Cellulitis

General

Clinicals - History

Fact Explanation
High fever Fever is due to the inflammatory mediators that are released during the multiplication and destruction of the bacteria due to the immune reactions.These endogenous pyrogens act on the hypothalamus and alter the temperature set point.,, High fever
Fever is due to the inflammatory mediators that are released during the multiplication and destruction of the bacteria due to the immune reactions.These endogenous pyrogens act on the hypothalamus and alter the temperature set point.,,
Swelling of the affected region This may affect the limbs,the peri orbital area in peri orbital cellulitis or the abdomen.This is due to exudation of tissue fluid due to increased permeability of capillary walls and lymphangitis. The increased vascular permeability occurs due to histamine release, direct endothelial injury and leukocyte-mediated endothelial injury. Swelling of the affected region
This may affect the limbs,the peri orbital area in peri orbital cellulitis or the abdomen.This is due to exudation of tissue fluid due to increased permeability of capillary walls and lymphangitis. The increased vascular permeability occurs due to histamine release, direct endothelial injury and leukocyte-mediated endothelial injury.
Pain and tenderness Cytokines, chemokines, nerve growth factor, and prostaglandins released by leukocytes and local cells stimulate the nerve endings and produce pain. , Pain and tenderness
Cytokines, chemokines, nerve growth factor, and prostaglandins released by leukocytes and local cells stimulate the nerve endings and produce pain. ,
Erythema of the affected area Occurs due to vasodilation, which opens up the arterioles and new capillary beds. The increased blood flow causes warmth and erythema. , Erythema of the affected area
Occurs due to vasodilation, which opens up the arterioles and new capillary beds. The increased blood flow causes warmth and erythema. ,
Limitation of movement Occurs due to pain and edema of the affected area. Limitation of movement
Occurs due to pain and edema of the affected area.
Vesicles and/or bullae Accumulation of pus beneath superficial layers of the skin. , Vesicles and/or bullae
Accumulation of pus beneath superficial layers of the skin. ,
History of trauma, cutaneous ulcers causing breach of skin Allows for the entry of pathogen to enter the tissues and multiply rapidly because the host defense is limited by factors such as local circulation,venous stagnation., History of trauma, cutaneous ulcers causing breach of skin
Allows for the entry of pathogen to enter the tissues and multiply rapidly because the host defense is limited by factors such as local circulation,venous stagnation.,
Predisposing factors Factors that reduce venous or lymph drainage such as lymph-edema,, chronic venous congestion are risk factors for the development of cellulitis. Factors that cause host immune suppression such as diabetes mellitus, Cushing's syndrome etc. also predispose to cellulitis. , Predisposing factors
Factors that reduce venous or lymph drainage such as lymph-edema,, chronic venous congestion are risk factors for the development of cellulitis. Factors that cause host immune suppression such as diabetes mellitus, Cushing's syndrome etc. also predispose to cellulitis. ,

Clinicals - Examination

Fact Explanation
Febrile Fever caused by the inflammatory mediators that are released during bacterial multiplication and destruction. These endogenous pyrogens act on the hypothalamus and alter the temperature set point, Febrile
Fever caused by the inflammatory mediators that are released during bacterial multiplication and destruction. These endogenous pyrogens act on the hypothalamus and alter the temperature set point,
Tachycardia Acute infections stimulate the release of catecholamines that have a chronotropic effect on the heart. Tachycardia
Acute infections stimulate the release of catecholamines that have a chronotropic effect on the heart.
Hypotension Low blood pressure defined as systolic<90mmHg or diastolic<60mmHg occurs only if sepsis results in generalized vasodilation subsequently causing septic shock. Hypotension
Low blood pressure defined as systolic<90mmHg or diastolic<60mmHg occurs only if sepsis results in generalized vasodilation subsequently causing septic shock.
Edema overlying the affected area This is due to exudation of tissue fluid due to increased permeability of capillary walls and lymphangitis. The increased vascular permeability occurs due to histamine release, direct endothelial injury and leukocyte-mediated endothelial injury. Edema overlying the affected area
This is due to exudation of tissue fluid due to increased permeability of capillary walls and lymphangitis. The increased vascular permeability occurs due to histamine release, direct endothelial injury and leukocyte-mediated endothelial injury.
Warmth and erythema Occurs due to vasodilation, which opens up the arterioles and new capillary beds. The increased blood flow causes warmth and erythema., Warmth and erythema
Occurs due to vasodilation, which opens up the arterioles and new capillary beds. The increased blood flow causes warmth and erythema.,
Localized lymphnodal enlargement Inflammatory reaction of the draining lymph nodes and increased lymphatic flow causes tender enlarged lymph nodes., Localized lymphnodal enlargement
Inflammatory reaction of the draining lymph nodes and increased lymphatic flow causes tender enlarged lymph nodes.,
Breaches of the skin Signs of trauma, skin infections
such as impetigo or ecthyma, chronic ulcers, fissured toe webs and inflammatory dermatoses such as eczema are predisposing factors.,
Breaches of the skin
Signs of trauma, skin infections
such as impetigo or ecthyma, chronic ulcers, fissured toe webs and inflammatory dermatoses such as eczema are predisposing factors.,
Signs pointing toward possible predisposing factors Surgical scars or radiotherapy marks may unmask limb lymphedema. Signs of peripheral vascular disease or peripheral neuropathy may point towards possible diabetes mellitus. , Signs pointing toward possible predisposing factors
Surgical scars or radiotherapy marks may unmask limb lymphedema. Signs of peripheral vascular disease or peripheral neuropathy may point towards possible diabetes mellitus. ,

