Clinical Notes : Infection and Sepsis

212. Cellulitis and Erysipelas

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Cellulitis and Erysipelas

 

Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue.

 

Erysipelas is a superficial infection affecting the upper layers of the skin.

 

Symptoms and signs can overlap so it is not always easy to differentiate them clinically; however, the recommended treatment is the same for both.

 

In cellulitis and erysipelas, the most common causative pathogens are Streptococcus pyogenes and Staphylococcus aureus.

Common organisms include: Streptococcus pneumoniae, Haemophilus influenza, Gram-negative bacilli and anaerobes.

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Cellulitis is more commonly seen in the lower limbs and usually affects only one limb.

Bilateral cellulitis is very rare and should prompt a rethink of the diagnosis.

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Typical features are an acute onset of red, painful, hot, swollen, and tender skin that spreads rapidly.

Fever, malaise, nausea, shivering, and rigors may accompany or precede skin changes.

Infection around the eyes or the nose (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes, including periorbital cellulitis) is of greater concern because of the risk of a serious intracranial complication.

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Treatment 

To ensure that cellulitis and erysipelas are treated appropriately, exclude other causes of skin redness such as:

  • an inflammatory reaction to an immunisation or an insect bite or

  • a non-infectious cause such as chronic venous insufficiency.

 

Consider taking a swab for microbiological testing from people with cellulitis or erysipelas to guide treatment, but only if the skin is broken and:

  • there is a penetrating injury or

  • there has been exposure to water-borne organisms or

  • the infection was acquired outside the country of residence.

 

Before treating cellulitis or erysipelas, consider drawing around the extent of the infection with a single-use surgical marker pen to monitor progress.

Be aware that redness may be less visible on darker skin tones.

 

Offer an antibiotic for people with cellulitis or erysipelas.

When choosing an antibiotic, take account of:

  • the severity of symptoms

  • the site of infection (for example, near the eyes or nose)

  • the risk of uncommon pathogens (for example, from a penetrating injury, after exposure to water-borne organisms, or an infection acquired outside the country of residence)

  • previous microbiological results from a swab

  • the person's meticillin-resistant Staphylococcus aureus (MRSA) status if known.

 

Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

 

If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

 

Manage any underlying condition that may predispose to cellulitis or erysipelas, for example:

  • diabetes

  • venous insufficiency

  • eczema

  • oedema, which may have an adverse effect of medicines such as calcium channel blockers.

 

Advice

 

When prescribing antibiotics for cellulitis or erysipelas, give advice about:

  • possible adverse effects of antibiotics

  • the skin taking some time to return to normal after the course of antibiotics has finished

  • seeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 2 to 3 days.

 

 

Reasessment

Reassess people with cellulitis or erysipelas if symptoms worsen rapidly or significantly at any time, do not start to improve within 2 to 3 days, or the person:

  • becomes systemically very unwell or

  • has severe pain out of proportion to the infection or

  • has redness or swelling spreading beyond the initial presentation (taking into account that some initial spreading may occur, and that redness may be less visible on darker skin tones)

 

When reassessing people with cellulitis or erysipelas, take account of:

  • other possible diagnoses, such as an inflammatory reaction to an immunisation or an insect bite, gout, superficial thrombophlebitis, eczema, allergic dermatitis or deep vein thrombosis

  • any underlying condition that may predispose to cellulitis or erysipelas, such as oedema, diabetes, venous insufficiency or eczema

  • any symptoms or signs suggesting a more serious illness or condition, such as lymphangitis, orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis

  • any results from microbiological testing

  • any previous antibiotic use, which may have led to resistant bacteria.

 

Consider taking a swab for microbiological testing from people with cellulitis or erysipelas if the skin is broken and this has not been done already.

 

If a swab has been sent for microbiological testing:

  • review the choice of antibiotic(s) when results are available and

  • change the antibiotic(s) according to results if symptoms or signs of the infection are not improving, using a narrow-spectrum antibiotic if possible.

  • be aware that swab cultures, especially those of chronic wounds or ulcers, are commonly polymicrobial or colonized with multidrug-resistant pathogens that are not involved in the aetiology of underlying cellulitis.

 

Referral and seeking specialist advice

 

Refer people to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis.

 

Consider referring people with cellulitis or erysipelas to hospital, or seek specialist advice, if they:

  • are severely unwell or

  • have infection near the eyes or nose (including periorbital cellulitis) or

  • could have uncommon pathogens, for example, after a penetrating injury, exposure to water-borne organisms, or an infection acquired outside the UK or

  • have spreading infection that is not responding to oral antibiotics or

  • lymphangitis or

  • cannot take oral antibiotics (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).

 
 
 
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Preventing recurrent cellulirtis and erysipelas

 

Do not routinely offer antibiotic prophylaxis to prevent recurrent cellulitis or erysipelas.

Give advice about seeking medical help if symptoms of cellulitis or erysipelas develop.

 

For adults who have had treatment in hospital, or under specialist advice, for at least 2 separate episodes of cellulitis or erysipelas in the previous 12 months, specialists may consider a trial of antibiotic prophylaxis.

Involve the person in a shared decision by discussing and taking account of:

  • the severity and frequency of previous symptoms

  • the risk of developing complications

  • underlying conditions (such as oedema, diabetes or venous insufficiency) and their management

  • the risk of resistance with long-term antibiotic use

  • the person's preference for antibiotic use.

 

When choosing an antibiotic for prophylaxis, take account of any previous microbiological results and previous antibiotic use.

 

When antibiotic prophylaxis is given, give advice about:

  • possible adverse effects of long-term antibiotics

  • returning for review within 6 months

  • seeking medical help if symptoms of cellulitis or erysipelas recur.

 

Review antibiotic prophylaxis for recurrent cellulitis or erysipelas at least every 6 months.

The review should include:

  • assessing the success of prophylaxis

  • discussing continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance).

 

Stop or change the prophylactic antibiotic to an alternative if cellulitis or erysipelas recurs.

Referral and seeking specialist advice

  • Refer to hospital:

    • people with impetigo and any symptoms or signs suggesting a more serious illness or condition (for example, cellulitis)

    • people with widespread impetigo who are immunocompromised

 

  • Consider referral or seeking specialist advice for people with impetigo if they:

    • have bullous impetigo, particularly in babies (aged 1 year and under)

    • have impetigo that recurs frequently

    • are systemically unwell

    • are at high risk of complications

 
 

Necrotising Fasciitis

 

In any patient presenting with skin infection, it is vital to exclude necrotising fasciitis, a rare but destructive and rapidly progressive infection that involves deep tissues, fascia, and muscles.

 

Necrotising fasciitis has a significant mortality rate and may require extensive surgical debridement.

 

The presenting signs are often non-specific (redness, swelling, and pyrexia); however, patients may be systemically unwell.

The key symptom is pain disproportionate to the clinical signs.

 

Immediate surgical referral and admission to hospital is vital if the condition is suspected.

 
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Cellulitis and erysipelas : antimicrobial prescribing.

NICE Guideline 141.

NICE, 2019

Access

Cellulitis

DermNetNZ

accesses March 2021

Access

Cellulitis - acute

NICE Clinical Knowledge Summary.

accessed March 2019

Access

Infective skin conditions : when is it appropriate to prescribe an antibiotic ?

Dr. Caroline Ward

Guidelines in Practice

June 2020

Access

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