CELLULITIS

IN ADULTS
PRSENTED BY LKC
 OUTLINE
I. Introduction
II. Clinical diagnosis of cellulitis
III.Drug Therapy and Treatment
IV.Prophylaxis
 INTROUDUCTION
• Cellulitis – spreading bacterial infection of the dermis and subcutaneous tissue.
• The most common infective organisms in adults are streptococci and
staphylococcus aureus.
• Less common – strep. Pneumoniae, haemophilus influenzae, gram-negative
bacilli and anaerobes.
• Risk factors : Lymphoedema, leg oedema , venous insufficiency and being
overweight.
• Following cellulitis of the leg, around 7% of patients develop chronic oedema
and a few Patient develop persistent leg ulceration, 29% of patients develop a
recurrence of cellulitis within a mean of 3 years.
• Necrotizing fasciitis ( NF ) – involve subcutaneous tissue and fascia
• NF – Rare  High mortality of approximately 50%
CLINICAL DIAGNOSIS OF CELLULITIS
• Cellulitis – acute and progressive onset of a red , painful ,
hot , swollen and tender area of skin
• Edge of the erythema maybe well demarcated or more
diffuse and typically spreads rapidly
• Constitutional upset with fever and malaise occurs in most
cases and may be present before the localizing signs,
• Blistering/ bullae, superficial haemorrage into blister ,
dermal necrosis , lymphangitis and lymphadenopathy may
occurs.
The absence of typical clinical features should make one
think of the main differential diagnoses , especially :
- Varicose eczema – often bilateral with crusting , scaling ,
and itch or other low leg eczema
- Deep veineuse thromboses – pain and swelling without
significant erythema
- Acute liposclerosis – have pain , redness and swelling no
significant systemic upset.
Complication include:
- Fasciitis
- Myositis
- Subcutaneous absesses
- Septicaemia
- Post streptococcal Nephritis and
- Death
A. Clinical classes of cellulitis :
+ Classification for skin and soft tissue infection ( Eron )
- Class I : no signs of systemic toxicity , no comorbidities and can usually
managed with oral antimicrobials on an outpatient basis
- Class II : systemically ill or systematically well but with a combidity such as
pheripheral vascular disease , chronic venous insufficiency or morbidity ,obesity
which may complicate or delay resolution of their infection.
- Class III : systemic upset such as acute confusion , tachycardia , tachypnea ,
hypotension , or unstable co-morbidities
- Class IV: patients have sepsis syndrome or severe life threatening infection
such as necrotizing fasciitis.
B. Laboratory investigations
- all patient  white cell count and elevated ESR
or C-reative protein
- Culture
- Blood culture rarely positive ( 2-4% )
III. DRUG THERAPY AND TREATMENT
- Class I : manage with oral antimicrobials
- Class II : 48 h – hospitalization , discharge on out patient parenteral
antimicrobial therapy ( OPAT )
- Class III and class IV  hospitalization – until infected area
improving , systemic signs of infection are resolving and any
comorbidities are stabilized , patient suspected necrotizing –
require urgent surgical assessment and extensive debridement of
affected area.
 Suggested criteria for oral switch and/ or
discharge :
- Pyrexia setting
- Co-morbidities stable
- Less intense erythema
- Falling inflammatory markers.
 SUITABLE DRUG THERAPY FOR
TYPICAL CELLULITIS
Fist line
Class I Flucloxacillin 500 mg po
Class II Fluxcloxacillin 2g IV or
Cefriaxone 1g IV ( OPAT
only )
Class III Flucloxacillin 2g IV
Class IV Benzylpenicillin 2.4g 2-4 h
IV
+ ciprofloxacin 400 mg IV
+ clindamycin 900 mg IV
Second line
Penicillin allergy
- Clarithromycin 500mg po
Penicillin allergy
- Clarithromycin 500 mg IV
- Clindamycin 600 mg IV
Penicillin allergy
- Clarithromycin 500 mg IV
- Clindamycin 900 mg IV
Local management of cellulitis
- Adequate analgesia to ensure pain relief
- Management of any pyrexia
- Mark of the extern of erythema present
Broken and exudating skin
- Cellulitis – cause tension and swelling  leads ulceration and loss
of large amouts of exudate
- Compression bandages
IV. PROPHYLAXIS
• Recurrence rate for cellulitis show that 29% - means of 3
years
• Venous insufficiency – commonest predisposing factor
• Other studies – lymphedema  risk factor in the
development of recurrent cellulitis
Longterm prophylaxis :
- 2 or more episodes at the same site
- Penicilline 250 mg or erythromycin 250 mg up to 2 years.