Cellulitis
Cellulitis: Excerpt from The 5-Minute Pediatric Consult
Nicholas Tsarouhas, MD
Cellulitis - BASICS
Cellulitis - description
- Cellulitis is an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, often complicating a wound or other skin condition.
- Cellulitis may be further classified by the unique area of the body it affects (e.g., periorbital or orbital cellulitis, peritonsillar cellulitis, etc.).
Cellulitis - general prevention
- Good wound care can prevent most cases.
- All wounds should be cleaned with soap and water, then covered with a clean, dry cloth.
- Topical antibiotic ointment is optional.
Cellulitis - epidemiology
- The most common cause of cellulitis in children is Staphylococcus aureus or Streptococcus pyogenes infection, which develops secondary to local trauma of the integument.
- Bacteremic disease, previously seen commonly when Haemophilus influenzae type b (HIB) was prevalent, has now been surpassed by Streptococcus pneumoniae.
- Clinical failures with penicillin-resistant S. pneumoniae have not yet become a significant problem in cases of uncomplicated cellulitis.
Cellulitis - incidence
Community-acquired methicillin-resistant S. aureus (CA-MRSA) infections continue to rise dramatically, and have become commonplace in the general population.
Cellulitis - prevalence
- MRSA is a worldwide problem; consistently high prevalence rates are found in the US, South America, Japan and southern Europe.
- Adult studies of hospitalized patients report prevalences of >30–40% of CA-MRSA among MRSA isolates.
- The prevalence of CA-MRSA is pediatric patients is much higher.
- CA-MRSA has predominantly been isolated from skin and soft tissue infections, such as cellulitis, abscesses, folliculitis and impetigo.
Cellulitis - pathophysiology
Most commonly due to local trauma with breaches in the integument (abrasions, lacerations, bite wounds, excoriated dermatitis, varicella, etc.)
- May develop secondary to local invasion or infection (e.g., sinusitis leading to orbital cellulitis)
- Hematogenous dissemination (rarely)
Cellulitis - etiology
- S. aureus
- Group A—hemolytic streptococci (S. pyogenes)
- S. pneumoniae: Less common since the advent of childhood vaccination with heptavalent pneumococcal conjugate vaccine (Prevnar)
- Group B streptococci (GBS), Gram-negative rods (GNR’s): neonates
- HIB: Rare, due to childhood immunization
- Pseudomonas aeruginosa, anaerobic bacteria: Immunocompromised children
- Pasteurella species: From cat and dog bites
- Eikenella corrodens: From human bites
Cellulitis - associated conditions
- Periorbital:
- Usually from local trauma (scratch, impetigo, eczema, excoriated Varicella, etc.)
- Hematogenous spread is very uncommon
- Rarely with infectious conjunctivitis
- Orbital:
- Commonly associated with severe sinusitis
- Less commonly: Dental abscess, trauma, hematogenous spread
- Buccal: Very similar to periorbital cellulitis
- Peritonsillar:
- Commonly secondary to severe group A— hemolytic streptococcal pharyngitis
- Cellulitis may progress to a peritonsillar abscess
- Extremity: Usually secondary to local trauma
- Breast: Usually with mastitis (neonates)
- Perianal:
- Seen in infants and young children
- Etiology: Group A streptococcus
- Perianal pain, pruritus, and erythema; sometimes associated with bloody stools
- Cellulitis–adenitis syndrome:
- Uncommon infection of neonates and infants
- Etiology: GBS, S. aureus, GNR’s
- Bacteremia/meningitis commonly associated
Cellulitis - DIAGNOSIS
Cellulitis - signs & symptoms
Cellulitis - history
- An expanding, red, painful area of swelling is the most common presentation.
- Mild constitutional symptoms (with or without fever) are commonly associated with cellulitis.
- A history of local trauma to the integument is the clue to the portal of bacterial entry.
- Visual changes, proptosis, or painful or limited eye movements are worrisome for orbital cellulitis.
- Painful swallowing, pain with opening the mouth (trismus), muffled (“hot-potato”) voice are classic presenting symptoms of peritonsillar cellulitis/abscess
Cellulitis - physical exam
- Erythema, edema, tenderness, and warmth: Classic clinical findings of cellulitis
- Distinct demarcation of raised erythema: Classic description of erysipelas, a superficial cellulitis usually associated with S. pyogenes
- A red streak extending proximally from the extremity: Lymphangitis, which usually implies more serious involvement
- Regional adenopathy: Commonly associated with minor cellulitis; occasionally complicated by lymphadenitis
Cellulitis - tests
Cellulitis - lab
- WBC: Normal or elevated
- Blood culture: Rarely positive. Ill-appearing children and children with extensive areas of cellulitis may warrant a blood culture.
- Wound culture: As resistance continues to rise (especially MRSA), wound cultures are useful.
Cellulitis - imaging
- Radiography: Sometimes helpful to rule out complications such as arthritis or osteomyelitis. Also useful in cases of suspected foreign bodies
- Head CT scan: Important in orbital cellulitis to delineate extent of disease; also when distinction from periorbital cellulitis is clinically difficult
Cellulitis - diag proced-surgery
In many cases, a cutaneous biopsy, examined by an experienced pathologist, may be needed to identify the correct diagnosis.
Cellulitis - differencial diagnosis
- Allergic angioedema can be excluded by its lack of tenderness and the absence of fever.
- Red giant urticaria lesions, similarly, may masquerade as cellulitis.
