Cellulitis

Clinical Knowledge Summaries: Previous version Cellulitis
Cellulitis
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Minibite. Please visit www.cks.library.nhs.uk to find the latest version.
About this topic

Have I got the right topic?
Age from 1 month onwards This guidance covers the management of cellulitis and erysipelas in primary care. It also covers referral criteria. 'Erysipelas' is now a largely obsolete term, and, in practice, it is a condition that is difficult to distinguish from cellulitis. Management recommendations throughout this guidance refer to 'cellulitis' as meaning both cellulitis and erysipelas. This guidance does not cover the detailed management of cellulitis associated with an animal or human bite wound, or diabetic foot ulcers. There are separate CKS topics on Bites human and animal, Boils and paronychia, Candida skin, Diabetes Type 1 and 2 foot disease, Fungal (dermatophyte) skin infections, Lacerations, Leg ulcer venous, and Otitis externa. The target audience for this guidance is healthcare professionals working within the NHS in England, and providing first-contact or primary health care. Patient information from NHS Direct is intended to be printed and given to people with this condition, and the Shared decision making sections are designed to provide a focus for discussion during the consultation about the treatment options.
Changes
Version 1.0.0, revision planned in 2008. Last revised in November 2005 October 2006 minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006. June 2005 written. Validated in September 2005 and issued in November 2005.
Previous changes
Update
New evidence
Evidence-based guidelines No new evidence-based guidelines since 1 March 2007. HTAs (Health Technology Assessments) No new HTAs since 1 March 2007. Economic appraisals No new economic appraisals relevant to England since 1 March 2007. Systematic reviews and meta-analyses No new systematic review or meta-analysis since 1 March 2007. Primary evidence No new high quality randomized controlled trials since 1 March 2007.
New policies
No new national policies or guidelines since 1 March 2007.
New safety alerts

No new safety alerts since 1 March 2007.
Changes in product availability

No changes in product availability since 1 March 2007.
Concise knowledge for clinical scenarios

Which scenario?
Acute cellulitis: covers the immediate management of acute presentations of cellulitis (either the first or recurrent episodes).
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.
Recurrent cellulitis: covers advice on measures that can be taken to try and reduce the risk of recurrent episodes of cellulitis.
Which therapy?
For cellulitis arising from a human or animal bite see the CKS topic on Bites human and animal. Consider whether admission is necessary (see Should I refer or investigate?). If managed at home: o Prescribe paracetamol or ibuprofen, if necessary, to reduce pain and fever. o Prescribe an oral antibiotic: Flucloxacillin: first-line in uncomplicated cellulitis Erythromycin: if the person is allergic to penicillin, or Clarithromycin: if the person is known to be intolerant of erythromycin o If there has been exposure to fresh water at the site of infection: add ciprofloxacin. o If there has been exposure to salt water at the site of infection: add doxycycline. o Note: if ciprofloxacin or doxycycline is contraindicated, seek advice from local microbiologist. o In people with facial involvement: prescribe co-amoxiclav. Seek advice from a local microbiologist if the person is allergic to penicillin. o Advise rest and elevation of the affected area, if possible, to reduce swelling and pain. o Manage underlying predisposing conditions, e.g. tinea pedis, skin trauma, ulcer. o Recommend use of an emollient to keep the skin well hydrated as the infection resolves and the skin begins to heal.
Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org).
Macrolides
Erythromycin commonly causes gastrointestinal adverse effects. If this is known to occur, consider prescribing clarithromycin instead. Erythromycin and clarithromycin may increase the level of certain drugs (e.g. theophylline, carbamazepine) or potentiate the effects of warfarin, and increased monitoring of these drugs may be necessary. There is an increased risk of myopathy when erythromycin or clarithromycin are given with statins.
Doxycycline
Doxycycline should not be used in pregnancy, during breastfeeding, or in children under 12 years of age. Women of childbearing age should use effective contraception. (Note that tetracyclines may cause oral contraceptives to fail during the first few weeks of treatment and women should be advised to use additional contraception during the course and for at least 7 days afterwards. If the 7 days run beyond the end of the packet, a new packet should be started without a break, omitting any of the inactive tablets.) Benign intracranial hypertension is a rare but important adverse effect of tetracyclines. If a person taking a tetracycline develops headache and visual disturbances, the tetracycline should be stopped. Doxycycline may cause photosensitivity reactions: advise the person to avoid exposure to direct sunlight or sunlamps.
Ciprofloxacin
Quinolones can rarely cause tendon damage. The Committee on Safety of Medicines (CSM) advises that treatment should be stopped if a tendon becomes painful or inflamed. Avoid using ciprofloxacin in children and growing adolescents, and during pregnancy and breastfeeding. Women of childbearing age should use effective contraception. Avoid using ciprofloxacin in people with epilepsy or in people who are predisposed to seizures (because of other conditions they have or other medicines they are taking).
Ibuprofen
Ibuprofen may cause gastrointestinal irritation and occasionally gastrointestinal haemorrhage. Avoid if there is a history of peptic ulceration. It can exacerbate asthma, hypertension, renal impairment, and cardiac failure.
Should I refer or investigate?

Refer?
Consider urgent hospital admission for intravenous antibiotic treatment if: o Severe or rapidly worsening infection o Systemic illness or vomiting o Suspected orbital or periorbital cellulitis, deep infection, or evidence of complications o Facial cellulitis in a child maintain a low threshold for hospital admission and ensure that regular monitoring is in place if managed at home o Immunocompromised o Diabetes mellitus admission may not be necessary if diabetes is stable, but maintain a low threshold for hospital admission and ensure that regular monitoring is in place if managed at home o Significant co-morbidity (e.g. heart failure, renal failure) o Neonate or child aged under 1 year o Lack of home support, frail people, or people with memory impairment o Failure to respond to initial treatment
Investigate?
Investigations are generally unhelpful in the initial diagnosis and management of cellulitis. o Consider taking swabs for culture and sensitivity when there is broken skin or an obvious portal for microbial entry. o Blood culture and fine-needle aspiration of tissue fluid might be considered if cellulitis is severe or is not responding to treatment, but hospital admission is usually required in these situations. o Radiological investigation is indicated if underlying osteomyelitis, a foreign body, or necrotizing fasciitis are suspected.
Follow-up advice
Review within 48 hours to ensure satisfactory response to treatment. Drawing round the margins of the erythematous area with a permanent marker may be useful for monitoring spread or regression of infection. Advise earlier review if the person becomes systemically unwell, if the symptoms worsen rapidly, or if oral treatment is not tolerated (e.g. due to vomiting). If symptoms are not responding or are deteriorating, consider hospital admission. If symptoms have not fully resolved after 7 days of treatment, consider continuing the antibiotic for up to a further 7 days. Assess and encourage compliance with antibiotics and other treatments at all stages. If symptoms are recurrent, consider preventative strategies to reduce the risk of further recurrent episodes (see scenario Recurrent cellulitis).
Prescriptions
Analgesia: use when required Paracetamol s/f susp: 30-60mg up to three times a day
Age from 1 month to 2 months Paracetamol 120mg/5ml oral suspension paediatric sugar free. Take 1.25ml to 2.5ml every 8 hours when required for relief of pain. Maximum of three doses in 24 hours. Supply 100 ml. NHS Cost 0.32 OTC Cost 0.56 Licensed use: no
Paracetamol s/f susp: 60mg to 120mg up to four times a day

