Updated 3/31/2017

By: Wajidah Abdul-Khabir

PGY-2
 To properly diagnose cellulitis
 To know what treatment is appropriate
 To know when hospitalization is needed
 Cellulitis is a skin infection that develops as a
result of bacterial entry via breaches in the
skin barrier.
 Manifests as erythema, edema, and warmth.
 Predisposing factors include disruption to the
skin barrier as a result of trauma,
inflammation, preexisting skin infection (ie
tinea pedis), and edema.
 Most common pathogens are gram positive
beta-hemolytic Strep and Staph aureus,
including MRSA.
 Diagnosis is based upon clinical
manifestations.
 Cultures of blood, needle aspirations, or
punch biopsies are not routinely
recommended.
 Cultures of blood are recommended in
patients with malignancy on chemotherapy,
neutropenia, severe cell-mediated
immunodeficiency, immersion injuries, and
animal bites
 Determine if purulent will need to
perform incision and drainage +/- antibiotics

Nonpurulent determine if infection is

mild/moderate or severe
Mild: a typical infection
 Should receive an antimicrobial agent that is
active against streptococci

Moderate: typical cellulitis plus systemic signs

of infection (temperature >38C, HR>90, RR>
24 or WBC<400 or>12,000)
 Systemic antibiotics are indicated
Severe infection:
-Failed oral antibiotics OR
-Immunocompromised OR
-Patients with clinical signs of deeper infection
such as bullae, skin sloughing, hypotension,
or evidence of organ dysfunction
 Vancomycin plus either pipercillin-
tazobactam or imipenem/meropenem is
recommended as a reasonable empiric
regimen for severe infections.
When should Vancomycin be utilized?

 penetrating trauma
 evidence of MRSA infection elsewhere
 nasal colonization with MRSA
 injection drug use or SIRS
 Duration of antimicrobial treatment should be
at least 5 days, but treatment should be
extended if the infection has not improved
 Elevation of the affected area and treatment
of predisposing factors such as edema or
tinea pedis are recommended to prevent
recurrent infections
 Outpatient therapy is recommended for
patients who do not have SIRS, altered mental
status or hemodynamic instability.
 Hospitalization is recommended if there is
concern for a deeper or necrotizing infection,
for patients with poor adherence to therapy,
for infection in a severely
immunocompromised patient or if outpatient
treatment is failing.
 A 25 year old man is admitted to the hospital
for chills and fever of 3 days duration. He
reports that he injects heroin daily. Medical
history is notable for multiple methicillin-
resistant Staphlococcus aureus- associated
skin and soft tissue infections and for
vancomycin hypersensitivity, which causes
respiratory failure and hypotension. He takes
no medications.
 On physical examination, temperature is
39.4, blood pressure is 104/65, pulse rate is
110 and respiration rate is 20. A recent
injection site in the antecubital fossa is noted,
with erythema, tenderness to palpation and
warmth. He has no mucosal lesions or
lymphadenopathy. Cardiopulmonary
examination is normal. The remainder of the
examination is normal.
 Laboratory studies show a leukocyte count of
19,000 with 95% neutrophils. Multiple blood
cultures reveal gram positive cocci in clusters.
Findings on chest imaging and
electrocardiography are normal.
 Which of the following is the most
appropriate empiric antibiotic treatment for
this patient?
 A. Ceftriaxone
 B. Daptomycin
 C. Imipenem
 D. Nafcillin
 Cellulitis manifests as erythema, edema, and
warmth.
 Most common microbiological cause is gram
positive beta-hemolytic Strep and Staph aureus.
 Treatment depends on purulent vs nonpurulent
and mild vs moderate vs severe infection
 Hospitalization is recommended if there is
concern for a deeper or necrotizing infection, for
patients with poor adherence to therapy, for
infection in a severely immunocompromised
patient or if outpatient treatment is failing.
 Sources for update: 2014 IDSA Guidelines