Management of Leg Cellulitis

Management of Lower Extremity Cellulitis

September 2004

From HealthPartners Medical Group & ClinicsDepartment of Infectious Diseases

Management of Lower Extremity Cellulitis

Cellulitis is defined as an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, usually complicating a wound, ulcer, or dermatosis. Cellulitis often involves the lower leg and is commonly accompanied by fever, pain/tenderness, warmth, erythema, and swelling. A recent New England Journal of Medicine article makes the following suggestions regarding the management of uncomplicated lower leg cellulitis.

Common predisposing factors include
- edema
- prior saphenous vein harvesting (such as for coronary artery bypass grafting), and
- fissuring in the toe webs or plantar skin cracking due to a fungal dematosis.
*lymphedema

The most common bacterial causes are

- Group A or
- non-group A beta hemolytic streptococcus and Staphylococcus aureus.

Tissue cultures (needle aspirate or punch biopsy) are usually not indicated in routine care.

Blood cultures are unlikely to be cost-effective as bacteremia is uncommon in cellulitis. Blood cultures might be considered in patients with chills and high fever.

Antibiotic treatment usually consists of a beta-lactam antibiotic with activity against penicillinase-producing S. aureus.

Examples of appropriate oral antibiotics include

a) cephalexin 500 mg every 6 hours,
b) dicloxacillin 500 mg every 6 hours, or
c) clindamycin 300 mg every 6 hours (in penicillin allergic patients).

Examples of appropriate parenteral antibiotics include

- cefazolin 1 g IV every 6 hours,
- ceftriaxone 1 g IV every 24 hours, or
- cefazolin 2 g intravenously once daily plus probenecid 1 g orally once daily (reported to be as effective as once daily ceftriaxone).

Vancomycin or linezolid may be necessary if methicillin-resistant S. aureus is suspected or if the patient is highly allergic to penicillin.

Hospitalization should be considered if the lesion is rapidly spreading, if the systemic response is prominent (i.e., chills and fever >100.5 degrees F), or if there are clinically significant comorbidities such as immunocompromise, neutropenia, asplenia, preexisting edema, cirrhosis, cardiac failure, or renal insufficiency.

Recurrences may be prevented by the use of support stockings to reduce edema, good skin hygiene, and prompt (or prophylactic) treatment of interdigital dermatophytic infections/tinea pedis.

Daily prophylaxis with penicillin G or amoxicillin or erythromycin 250 mg twice daily long-term may help prevent recurrences in individuals who have experienced two or more episodes of cellulitis at the same site.

ReferencesSwartz MN. Cellulitis. NEJM 2004; 350: 904-912.If you have questions relating to this Pearl of the Month, please email your questions to IME Pearl .

Health Partners Clinical Pearls

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Additional Risk Factors for Leg Lymphedema

Age. As you age, your circulatory system becomes less effective at delivering blood — with its infection-fighting white blood cells — to some areas of your body. As a result, skin abrasions may lead to infections such as cellulitis where your circulation is poor.

Weakened immune system. Illnesses that result in a weakening of your immune system leave you more susceptible to infections such as cellulitis. Examples of these illnesses include chronic lymphocytic leukemia and HIV infection. Taking immune-suppressing drugs, such as prednisone or cyclosporine, also can leave you vulnerable to infections. Immune-suppressing drugs are used to treat a variety of illnesses and to help prevent rejection in people who receive organ transplants.

Diabetes. Having diabetes not only increases your blood sugar but also impairs your immune system and increases your risk of infections. Your skin is one of the many areas of your body that becomes more susceptible to infection. Diabetes may also lead to chronic ulcers of your feet. These ulcers can serve as portals of entry for bacterial infections.

Chickenpox and shingles. These common viral diseases typically cause broken blisters on the skin that can serve as potential entry points for bacterial invasion and infection.

Chronic swelling of your arms or legs (lymphedema). Swollen tissue may crack, leaving your skin vulnerable to bacterial infection.

Complications from Leg Cellulitis

Tissue death (gangrene)
Sepsis, generalized infection and shock
Meningitis (if cellulitis is on the face)
Lymphangitis (inflammation of the lymph vessels)
Bacteremia
Gangrene - tissue death

Cellulitis Can Strike Anyone

July 13, 2006

CAPITOL HILL House Speaker Dennis Hastert has been admitted to Bethesda Naval Hospital so he can be treated for a bacterial skin infection.Hastert's office says his doctor wants him to stay there through the weekend.