Age from 3 to 11 months This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.
Paracetamol 120mg/5ml oral suspension paediatric sugar free. Take 2.5ml to 5ml every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours. Supply 150 ml. NHS Cost 0.48 OTC Cost 0.84 Licensed use: yes

Age from 1 year to 5 years 11 months Paracetamol 120mg/5ml oral suspension paediatric sugar free. Take one to two 5ml spoonfuls every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours. Supply 300 ml. NHS Cost 0.96 OTC Cost 1.69 Licensed use: yes

Age from 6 years to 11 years 11 months Paracetamol 250mg/5ml oral suspension sugar free. Take one to two 5ml spoonfuls every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours. Supply 300 ml. NHS Cost 2.19 OTC Cost 3.85 Licensed use: yes
Paracetamol tablets: 500mg to 1g up to four times a day

Age from 12 years to 17 years 11 months Paracetamol 500mg tablets. Take one to two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 56 tablets. NHS Cost 1.05 Licensed use: yes
Paracetamol tablets: 1g up to four times a day

Age from 18 years onwards Paracetamol 500mg tablets. Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 56 tablets. NHS Cost 1.05 Licensed use: yes
Ibuprofen s/f susp: 5mg/kg three to four times a day (>5kg)

Age from 1 month to 2 months Ibuprofen 100mg/5ml oral suspension sugar free. *WEIGHT REQUIRED* Take 5mg per kg bodyweight three to four times a day when required for relief of pain. Do not exceed the stated dose. Supply 50 ml. NHS Cost 0.90 Licensed use: no
Ibuprofen s/f susp: 50mg three times a day

Age from 3 to 5 months Ibuprofen 100mg/5ml oral suspension sugar free. Take 2.5ml three times a day when required for pain relief. Do not exceed the stated dose. Supply 50 ml. NHS Cost 0.90 OTC Cost 1.58 Licensed use: yes
Ibuprofen s/f susp: 50mg three to four times a day

Age from 6 to 11 months Ibuprofen 100mg/5ml oral suspension sugar free. Take 2.5ml three to four times a day when required for pain relief. Do not exceed the stated dose. Supply 100 ml. NHS Cost 2.69 OTC Cost 4.73 Licensed use: yes

Age from 1 year to 3 years 11 months Ibuprofen 100mg/5ml oral suspension sugar free. Take one 5ml spoonful three times a day when required for pain relief. Do not exceed the stated dose. Supply 100 ml. NHS Cost 2.69 OTC Cost 4.73 Licensed use: yes

Age from 4 years to 6 years 11 months Ibuprofen 100mg/5ml oral suspension sugar free. Take 7.5ml three times a day when required for pain relief. Do not exceed the stated dose. Supply 150 ml. NHS Cost 2.71 OTC Cost 4.77 Licensed use: yes

Age from 7 years to 9 years 11 months Ibuprofen 100mg/5ml oral suspension sugar free. Take two 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose. Supply 150 ml. NHS Cost 2.71 OTC Cost 4.77 Licensed use: yes

Age from 10 years to 11 years 11 months Ibuprofen 100mg/5ml oral suspension sugar free. Take three 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose. Supply 300 ml. NHS Cost 5.42 OTC Cost 9.54 Licensed use: yes
Ibuprofen tablets: 200mg to 400mg three to four times a day

Age from 12 years to 17 years 11 months Ibuprofen 200mg tablets. Take one to two tablets three or four times a day when required for pain relief. Do not exceed the stated dose. Supply 56 tablets. NHS Cost 1.68 OTC Cost 2.96 Licensed use: yes
Ibuprofen tablets: 400mg three or four times a day

Age from 18 years onwards Ibuprofen 400mg tablets. Take one tablet three or four times a day when required for pain relief. Do not exceed the stated dose. Supply 28 tablets. NHS Cost 1.05 OTC Cost 1.85 Licensed use: yes
1st-line antibiotic: flucloxacillin for 7 days Flucloxacillin syrup: 125mg four times a day
Age from 1 year to 1 year 11 months Flucloxacillin 125mg/5ml oral solution. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 11.04 Licensed use: yes Patient Information: Discard any remaining medicine.
Flucloxacillin syrup: 250mg four times a day

Age from 2 years to 9 years 11 months Flucloxacillin 250mg/5ml oral solution. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml.
NHS Cost 13.94 Licensed use: yes Patient Information: Discard any remaining medicine.
Flucloxacillin syrup: 500mg four times a day

Age from 10 years to 11 years 11 months Flucloxacillin 250mg/5ml oral solution. Take two 5ml spoonfuls four times a day for 7 days. Supply 300 ml. NHS Cost 20.91 Licensed use: yes Patient Information: Discard any remaining medicine safely.
Flucloxacillin capsules: 500mg four times a day

Age from 12 years onwards Flucloxacillin 500mg capsules. Take one capsule four times a day for 7 days. Supply 28 capsules. NHS Cost 6.34 Licensed use: yes
1st-line in penicillin allergy: macrolide for 7 days Erythromycin s/f suspension: 125mg four times a day
Age from 1 year to 1 year 11 months Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 5.42 Licensed use: yes Patient Information: Discard any remaining medicine.
Erythromycin s/f suspension: 250mg four times a day

Age from 2 years to 8 years 11 months Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 7.00 Licensed use: yes Patient Information: Discard any remaining medicine.
Erythromycin s/f suspension: 500mg four times a day

Age from 9 years to 11 years 11 months Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 11.08 Licensed use: yes Patient Information: Discard any remaining medicine.
Erythromycin e/c tablets: 500mg four times a day

Age from 12 years onwards Erythromycin 250mg gastro-resistant tablets. Take two tablets four times a day for 7 days. Supply 56 tablets. NHS Cost 6.42 Licensed use: yes
Clarithromycin suspension: 62.5mg twice a day

Age from 1 year to 2 years 11 months Clarithromycin 125mg/5ml oral suspension. Take 2.5ml twice a day for 7 days. Supply 70 ml. NHS Cost 5.58 Licensed use: yes Patient Information: Discard any remaining medicine safely.
Clarithromycin suspension: 125mg twice a day

Age from 3 years to 6 years 11 months This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.
Clarithromycin 125mg/5ml oral suspension. Take one 5ml spoonful twice a day for 7 days. Supply 70 ml. NHS Cost 5.58 Licensed use: yes
Clarithromycin suspension: 187.5mg twice a day

