Name
CELLULITIS
DESCRIPTION
DETAIL
CAUSES: . By site . Cellulitis of the extremities: Group A streptococcus, Staphylococcus aureus . Recurrent cellulitis of the leg: Non-group A beta hemolytic Streptococci (group C,G,B) . Dissecting cellulitis of the scalp: Staphylococcus aureus . Facial cellulitis in adults: H. influenzae type B . Facial cellulitis in children: H. influenzae type B, over 3 years with portal of entry: staphylococcal and streptococcal . Synergetic necrotizing cellulitis: Mixed aerobic-anaerobic flora . Intravenous drug use: Staphylococcus aureus, Streptococci, Enterobacteriaceae, Pseudomonas, Fungi . Synergetic necrotizing cellulitis: Mixed aerobic-anaerobic flora . Specific diseases . Diabetes mellitus: Staphylococcus aureus , Streptococci, Enterobacteriaceae, Anaerobes . Human bites: Eikenella corrodens . Animal bites (cat and dog): Staphylococci, Pasteurella multocida . Patient groups . Neonates: Group B streptococcus . Immunocompromised - Bacteria (Serratia, Proteus and other Enterobacteriaceae) - Fungi ( Cryptococcus neoformans ) - Atypical mycobacterium . Children with nephrotic syndrome: E. coli . Environmental and occupational exposures - Erysipelothrix rhusiopathiae - Vibrio species - Aeromonas hydrophilia . Rare causes . Anaerobic . Clostridium perfringens (gas forming cellulitis) . Tuberculosis . Syphilitic gumma . Fungal: Mucormycosis, Aspergillosis -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS . Perianal cellulitis . Candida intertrigo . Psoriasis . Pinworm infection . Inflammatory bowel disease . Behavioral problem . Child abuse . Others . Acute gout . Fasciitis/myositis . Mycotic aneurysm . Ruptured Bakers cyst . Thrombophlebitis . Osteomyelitis . Herpetic whitlow . Cutaneous diphtheria . Pseudogoutβ’ Aspirates from the point of maximum inflammation Yield a 45% positive culture rate as compared to a 5% from leading edge culture. β’ Blood cultures - potential pathogens isolated in 25% of patients β’ Mild leucocytosis with a left shift β’ A mildly elevated sedimentation rate β’ CBC SPECIAL TESTS . Serial serological testing with antistreptolysin O, antideoxyribonuclease B, and anti-hyaluronidase tests may be successful in diagnosing cellulitis caused by groupA, C, or G hemolytic streptococci . Sinus drainage and culture of aspirate IMAGING : . Gas forming cellulitis . Plain x-rays show gas bubbles in the soft tissue . CT shows gas and myonecrosis DIAGNOSTIC PROCEDURES: . Skin biopsy . Lumbar puncture should be considered for all children with H. influenzae type B cellulitis
TYPENOTES
RISK FACTORS: Previous trauma (laceration, puncture, human or animal bite), Underlying skin lesion (furuncle, ulcer), Surgical wound, Recurrent cellulitis, Post coronary artery bypass in patients whose saphenous veins have been removedENERAL MEASURES: Immobilization and elevation of the involved limb to reduce swelling may be needed in H. influenzae type B β’ Sterile saline dressings to decrease local pain β’ Moist heat to localize the infection β’ Cool aluminum acetate (Burowβs solution) compresses for pain relief SURGICAL MEASURES: β’ Debridement for gas/purulent collections β’ Intubation or tracheotomy may be needed for cellulitis of the head or neck β’ Hand infections - wide fi lleting incision in necrotizing cellulitis PATIENT EDUCATION : β’ Good skin hygiene β’ Avoid skin traumas β’ Report early skin changes to physician DRUG(S) OF CHOICE : Treat 10-30 days. Guided by culture results whenever possible. β’ Mild early suspected streptococcal etiology: Aqueous penicillin G, 600,000 U, then IM procaine penicillin at 600,000 U q8-12 hrs β’ Staphylococcal infection or no clues to etiology: penicillinase-resistant penicillin (e.g., oxacillin 0.5-1.0 g po q6 hrs) β’ Severe infection: penicillinase-resistant penicillin (e.g., nafcillin 1.0-1.5 g IV q4 hrs) β’ Gram negative bacillus as possible etiology: aminoglycoside (gentamicin) plus a semisynthetic penicillin β’ Rapidly progressive cellulitis after a fresh water injury: penicillinase-resistant penicillin plus gentamicin or chloramphenicol β’ Human bites: amoxicillin-clavulanate (Augmentin) β’ Animal bites (cellulitis at the saphenous site): penicillin or nafcillin, in high dosage, IV for 7 days before switching to oral therapy β’ Facial cellulitis in adults and children: (H. infl uenza B) cefotaxime IV β’ Gas forming cellulitis: Aqueous penicillin G 10-20 million U/day IV β’ Diabetes mellitus: Cefoxitin or if toxic, clindamycin and gentamicin β’ Intravenous drug abuse: Vancomycin and gentamicin β’ Compromised hosts: clindamycin and gentamicin β’ Burn patients: vancomycin and gentamicin ALTERNATIVE DRUGS: . Mild infection . Penicillin allergy: erythromycin, 500 mg po q6 hrs . Severe infection . Vancomycin 1.0-1.5 g/day IV . Human bite and animal bites: IV cefoxitin . Gas forming cellulitis . Metronidazole 500 mg IV q6h . Clindamycin 600 mg IV q8h . Fluoroquinolones (adults) PATIENT MONITORING; β’ A blood culture at the end of treatment to ensure cure β’ Repeat needle aspirate culture β’ Repeat blood count if patient was toxic β’ Repeat lumbar puncture in case of meningitis PREVENTION/AVOIDANCE : β’ Treatment of tinea pedis with antifungal (such as clotrimazole) will prevent recurrent cellulitis of the legs in patients who have had coronary bypass β’ Avoid trauma β’ Avoid swimming in fresh water or salt water in the presence of skin abrasion β’ Avoid human or animal bite β’ Support stocking with peripheral edema β’ Good skin hygiene β’ For recurrent cellulitis - prophylactic penicillin G (250-500 mg po bid) β’ H. influenzae cellulitis - rifampin prophylaxis for entire family of index case or in day-care classroom in which one or two children exposed. Dosage: 20 mg/kg/day (maximum: 600 mg/day) for 4 days. POSSIBLE COMPLICATIONS: β’ Bacteremia β’ Local abscesses β’ Super infection with gram negative organisms β’ Lymphangitis especially in recurrent cellulitis β’ Thrombophlebitis of lower extremities in older patients β’ Dissecting cellulitis of the scalp - scarring; alopecia β’ Facial cellulitis in children - meningitis in 8% of patients β’ Gas forming cellulitis - gangrene; amputation; 25% mortality EXPECTED COURSE/PROGNOSIS: With adequate antibiotic treatment, outlook is good
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
BLOOD SUGAR ( FASTING ), COMPLETE BLOOD COUNT, PUS CULTURE TEST, CT SCAN, X-RAY
[CELLULITIS]