Cellulitis
This clinical information sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with cellulitis.
It covers:
About Cellulitis; Assessment; Management; and Sources of Information.
The clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan Health professional’s role, knowledge, preferences and professional experience Policies and resources available within the RACF Requirements of local professional registration and regulatory bodies Relevant local legislation.
About Cellulitis
Skin and soft tissue infections, particularly cellulitis, account for 2.2% of visits to general practitioners [1] and are the third most common type of infection affecting the elderly, after urinary tract and respiratory infections [2].
Cellulitis is an acute inflammatory process involving the skin and soft tissues, which presents as a spreading erythematous rash (reddened area of the skin), fever and systemic toxicity [2, 3]. It may be associated with lymphangitis and lymphadenopathy (swelling of the lymph nodes). Streptococcus pyogenes and Staphylococcus aureus are the most common causative organisms.
Cellulitis is usually unilateral and most often affects the foot and lower leg, although it can affect any area of the body [1, 3, 4]. Cellulitis most commonly occurs near breaks in the skin, for example at the site of surgical wounds, tinea, ulcers or trauma [1, 4], with one study finding that 66% of cellulitis cases were related primarily to tinea [4]. Presence of lymphoedema has also been found to be a significant risk factor for development of cellulitis, occurring in approximately 19% of cellulitis cases [2-4, 6]. Erysipelas, a well demarcated superficial form of cellulitis, can occur on the face or lower legs and is usually caused by Streptococcus pyogenes [5].
Pathogens are identified in only a small proportion of people with cellulitis [3, 6, 7]. Incubation period is pathogen dependent, with cellulitis caused by Streptococcus usually developing quickly whilst Staphylococcus cellulitis generally has a delayed onset [6].
In diabetic or immunosuppressed patients, a wide variety of organisms including Gram-negative bacteria, fungi and mycobacteria may be responsible. In older adults with diabetes, unstable blood sugar levels, impaired immunity, poor vascular supply and peripheral neuropathy all contribute to high rates of ulcers with associated cellulitis [2, 4]. Diabetic ulcers are commonly polymicrobial and may be further complicated by underlying osteomyelitis [2].
Factors leading to poor outcomes in elderly patients with cellulitis include male gender, multiple co-morbidities and presence of shock [2, 4]. Mortality from cellulitis is rare (5% of cases) but may occur in cases caused by highly virulent organisms (eg, Pseudomonas aeruginosa) [6]. Risk of mortality from cellulitis increases in patients with significant co-morbidity (eg renal failure, CCF), those with severe complications (eg shock) and those for whom an appropriate management plan is not implemented [6].
Assessment
Diagnosis is predominately clinical. See Reference Card: Cellulitis Assessment.
Presenting clinical signs and symptoms are [1-4, 6]:
Patients who also exhibit the following signs and symptoms are more likely to have cellulitis related to bacteremia and/or be classified as having severe cellulitis requiring assessment in hospital [6, 7]:
A search for a portal of entry should be made to prevent possible recurrences. Look for an underlying condition such as tinea pedis, fissured dermatitis, lymphoedema, ulcer, wounds, insect bite or scabies.
Differential diagnosisThe following differential diagnoses should be considered in patients presenting with cellulitis [2, 3]:
Deep rapidly spreading soft tissue infections (eg necrotising fasciitis) are a medical emergency and may mimic cellulitis. Unfortunately they have no single consistent diagnostic feature. The following clinical features in the patient with “cellulitis” should prompt concern and may require transfer to hospital for assessment and management [2, 3]:
Pain at the site of infection out of proportion to clinical findings; History of inoculation of environmental water, dirt or other foreign body into traumatic wounds; Prominent systemic toxicity (hypotension, tachycardia), high fever; Presence of gas in the soft tissues (clinically or on x-ray); Clinical deterioration despite antibiotic therapy; Progressive skin necrosis; Foul smelling discharge; Bullous formation (also seen in cellulitis but should raise the possibility of more serious infection); Elevated CK indicating muscle destruction; and/or Hypocalcaemia.
Management
Good skin care, use of support stockings, and early treatment of tinea are important to prevent cellulitis & recurrences [3, 6].
The following non-pharmacological interventions are recommended to promote healing and patient comfort [1, 3, 6, 9]:
Elevation of the affected limb to reduce swelling; Immobilisation of the affected limb; Skin care, including application of a cool compress; Regular pain assessment and appropriate analgesia; Management of associated pressure ulcers according to the RACF wound management procedures; and Treatment of associated fungal infections (e.g. tinea) with a topical anti-fungal preparation.
Good skin care can assist in a faster recovery from cellulitis. Assess skin according to the RACF procedures and provide appropriate skin care. Where the cellulitis area has profuse exudate or is assessed as being at risk of skin breakdown, use a foam dressing [3]. When the cellulitis begins to improve, skin can become dry and cracked and can be treated with 50/50 white soft paraffin and liquid paraffin ointment [3].
Patients with cellulitis of the lower limbs are at risk of deep vein thrombosis due to swelling and immobility. The risk is increased for older patients, especially those with co-existing vascular disease. Consider prescribing heparin S/C for prophylaxis where there are no contraindications [3].