A spokesman says the speaker will be off his feet for at least 72 hours while he's treated with intravenous antibiotics for the infection, known as cellulitis. Hastert's office says he applied some ointment after discovering the infection on his lower left leg.

A few days later his doctor took a look at it and diagnosed it as cellulitis.

That's a skin infection which appears as a swollen, red area that feels hot and tender, and can can spread rapidly without treatment.

Hastert Leaves Hospital - Is Doing Well

Items compiled from Tribune news services

Published July 18, 2006

WASHINGTON, D.C. -- House Speaker Dennis Hastert was released from Bethesda Naval Hospital on Monday afternoon after four days of treatment for a leg infection, according to spokesman Ron Bonjean."He's doing well," Bonjean said. "He's healthy and over this."

The 64-year-old Illinois Republican was admitted to the military hospital on Thursday with a case of cellulitis, a skin infection, on his lower left leg. He was treated with intravenous antibiotics, Bonjean said.Hastert was expected to return to his office and perform his normal duties the remainder of the week, Bonjean said."The staff spent the weekend visiting him, bringing work to him," Bonjean said.Hastert has diabetes, which can lead to poor blood circulation in the extremities. The disease can cause cellulitis to spread rapidly, and consequently doctors frequently treat cellulitis aggressively in diabetics.

Copyright © 2006, Chicago Tribune

Targeting cellulitis

Targeting cellulitis

Nursing Dec 2002

Deborah E. Roy; Nancy A. Stotts

Find out how to help a patient who gets this nasty inflammatory condition.

FOUR DAYS AGO, Eric LeMay, 34, cut his right thigh while working on his car. Now he comes to the emergency department complaining of pain at the site. The wound is approximately 1 1/2 inches (3.8 cm) long with 2 1/2 inches (6.4 cm) of swelling and redness all around it. The physician who evaluates him diagnoses cellulitis and admits him to the hospital.

Cellulitis is a rapidly spreading acute inflammation with infection of the skin and subcutaneous tissue, usually caused by bacteria. It can progress to tissue death and systemic infection, so the patient needs immediate treatment and close monitoring. In this article, we'll explain how cellulitis develops, how it's treated, and what you can do to help Mr. LeMay.

Common culprits: Strep, staph, and Haemophilus

Although it can develop in and under the skin anywhere, cellulitis most often affects the extremities. The classic signs are erythema, edema, and pain.

Cellulitis can develop in apparently normal skin, but its usually associated with a break in skin integrity. The most common causes in adults are group A streptococci and Staphylococcus aureus;
H. influenzae Type B is more common in children.

The following conditions increase the risk:

* venous insufficiency or stasis
* thrombophlebitis
* diabetes
* lymphedema
* surgery
* malnutrition
* substance abuse
* presence of another infection
* compromised immune function due to human immunodeficiency virus (HIV), treatment with steroids or cancer chemotherapy, or autoimmune diseases, such as lupus erythematosus.

How the immune system responds

Tissue injury precipitates most cases of cellulitis. Initially, cells at the injury site release chemicals that call in white blood cells (WBCs), dilate the blood vessels, and increase capillary permeability. The WBCs engulf and digest bacteria and debris and, as they die, their digested debris is released and forms pus. Fibrin passes from the blood to the involved tissue to wall off the injury and limit the spread of infection.

The larger the bacterial load at the site, the larger the affected area and the greater the patients immune response to combat infection. In many cases, the immune response alone resolves cellulitis, but if the bacterial load is large enough or the strain is very virulent, it may not be adequate and he'll need antibiotic therapy In some cases, a painful abscess forms-a sac of pus walled off by fibroblasts and collagen and a rich medium for bacteria. Incision and drainage (IUD) of the abscess will relieve pain and aid healing.

Identifying and responding to the problem.

The diagnosis of cellulitis is based on the patients clinical signs and history.

He may need a WBC count drawn to screen for infection and blood cultures if bacteremia is suspected. When drainage, an open wound, or another obvious portal of entry is present, a culture and Gram's stain usually determine the causative organism and appropriate antibiotic therapy. Occasionally, X-ray, ultrasound, computed tomography, or magnetic resonance imaging is used to determine the extent of inflammation and to identify abscess formation.