Age from 7 years to 9 years 11 months Clarithromycin 125mg/5ml oral suspension. Take 7.5ml twice a day for 7 days. Supply 140 ml. NHS Cost 11.16 Licensed use: yes Patient Information: Discard any remaining medicine safely.
Clarithromycin suspension: 250mg twice a day

Age from 10 years to 11 years 11 months Clarithromycin 250mg/5ml oral suspension. Take one 5ml spoonful twice a day for 7 days. Supply 70 ml. NHS Cost 11.16 Licensed use: yes
Clarithromycin tablets: 500mg twice a day

Age from 12 years onwards Clarithromycin 500mg tablets. Take one tablet twice a day for 7 days. Supply 14 tablets. NHS Cost 16.06 Licensed use: yes
Exposure to water: add on antibiotics Salt water: add doxycycline 100mg once a day
Age from 12 years onwards Doxycycline 100mg capsules. Take TWO capsules now and then take ONE capsule once a day for the next 6 days. Supply 8 capsules. NHS Cost 2.25 Licensed use: yes Patient Information: Take doxycycline capsules during a meal. Swallow capsules whole with plenty of fluid while sitting or standing. Do not sunbathe or use sunlamps while taking this medicine.
Fresh water: add ciprofloxacin 750mg twice a day

Age from 18 years onwards Ciprofloxacin 750mg tablets. Take one tablet twice a day for 7 days. Supply 14 tablets. NHS Cost 4.86 Licensed use: no Patient Information: Tell the doctor if you are taking any other medicines.
Facial involvement: co-amoxiclav for 7 days Co-amoxiclav s/f suspension: 125/31mg three times a day
Age from 1 year to 6 years 11 months Co-amoxiclav 125mg/31mg/5ml oral suspension sugar free. Take one 5ml spoonful three times a day for 7 days. Supply 100 ml. NHS Cost 5.73 Licensed use: yes
Co-amoxiclav s/f suspension: 250/62mg three times a day

Age from 7 years to 11 years 11 months Co-amoxiclav 250mg/62mg/5ml oral suspension sugar free. Take one 5ml spoonful three times a day for 7 days. Supply 100 ml. NHS Cost 7.44 Licensed use: yes
Co-amoxiclav tablets: 500/125mg three times a day

Age from 12 years onwards Co-amoxiclav 500mg/125mg tablets. Take one tablet three times a day for 7 days. Supply 21 tablets. NHS Cost 13.27 Licensed use: yes
Drug rationale
Drugs not included
Clindamycin is effective against both streptococci and staphylococci, and has good tissue penetration. Although some experts recommend its use for cellulitis treatment, it is not included here as a first-line antibiotic in primary care because of the associated increased risk of antibiotic-associated colitis. In addition, there may be dissociated resistance with erythromycin-resistant bacteria. Phenoxymethylpenicillin is active against beta-haemolytic streptococci, however, empirical treatment should also ideally cover Staphylococcus aureus. Macrolide antibiotics other than erythromycin and clarithromycin are not recommended as there are concerns about increasing resistance. Topical antibiotics are not recommended for the treatment of cellulitis.
Drugs included
Antibiotics
Flucloxacillin is active against both streptococci and staphylococci, which are the common micro-organisms implicated in cellulitis. Erythromycin is active against both streptococci and staphylococci and is recommended as an alternative to flucloxacillin for people who are allergic to penicillins. Clarithromycin may be used instead in people who are known not to tolerate erythromycin. Note: up to 20% of Staphylococcus aureus and Streptococcus pyogenes organisms are resistant to erythromycin, and there may be cross-class resistance with other macrolides. Co-amoxiclav is a broad-spectrum antibiotic with activity against both streptococci and staphylococci. Its use should be limited to people with facial involvement, or people who have developed cellulitis after an animal or human bite. Doxycycline is active against Vibrio vulnificus, which may complicate cellulitis resulting from a wound exposed to salt water, and should be added to the antibiotic regimen when this is suspected. Ciprofloxacin is active against Aeromonas species, which may complicate cellulitis resulting from a wound exposed to fresh water, and should be added to the antibiotic regimen when this is suspected.
Analgesia
Paracetamol is an effective and safe analgesic with few gastrointestinal adverse effects. Ibuprofen is included as an alternative to paracetamol.
Shared decision making

Cellulitis is an infection of the skin and underlying tissues. A course of antibiotics will usually clear the infection. See a doctor if the symptoms do not ease soon after starting antibiotics. Paracetamol or ibuprofen will help to ease pain and reduce fever. If possible, keep the infected area raised as much as you can, in order to reduce swelling and pain, meaning that o If you have cellulitis of the leg, keep the leg elevated when you are resting. o If the cellulitis is in the forearm or hand, a high sling may help. Do you have athlete's foot (a common cause of cellulitis of the leg) which may need treatment? Use a moisturiser cream to keep the skin supple and moist as the infection clears and the skin begins to heal.
Which therapy?
Ensure that the acute episode of cellulitis has been adequately treated with antibiotics, rest, and elevation, as appropriate, before preventative strategies are employed.
Encourage people to report any recurrent symptoms early, so that further episodes of cellulitis can be treated quickly and effectively (see scenario Acute cellulitis). Treat predisposing conditions: o Reduce leg swelling and lymphoedema (limb elevation, calf-muscle exercises, and support stockings may be helpful). o Treat tinea pedis, dermatitis, and ulcers. o Optimize glycaemic control in people with diabetes mellitus. o Advise weight reduction in people who are overweight. o Manage any alcohol excess or drug misuse. Advise people to minimize injury to the skin. For people with risk factors who have had at least two previous episodes of cellulitis at the same site, long-term prophylactic antibiotic treatment may be appropriate seek specialist advice. Assess and encourage compliance with the agreed management plan and followup.
Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org). Compression stockings: adequate arterial circulation should be ensured by Doppler assessment before compression stockings are prescribed.
Should I refer or investigate?

Refer?
Consider specialist referral if the person has: o A treatable predisposing condition that is not responding to primary care management (e.g. persistent tinea pedis, dermatitis, leg ulcer). o Risk factors for developing cellulitis (chronic oedema, obesity, immunocompromised, intravenous drug misuser) and at least two previous episodes of cellulitis at the same site, as prophylactic antibiotics may be appropriate. o Recurrent cellulitis that is not responding to prophylactic antibiotics.
Investigate?
If recurrent cellulitis, check fasting blood glucose to exclude diabetes mellitus.
Follow-up advice
Arrange regular review for people taking prophylactic antibiotics, to assess compliance, to monitor for adverse effects, and to evaluate the effectiveness of the treatment.
Prescriptions
Class II below-knee stockings Class II knee-length stockings
Age from 18 years onwards Compression hosiery class II below knee stocking circular knit standard stock size. One pair of circular knit, knee length class II compression stockings to be measured and fitted in the pharmacy. Supply 2 single stockings. NHS Cost 9.37 Licensed use: no Patient Information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class III below-knee stockings Class III knee-length stockings