Oral antibiotics
Oral antibiotics are often adequate in mild cases where the disease is limited [1-3, 6, 9]. If Streptococcus pyogenes is suspected or confirmed, treat for 10 days as 5 days therapy does not eradicate streptococci [5].
Mild Cellulitis
To cover Staphylococcus aureus and Streptococcus pyogenes use [2, 3, 5, 9]:
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Di / flucloxacillin 500mg orally, 6-hourly for 7 to 10 days
For patients hypersensitive to penicillin (excluding immediate hypersensitivity) use:
Cephalexin 500mg orally, 6 hourly for 7 to 10 days
For patients with immediate penicillin hypersensitivity use:
Clindamycin 300-450mg orally, 8-hourly for 7 to 10 days
Watch for diarrhoea (due to Cl. Difficile) which may be caused by clindamycin.
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Cellulitis and diabetic foot ulcers
Cellulitis complicating diabetic ulcers requires a multidisciplinary approach, involving assessments of the ulcer, diabetic control, vascular supply and degree of neuropathy. Broad spectrum antibiotics are usually indicated [2, 9].
IV antibiotics
More severe and extensive cellulitis requires intravenous therapy [1, 6]. Patients who are likely to require transfer to an acute care facility for management with intravenous antibiotics include [2]:
Those exhibiting signs and symptoms of severe cellulitis (see Assessment); Those with clinical features suggestive of deep rapidly spreading soft tissue infection; Those with facial cellulitis (to minimise risk of spread to orbit/intracranial venous sinuses); Severely immunocompromised patients and/or those with unstable diabetes; Those with significant local factors that may slow resolution of the infection. (eg ulcers, lymphoedema); and Those for whom treatment with oral antibiotics has not been successful.
IV treatment in Hospital
Treatment for patients with severe cellulitis requiring hospitalisation targets both Streptococci and Staphylococci. In general therapy consists of Di/flucloxacillin 2g IV, 6-hourly, unless the patient has a penicillin allergy.
For patients with mild penicillin allergy treatment regime is generally Cephazolin 1g IV, 8-hourly.
Patients with severe penicillin hypersensitivity are treated with a variety of regimes including Clindamycin 300-450 mg IV, 8-hourlyTHEN clindamycin 300-450 mg orally, 8-hourly; or Lincomycin 600 mg IV, 8-hourlyTHEN clindamycin 300-450 mg orally, 8-hourly; OR Vancomycin 1g IV, 12-hourly[2, 5, 6].
IV treatment in the RACF
Some residents may receive IV antibiotic treatment at the RACF, through a Hospital in the Home service. Intravenous home-based therapy used in suitable patients, include:
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Cephazolin 2g IV, 12-hourly [5, 9, 10], OR
Cephazolin 2g IV, daily PLUS Probenecid 1g orally, daily [5, 11], OR
Flucloxacillin 8g/day as a continuous infusion [5]; OR
Ceftriaxone 1mg IV, daily [8].
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These regimes are selected for their convenience. Clinical trial results suggest equivalence to conventional dosing regimens in most patients. However they may not be adequate for more severe infection, or in patients with multiple co-morbidities. Daily ceftriaxone is broader spectrum than routinely required (where Staphylococcus and Streptococcusare likely) but is used by some services for its convenience. Patients on these regimens should be assessed daily for evidence of response to therapy [1]. Probenecid is associated with significant nausea and HITH programs using it routinely prescribe antiemetics.
For further information on Hospital in the Home services see the Reference Card: Hospital in the Home IV Antibiotic Therapy, with the Urinary Tract Infection Clinical Information Sheet. Contact your local public hospital to establish Hospital in the Home availability and referral procedures.
Duration of therapy
The duration of therapy is determined by the clinical response. Intravenous treatment usually lasts 4 to 7 days. Signs and symptoms of improvement that indicates intravenous therapy can be ceased include [3]:
Patients should be reviewed daily by the general practitioner and switched to oral therapy when signs and symptoms suggest significant improvement. The rash may not improve substantially, and may even worsen slightly, in the first 48 hours of antibiotic treatment. Advanced age, pre-existing oedema or ischaemia of the infected area are associated with slow clinical response. Cellulitis is often a 3-week illness in the elderly. In a patient with normal immune status who is otherwise improving, it is appropriate to continue with the initial antibiotics [2].
Oral antibiotics should be continued until 3 to 5 days following the resolution of erythema and warmth [3, 9].
Sources of Information
Where to go for more information
Therapeutic Guidelines
Therapeutic Guidelines have been prepared by writing groups of experienced clinicians, and represent independent consensus opinion based on the evidence available at the time of publication. The guidelines are available as pocket-sized book, CD-ROMs for installation on personal computers, and electronic versions for use on Health Department intranets, integration with commercial prescribing software, and hand-held computers. See Antibiotic Guidelines, version 12, 2003.
Website: http://www.tg.com.au
Further Reading
Richards M and Padiglione AA, (2001). Skin & Soft tissue Infections in Yung, McDonald, Spelman, Street & Johnson(Eds) (2001) Infectious diseases: A Clinical Approach; The University of Melbourne and Monash University: Melbourne.
