Overview
Which imaging studies are suggested for cellulitis?
What are the signs and symptoms of cellulitis?
What workup or tests should be completed in cellulitis diagnosis?
When are aspiration, dissection, and biopsy suggested for cellulitis?
When is hospital admission suggested for cellulitis?
What is the pathophysiology of cellulitis?
What does the term cellulitis indicate?
How do streptococcal species relate to cellulitis?
What are the most common etiologies of cellulitis in injection drug users?
Which host factors predispose to cellulitis?
What are the most common causative organisms of cellulitis in infants and children?
Which nontraditional organisms can cause cellulitis in immunocompromised patients?
How is malignant cellulitis caused by pneumococci recognized?
How do mycobacterial infections differ from cellulitis?
What causes bullous cellulitis in patients with cirrhosis?
What causes recurrent staphylococcal cellulitis?
Which hospital-acquired infections lead to cellulitis?
How does cellulitis affect varicella?
How common is MRSA as a cause of cellulitis?
Which pathogens cause cellulitis due to puncture wounds, lacerations, and bite wounds?
What is the prevalence of cellulitis?
What types of cellulitis are commonly found in specific age groups?
What is the prognosis of cellulitis?
What information should be provided to patients with cellulitis?
Presentation
What is the role of the patient’s medical history in determining cellulitis treatment?
During the medical history review, which findings might offer a clue to cellulitis etiology?
Which skin disorders should be asked about in a patient presenting with cellulitis?
Which comorbid conditions increase the risk of cellulitis?
Why is surgical history important when cellulitis is present?
Which physical findings suggest cellulitis and which indicate severe infection?
DDX
What are the differential diagnoses for Cellulitis?
Workup
When is a workup for cellulitis unnecessary?
When is a blood culture or bloodwork necessary in the workup of cellulitis?
What are the IDSA guidelines for the workup for cellulitis?
When should hospitalization of a patient with cellulitis be considered?
What role does ultrasonography play in the workup of cellulitis?
What role does CT imaging and MRI play in the workup of cellulitis?
What are the roles of aspiration, dissection, and biopsy in the workup of cellulitis?
Treatment
How is severe cellulitis treated?
How effective are antibiotics in the treatment of MRSA cellulitis?
When should cellulitis prompt consultation with a specialist?
How is cellulitis without draining wounds or abscess treated?
How is recurrent cellulitis treated?
How is cellulitis associated with bite wounds treated?
How is odontogenic cellulitis treated?
How is MRSA cellulitis treated?
When can cellulitis be treated on an outpatient basis?
What is the treatment duration of cellulitis for outpatients?
When should IV antibiotic therapy be considered for cellulitis and how is the antibiotic selected?
When should surgical consultation and exam be considered for cases of cellulitis?
What are the causes and treatments for impetigo in adults?
What are the IDSA guidelines on the treatment of impetigo in children?
Which antibiotics are recommended to treat MRSA skin and soft-tissue infections (SSTIs)?
Which antibiotics are recommended to treat MRSA skin and soft-tissue infections (SSTIs) in children?
What are the causes of refractory erysipelas?
When is an aggressive evaluation and management strategy needed in patients with erysipelas?
Which antibiotics are recommended in the treatment of adult Staphylococcus aureus (MSSA) infections?
What are the common causes of monomicrobial necrotizing fasciitis?
Which antibiotics are recommended in the treatment of mixed necrotizing infections?
Which antibiotics are recommended in the treatment of clostridial necrotizing infections?
How should animal bites be treated to prevent infection?
How should human bites be treated to prevent infection?
How should surgical site infections be treated?
Which organisms cause skin and soft-tissue infections (SSTIs) in immunocompromised patients?
Guidelines
Which oral antibiotics are indicated in the treatment of mild nonpurulent cellulitis?
Which IV antibiotics are indicated in the treatment of moderate nonpurulent cellulitis?
Which antibiotics are indicated in the treatment of severe nonpurulent cellulitis?
What are the treatment guidelines for mild purulent cellulitis?
Which oral antibiotics are recommended in the treatment of moderate purulent cellulitis?
Which IV antibiotics are recommended in the treatment of severe purulent cellulitis?
Medications
What are the goals of antimicrobial therapy for cellulitis?
What is the role of beta-lactam agents in the treatment of cellulitis?
How should antimicrobials be chosen for common pathogens in patients with cellulitis?
How are uncommon organisms treated in cellulitis?
Which medications in the drug class Penicillins, Natural are used in the treatment of Cellulitis?
Which medications in the drug class Penicillins, Amino are used in the treatment of Cellulitis?
Which medications in the drug class Cephalosporins, Other are used in the treatment of Cellulitis?