To care for Mr. LeMay, administer drug therapy and supportive measures.

Administer antibiotics. Therapy will depend on the identified or suspected organism. Penicillins (nafcillin, oxacillin), cephalosporins (cephalexin), vancomycin, and aminoglycosides (gentamicin) are common choices. If cultures identify a specific pathogen, make sure the prescribed antibiotic is effective against it. Administer intravenous (LV) and oral doses as soon as possible and at the prescribed times to maintain steady blood levels.

Monitor his progress. Regularly assess Mr. LeMay for improvement or worsening cellulitis-every 4 hours at first, then twice a day as he improves. Outline the area of redness and swelling with a skin marker so you can see whether the inflammation is spreading or shrinking. After each assessment, document the size, shape, color, and temperature of the wound and surrounding tissue. Describe the type of drainage, if present, and whether the patient reports pain; also indicate the date and time. If the area of erythema increases or he develops fever, chills, drainage, or more pain, document your findings and notify the primary care provider.

Change dressings.

Mr. LeMay develops an abscess, and his primary care provider performs IUD, withdrawing about 10 ml of pus. He leaves the wound open to heal by secondary intention.

Change the dressing two or three times daily with a wet-to-- moist sterile dressing to keep the wound open and to wick away exudate. Fluff the dressing and fill the space loosely (packing in too much could cause ischemia and delay healing). Don't let the gauze in the wound dry out; besides being painful, removing dry gauze would disturb new granulation tissue, cause bleeding, and inhibit healing. If it dries before you can change it, slightly moisten it with sterile 0.9% sodium chloride solution to loosen it before removal.

After changing the dressing, document your observations of tissue in the wound base, the surrounding skin, and the old dressing. Also chart the type of new dressing and the time you applied it.

Provide pain relief. The pain of cellulitis may spring from inflammation or the I&D procedure. As ordered, administer oral analgesics such as acetaminophen with oxycodone for pain and a nonsteroidal anti-inflammatory drug to decrease inflammation. Provide IN analgesics or extra doses as ordered; for example, before an I&D procedure or dressing change and for breakthrough pain.

Assess Mr. LeMay's pain using a standard numeric pain-rating scale ranging from 0 (no pain) to 10 (worst pain imaginable). Using the same scale each time, document his pain rating whenever you take his vital signs, before you administer an analgesic, and an hour afterward. Adjust his medication or dosage to maintain his pain rating at a level he's targeted.

Apply local treatments. Elevate the site, if possible. Apply warm compresses to improve blood flow and delivery of oxygen and immune components to ease pain and swelling.

Maximize nutrition and hydration. Mr. LeMay needs good nutrition for tissue repair and to fight infection. Even a well-nourished patient needs plenty of calories and extra protein, carbohydrates, essential fats, and micronutrients (such as vitamins A, B, C, and D) to heal. If you suspect he's malnourished, arrange a nutritional consult.

Adequate hydration is also critical for cell function and to remove bacteria and their by-products from tissues. Carefully evaluate your patient's intake and output and assess him for dry mucous membranes, decreased urine output, and orthostatic hypotension. Unless he must restrict fluids because of a renal or cardiac problem, have him drink eight glasses of fluid a day.

Looking forward to full recovery

After 3 days, Mr. LeMay is ready to go home. You teach him about his medications and review the method for changing his wound dressings, which he'll do twice a day until he sees his primary care provider. With the appropriate medical treatments and your timely care, he's looking forward to a full recovery and should soon return to his normal activities.

Find Articles

The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.

The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.

Tayal VS, Hasan N, Norton HJ, Tomaszewski CA.
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
vtayal@carolinas.org

OBJECTIVES:

To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis.

METHODS:

This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded.

RESULTS:

Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%.

CONCLUSIONS:

Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.

Publication Types:

Evaluation Studies

PMID: 16531602 [PubMed - indexed for MEDLINE]

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ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections.

Squire BT, Fox JC, Anderson C.

Department of Emergency Medicine, University of California, Irvine, Orange, CA 92868, USA.


OBJECTIVES:

Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses.

