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Cellulitis
Aka: Cellulitis, Staphylococcal Cellulitis, Streptococcal Cellulitis
- See Also
- Skin Infection
- Hand Infection
- Nodular Lymphangitis
- Erysipelas
- Impetigo
- Preseptal Cellulitis and Periorbital Cellulitis
- Cellulitis in Diabetes Mellitus
- Epidemiology
- Accounts for 2% of all Emergency Department visits
- Risk factors
- See Skin Infection
- Also see Group A Streptococcus Cellulitis (Erysipelas)
- Trauma
- Laceration
- Puncture Wound
- Post-operative infection at incision site
- Underlying skin lesion
- Superficial Folliculitis or Furuncle (Staphylococcus infection)
- Skin Ulcer
- Fungal Dermatoses
- Non-Group A Streptococcus Cellulitis related lesions
- Coronary Artery bypass with saphenous vein graft
- Radical pelvic surgery or radiation
- Neoplasms
- Lymphatic Cutaneous metastases from neoplasms
- Inflammatory Breast Cancer
- Carcinoma Erysipeloides
- Extremity Stasis or Edema
- Chronic Dependent Edema (may progress rapidly)
- Peripheral Vascular Disease
- Lymphedema
- Perianal Streptococcal Cellulitis (in children)
- Diabetes Mellitus
- See Cellulitis in Diabetes Mellitus
- Immunocompromised patients
- Causes: General
- Common (most Cellulitis cases)
- Staphylococcal Cellulitis (typically with abscess)
- Group A Streptococcus Cellulitis (Erysipelas)
- Less common Streptococcal infections
- Pneumococcus
- Non-Group A Streptococcus Cellulitis
- Group C or G Streptococcus Cellulitis
- Group B Streptococcus Cellulitis in newborns
- Rapidly progressive Cellulitis
- See Necrotizing Fasciitis
- Vibrio Cellulitis (Vibrio vulnificus)
- Clostridium perfringens
- Pasteurella multocida
- Aeromonas Hydrophila
- Causes: Exposure
- See Nodular Lymphangitis
- See Pet-Borne Infection
- See Dermatologic Manifestations in Returning Traveler
- Fish Handlers or water exposure (See Marine Trauma)
- Erysipelothrix rhusiopathiae (Erysipeloid, fish handler's disease)
- Mycobacterium marinum (Fish tank exposure)
- Aeromonas Hydrophila
- Spines of stonefish (South Pacific) risk of serious systemic toxicity, Pulmonary Edema
- Vibrio vulnificus (Vibrio Cellulitis, high risk of rapid progression)
- Vibrio alginolyticus
- Vibrio parahaemolyticus
- Streptococcus iniae (from farmed tilapia)
- Gardening or splinter exposure
- See Nodular Lymphangitis
- Nocardia brasiliensis (Nocardiosis)
- Sporotrichosis: Sporothrix schenckii (fungus)
- Tetanus
- Hospitalized patients
- Methicillin Resistant Staphylococcus Aureus (MRSA)
- Pseudomonas aeruginosa
- Enterococcus
- Escherichia coli
- Animal Bites
- See Marine Envenomation
- Cat Bites
- Pasteurella multocida
- Dog Bite Infection
- Mixed Bacterial flora (Staphylococcus, Streptococcus, Anaerobes)
- Pasteurella multocida
- Capnocytophaga canimorsus (DF-2)
- Staphylococcus intermedius
- Human Bites
- See Fight Bite
- Mixed Anaerobes and aerobes
- Staphylococcus aureus and Streptococcus
- Bacteroides, Fusobacterium, Eikenella corrodens
- Miscellaneous
- Eosinophilic Cellulitis
- Pseudomonas aeruginosa
- Sweaty Tennis Shoe Syndrome
- Causes: Immunocompromised Patients
- Serratia
- Proteus
- Enterobacteriaceae
- Cryptococcus
- Legionella pneumophila
- Associated with Legionella pneumonia
- Legionella micdadei
- Seen in renal transplant patients
- Escherichia coli
- Seen in children with relapsing Nephrotic Syndrome
- Symptoms
- Inflamed Skin Wound develops rapidly days after injury
- Local tenderness
- Pain (contrast with Pruritus of other skin conditions)
- Very red, hot, swollen an painful
- Unilateral
- Associated symptoms
- Malaise
- Fever, chills
- Signs
- Draw margins of erythema with marker
- Follow course of infection on antibiotics (but do not expect significant improvement in first 24 hours)