Age from 18 years onwards Compression hosiery class III below knee stocking circular knit standard stock size. One pair of circular knit, knee length class III compression stockings to be measured and fitted in the pharmacy. Supply 2 single stockings.
NHS Cost 10.63 Licensed use: no Patient Information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Drug rationale
Drugs not included
Prophylactic antibiotics are not offered for initiation in primary care. Evidence supporting their use is inconsistent and of poor quality. We recommend seeking specialist advice if prophylactic antibiotics are being considered. Class I (light) support stockings are not offered. Greater support is required for the management of oedema.
Drugs included
Class II (medium) support stockings and Class III (strong) support stockings are offered to reduce lymphoedema and leg swelling, although there is no direct evidence that this reduces the rate of recurrence of cellulitis.
Shared decision making

Recurring bouts of cellulitis may be due to an underlying problem which may need treatment, such as: o Swollen legs (which may be helped by elevation, calf-muscle exercises, and support stockings) o Athlete's foot o Skin ulcers or eczema o Diabetes o Obesity o Alcohol or drug misuse As much as possible, try not to injure or cut the skin. In some cases where the cellulitis recurs, an option is to take antibiotics every day to prevent the cellulitis from returning.
Detailed knowledge about this topic

Goals and outcome measures
Goals
To To To To alleviate symptoms cure infection minimize the risk of complications minimize the risk of recurrence
Outcome measures
Clinical cure rate: resolution at 14 days Recurrence rate: absence of relapse by 28 days
[Hepburn et al, 2004]
Background information
What is it?
Cellulitis and erysipelas are caused by an acute spreading infection of the skin. o In cellulitis, the infection involves the dermis and subcutaneous tissues. o In erysipelas, the infection is more superficial, involving the dermis and upper subcutaneous tissues. o In practice it is difficult to tell how deep the skin involvement is, and therefore to differentiate between cellulitis and erysipelas. Cellulitis is usually caused by infection with beta-haemolytic streptococci (80% of isolated organisms) or Staphylococcus aureus. Erysipelas is usually due to infection with group A, group C, or group G streptococci [Jones, 2002].
Less commonly, other organisms may be implicated (see Table 1). There is often a history of skin abrasion or trauma, which allows a portal for entry for infection. Recurrent cellulitis is often defined as at least two previous episodes of cellulitis [Kremer et al, 1991].
Table 1. Likely micro-organisms implicated in specific presentations of cellulitis.
Presentation
Infant under the age of 3 months Lymphatic or venous insufficiency Facial cellulitis in a child under the age of 2 years Perianal cellulitis (mainly in young children) Cellulitis secondary to otitis externa Immunocompromised
Micro-organisms
Group B streptococcus Non-group-A streptococci Haemophilus influenzae type B (now rare since implementation of the national Haemophilus B vaccination programme) Group A streptococcus Usually Staphylococcus aureus, consider Pseudomonas aeruginosa in people with diabetes A wide range of opportunistic bacteria including gram negative bacilli (e.g. Pseudomonas, Proteus, Enterobacter) anaerobes, and fungi (e.g. Cryptococcus). Infection may be polymicrobial Escherichia coli Pasteurella multocida (but often polymicrobial, including anaerobes and S aureus) Eikenella corrodens, anaerobes S aureus or streptococci (groups A, C, F, G) but may be polymicrobial, including enterobacteria and anaerobes such as Bacteroides fragilis, peptostreptococci, and peptococci Vibrio vulnificus Aeromonas species Upper respiratory pathogens, including Group B streptococcus, Moraxella catarrhalis, and non-typeable Haemophilus influenzae S aureus is more likely to be implicated if there is a history of trauma S aureus
Nephrotic syndrome Animal bite Human bite Intravenous drug misuser
Sea water injury Freshwater injury Periorbital cellulitis
Cellulitis complicating body piercing (e.g. ear, nose, umbilicus) Puncture wound to the foot
Adapted from [Jones, 2002] and [Swartz, 2004]
S aureus or streptococci, rarely P aeruginosa
How common is it?

There are few published data on the incidence of cellulitis, but it is thought to be common. A GP with a list size of 2000 people will have about 30 consultations for 'cellulitis and abscess' each year [McCormick et al, 1995]. Many more people probably present to Accident and Emergency departments. In 20032004 cellulitis or erysipelas accounted for approximately 49,500 hospital admissions in England (0.4%) [Hospital Episode Statistics, 2004]. The consultation rate rises with increasing age [McCormick et al, 1995]. The leg is the site most commonly affected by cellulitis, accounting for up to 75% of hospital admissions for cellulitis [Bishara et al, 2001; DTB, 2003].
How do I know my patient has it?

Clinical features
Cellulitis is characterized by initial flu-like symptoms (e.g. fever and shivering) which last for a few hours, followed by redness, heat, swelling, and pain or tenderness of the affected skin. It most commonly affects the leg, and has an indistinct edge and an advancing border. Erysipelas typically has a well-demarcated, elevated border and an indurated appearance, and typically affects the leg or the face. However, in practice, it may be difficult to distinguish between erysipelas and cellulitis. Infection is usually unilateral, unless it is on the face, when it is typically symmetrical, spreading from the paranasal area to the cheeks. There is often an identifiable portal of entry for infection (e.g. tinea pedis, wound, ulcer). The person may be systemically unwell, with fever, malaise, rigors, and vomiting. There may be associated lymphadenopathy and lymphangitis (red streaking of the skin spreading proximally from the area of cellulitis). Facial cellulitis is more likely to develop in children. It is typically unilateral and may be associated with upper respiratory tract infection [Hay and Adriaans, 2004]. Perianal cellulitis also mainly occurs in young children. It commonly presents with pruritus ani, purulent secretions, and rectal bleeding [Swartz, 2004]. Periorbital cellulitis is characterized by acute eyelid erythema and oedema, sometimes with associated pain, conjunctivitis, and excessive eye watering and blurred vision [Sobol, 2004].
Investigations
Investigations are generally not helpful in diagnosing cellulitis, as this should be based on clinical findings. See How should the person be managed if not admitted? for investigations that may be useful in the management of cellulitis.
What are the risk factors for developing cellulitis?

Portals of entry for infection
Skin trauma, lacerations, puncture wounds, human or animal bites Underlying skin lesions, e.g. furuncles, ulcers, dermatitis, tinea pedis [Dupuy et al, 1999; Roujeau et al, 2004]
Predisposing factors
Previous history of cellulitis Venous insufficiency Chronic dependent oedema and lymphoedema (swelling due to obstruction of lymphatic channels) [Dupuy et al, 1999; Hay and Adriaans, 2004] Damaged lymphatic system (e.g. postsaphenous venectomy for coronary artery bypass grafting, post-mastectomy) Obesity Immunosuppression, including malignancy, HIV/AIDS, and corticosteroid use Intravenous drug misuse (the prevalence of soft-tissue infections was estimated to be between 21% and 32% in one study) [Takahashi et al, 2003] Diabetes mellitus: known to be a predisposing factor for malignant otitis externa, but its role in other forms of cellulitis is debatable [Wang et al, 1997; Dupuy et al, 1999; Kilburn et al, 2003; Roujeau et al, 2004] Alcohol misuse, although this is contentious [Dupuy et al, 1999; Kilburn et al, 2003]
What else might it be?