Which medications in the drug class Macrolides are used in the treatment of Cellulitis?
Which medications in the drug class Carbapenems are used in the treatment of Cellulitis?
Which medications in the drug class Fluoroquinolones are used in the treatment of Cellulitis?
Which medications in the drug class Antibiotics, Other are used in the treatment of Cellulitis?
Which medications in the drug class Tetracyclines are used in the treatment of Cellulitis?
Which medications in the drug class Antifungal Agents are used in the treatment of Cellulitis?
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Mild cellulitis with a fine lacelike pattern of erythema. This lesion was only slightly warm and caused minimal pain, which is typical for the initial presentation of mild cellulitis.
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Swelling seen in cellulitis involving the hand. In a situation with hand cellulitis, always rule out deep infection by imaging studies or by obtaining surgical consultation.
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Severe cellulitis of the leg in a woman aged 80 years. The cellulitis developed beneath a cast and was painful and warm to the touch. Significant erythema is evident. The margins are irregular but not raised. An ulcerated area is visible in the center of the photograph.
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Burns complicated by cellulitis. The larger lesion is a second-degree burn (left), and the smaller lesion is a first-degree burn (right), each with an expanding zone of erythema consistent with cellulitis.
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Cellulitis due to documented Vibrio vulnificus infection. (Image courtesy of Kepler Davis.)
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A case of cellulitis without associated purulence in an infant. Note the presence of lymphedema, a risk factor for cellulitis.(Photo courtesy of Amy Williams.)
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Patient with cellulitis of the left ankle. This cellulitis was caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). (Photo courtesy of Texas Dept. of Public Health.)
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Abscess and associated cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). (Photo courtesy of Texas Dept. of Public Health.)
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Guidelines for the management of patients who require hospitalization for cellulitis or cutaneous abscess. AFB = acid-fast bacilli; BID = twice daily; CRP = C reactive protein; CT = computed tomography scanning; DS = double strength; DM = diabetes mellitus; ESR = erythrocyte sedimentation rate; ESRD = end-stage renal disease; HIV = human immunodeficiency virus; ICU = intensive care unit; I&D = incision and drainage; ID = infectious disease; IDU = injection drug user; IV = intravenous; LRINEC = Laboratory Risk Indicator for Necrotizing Fasciitis; MRI = magnetic resonance imaging; MSRA = methicillin-resistant Staphylococcus aureus; NSAIDS = nonsteroidal anti-inflammatory drugs; PO = by mouth; SSTI = skin and soft-tissue infections; TID = 3 times daily. Adapted from Jenkins TC, Knepper BC, Sabel AL, et al. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess. Arch Intern Med. 2011;171(12):1072-9.
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A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.
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A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.
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Gross photograph of complicated cellulitis. Instead of the presence of yellow fat, the tissue is hemorrhagic and necrotic.
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Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis.
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Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture.
Tables
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 or clindamycin |
|
Cefazolin or oxacillin or nafcillin |
Cellulitis, concern for methicillin-resistant S aureus is a concern |
Group A streptococci and S aureus |
|
|
[(Cephalexin or dicloxacillin or clindamycin) plus trimethoprim/ sulfamethoxazole] or Clindamycin |
|
Vancomycin Daptomycin Ceftaroline |
Dog bite |
Pasteurella species (50% of wounds) S aureus Streptococcus pyogenes |
Staphylococci, streptococci 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. |
Amoxicillin/ clavulanate Penicillin allergic: Moxifloxacin |
Deep wounds or severe wounds; infections not responding to oral antibiotics |
Third-generation cephalosporin (ceftriaxone [Rocephin]) plus metronidazole or beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or fluoroquinolone plus metronidazole or carbapenem (ertapenem) |
Human bite |
Eikenella corrodens (gram-negative facultative anaerobe, 29% of wounds) Aerobic gram-positive cocci, anaerobes |
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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. |
Amoxicillin/ clavulanate Penicillin allergic: Moxifloxacin or (Clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole) |
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Third-generation cephalosporin (Rocephin) plus metronidazole or beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or fluoroquinolone plus metronidazole or carbapenem (ertapenem) |
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. |
Amoxicillin/ clavulanate Penicillin allergic -- Moxifloxacin or (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 or beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or fluoroquinolone plus metronidazole or carbapenem (ertapenem) |
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 [29] |
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 |
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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 |
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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 |
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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; or ciprofloxacin plus beta-lactam or monotherapy with piperacillin/tazobactam or cefepime |
Aquatic environment -- Fresh water/ salt water/ brackish water/ swimming pools/ aquarium Puncture/ laceration |
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 |
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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 |
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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: Moxifloxacin or (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 or clindamycin |
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Beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or clindamycin |