- Wound with contiguous inflammation
- Erythema (Rubor)
- Swelling (Tumor)
- Local tenderness (Dolor)
- Warm to touch (Calor)
- Unilateral involvement
- Contrast with stasis and edematous conditions which are bilateral
- Abscess (or purulent drainage)
- Hallmark of Staphylococcus aureus
- Peau d'orange Skin (orange-peel like skin)
- Cellulitis results in edema including the fat layer
- Hair Follicles remain anchored to the Dermis
- Results in an indentation or pitting at each Hair Follicle in the midst of edema of the surrounding tissue
- Regional spread
- Ascending lymphangitis
- Regional Lymphadenopathy
- Small patches of necrosis
- Gram Negative superinfection may also be present
- Hemorrhagic and necrotic bullae (specific conditions)
- Group A Streptococcal Cellulitis
- Pseudomonas Cellulitis
- Vibrio Cellulitis (Vibrio vulnificus)
- Clostridium perfringens
- Aeromonas Hydrophila
- Bullous Impetigo (not typically hemorrhagic)
- Differential Diagnosis: Non-infectious Conditions (Pseudocellulitis)
- Precautions
- Cellulitis is overdiagnosed, with the risk of antibiotic adverse effects (e.g. Clostridium difficile) and Antibiotic Resistance
- Consider alternative diagnoses (e.g. Stasis Dermatitis) when bilateral, pruritic, chronic, non-progressive
- Vascular Conditions
- Venous Insufficiency and Stasis Dermatitis (most common)
- Acute stasis appears with bilateral leg erythema
- Lipodermatosclerosis
- Panniculitis with bilateral, medial ankle erythema
- Superficial Thrombophlebitis
- Deep Vein Thrombosis
- Lymphedema
- Dermatologic Conditions
- Contact Dermatitis
- Insect Bites
- Acute Drug Reaction
- Eosinophilic Cellulitis
- Sweet Syndrome
- Shingles
- Calciphylaxis
- Calcium deposition due to ESRD, DM, Obesity, liver disease, Warfarin
- Rheumatologic Conditions
- Gouty Arthritis
- Relapsing Polychondritis
- Miscellaneous
- Edematous conditions (e.g. CHF, Cirrhosis)
- Erythromelalgia
- Inflammatory Carcinoma (metastatic cancer to skin)
- Foreign body reaction (mesh, metal, silicone implant)
- Familial Mediterranean fever
- Erythema Migrans (Lyme Disease)
- References
- Swadron and DeClerck in Herbert (2017) EM:Rap 17(5): 11-2
- Vergidis (2005) Ann Intern Med 142:47-55 [PubMed]
- Labs
- See Laboratory Risk Indicator for Necrotizing Fasciitis ( LRINEC Score)
- Pustular drainage or abscess culture
- Recommended if antibiotics are being used, systemic symptoms or severe localized findings
- Blood Culture (25% sensitivity)
- Not recommended in uncomplicated Cellulitis without associated systemic symptoms
- Indications (risk of deep tissue involvement)
- Severe infection or systemic symptoms or signs (lymphangitis, Sepsis)
- Immunocompromised patients or elderly
- Patients requiring surgery
- Recurrent, persistent or large abscess
- Human Bite or Animal Bite
- Skin biopsy (25% sensitivity)
- Indicated in necrotizing lesions (especially those requiring derbidement)
- Obtain sample of leading margin of lesion
- Fine Needle Aspiration
- Saline injection and aspiration
- Listed for historical purposes only (rarely done in clinical practice)
- Technique
- Leading edge injection and aspiration with saline
- Efficacy
- May assist diagnosis with Cellulitis, but yield is typically very low
- Not useful in Erysipelas
- Test Sensitivity may approach 30% from closed lesions
- However overall Test Sensitivity may be as low as 5%
- Indication
- Unusual pathogens suspected
- Cellulitis refractory to current antibiotics
- Imaging
- Soft tissue Ultrasound
- Abcess formation is consistent with staphylococcal infection
- Computed Tomography (CT)
- Consider in suspicion of deep space infection
- MRI
- Consider in suspected Necrotizing Fasciitis
- Management: General Care
- Tetanus Prophylaxis
- Clean wound site