References
D Stulberg, M Penrod, R Blatny, Common Bacterial Skin Infections. American Family Physician, 2002. 66(1): p. 119-124. Spicer WJ, et al, Skin and soft tissue infections, in Therapeutic guidelines: Antibiotic. 2003, Therapeutic Guidelines Limited: Canberra. Oxford Radcliffe Hospitals, Guidelines for the Management of Cellulitis. Medicines Information Leaflet, 2003. 3(10). A Dupuy, H Benchikhi, J Roujeau, et al., Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ, 1999. 318(7198): p. 1591–1594. eTG, Therapeutic Guidelines: Antibiotic guidelines - cellulitis and erysipelas, in http://www.emedicine.com/derm/topic464.htm, Inc. eMedicine.com. 2004 B Perl, N Gottehrer, D Raveh, Y Schlesinger, Rudensky B, Yinnon A, Cost-Effectiveness of Blood Cultures for Adult Patients with Cellulitis. Clinical Infectious Diseases, 1999. 29: p. 1483-8. Howden BP,Richards MJ, The efficacy of continuous infusion flucloxacillin in home therapy for serious staphylococcal infections and cellulitis. Journal of Antimicrobial Chemotherapy, 2001. 48(3): p. 311-4. A Dent, G Phillips, J Daffy, P Stanley, A Beswick, O'Sullivan E, Hospital in the Home Cellulitis Treatment. 2004 Leder K, Turnidge JD, Grayson ML, Home-based treatment of cellulitis with twice-daily cefazolin. Medical Journal of Australia, 1998. 169(10): p. 519-22. Grayson ML.,2002 Jun 1 et al. . , Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the treatment of moderate-to-severe cellulitis in adults. Clinical Infectious Diseases, 2002. 34(11): p. 1440-1448. M Swartz, Cellulitis. The New England Journal of Medicine, 2004. 350(9): p. 904-912. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on cellulitis provided in this Clinical Information Sheet is based on Level IV evidence produced by expert opinions in the field, particularly guidelines produced by the NHS Trust medications review authority (Level IV B). Information provided on medication regimes is based on current Australian recommendations published in the Australian Antibiotics Guidelines [2] and supported by numerous Level III evidence research studies [7, 8, 10, 11].
The following table outlines the level of evidence of each reference:
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Reference |
Year |
Level of Evidence |
1. |
D Stulberg, M Penrod, R Blatny, Common Bacterial Skin Infections. American Family Physician, 2002. 66(1): p. 119-124. |
2002 |
Level IV C evidence |
2. |
Spicer WJ, et al, Skin and soft tissue infections, in Therapeutic guidelines: Antibiotic. 2003, Therapeutic Guidelines Limited: Canberra. |
2003 |
Level IV B evidence |
3. |
Oxford Radcliffe Hospitals, Guidelines for the Management of Cellulitis. Medicines Information Leaflet, 2003. 3(10). |
2003 |
Level IV B evidence |
4. |
A Dupuy, H Benchikhi, J Roujeau, et al., Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ, 1999. 318(7198): p. 1591–1594. |
1999 |
Level III evidence |
5. |
eTG, Therapeutic Guidelines: Antibiotic guidelines - cellulitis and erysipelas, in 2006 |
Level IV C evidence |
6. |
G Micali,V Dhawan, Cellulitis, in http://www.emedicine.com/derm/topic464.htm, Inc. eMedicine.com. 2004 |
2004 |
Level IV C evidence |
7. |
B Perl, N Gottehrer, D Raveh, Y Schlesinger, Rudensky B, Yinnon A, Cost-Effectiveness of Blood Cultures for Adult Patients with Cellulitis. Clinical Infectious Diseases, 1999. 29: p. 1483-8. |
1999 |
Level III evidence |
8. |
Howden BP,Richards MJ, The efficacy of continuous infusion flucloxacillin in home therapy for serious staphylococcal infections and cellulitis. Journal of Antimicrobial Chemotherapy, 2001. 48(3): p. 311-4. |
2001 |
Level IV C evidence |
9. |
A Dent, G Phillips, J Daffy, P Stanley, A Beswick, O'Sullivan E, Hospital in the Home Cellulitis Treatment. 2004 |
2004 |
Level V evidence |
10. |
Leder K, Turnidge JD, Grayson ML, Home-based treatment of cellulitis with twice-daily cefazolin. Medical Journal of Australia, 1998. 169(10): p. 519-22. |
1998 |
Level III evidence |
11. |
Grayson ML.,2002 Jun 1 et al. . , Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the treatment of moderate-to-severe cellulitis in adults. Clinical Infectious Diseases, 2002. 34(11): p. 1440-1448. |
2002 |
Level III evidence |
12. |
M Swartz, Cellulitis. The New England Journal of Medicine, 2004. 350(9): p. 904-912. |
2004 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [13] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material developed in local RACFs. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, eg developed in RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Cellulitis
The following reference cards are designed to be used in conjunction with the Cellulitis Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Cellulitis Assessment
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