drkemcolian26

· 23 Dec 2021

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Cellulitis when to worry? :

Cellulitis is an acute inflammation of the dermis and subcutaneous tissue due to bacterial infection, that usually involves the lower extremity.

Symptoms and signs:

Cellulitis starts as a tender small patch, with swelling, erythema (redness), pain, warmth with or without vesicles or bullae. The lesion expands within hours, so that from onset to presentation is usually 6 to 36 hours. With the progression of the lesion, the patient becomes more ill with malaise, fever, and chills. Lymphangitis with lymph-node enlargement is usually present. In case septicemia develops, hypotension followed by shock occurs.

Causative agents:

Most commonly it is caused by gram-positive cocci, especially group A beta-hemolytic streptococci and staphylococcus aureus. Rarely gram-negative bacilli or fungi may produce a similar picture.

Predisposing factors:

The most common portal of entry for lower extremity cellulitis is interdigital spaces of toes or toe webs with fissuring usually a complication of interdigital fungal infection of the foot. Other predisposing factors include preceding episodes of cellulitis, chronic edema, venous insufficiency with secondary edema, lymphatic obstruction, splenectomy, and other perturbations of the skin barrier.

Differential diagnosis:

Red Leg - Cellulitis Mimickers
Unilateral

     • Contact Dermatitis
     • Tinea Pedis / Corporis

Bilateral

     • Stasis Dermatitis
     • Lipodermatosclerosis

Non-infectious

     • DVT
     • Acute Gout
     • Erythema Nodosum
     • Vasculitis

Infectious

     • Necrotizing Fasciitis
     • Septic Arthritis
     • Erythema Migrans

Clinical Criteria for Effective Cellulitis Diagnosis:

•    Acute onset ≤3 day (1 point)
•    Erythema, pink to light red discoloration resulting from microvascular dilation (1 point)
•    Pyrexia >100.4°F (1 point)
•    History of associated trauma-mechanical, surgical, insect bite, or burn; associated with the time course of infection (1 point)
•    Tenderness to light touch (1 point)
•    Unilaterality-lesion of concern appears on a single lower extremity; generally asymmetric anatomic involvement (1 point)
•    Leukocytosis is defined as a white blood cell count >10x103 /µL (1 point)
•    Total score = 7

ALT-70 Score for Cellulitis: Model for predicting the presence of true cellulitis in the emergency department:

+ Asymmetry-unilateral leg involvement (3 points)
+ Leukocytosis (White blood cells count ≥10 x 103 µL (1 point)
+ Tachycardia (heart rate > 90 bpm) (1 point)
+ Age ≥ 70 years (2 points)

The outcome recommendations are:

+ Score 0-1:  cellulitis unlikely so review the diagnosis or consider causes of pseudo-cellulitis
+ Score 3-4:  indeterminate, obtain additional information, and consider the consultation
+ Score 5-7:  True cellulitis is likely, consider empiric antibiotic therapy.

Laboratory findings:
Complete blood count (CBC): leukocytosis with neutrophilia with left shift. Blood culture positive in only 4% of patients. Culture of a swab from central ulceration, pustule, or abscess.
In patients with compromised immunity or if an unusual organism is suspected and there is no loculated site to culture, a full-thickness skin biopsy should be sent for routine histologic evaluation and culture (bacterial, fungal, and mycobacterial).

Treatment:

Patients with a non-purulent infection that is cellulitis or erysipelas in the absence of abscess or purulent drainage are managed with empiric antibiotic therapy.

Oral vs parenteral therapy: Patients with a mild infection may be treated with oral antibiotics. Patients with moderate to severe infection having the following features are treated with parenteral therapy.

    Systemic signs of toxicity such as fever >100.5°F, hypotension, or sustained tachycardia.
    Rapid progression of erythema
    Progression of disease process 48 hours after the oral antibiotic therapy.
    Inability to tolerate oral therapy
    The proximity of the lesion to an indwelling medical device such as a central venous line, or prosthetic joint, or vascular graft.
Additional empiric therapy for MRSA is advised in the following circumstances:
    Systemic signs of toxicity such as fever >100.5°F, hypotension, or sustained tachycardia.
    The previous episode of MRSA infection or known MRSA colonization.
    Lack of clinical response to the antibiotic regimen with no activity against MRSA
    Presence of risk factors for MRSA infection including recent hospitalization, residence in a long-term care facility, recent surgery, hemodialysis, and HIV infection.
    The proximity of the lesion to an indwelling medical device such as a central venous line, prosthetic joint, or vascular graft.
https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html
#cellulitis #body #disorder