- Copious irrigation
- Debride devitalized tissue
- Incision and Drainage if deep fluctuant pocket
- Compresses
- Cool sterile saline dressings decrease pain
- Later, moist heat helps localize infection
- Consider immobilization and elevation of involved limb
- Splinting in a position of function may decrease swelling
- Uncommonly done in practice
- Consider Corticosteroids in non-diabetic adults with Cellulitis (especially leg Cellulitis)
- Associated with faster Cellulitis resolution
- Dall (2005) Cutis 75(3): 177-80 +PMID:15839362 [PubMed]
- Management: Factors affecting antibiotic selection and course
- Distinguish Erysipelas, abscess and Cellulitis
- Erysipelas (superficial)
- Sharply demarcated, bright red, indurated
- Typically caused by Group A Streptococcus
- Although Staphylococcus aureus can have a similar appearance on the face
- Cellulitis (deep, subcutaneous)
- Abrupt onset of indistinct faint erythema with rapidly advancing border
- Typically caused by group A. Streptococcus or Group G
- Although Staphylococcus can cause this as well
- Purulent Cellulitis
- Cellulitis with pustular drainage or exudate without definitive, drainable abscess
- Abscess
- Hallmark of Staphylococcus aureus infection
- Primary management is Incision and Drainage
- If antibiotics are needed (Cellulitis with abscess), then cover MRSA (see below)
- Other Bacterial Skin Infections
- Folliculitis
- Impetigo
- Consider exposures in antibiotic selection
- Fresh water exposure
- Fluoroquinolone
- Salt water exposure
- Doxycycline
- Dog Bite, Cat Bite or Human Bite
- Amoxicillin-Clavulanate (Augmentin)
- If Penicillin Allergy
- Clindamycin or Metronidazole AND
- Trimethoprim-Sulfamethoxazole or Fluoroquinolone
- Distinguish most likely organism: Streptococcus or Staphylococcus
- Streptococcus (especially Group A Streptococcus)
- Streptococcus (especially Group A) is the most common cause of Cellulitis and Erysipelas
- Abrupt onset with rapid spread
- May be associated with fever and ascending lymphangitis
- Typically associated with an inciting Skin Injury with associated break in the skin (e.g. Tinea Pedis)
- Staphylococcus aureus (typically MRSA)
- Less common cause of Cellulitis (causes only 14% of uncomplicated Cellulitis)
- However, purulent drainage or abscess is typically caused by Staphylococcus aureus
- Typically presents without a primary Skin Injury site
- Primary source is often a Folliculitis
- Abscess is often present (Incision and Drainage is primary treatment)
- May present initially as pustular drainage or exudate (pustular Cellulitis)
- Consider soft tissue Ultrasound if suspect occult abscess
- Consider Antibiotic Resistance
- Avoid Fluoroquinolones in Cellulitis due to high resistance
- Staphylococcus aureus infections are often due to MRSA
- Course: Uncomplicated
- Standard course has been 10 days of antibiotics
- New: 5 day as effective as 10 day if uncomplicated
- Hepburn (2004) Arch Intern Med 164:1669-74 [PubMed]
- Course: Complicated
- Course 7-14 days (6 weeks if joint involvement)
- Management: Emergency Department Approach
- Factors associated with oral, outpatient treatment failure
- Fever with Temperature >38 C at triage (OR 4.3)
- Chronic leg ulcers (OR 2.5)
- Chronic edema or lympedema (OR 2.5)
- Prior Cellulitis in the same area (OR 2.1)
- Cellulitis at a wound site (OR 1.9)
- Peterson (2014) Acad Emerg Med 21(5):526-31 +PMID:24842503 [PubMed]
- Localized, uncomplicated Cellulitis without serious local or systemic findings
- Start oral therapy without initial intravenous dose
- Single intravenous dose prior to discharge on oral dosing does NOT speed resolution or improve efficacy
- Most oral antibiotics used for Skin Infections have excellent, rapid oral absorption