Insect bite Deep vein thrombosis Superficial thrombophlebitis Lymphoedema Chronic venous insufficiency Varicose eczema Contact dermatitis Vasculitis Gout Septic arthritis/osteomyelitis Severe ischaemia/compartment syndrome Eosinophilic cellulitis (non-infective) Erythema nodosum
Fixed drug reaction Plant toxin allergy Sarcoidosis (very rare) Cutaneous metastases (very rare)
Complications and prognosis

Complications
The complications of cellulitis can be serious and, occasionally, life-threatening. Such complications may result from spread of infection via lymphatics or blood.
Early complications
Septicaemia/bacteraemia Lymphangitis/thrombophlebitis Abscess formation (e.g. orbital cellulitis may progress to form a subperiosteal, orbital, or cerebral abscess) Cavernous sinus thrombosis or meningitis (from spread of orbital cellulitis) Osteomyelitis/compartment syndrome Infective endocarditis Toxin-mediated disease (toxic shock syndrome/scalded skin syndrome) Myositis Necrotizing fasciitis
Late complications
Lymphoedema o Damage to the lymphatic drainage system may be subclinical or may cause symptomatic lymphoedema with chronic leg oedema [Cox et al, 1998]. o Up to 7% of people will develop chronic oedema after an episode of leg cellulitis [DTB, 2003]. o Lymphoedema predisposes to further episodes of cellulitis. Streptococcal nephritis (rare).
Prognosis
If treated promptly and effectively, most people recover completely. o In one hospital-based study, 98% of people made a good recovery [Hepburn et al, 2004]. Recurrence is common: o Over 25% of people admitted to hospital with cellulitis have recurrent episodes [Cox et al, 1998; Baddour, 2000]. o One study found that 29% of people with erysipelas had a recurrence within 3 years [Jorup-Ronstrom and Britton, 1987].
Management issues
Overview of management
Consider whether admission is necessary (see Who should be admitted to hospital?) If managed at home: Consider taking swabs for culture and sensitivity when there is broken skin or an obvious portal for microbial entry. Prescribe an analgesic (e.g. paracetamol) if required, to provide pain relief and reduce fever. Prescribe an antibiotic, taking into account the site of infection and the likely causative organism (see Which oral antibiotic should I prescribe?). Advise elevation of the affected area, if possible, to reduce swelling and pain. Manage underlying predisposing factors, e.g. tinea pedis (see the CKS topic on Fungal (dermatophyte) skin infections). Review within 48 hours, earlier if symptoms worsen rapidly or if oral treatment is not tolerated (e.g. due to vomiting). If symptoms are not responding or are deteriorating with oral antibiotics, consider admission.
Who should be admitted to hospital?

People who have no signs of systemic toxicity and no uncontrolled comorbidities can usually be managed in primary care. Consider urgent hospital admission for intravenous antibiotics if: o Severe or rapidly worsening infection o Systemic illness or vomiting o Suspected orbital or periorbital cellulitis (admit urgently for ophthalmology assessment if there is decreased ocular motility or decreased visual acuity) o Facial cellulitis in a child maintain a low threshold for hospital admission and ensure that regular monitoring is in place if managed at home o Evidence of complications (see Complications and prognosis) o Immunocompromised o Diabetes mellitus admission may not be necessary if diabetes is stable, but maintain a low threshold for hospital admission and ensure that regular monitoring is in place if managed at home o Significant comorbidity (e.g. heart failure, renal failure) o Neonate or child aged under 1 year o Lack of home support, frail people, or people with memory impairment o Not responding to initial treatment
How should the person be managed if not admitted?

Investigations are generally not helpful in the management of cellulitis. o Swabs from intact skin are of no value as they are frequently contaminated and provide a poor yield of pathogens [Jones, 2002]. o Swabs of broken skin or of an obvious portal for microbial entry are recommended by some experts [CREST, 2005]. This may help guide antibiotic choice if empirical treatment fails, and should be done before commencing empirical treatment. The yield is often poor, however, with pathogens isolated from only 25% of swabs in some studies [Swartz, 1995; Bishara et al, 2001]. o Radiological investigation is indicated if any of the following are suspected: Underlying osteomyelitis (e.g. rapid onset of pain, systemic illness, significant skin ulceration, palpable bone at the base of an ulcer) Foreign body Necrotizing fasciitis o Blood cultures and needle aspiration of tissue fluid may be helpful if cellulitis is severe or refractory to treatment, but these are rarely useful in primary care [Leppard et al, 1985; Jones, 2002]. Advise rest and elevation of the affected area, if possible, to reduce swelling and pain. Drawing around the margins of the erythematous area with a permanent marker may be useful for monitoring spread or regression of infection [Baxter and McGregor, 2001]. Prescribe an analgesic (e.g. paracetamol) if required, to provide pain relief and reduce fever. Prescribe an antibiotic, taking into account the site of infection and the likely causative micro-organism (see Which oral antibiotic should I prescribe?). o For people who are managed in primary care, oral antibiotics are usually appropriate for the management of cellulitis. o In some areas, outpatient parenteral antibiotic therapy (OPAT) services are available for the management of people with systemic symptoms or comorbidities. Refer to local protocols where these services are available. Manage underlying predisposing factors (see What are the risk factors for developing cellulitis?). The management of tinea pedis and venous leg ulcer is covered in separate CKS topics on Fungal (dermatophyte) skin infections and Leg ulcer venous. If cellulitis is secondary to a puncture wound or laceration, assess tetanus risk and status (see the CKS topic on Lacerations). Consider the use of an emollient to keep the skin well hydrated as the infection resolves and skin begins to heal [Baxter and McGregor, 2001]. However, there is no evidence that this helps resolution or reduces recurrence. In some instances cellulitis may lead to skin blistering and subsequent breakdown of the skin.
Do not aspirate or deroof blisters routinely, as this creates another potential entry site for infection [Baxter and McGregor, 2001]. o Aseptic aspiration or deroofing may be appropriate if it is felt likely that the blisters will burst spontaneously [CREST, 2005]. Do not prescribe topical antibiotics [CREST, 2005]. There is no published evidence to support their use, and widespread use is likely to increase antibiotic resistance. There is no evidence to support the use of hot moist soaks or of potassium permanganate [DTB, 2003].
Which oral antibiotic should I prescribe?