- Allergic reactions to insect stings are usually pruritic, and may present with mild to severe local erythema; a bite history should be sought.
- Contact dermatitis, is distinguished by its painlessness, pruritus, and the Koebner phenomenon (appearance of isomorphic lesions in the lines of scratching).
- A traumatic contusion may be mistaken for cellulitis, but the history should be confirmatory.
- Severe conjunctivitis presents with conjunctival injection, chemosis, and discharge.
- “Popsicle panniculitis,” a cold-induced fat injury to the cheeks of infants, mimics buccal cellulitis; a history of cold weather exposure or ice or popsicle sucking should be sought.
- Erythema nodosum, a panniculitis, consists of raised, tender lesions that are frequently over the shins; it may present as a single erythematous lesion. It is associated with systemic disorders, including inflammatory bowel disease.
- Superficial thrombophlebitis is distinguished by a tender cord palpable along the course of the affected superficial vein.
- An eye malignancy (retinoblastoma), invasive tumor (rhabdomyosarcoma), or metastatic disease (neuroblastoma, leukemia, lymphoma) may simulate periorbital or orbital cellulitis.
Cellulitis - TREATMENT
Cellulitis - general measures
Local care of cellulitis involves elevation and immobilization of the limb to reduce swelling, and cool sterile saline dressings to remove purulence from open lesions.
Cellulitis - medication
- Most cases of uncomplicated, superficial cellulitis may be treated with oral antibiotics active against Staphylococcus and Streptococcus (e.g., amoxicillin–clavulanate, cephalexin, and erythromycin).
- Isolates resistant to erythromycin may be cross-resistant to clindamycin, as well.
- Abscesses, (in which S. aureus is a likely pathogen), should be treated with clindamycin, after appropriate incision and drainage; trimethoprim–sulfamethoxazole is an alternative.
- Ill-appearing children or those with extensive cellulitic lesions require IV antibiotics.
- As MRSA infections continue to rise, many experts now recommend clindamycin as initial parenteral therapy.
- Oxacillin, nafcillin, cefazolin, and ampicillin–sulbactam are reasonable alternatives when MRSA is not strongly suspected.
- Vancomycin is used as empiric therapy in severe or rapidly progressive infections.
- Linezolid, a newer antibiotic, is very effective against MRSA, but it is expensive and should mostly be reserved for multiresistant organisms.
- If hematogenous dissemination is a strong possibility, an agent active against HIB also should be added (e.g., ceftriaxone, cefotaxime).
- The duration of antibiotics (IV and PO) should generally be 7–10 days.
- Bite wounds should have tetanus and rabies prophylaxis issues addressed.
- Remember to consider the possibility of MRSA in all deep, invasive, or persistent infections (i.e., consider clindamycin).
- Penicillin and amoxicillin are never good empiric choices for even superficial cellulitis (poor S. aureus coverage).
Cellulitis - surgery
Abscesses should be surgically drained.
Cellulitis - FOLLOW UP
- Steady improvement should be expected.
- If daily improvement is not noted, inappropriate antimicrobial coverage, a deeper infection or abscess, or some other complication should be suspected (e.g., foreign body).
Cellulitis - prognosis
The prognosis for complete recovery is good as long as appropriate antimicrobials are administered in a timely fashion.
Cellulitis - complications
- Local or distant spread of infection is possible.
- Suppuration and abscess formation may occur (e.g., peritonsillar abscess).
- Extremity cellulitis may extend into the deep tissues to produce an arthritis or osteomyelitis, or it may extend proximally as a lymphangitis.
- Orbital cellulitis may be complicated by visual loss and/or cavernous sinus thrombosis.
- Prior to widespread immunization against HIB, the bacteremia associated with facial cellulitis was associated with pneumonia, meningitis, pericarditis, epiglottitis, arthritis and osteomyelitis.
Cellulitis - bibliography
- Eady EA, Cove JH. Staphylococcal resistance revisited: Community-acquired methicillin resistant Staphylococcal aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis. 2003;16:103–124.
- Falagas ME. Vergidis PI. Diseases that masquerade as infectious cellulitis. Annals of Internal Medicine. 2005;142(1):47–55.
- Kluytmans-Vandenbergh MF, Kluytmans JA. Community-acquired methicillin-resistant Staphylococcus aureus: Current perspectives. Clin Microbiol Infect. 2006;12(Suppl 1):9–15.
- Ladhani S, Garbash M. Staphylococcal skin infections in children: Rational drug therapy recommendations. Paediatric Drugs. 2005;7(2):77–102.
- Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin resistant Staphylococcal aureus. Pediatr Infect Dis J. 2004;23:123–127.
- Roberts S, Chambers S. Diagnosis and management of Staphylococcus aureus infections of the skin and soft tissue. Int Med J. 2005;35 Suppl 2:S97–S105.
- Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904–912.
- Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25(9):312–320.
Cellulitis - CODES
Cellulitis - icd9
682.9 Cellulitis and abscess, unspecified site
Cellulitis - FAQ
- Q: Should MRSA be considered only in patients with risk factors such as recent hospitalization, chronic illness, health care worker contact, and recent antibiotic use?
- A: No. MRSA is commonly isolated now from patients with no identified risk factors.
- Q: Is ophthalmology consultation necessary in all cases of periorbital cellulitis?
- A: Ophthalmology consultation is not necessary in simple, uncomplicated cases of periorbital cellulitis that clearly have no associated proptosis, limitation in extraocular eye movement, or visual impairment that would suggest a more serious orbital cellulitis.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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