METHODS:

Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30-minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven-day follow-up was the criterion standard when I + D was not performed.

RESULTS:

Sixty-four of 107 patients had I + D-proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, chi(2) = 14.2, p = 0.0002).

CONCLUSIONS:

ED bedside US improves accuracy in detection of superficial abscesses.

Publication Types:
Clinical Trial

PMID: 15995090 [PubMed - indexed for MEDLINE]

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Bilateral peritonsillar cellulitis

Bilateral peritonsillar cellulitis

An acute infection located between the tonsil and the superior pharyngeal constrictor muscle.

Peritonsillar abscess (quinsy) is rare in children but more common in young adults. Although usually due to a group A -hemolytic streptococcus, peritonsillar infection can also be caused by anaerobic microorganisms, such as bacteroides. Swallowing causes severe pain; the patient is febrile and toxic, tilts the head toward the side of the abscess, and has marked trismus. The tonsil is displaced medially by the peritonsillar cellulitis and abscess, the soft palate is erythematous and swollen, and the uvula is edematous and displaced to the opposite side.

Treatment

Cellulitis without pus formation responds to penicillin in 24 to 48 h. Initially, penicillin G 1 million U IV q 4 h is given. If pus is present and does not drain spontaneously, aspiration or incision and drainage are required. Antibiotic therapy with penicillin V 250 mg q 6 h should be continued orally for 12 days unless cultures and sensitivity studies indicate that another antibiotic is preferable. Peritonsillar abscesses may recur, and tonsillectomy may be considered, especially for patients with recurrent abscesses. It is usually performed 6 wk after the acute infection has subsided, but if antibiotic therapy is given, it can be performed during the acute infection.

Merck Manual

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Peritonsillar abscess (Quinsy)

Suppurative complication of streptococcal tonsillitis with formation of abscess containing range of oropharyngeal flora, including anaerobes. Risk factor from not giving antibiotics but many develop quinsy even after being given penicillin for sore throat.

EpidemiologyIncidence Now relatively uncommon

Presentation

Symptoms

Very painful sore throat with difficulty in opening mouth (trismus - present in 60%). Fever, malaise, headache, swelling in neck, referred ear pain and dysphagia. "Plummy" or "hot potato voice"Signs Displacement of the tonsil on the affected side towards the midline ±exudate. Fluctuant mass may be felt in affected area; fetor oris, drooling and excessive salivation. Cervical lymphadenopathy ++

Common Causative Organisms

Streptococcus pyogenes(30%), Streptococcus milleri, Haemophilus influenzae, Staphylococcus aureus, peptostreptococcal microbes and other anerobes.3

Differential Diagnosis

Peritonsillar cellulitis (peritonsillitis) - responds to antibiotics without need for drainage (ie no abscess)

Management

Broad spectrum antibiotics - High dose penicillin, or combination therapy of a penicillin and metronidazole depending on local degree of penicillin resistance.

Surgical - Incision or needle aspiration

Elective tonsillectomy may be required. Emergency tonsillectomy is not usually recommended (higher cost and complication rates).

Complications

Infection may spread into neck and surrounding tissues. Airway obstruction (rare) - may require cricothyroidotomy or tracheotomy. Rupture of abscess may result in aspiration pneumonitis or pneumonia.

References Used

Cecil Textbook of Medicine 18th Edition. Eds Wingaarden JB & Smith LH. WB Saunders 1988 p.1576
Mehanna HM, Al-Bahnasawi L, White A; National audit of the management of peritonsillar abscess.;Postgrad Med J 2002 Sep; 78(923):545-8.
eMedicine - Quinsy

Acknowledgements

EMIS is grateful to doctoronline.nhs.uk for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2003.

Patient UK

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Related Abstracts:

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Demographics of pediatric head and neck infections in a tertiary care hospital.

Schweinfurth JM.

Department of Otolaryngology-Head and Neck Surgery, Laryngology and Voice Disorders, University of Mississippi Medical Center, Jackson, Mississippi 29216, USA.

JSchweinfurth@ent.umsmed.edu

EDUCATIONAL OBJECTIVE:

Discuss potential patterns in the epidemiology of infectious disease of the head and neck.

STUDY OBJECTIVES: To investigate patterns in the epidemiology of severe head and neck infections that may reflect the impact of host factors.