There is little evidence to guide the choice of antibiotic in the treatment of cellulitis. Most trials comparing antibiotics have been small, inconclusive, and often hospital-based [DTB, 2003; Morris, 2004]. Choice of antibiotic is usually empirical, guided by the anatomical location of the cellulitis and the history of exposure (see Table 2). Local patterns of antibiotic resistance should also be considered. For most people with cellulitis, the chosen antibiotic should cover beta-haemolytic streptococci and Staphylococcus aureus. o Flucloxacillin is an appropriate first-line antibiotic [CREST, 2005]. We recommend using flucloxacillin alone, without the addition of phenoxymethylpenicillin (as advocated by some authorities). In sufficient dosage, flucloxacillin covers both beta-haemolytic streptococci and penicillinase-resistant staphylococci [Jones, 2002; CREST, 2005]. o Erythromycin is recommended for people who are allergic to penicillin. Clarithromycin is an alternative for people who cannot tolerate erythromycin. Note: up to 20% of Staphylococcus aureus and Streptococcus pyogenes organisms are resistant to erythromycin, and there may be cross-class resistance with other macrolides. Make sure that the person is reviewed within 48 hours to check that the infection is responding to treatment, and that they are aware of the need for earlier review if their symptoms worsen significantly. o Clindamycin is recommended as an alternative by some experts. Clindamycin has good soft-tissue penetration, and suppresses streptococcal toxin production. Its use has been limited by concern about antibiotic-associated colitis although in practice this may not be common, it is potentially fatal. Clindamycin often shows dissociated resistance it may appear sensitive in vitro but if the strain is erythromycin-resistant, resistance to clindamycin may be induced in vivo. If there has been exposure to salt water at the site of the skin break, add doxycycline to the antibiotic regimen to cover the possibility of infection with Vibrio vulnificus [Swartz, 2004]. If a tetracycline cannot be used (e.g. in children under 12 years, pregnant women, or breastfeeding women), seek advice from the local microbiologist. If there has been exposure to fresh water at the site of the skin break, add ciprofloxacin to the antibiotic regimen to cover the possibility of infection with Aeromonas species [Swartz, 2004; CREST, 2005]. If a quinolone cannot be used (e.g. in children and growing adolescents, pregnant women, or breastfeeding women), seek advice from the local microbiologist. In facial cellulitis, co-amoxiclav is recommended to cover organisms from the mouth and sinuses [HPA, 2003]. If facial cellulitis is secondary to a superficial abrasion on the face distal to the mouth, flucloxacillin should be sufficient. If the person is allergic to penicillin, discuss a suitable alternative with the local microbiologist. Intravenous drug users (IVDUs): if the cellulitis is mild and the person is systemically well, treat with oral flucloxacillin. o If there is groin involvement or crepitant cellulitis, if the cellulitis is spreading rapidly, or if the person has an abscess or is systemically unwell, admit for intravenous antibiotics. If the person refuses admission, seek local microbiology advice regarding the appropriate choice of antibiotic. For cellulitis arising from a human or animal bite, co-amoxiclav is the recommended first-line antibiotic. For people allergic to penicillin: o Animal bite: oxytetracycline or doxycycline plus metronidazole is recommended. If a tetracycline cannot be used (e.g. in children under 12 years, pregnant women, or breastfeeding women), seek advice from the local microbiologist.
o o
Human bite: erythromycin (or clarithromycin) plus metronidazole is recommended. See the CKS topic on Bites human and animal for further information.
[Jones, 2002; HPA, 2003; CREST, 2005] Table 2. Recommended antibiotics for treating uncomplicated cellulitis in primary care.
Presentation
Typical cellulitis Sea water injury Freshwater injury Facial cellulitis Animal bites Human bites
Antibiotic
Flucloxacillin Add doxycycline* Add ciprofloxacin Co-amoxiclav Co-amoxiclav Co-amoxiclav
Penicillin allergy
Erythromycin or clarithromycin Add doxycycline* Add ciprofloxacin Seek advice from local microbiologist Doxycycline* + metronidazole Erythromycin or clarithromycin + metronidazole
* Avoid doxycycline in children under 12 years of age, and in women who are pregnant or breastfeeding. Avoid ciprofloxacin in children and growing adolescents, and in women who are pregnant or breastfeeding.
What dose of antibiotic is recommended?

When treating cellulitis it is necessary to prescribe doses high enough to ensure adequate tissue penetration. o For adults this is equivalent to flucloxacillin 500 mg four times a day, erythromycin 500 mg four times a day, or clarithromycin 500 mg twice a day. When co-amoxiclav is prescribed, some experts recommend using amoxicillin-boosted co-amoxiclav (e.g. co-amoxiclav 375 mg plus amoxicillin 500 mg) which means that there is a greater beta-lactam component without the adverse effects associated with clavulanic acid. Formulations are available which contain higher concentrations of amoxicillin and these are recommended where available.
How long should I prescribe an antibiotic for?

There is lack of consensus regarding the optimal duration of antibiotic treatment. Most of the studies have used 710 days of antibiotic treatment [Morris, 2004]. We recommend treatment for 7 days initially. If symptoms have not fully resolved after 7 days of treatment, consider continuing the antibiotic for up to a further 7 days, depending on the severity of infection and the speed of response to treatment. o Mild infection usually responds to 7 days of oral antibiotics [Jones, 2002]. o More severe infections may require 10 days or more, to ensure complete resolution [Jones, 2002]. o One randomized controlled trial suggested that if a person seems to be responding to antibiotic treatment after 5 days, continuing the treatment may not provide any additional benefit [Hepburn et al, 2004]. However, the trial drug was levofloxacin, which is not commonly used in the UK for the treatment of cellulitis, and 14% of people initially received intravenous antibiotics. More evidence is required before short-course antibiotic treatment can be recommended.
What follow-up is necessary?

Review within 48 hours, to ensure a satisfactory response to treatment [Williams and Luggen, 2004]. Advise earlier review if the person becomes systemically unwell, if they cannot tolerate oral treatment (e.g. due to vomiting), or if symptoms worsen rapidly. There may be an increase in erythema in the first 2448 hours of treatment, possibly related to toxin release [CREST, 2005]. This is of no importance, providing there are no other features to suggest deterioration. If symptoms are not responding or are deteriorating, consider hospital admission. Assess and encourage compliance with antibiotics and other treatments at all stages.
How do I manage people with recurrent cellulitis?

