Cellulitis

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Introduction

  • An acute suppurative bacterial infection of the skin and soft tissue, often with involvement of underlying structures: fascia, muscles and tendons
  • Most often due to ß-haemolytic streptococci or Staphylococcus aureus
  • Less common causes include: Anaerobic bacteria, Mycobacteria, Proteus, Pseudomonas and rarely Cryptococcus. Usually (but not always) follows some discernible wound.
  • Often a complication of immunosuppression like diabetes and HIV/AIDS

Epidemiology

  • The prevalence is unclear.
  • It is commoner in adult males above 45 years of age and young children.
  • Risk factors include: immunosuppression, malnutrition, obesity, elderly persons, peripheral vascular disease, lymphoedema and recent injuries to the skin.

Clinical features

  • Areas of oedema; rapidly spreading
  • Erythema (rapidly becomes intense and spreads)
  • Tenderness and warmth
    • Often accompanied by fever, lymphangitis, regional lymphadenitis

Systemic signs of toxicity

  • Area becomes infiltrated and pits on pressure
  • Sometimes the central part becomes nodular and surrounded by a vesicle that ruptures and discharges pus and necrotic material

Differential diagnoses

  • Erysipelas
  • Deep vein thrombosis

ComplicationsUnusual in immunocompetent adults; children and compromised adults are at higher risk.

  • Septicaemia
  • Gangrene
  • Metastatic abscesses
  • Recurrent cellulitis may predispose to chronic lymphoedema

Investigations

  • Blood culture
  • Full Blood Count with differentials
  • Fasting blood glucose
  • HIV screening
  • Wound swab for microscopy, culture and sensitivity
  • Urinalysis

Treatment goals

  • Eradicate infection
  • Treat underlying immune suppression
  • Prevent complications

Drug treatment

Ampicillin/cloxacillin

  • Adult: 500 mg - 1 g orally every 6 hours for 5 - 7 days
  • Child
    • under 5 years: 125 mg every 6 hours for 5-7 days
    • 5 - 10 years: 250 mg orally every 6 hours for 5-7 days

Or:

Cloxacillin

  • Adult: 500 mg orally every 6 hours for 5 - 7 days
  • Child:
    • under 5 years: 125 mg orally every 6 hours for 5-7 days
    • 5-10years: 250 mg orally every 6 hours for 5-7 days

Ciprofloxacin

  • Adult: 250 - 750 mg orally every 12 hours for 5 - 7 days
  • Child: see note on caution

Ceftriaxone

  • Adult: 1 g intravenously or intramuscularly daily for 3 days
  • Child:
    • neonate, 20 - 50 mg/kg by intravenous infusion over 60 minutes;
    • 1 month - 12 years, body weight less than 50 kg: 50 mg/kg by deep intramuscular injection or intravenous injection over 2 -4 minutes, or by intravenous infusion
  • Intramuscular injections over 1 g should be divided over more than 1 site
  • Doses of 50 mg/kg and more should be given by intravenous infusion only
  • Use only when there is significant resistance to other drugs

Tetanus Prophylaxis

Surgical treatment

May need incision and drainage or debridement

Notable adverse drug reactions, contraindications and caution

  • Ciprofloxacin is contraindicated in growing adolescents and children below 12 years; also contraindicated in pregnancy

Prevention

  • Treat any wound promptly