STUDY DESIGN: Population-based, historic cohort study.

METHODS: Information on 1,010, incident head and neck infections occurring over a 5-year period was reviewed for demographics, location, and time of year. A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pair-wise comparison procedure was used for comparison of the average age of first onset of severe head and neck infections. Chi-square test was used to identify any significant association between season of the year and disease.

RESULTS: Significant differences were identified in the age distributions among the diagnosis groups (P < .001). The average age of first onset of cellulitis of the neck and retropharyngeal abscess is earlier than peritonsillar abscess, at 2 to 3 years and 13 years, respectively. Parapharyngeal and periapical abscesses and cellulitis of the face occur at approximately age 6. The incidence of parapharyngeal abscess and diseases of the pharynx is decreased during Spring, whereas peritonsillar abscesses and acute periodontitis occurs more often in Spring and Summer. Age does not appear to be related to season of first occurrence.

CONCLUSIONS: Head and neck infections are not random occurrences based on exposure alone; host factors are clearly important. Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone. Developmental patterns of the host immune response may be related to the age differential identified in the current study and are cause for further investigation.

PMID: 16735893 [PubMed - indexed for MEDLINE]

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The role of anaerobic bacteria in tonsillitis.

Brook I.

Department of Pediatrics, Georgetown University School of Medicine, 4431 Albemarlr St. NW, Washington, DC 20016, USA. ib6@georgetown.edu

This review summarizes the information that supports the potential importance of anaerobic bacteria in tonsillitis. Some anaerobic bacteria possess interfering capability with Group A beta-hemolytic streptococci (GABHS) and other pathogens. The possible role of anaerobes in the acute inflammatory process in the tonsils is supported by several observations: anaerobes have been isolated from the cores of tonsils of patients with recurrent GABHS and non-GABHS tonsillitis (NST); the recovery of anaerobes as predominant pathogens in abscesses of tonsils, in many cases without any aerobic bacteria; their recovery as pathogens in well-established anaerobic infections of the tonsils (Vincent's angina); the increased recovery rate of encapsulated pigmented Prevotella and Porphyromonas spp. in acutely inflamed tonsils; their isolation from the cores of recurrently inflamed NST; and the response to antibiotics in patients with NST. Furthermore, immune response against Prevotella intermedia is present in patients with recurrent NST, and an immune response can also be detected against P. intermedia and Fusobacterium nucleatum in patients who recovered from peritonsillar cellulitis or abscesses, infectious mononucleosis and acute non-streptococcal and GABHS tonsillitis. Although more studies are needed, these findings support the possible pathogenicity of Gram-negative anaerobic bacilli in tonsillitis.

Publication Types:
ReviewPMID: 15627441 [PubMed - indexed for MEDLINE]

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Peritonsillar infections: local experience.

Ong YK, Goh YH, Lee YL.Department of Otolaryngology, Singapore General Hospital, Outram Road, Singapore 169608. ykong@pacific.net.sg

INTRODUCTION: The disease pattern and management of peritonsillar infections in Singapore General Hospital are studied. Other objectives are to determine if a seasonal variation exists and to examine the role of routine bacterial cultures and interval tonsillectomy.

METHODS: This is a retrospective review of the management and outcome of patients with peritonsillar infections who were admitted acutely to Singapore General Hospital over a three-year period.

RESULTS: Of 185 patients studied, 151 (81.6 percent) had peritonsillar abscess or quinsy and 34 (18.4 percent) had peritonsillar cellulitis. There were 139 males and 46 females, with a racial predisposition among Malays (p value is less than 0.0005). There may be a seasonal variation with a bi-annual trend, though no correlation with upper respiration tract infections was noted. Treatment consisted mainly of incision and drainage (66 percent) or needle aspiration (34 percent). No significant difference in the length of stay was noted in patients receiving penicillin alone, penicillin with metronidazole, or broad-spectrum antibiotics (p value is equal to 0.062). Fourteen (7.6 percent) patients had recurrences, all of which occurred after the first month. Two patients (1 percent) had bilateral quinsy.

CONCLUSION: Peritonsillar infections remain a common admitting diagnosis to the Otolaryngology department. A single episode of infection should no longer be an indication for tonsillectomy as the incidence of recurrence is low.

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