Management of the acute presentation of cellulitis is the same, whether it is the first episode or a recurrent episode (see How should the person be managed if not admitted?).
Check for predisposing factors for recurrent infection and check fasting blood glucose to exclude diabetes mellitus. Treat predisposing conditions, such as chronic oedema, lymphoedema, obesity, and tinea pedis (see What are the risk factors for developing cellulitis?). Consensus opinion is that treating predisposing conditions reduces the risk of recurrence. However, there are no randomized controlled trials to support this view [Morris, 2004], and one observational study suggests that there may be little difference in recurrence rates between people with predisposing conditions and those without [Wang et al, 1997].
Skin care
Advise people to avoid injury to the skin, as the skin remains friable and sensitive for several weeks after an episode of cellulitis. Treat local skin damage (e.g. skin ulcers) to prevent re-entry of infection [Roujeau et al, 2004]. Treat tinea pedis, if present (see the CKS topic on Fungal (dermatophyte) skin infections). For people with diabetes, assess for peripheral pulses and neuropathy, and inspect footwear. Arrange podiatry or orthotics input if required (see the CKS topic on Diabetes Type 1 and 2 foot disease).
Minimizing chronic oedema

Treat chronic oedema, as this may reduce the risk of recurrent cellulitis [Butcher et al, 2003; Stalbow, 2004]. Limb elevation, calf-muscle exercises, and support stockings help to reduce leg swelling and lymphoedema [Hofman, 1998; Baddour, 2000; Baxter and McGregor, 2001; Stalbow, 2004; Swartz, 2004]. We found no direct evidence that these measures reduce the risk of recurrent cellulitis, but it would seem sensible to encourage these practices in people with chronic oedema.
Prophylactic antibiotics
We recommend seeking specialist advice before starting long-term antibiotics. It is not known whether prophylactic antibiotics reduce the risk of recurrence of cellulitis. Published studies are of small size and poor quality, and provide conflicting results [Kremer et al, 1991; Sjblom et al, 1993; Wang et al, 1997]. Some experts advocate prophylactic antibiotics for high-risk groups (often defined as those who have had at least two previous episodes of cellulitis at the same site) [Kremer et al, 1991; DTB, 2003; CREST, 2005].
Medicines management
Flucloxacillin
Flucloxacillin has been associated with an increased risk of hepatic disorders, namely hepatitis and cholestatic jaundice. The Committee on Safety of Medicines (CSM) advises that hepatic reactions may occur up to 2 months after treatment with flucloxacillin has stopped. Risk factors include treatment for more than 14 days and increasing age. The dose and route of administration do not appear to affect this risk.
Co-amoxiclav
Cholestatic jaundice may rarely occur during or shortly after the use of coamoxiclav [CSM, 1997]. This is more common in men, in people over the age of 65 years, and with longer courses of treatment (over 14 days).
Macrolides
Erythromycin commonly causes gastrointestinal adverse effects, especially at higher doses. If this is known to occur, consider prescribing clarithromycin instead. Erythromycin and clarithromycin can increase the levels of certain other drugs (e.g. theophylline, carbamazepine) and can potentiate the effects of warfarin. If erythromycin or clarithromycin are taken with a statin, there is an increased risk of myopathy.
Doxycycline
Doxycycline should not be used in pregnancy, during breastfeeding, or in children under 12 years of age, as it is deposited in the teeth and bones of the unborn or developing child. Women of childbearing age should use effective contraception. (Note that tetracyclines may cause oral contraceptives to fail during the first few weeks of treatment and women should be advised to use additional contraception during the course and for at least 7 days afterwards. If the 7 days run
beyond the end of the packet, a new packet should be started without a break, omitting any of the inactive tablets [Stockley, 2002].) Benign intracranial hypertension is a rare but important adverse effect of tetracyclines. If a person taking a tetracycline develops headache and visual disturbances, the tetracycline should be stopped. Doxycycline may cause photosensitivity reactions: advise the person to avoid exposure to direct sunlight or to sunlamps.
Ciprofloxacin
Quinolones can rarely cause tendon damage. The CSM advises that treatment should be stopped if a tendon becomes painful or inflamed [CSM, 2002]. Avoid using ciprofloxacin in children and growing adolescents, as quinolones have been shown to cause arthropathy in animals. Their use may be considered where clearly indicated, but discussion of the alternatives with the local microbiologist is recommended. Avoid using ciprofloxacin in people with epilepsy or conditions that predispose to seizures, and in people taking other medication that may predispose to seizures, as quinolones can lower the seizure threshold. The CSM warns that, rarely, seizures have occurred in people without a previous history of seizures; concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) or theophylline may increase this risk [CSM, 1991]. Avoid using ciprofloxacin in pregnant women and in breastfeeding women. Women of childbearing age should use effective contraception.
[BNF 49, 2005]
NSAIDs
A number of case reports have suggested a possible association between the use of NSAIDs and the development of necrotizing fasciitis. However, a causal relationship has not been established and, on the basis of the available information, we do not recommend withholding NSAIDs in people with cellulitis [Holder et al, 1997].
Compression hosiery
Three different classes of stocking or graduated support stockings are available (see Table 3):
Table 3. Compression hosiery.
Class
I II
Type
Light Medium
Ankle compression
1417 mmHg 1824 mmHg
Indications
Superficial or early varices, varicosis during pregnancy Varices of medium severity, ulcer treatment and prophylaxis, mild oedema, postoperative prevention and treatment of DVT Severe varices, post-thrombotic venous insufficiency, severe oedema, ulcer treatment and prophylaxis
III
High
2535 mmHg
Medium to high support stockings are recommended for leg swelling and lymphoedema. A range of styles and colours are available to encourage compliance. Support stockings are available in two lengths, 'below the knee' and 'thigh' length. If compression hosiery products are prescribed, it is essential to check that the arterial circulation is not compromised. Such assessment would usually include measurement of the anklebrachial pressure index (ABPI) by Doppler (see the CKS topic on Leg ulcer venous): o ABPI less than 0.5: arterial ulcers are likely and compression treatment is contraindicated. o ABPI between 0.5 and 0.8: assume that the person has arterial disease. Compression in such instances may further compromise the arterial blood supply, and should generally be avoided. o ABPI greater than 0.8: graduated support stockings may be applied safely. o Note: arterial disease may develop in people with venous disease, and health professionals should be aware that the ABPI may drop after the initial measurement [Royal College of Nursing, 2000].
References
NHS staff in England can link, free of charge, from references to the full text journal articles by clicking on [NHS Athens Full-text]. You will need an NHS Athens password to access these resources. Click here for Athens registration. All references with links to [Free Full-text] are freely available online to users in England and Wales. This includes the full text of Department of Health papers and Cochrane Library reviews. 1 2 3 Baddour, L.M. (2000) Cellulitis syndromes: an update. International Journal of Antimicrobial Agents 14(2), 113-116. Baxter, H. and McGregor, F. (2001) Understanding and managing cellulitis. Nursing Standard 15(44), 50-56. [NHS Athens Full-text] Bishara, J., Golan-Cohen, A., Robenshtok, E. et al. (2001) Antibiotic use in patients with erysipelas: a retrospective study. Israel Medical Association Journal 3(10), 722-724. [Free Full-text] BNF 49 (2005) British National Formulary. 49th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. Butcher, W.B., Papworth, S.E., Parvin, S.D. and Darke, S.G. (2003) Eighty-five consecutive cases of cellulitis: clinical features, management and implications for hospital care. Podiatry Now 6(11), 26-29. Cox, N.H., Colver, G.B. and Paterson, W.D. (1998) Management and morbidity of cellulitis of the leg. Journal of the Royal Society of Medicine 91(12), 634-635. [Free Full-text] CREST (2005) Guidelines on the management of cellulitis in adults. Clinical Resource Efficiency Support Team. www.crestni.org.uk [Accessed: 01/08/2005]. [Free Full-text] CSM (1991) Convulsions due to quinolone antimicrobial agents. Current Problems in Pharmacovigilance 32(Oct), 2. [Free Full-text] CSM (1997) Revised indications for co-amoxiclav (Augmentin). Current Problems in Pharmacovigilance 23(May), 8. [Free Full-text] CSM (2002) Reminder: fluoroquinolone antibiotics and tendon disorders. Current Problems in Pharmacovigilance 28(Apr), 3-4. [Free Full-text] DTB (2003) Dilemmas when managing cellulitis. Drug & Therapeutics Bulletin 41(6), 43-46. Dupuy, A., Benchikhi, H., Roujeau, J.C. et al. (1999) Risk factors for erysipelas of the leg (cellulitis): case-control study. British Medical Journal 318(7198), 1591-1594. [Free Fulltext] Hay, R.J. and Adriaans, B.M. (2004) Bacterial infections. In: Burns, T., Breathnach, S., Cox, N. and Griffiths, C. (Eds.) Rook's textbook of dermatology. 7th edn. Oxford: Blackwell Science Ltd. Hepburn, M.J., Dooley, D.P., Skidmore, P.J. et al. (2004) Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Archives of Internal Medicine 164(15), 1669-1674. Hofman, D. (1998) Oedema and the management of venous ulcers. Journal of Wound Care 7(7), 345-348. Holder, E.P., Moore, P.T. and Browne, B.A. (1997) Nonsteroidal anti-inflammatory drugs and necrotising fasciitis. An update. Drug Safety 17(6), 369-373. Hospital Episode Statistics (2004) Hospital Episode Statistics - 2003/04. Department of Health. www.hesonline.nhs.uk [Accessed: 01/06/2007]. HPA (2003) Management of infection guidance for primary care: for consultation and local adaptation. Health Protection Agency. www.hpa.org.uk [Accessed: 26/02/2004]. Jones, G.R. (2002) Principles and practice of antibiotic therapy for cellulitis. CPD Journal Acute Medicine 1(2), 44-49. Jorup-Ronstrom, C. and Britton, S. (1987) Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection 15(2), 105-106. Kilburn, S., Featherstone, P., Higgins, B. et al. (2003) Interventions for cellulitis and erysipelas (Protocol for a Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 07/02/2007]. [Free Fulltext] Kremer, M., Zuckerman, R., Avraham, Z. and Raz, R. (1991) Long-term antimicrobial therapy in the prevention of recurrent soft-tissue infections. Journal of Infection 22(1), 3740. Leppard, B.J., Seal, D.V., Colman, G. and Hallas, G. (1985) The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. British Journal of Dermatology 112(5), 559-567. McCormick, A., Fleming, D. and Charlton, J. (1995) Morbidity statistics from general practice. Fourth national study 1991-1992. Office of Population Censuses and Surveys. www.statistics.gov.uk [Accessed: 30/05/2007]. [Free Full-text]
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Morris, A. (2004) Cellulitis and erysipelas. Clinical Evidence. Volume 12. www.clinicalevidence.com [Accessed: 01/03/2005]. Roujeau, J.C., Sigurgeirsson, B., Korting, H.C. et al. (2004) Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study. Dermatology 209(4), 301-307. [NHS Athens Full-text] Royal College of Nursing (2000) The management of patients with venous leg ulcers. Audit protocol. Royal College of Nursing. www.rcn.org.uk [Accessed: 07/02/2007]. [Free Full-text] Sjblom, A.C., Eriksson, B., Jorup-Ronstrom, C. et al. (1993) Antibiotic prophylaxis in recurrent erysipelas. Infection 21(6), 390-393. Sobol, A.L. (2004) Cellulitis, preseptal. eMedicine. eMedicine.com, Inc. www.emedicine.com [Accessed: 01/03/2005]. [Free Full-text] Stalbow, J. (2004) Preventing cellulitis in older people with persistent lower limb oedema. British Journal of Nursing 13(12), 725-732. [NHS Athens Full-text] Stockley, I.H. (Ed.) (2002) Drug interactions. 6th edn. London: The Pharmaceutical Press. Swartz, M.N. (1995) Cellulitis and subcutaneous tissue infections. In: Mandell, G.L., Bennett, J.E. and Dolin, R. (Eds.) Principles and practice of infectious diseases. 4th edn. London: Churchill Livingstone. 914-916. Swartz, M.N. (2004) Cellulitis. New England Journal of Medicine 350(9), 904-912. [NHS Athens Full-text] Takahashi, T.A., Merrill, J.O., Boyko, E.J. and Bradley, K.A. (2003) Type and location of injection drug use-related soft tissue infections predict hospitalization. Journal of Urban Health 80(1), 127-136. Wang, J.H., Liu, Y.C., Cheng, D.L. et al. (1997) Role of benzathine penicillin G in prophylaxis for recurrent streptococcal cellulitis of the lower legs. Clinical Infectious Diseases 25(3), 685-689. [Free Full-text] Williams, J.R. and Luggen, A.S. (2004) National Conference of Gerontological Nurse Practitioners. Gerontologic nurse practitioner care guidelines: cellulitis in the elderly person. Geriatric Nursing 25(6), 373-374.
Patient information
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Paracetamol s/f susp: 60mg to 120mg up to four times a day

