aug 12-26 2002;162(15):1746-52. [Medline].

  14. [Guideline] Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373-406. [Medline].

  15. 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. [Medline].

  16. 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. [Medline].

  17. 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. [Medline].

  18. 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;[Medline].

  19. 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. [Medline].

  20. 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. [Medline].

  21. 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. [Medline].

  22. 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. [Medline].

  23. 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. [Medline].

  24. 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. [Medline].

  25. 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. [Medline].

  26. 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. [Medline].

  27. Falagas ME, Vergidis PI. Narrative review: diseases that masquerade as infectious cellulitis. Ann Intern Med. Jan 4 2005;142(1):47-55. [Medline].

  28. Cox NH. Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up. Br J Dermatol. Nov 2006;155(5):947-50. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

cellulitis, gram-positive bacteria, group A beta-hemolytic Streptococcus, GABHS, Staphylococcus aureus, S aureus, MRSA, methicillin-resistant Staphylococcus aureus, CA-MRSA, community-acquired MRSA, Streptococcus pyogenes, S pyogenes, systemic toxins, bacteremia, sepsis, buccal cellulitis, Haemophilus influenzae type B, HIB, facial cellulitis, perianal cellulitis, group B Streptococcus cellulitis, Pseudomonas osteomyelitis, septic arthritis, thrombophlebitis, Pasteurella multocida, P multocida, Vibrio vulnificus, V vulnificus, Aeromonas species, Clostridium perfringens, C perfringens, crepitus, crepitation, Escherichia coli cellulitis, E coli, septic shock

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Isaac P Humphrey, MD, Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Instructor of Internal Medicine, Wright State University Boonshoft School of Medicine
Isaac P Humphrey, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Eric S Halsey, MD, Chief, Department of Infectious Diseases, Wright-Patterson Air Force Base; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Assistant Professor of Medicine, Wright State University
Eric S Halsey, MD is a member of the following medical societies: American College of Physicians, Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Fred A Lopez, MD, Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine
Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.