Cellulitis

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Introduction

• A rapidly spreading, poorly localized / diffuse erythematous inflammation of the soft tissues particularly associated with streptococcal infection to break down fibrin and ground substance, lyse cellular debris and enhance spread of infection.

Pathogenesis

• Rapid spread is most likely related to release of large amounts of streptokinase and hyaluronidase which are produced by most strains of streptococci
• The fascial space infections may involve sublingual, submandibular and/or parapharyngeal spaces
• Ludwig's angina is bilateral brawny cellulitis of the sublingual, submandibular and submental spaces

Clinical features

• Diffuse, tense, painful swelling of the involved soft tissues
• Malaise
• Elevated temperature
• Ludwig's angina
  • This is a surgical emergency!
  • It causes airway obstruction, which can quickly result in asphyxia
  • Suppuration and abscess formation may occur later if treatment is neglected or delayed

Complications

• Extension towards the eyes, and risk of cavernous sinus thrombosis: cellulitis affecting maxillary teeth
• Respiratory difficulty: cellulitis affecting mandibular teeth

Investigations

• M/C/S (blood and swab)

Non-drug treatment

• Decompression and drainage of the swelling to reduce pressure (oral drain may also be placed)
• Intravenous fluid resuscitation
• Nutritional support
• Secure the airway by tracheostomy if necessary

Drug treatment

• Aggressive antibiotic treatment
  • Injection co-amoxiclav
  • Adult: 1000/2000 mg intravenously every 8 hours for 5 days
  • Child:
    • Neonate and premature infants, 25 mg/kg every 12 hours for 5 days
    • Infants up to 3 months, 25 mg/kg every 8 hours for 5 days
    • 3 months to 12 years, 25 mg/kg every 8 hours for 5 days increased to 25 mg/kg every 6 hours in more severe infections

Plus

• Injection gentamicin:
  • Adult: 3 - 5 mg/kg daily in divided doses every 8 hours for 5 days
  • Child:
    • up to 2 weeks: 3 mg/kg every 12 hours for 5 days
    • 2 weeks - 12 years: 2 mg/kg every 8 hours for 5 days

Notable adverse drug reactions, contraindications and caution

• Gentamicin may cause significant ototoxic and nephrotoxic effects

Prevention

• Early treatment of carious teeth