- Cephalexin (>90% GI absorption)
- Clindamycin (>90% GI absorption)
- Doxycycline (>90% GI absorption)
- Bactrim or Septra (>70% GI absorption)
- Amoxicillin (>75% GI absorption)
- Oral antibiotics result in as good if not better efficacy than IV antibiotics
- Faster resolution, shorter hospital stays and lower cost
- IV antibiotic selection may be ill fitted for convience (e.g. Ceftriaxone for once daily dosing)
- IV antibiotics are associated with a higher rate of Antibiotic Associated Diarrhea
- Kilburn (2010) Cochrane Database Syst Rev 16(6): CD004299 +PMID:20556757 [PubMed]
- Aboltins (2015) J Antimicrob Chemother 70(2): 581-6 [PubMed]
- Do not empirically start MRSA for uncomplicated Cellulitis without abscess or purulent drainage
- Majority of uncomplicated Cellulitis without abscess is caused by Streptococcus
- Cephalexin alone has excellent coverage for Streptococcus and MSSA
- Added MRSA coverage (e.g. Septra) offers no benefit in non-purulent Cellulitis
- Moran (2017) JAMA 317(20): 2088-96 +PMID:28535235 [PubMed]
- Do not use a single Vancomycin dose prior to oral antibiotic dosing
- Vancomycin serum concentrations after a single dose offer no benefit
- Multiple doses are required to reach MIC
- Risk of a single Vancomycin dose
- Will only lengthen ED time by 60-90 minutes
- Increases the risk for Antibiotic Resistance and reactions
- Localized Cellulitis with borderline indications for parenteral antibiotics
- Start Intravenous Fluids
- Give initial oral antibiotic dose
- Administer Analgesics
- Reassess in 1 hour and reconsider parenteral antibiotics versus discharge on oral antibiotics
- Localized Cellulitis with failure to respond to oral therapy
- Consider Cellulitis Differential Diagnosis
- Maintain same antibiotic course for at least 24-48 hours (unless significant progression)
- Cellulitis is unlikely to improve on any antibiotics regimen for the first 24 hours
- Assess for Cellulitis with abscess
- Consider soft tissue Ultrasound or attempt needle aspiration
- Incision and Drainage of abscess
- Abscess complicating Cellulitis typically defines Staphylococcal Cellulitis (see antibiotic selection below)
- Consider broadening oral antibiotic regimen
- Include MRSA coverage if not already added (especially for purulent Cellulitis)
- Parenteral antibiotics (esp. for serious findings such as Necrotizing Fasciitis, Sepsis)
- See regimens below
- Place and IV line and patient returns at intervals (typically every 12 hours) for next antibiotic infusion
- Patient returns to ED for infusion only RN visits with a planned recheck by a provider at 24-48 hours
- RN alerts provider earlier if concerning findings at time of routine infusion
- Admit or observe a patient developing systemic symptoms or other concerning findings
- Consider Consultation
- Infectious Disease
- General Surgery
- Consider inpatient management
- See below
- References
- Morgenstern in Herbert (2019) EM:Rap 19(1): 14-5
- Lin in Herbert (2014) EM:Rap 14(1): 6-7
- Management: Inpatient
- Indications
- Cellulitis with serious associated findings or comorbidity
- Severe extremity Cellulitis in Diabetes Mellitus
- Skin Abscess involving the face, hands, genitalia
- Sepsis
- Immunocompromised state
- Diagnostics
- See Laboratory Risk Indicator for Necrotizing Fasciitis ( LRINEC Score)
- Complete Blood Count (CBC)
- C-Reactive Protein
- Comprehensive metabolic panel
- Blood Cultures (in severe infections or immunocompromised patients)
- Wound aspirate, culture or biopsy (advancing edge)
- Imaging indications
- Necrotizing Fasciitis (MRI)
- Other deep space infection (soft tissue Ultrasound or CT)
- Consultation
- Consider Consultation with infectious disease
- General surgery or orthopedic Consultation indications
