Cellulitis: a practical guide
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1 Cellulitis: a practical guide Dr John Day Consultant in Infectious Diseases & General Medicine Southend University Hospital NHS Foundation Trust
2 77 yr old retired civil servant A&E presentation c/o rigors No significant past history o/e pyrexial, lung creps
3 Investigations & Treatment Neuts 20.3 x 10 9 /L CRP 19 mg/l CXR Normal Δ Pneumonia Rx antibiotic Discharged
4 Two days later Left lower leg Red Swollen Painful Wife (retired casualty sister) Δ cellulitis Investigations Neuts CRP
5 OPAT: Out-Patient Antibiotic Treatment Ceftriaxone 2g od iv for 7 days Reviewed Days 1, 3 & 7 Day Unit Days 2, 4, 5 & 6 District Nurse CRP Days 1,3 & 7: week review Erythema, desquamation, oedema Bilateral VVs and chronic pedal oedema noted
6 Definition Cellulitis an acute or sub-acute inflammation of subcutaneous tissue caused by bacterial infection Erysipelas a type of cellulitis affecting dermal layer
7 Symptoms & Signs Flu-like symptoms: fever, rigors, chills Delirium Lethargy Nausea & vomiting Lower limb rash Rapidly-progressive Erythematous areas Painful when swollen
8 Precipitating Cause Leg ulcer Penetrating injury Blunt injury Inter-digital intertrigo Insect bites None obvious
9 Predisposing Factors: Lymphoedema Chronic lymphoedema Venous insufficiency Obesity Trauma Surgery Congenital Previous Cellulitis The Lymphoedema Support Network
10 Examination Inspect skin Demarcation Ulcers, Bullae Features of chronic venous stasis or lymphoedema Lymphangitis Palpate Tenderness Oedema, Fluctuance, Crepitus Lymphadenopathy Pedal pulses
11 Differential Diagnosis: Chronic Venous Disease Varicose eczema Lipodermatosclerosis Deep vein thrombosis Thrombophlebitis
12 Differential Diagnosis: Other Oedema Gout Allergic reaction Contact dermatitis Erythema nodosum Vasculitis
13 Differential Diagnosis: Complex Infections Diabetic feet Pyomyositis Septic arthritis Osteomyelitis Foreign bodies Necrotizing fasciitis
14 Investigations WCC, CRP Blood culture Wound swab? Doppler US?
15 Bacteria Isolated in only ¼ of hospital cases Yield increased by skin biopsy testing 80% of isolated organisms are β- haemolytic streptococci (Group A or G) Staphylococcus aureus may contribute to some cases
16 Antibiotic Treatment Cochrane Review 2010: most recommendations made on single trials Mild-Moderate Flucloxacillin +/or Amoxicillin Erythromycin or Clindamycin Severe Benzylpenicillin + Flucloxacillin iv Vancomycin or Clindamycin
17 Antibiotic Treatment OPAT Ceftriaxone Daptomycin
18 Considerations for IV treatment No studies of risk factors for complications Septic shock Rapid progression Chronic oedema Immunocompromised Poorly-controlled diabetes Other significant co-morbidities
19 Duration Duration of treatment 5-10 days The natural course of treated cellulitis: Rapid defervesence Skin gets worse before better The post-cellulitic leg
20 Day 2 CRP Day 0: 64 mg/l Day 1: 180 Day 2: 132 Day 5: 75 Day 7: 34 Day 5 Day 7
21 Other Measures Analgesia Anti-inflammatories? Wound Care Elevation Emollients Exercise Elasticated compression
22 Chronic oedema Cellulitis
23 Risk of recurrence Hospital cohort: 25-46% 1 Population-based cohort: 11% 2 Associated with 1 Chronic venous insufficiency Lymphoedema Obesity Smoking Tinea pedis Local injury 1 Cox 1998; Jorup-Rönström 1987; Pavlotsky Ellis Simonsen 2006
24 Prophylactic Antibiotics PATCH study 1 Randomised control trial 2 previous episodes of cellulitis Penicillin 250mg bd Recurrence rate 22 vs 37% (HR 0.55, P=0.01) However: effect less in patients with lymphoedema 1 Thomas 2013
25 What came first the systemic or the local infection?
26 Top Cellulitis Tips Often preceded by chills & rigors If it s not a UTI or an RTI, check the legs Be sceptical about chronic and bilateral cellulitis Cellulitis and DVT rarely co-exist Beware of treating wound swabs Recognise the post-cellulitic leg and the value of the CRP
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