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Second Line
Mild infection
- Penicillin allergy: erythromycin 500 mg PO q6h
- Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels.
SURGERY/OTHER PROCEDURES
- D ©bridement for gas and purulent matter
- Intubation or tracheotomy may be needed for cellulitis of the head or neck.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Severe infection, suspicion of deeper or rapidly spreading infection, tissue necrosis, or severe pain
- Marked systemic toxicity or worsening symptoms that do not resolve after 24 to 48 hours of therapy
- Patients with underlying risk factors or severe comorbidities
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Repeat relevant labs (blood culture, CBC, potentially LP) if patient is toxic or not improving.
- Consider deep vein thrombosis prophylaxis.
- Cutaneous inflammation may worsen in the first 24 hours due to release of bacterial antigens. Symptomatic improvement usually occurs in 24 to 48 hours, but visible improvement may take 72 hours.
DIET
Glucose control in diabetics
PATIENT EDUCATION
Good skin hygiene.
PROGNOSIS
With adequate antibiotic treatment, prognosis is good.
- Low-dose penicillin prophylaxis in patients with recurrent cellulitis decreases recurrence (4)[A].
COMPLICATIONS
- Local abscess or bacteremia, sepsis
- Superinfection with gram-negative organisms
- Lymphangitis, especially if recurrent
- Thrombophlebitis or venous thrombosis
- Bacterial meningitis
- Gangrene
REFERENCES
11 Figtree M, Konecny P, Jennings Z, et al. Risk stratification and outcome of cellulitis admitted to hospital. J Infect. 2010;60(6):431-439.22 Tay EY, Fook-Chong S, Oh CC, et al. Cellulitis recurrence score: a tool for predicting recurrence of lower limb cellulitis. J Am Acad Dermatol. 2015;72(1):140-145.33 Champion AE, Goodwin TA, Brolinson PG, et al. Prevalence and characterization of methicillin-resistant Staphylococcus aureus isolates from healthy university student athletes. Ann Clin Microbiol Antimicrob. 2014;13(1):33.44 Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.
ADDITIONAL READING
- Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. 2005;18(4):197-203.
- Gunderson CG. Cellulitis: definition, etiology, and clinical features. Am J Med. 2011;124(12):1113-1122.
- Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):285-292.
- Oh CC, Ko HC, Lee HY, et al. Antibiotic prophylaxis for preventing recurrent cellulitis: a systematic review and meta-analysis. J Infect. 2014;69(1):26-34.
- Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ. 2012;345:e4955.
- Quirke M, O'Sullivan R, McCabe A, et al. Are two penicillins better than one? A systematic review of oral flucloxacillin and penicillin V versus oral flucloxacillin alone for the emergency department treatment of cellulitis. Eur J Emerg Med. 2013;21(3):170-174.
CODES
ICD10
- L03.90 Cellulitis, unspecified
- H05.019 Cellulitis of unspecified orbit
- L03.211 Cellulitis of face
- J36 Peritonsillar abscess
- H05.012 Cellulitis of left orbit
- H05.013 Cellulitis of bilateral orbits
- L03.119 Cellulitis of unspecified part of limb
- L03.221 Cellulitis of neck
- L03.317 Cellulitis of buttock
- L03.319 Cellulitis of trunk, unspecified
- L03.818 Cellulitis of other sites
- H05.011 Cellulitis of right orbit
ICD9
- 682.9 Cellulitis and abscess of unspecified sites
- 376.01 Orbital cellulitis
- 682.0 Cellulitis and abscess of face
- 475 Peritonsillar abscess
- 682.1 Cellulitis and abscess of neck
- 682.2 Cellulitis and abscess of trunk
- 682.3 Cellulitis and abscess of upper arm and forearm
- 682.4 Cellulitis and abscess of hand, except fingers and thumb
- 682.5 Cellulitis and abscess of buttock
- 682.6 Cellulitis and abscess of leg, except foot
- 682.7 Cellulitis and abscess of foot, except toes
- 682.8 Cellulitis and abscess of other specified sites
SNOMED
- 128045006 cellulitis (disorder)
- 109245003 Cellulitis of periorbital region
- 200652002 cellulitis of face (disorder)
- 102453009 Peritonsillar cellulitis (disorder)
- 62837005 Cellulitis of hand
- 128276007 Cellulitis of foot
- 13680009 Cellulitis of forearm (disorder)
- 287001000 Cellulitis of leg, excluding foot (disorder)
- 37223007 Cellulitis of neck
- 38217004 Cellulitis of upper arm (disorder)
- 44428005 Cellulitis of buttock
- 46876003 Cellulitis of trunk (disorder)
CLINICAL PEARLS
- S. aureus and group A Streptococcus are the most common organisms that cause cellulitis.
- Consider MRSA if cellulitis is not responding to antibiotics in the first 48 hours.
- Rapid expansion of infected area with red/purple discoloration and severe pain may suggest necrotizing fasciitis, requiring urgent surgical evaluation.