- Suspected Necrotizing Fasciitis
- Suspected Gas Gangrene
- Suspected other deep space infection
- Suspected joint involvement
- Approach
- Admit
- Incision and Drainage of abscess
- Debride necrotic tissue
- Intravenous antibiotic regimen as described below (typically with MRSA coverage)
- Modify antibiotics based on wound culture results (if performed)
- Transition to oral antibiotics
- When tolerated and improving
- Continue antibiotics for 7-14 day total course
- Management: Extremity Infections (non-diabetic patients)
- See Skin Infections in Diabetes Mellitus
- Erysipelas (well demarcated and bright red): Streptococcus coverage
- Treat as Cellulitis with broader coverage unless classic Erysipelas appearance
- Mild-Moderate infections (oral, oupatient management)
- Penicillin VK 500 mg orally four times per day for 7-10 days or
- Amoxicillin 500 mg orally three times per day for 7-10 days or
- Cephalexin 500 mg orally four times per day for 7-10 days
- Penicillin Allergy
- Azithromycin 500 mg orally on day 1, then 250 mg orally on days 2-5
- Clindamycin 300 mg orally four times per day for 7-10 days
- Severe infections (requiring IV antibiotics)
- Penicillin G 2 million units IV every 6 hours or
- Cefazolin 1 gram IV every 8 hours or
- Clindamycin 600 mg IV every 8 hours or
- Vancomycin 15 mg/kg IV every 12 hours
- Cellulitis (less distinct margins): Streptococcus and Staphylococcus coverage
- First Line: Uncomplicated Cellulitis coverage for Streptococcus (most likely) and MSSA coverage
- Oral
- Cephalexin 500 mg orally four times per day for 7-10 days or
- Dicloxacillin 500 mg orally four times per day for 7-10 days or
- Amoxicillin-Clavulanate (Augmentin) 875 mg orally twice per day for 7-10 days
- Parenteral (more severe infections)
- Cefazolin 1 gram IV every 8 hours or
- Nafcillin 2 grams IV q4 hours or
- Oxacillin 2 grams IV q4 hours
- Outpatient parenteral (adults, narrower spectrum parenteral protocol)
- Protocol: Both medications for 7-10 days
- Cefazolin 2 gram IV q24 hours AND
- Probenacid 1 gram PO q24 hours (Decreases Cefazolin excretion)
- References
- Grayson (2002) Clin Infect Dis 34:1440-8 [PubMed]
- Second Line: Complicated, refractory or pustular Cellulitis coverage for Streptococcus and MRSA coverage
- Oral (choose 1)
- Septra DS 1 tab orally twice daily
- Some recommend 2 tabs if normal Renal Function, serious infections or weight >100 kg
- However no advantage found clinically to the higher dosing
- Cadena (2011) Antimicrob Agents Chemother 55(12):5430-2 +PMID: 21930870 [PubMed]
- Use with Penicillin, Amoxicillin, or Cephalexin (see dosing above)
- Clindamycin 300 mg orally four times per day for 7-10 days (increasing MRSA resistance) or
- Linezolid 600 mg orally twice daily
- Has been very expensive, but generic in 2017
- Parenteral (more severe infections)
- Vancomycin 15 mg/kg IV every 12 hours (adjusted for Renal Function) or
- Linezolid 600 mg IV q12 hours or
- Clindamycin 600-900 mg IV q8 hours
- Cellulitis with Abscess (or per Gram Stain): Staphylococcus coverage
- See Skin Abscess
- Incision and Drainage is primary treatment of solitary abscess (without accompanying Cellulitis)
- Antibiotics are not uniformly required if no Cellulitis is present
- Antibiotics are at the discretion of the provider and may be warranted despite lack of Cellulitis
- Serious comorbidity such as Diabetes Mellitus, immunosuppression or extremes of age
- Multiple sites of infection
- Systemic symptoms
- Rapid progression with concurrent Cellulitis
- Infection involving face, hand or genitalia
- Associated septic phlebitis
- Unreliable follow-up
- Large abscess (e.g. 5 cm and greater, Carbuncle)
- Failure to improve after Incision and Drainage
- Antibiotic selection and course