Clinical Knowledge Summaries: Previous version Cellulitis

Paracetamol s/f susp: 120mg to 240mg up to four times a day

Paracetamol s/f susp: 250mg to 500mg up to four times a day

Paracetamol tablets: 500mg to 1g up to four times a day

Paracetamol tablets: 1g up to four times a day

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Ibuprofen s/f susp: 50mg three times a day

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Ibuprofen s/f susp: 100mg three times a day

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Ibuprofen s/f susp: 200mg three times a day

Ibuprofen s/f susp: 300mg three times a day

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Flucloxacillin syrup: 500mg four times a day

Flucloxacillin capsules: 500mg four times a day

Erythromycin s/f suspension: 250mg four times a day

Erythromycin s/f suspension: 500mg four times a day

Erythromycin e/c tablets: 500mg four times a day

Clarithromycin suspension: 62.5mg twice a day

Clarithromycin suspension: 125mg twice a day

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Clarithromycin suspension: 187.5mg twice a day

Clarithromycin suspension: 250mg twice a day

Clarithromycin tablets: 500mg twice a day

Fresh water: add ciprofloxacin 750mg twice a day

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Class III below-knee stockings Class III knee-length stockings

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Table 1. Likely micro-organisms implicated in specific presentations of cellulitis.

Nephrotic syndrome Animal bite Human bite Intravenous drug misuser

Sea water injury Freshwater injury Periorbital cellulitis

S aureus or streptococci, rarely P aeruginosa

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