- Antibiotic selection is the same as for abscess with Cellulitis (typically MRSA)
- Choose a single agent (esp. Septra)
- Course is brief in most cases (3-5 days)
- Staphylococcus Cellulitis (purulent Cellulitis) present: MRSA coverage
- Septra DS 1-2 tabs twice daily for 7-10 days or
- Use 2 tabs if normal Renal Function, serious infections or weight >100 kg
- Minocycline of Doxycycline 100 mg twice daily for 7-10 days or
- Linezolid 600 mg PO bid (very expensive)
- Clindamycin is no longer recommended for MRSA coverage due to growing resistance
- Historical dosing Clindamycin 300 mg orally four times per day for 7-10 days
- Severe infections
- Vancomycin 15 mg/kg IV every 12 hours (adjusted for Renal Function)
- Linezolid 600 mg IV q12 hours (very expensive)
- Daptomycin
- Telavancin
- Ceftaroline fosamil
- Management: Facial Erysipelas
- Staphylococcus aureus may be difficult to exclude (despite most cases being Group A Streptococcus)
- Guidelines as of 2012 recommend covering for MRSA
- Sanford guide recommends Vancomycin parenterally or Linezolid orally or IV
- Mild to moderate infections
- Clindamycin 300 mg orally four times per day or
- Augmentin high dose with Septra DS 2 tabs twice daily or
- Severe infections
- Vancomycin 15 mg/kg IV every 12 hours (adjusted for Renal Function) or
- Linezolid 600 mg IV q12 hours
- Management: Special circumstances (including complicated Cellulitis)
- Cellulitis in comorbid Diabetes Mellitus
- See Skin Infections in Diabetes Mellitus
- Complicated skin and subcutaneous tissue infection (SSTI)
- Indications
- Deep soft tissue infection
- Surgical or Traumatic Wound Infection
- Infected ulcers or burns
- Large abscess with Cellulitis
- Management
- Inpatient management is typically indicated
- Consider surgical Consultation (and possibly infectious disease Consultation)
- Obtain wound cultures
- Initiate empiric broad spectrum antibiotic coverage including MRSA
- Prevention: Recurrent skin and subcutaneous tissue infection (SSTI)
- Recurrent infection definition
- Two or more discrete episodes of active infection and different sites over a 6 month period
- Recurrent abscess
- See Skin Abscess for complete list of preventive strategies
- Wash all sheets, towels and clothes after an episode
- Dispose of used razors
- Consider Antibacterial soap (e.g. Chlorhexidine)
- Consider Mupirocin (Bactroban) in nares twice daily for 5 days (decolonization)
- Dilute bleach bath
- Dilute bleach: 1 teaspoon bleach per gallon water OR
- One quarter cup bleach per 20 gallons water (or 1/4 tub of water)
- Soak in the dilute bleach for 15 minutes twice weekly for 3 months
- Shower to rinse off bleach completely
- Make certain to rinse and dry feet before walking across carpet (and bleaching the carpet)
- Recurrent Cellulitis
- See measures above under Recurrent Skin Abscess
- Reduce Peripheral Edema (support stockings)
- Weight loss
- Treat underlying Venous Insufficiency
- Good skin hygiene
- Prophylactic antibiotics are not recommended
- Not typically effective, especially if there is an underlying predisposing condition
- Strategies that have been used historically for 4-52 weeks (not recommended)
- Penicllin G 1.2 MU IM every 4 weeks or Penicillin V 250 mg orally twice daily
- Macrolides (e.g. Erythromycin 500 mg orally daily) was used as alternative in Penicillin Allergy
- Complications:
- Thrombophlebitis in older patients
- Necrotizing Fasciitis
- References
- Chan (2014) Crit Dec Emerg Med 28(9): 2-7
- Gilbert (2011) Sanford Guide
- Moran in Majoewsky (2013) EM:Rap 13(2): 11
- Orman and Hayes in Herbert (2015) EM:Rap 15(4):4-6
- Ramakrishnan (2015) Am Fam Physician 92(6): 474-83 [PubMed]
- Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]