Investigations - Diagnosis

Fact Explanation
Full blood count with differential count Raised white cell with neutrophil leucocytosis is observed. The bone marrow is stimulated to produce and release increased numbers of neutrophils in response to bacterial pathogen invasion of the blood.,, Full blood count with differential count
Raised white cell with neutrophil leucocytosis is observed. The bone marrow is stimulated to produce and release increased numbers of neutrophils in response to bacterial pathogen invasion of the blood.,,
C-reactive protein Is an acute phase protein that is elevated in bacterial infections. Useful in diagnosis and monitoring response to treatment. C-reactive protein
Is an acute phase protein that is elevated in bacterial infections. Useful in diagnosis and monitoring response to treatment.
Culture and antibiogram of aspirate/ wound swab Aspirates are positive in 10% while punch biopsy is positive in 20%. , Culture and antibiogram of aspirate/ wound swab
Aspirates are positive in 10% while punch biopsy is positive in 20%. ,
Blood culture Blood cultures are positive in 2-4% of cases, however contaminants may give false positives. This investigation is indicated if sepsis is suspected., Blood culture
Blood cultures are positive in 2-4% of cases, however contaminants may give false positives. This investigation is indicated if sepsis is suspected.,
Anti Streptolysin O Titres (ASOT) Serological tests are not used regularly. This is useful if cellulitis has led to a subsequent acute glomerulonephritis. Anti Streptolysin O Titres (ASOT)
Serological tests are not used regularly. This is useful if cellulitis has led to a subsequent acute glomerulonephritis.
Blood urea and serum electrolytes. Indicates renal compromise in shock and acute glomerulonephritis. Blood urea and serum electrolytes.
Indicates renal compromise in shock and acute glomerulonephritis.
X-ray Indicated if underlying osteomyelitis is suspected. X-ray
Indicated if underlying osteomyelitis is suspected.
MRI If gas gangrene, necrotising fasciitis or an abscess is suspected an MRI may be useful. MRI
If gas gangrene, necrotising fasciitis or an abscess is suspected an MRI may be useful.

Investigations - Management

Fact Explanation
Assessment of blood glucose levels Diabetes Mellitus is a recognized risk factor for cellulitis, therefore it is important to screen for diabetes. In addition acute inflammation will elevate plasma glucose levels. Assessment of blood glucose levels
Diabetes Mellitus is a recognized risk factor for cellulitis, therefore it is important to screen for diabetes. In addition acute inflammation will elevate plasma glucose levels.
Assessment for Peripheral Vascular Disease (PVD) Ankle Brachial Pressure Index (ABPI) testing should be performed. Additional investigations such as duplex ultrasonography, magnetic resonance arteriography, and angiography are used only if there is a strong suggestion of PVD. Assessment for Peripheral Vascular Disease (PVD)
Ankle Brachial Pressure Index (ABPI) testing should be performed. Additional investigations such as duplex ultrasonography, magnetic resonance arteriography, and angiography are used only if there is a strong suggestion of PVD.
Assessment for varicose veins A venous duplex scan or a venogram is useful in the assessment of chronic varicose veins. Assessment for varicose veins
A venous duplex scan or a venogram is useful in the assessment of chronic varicose veins.

Management - Supportive

Fact Explanation
Choice of management setting Signs of sepsis, deteriorating systemic signs or deteriorating local signs even with optimal outpatient treatment are indications for hospitalization, unless close follow up can provided by a primary care physician. Choice of management setting
Signs of sepsis, deteriorating systemic signs or deteriorating local signs even with optimal outpatient treatment are indications for hospitalization, unless close follow up can provided by a primary care physician.
Analgesia This makes the patient comfortable and improves recovery. Commonly used analgesics are paracetamol, NSAIDs and oral opioids. , Analgesia
This makes the patient comfortable and improves recovery. Commonly used analgesics are paracetamol, NSAIDs and oral opioids. ,
Anti-pyretics Use of antipyretics improves the general patient condition. , Anti-pyretics
Use of antipyretics improves the general patient condition. ,
Ensure adequate hydration Febrile patients are likely to become dehydrated. This can be aggravated due to inadequate fluid intake. Dehydration reduces organ perfusion and may lead to acute kidney injury. Ensure adequate hydration
Febrile patients are likely to become dehydrated. This can be aggravated due to inadequate fluid intake. Dehydration reduces organ perfusion and may lead to acute kidney injury.
Elevation of the affected limb Improves lymphatic and venous return.,, Elevation of the affected limb
Improves lymphatic and venous return.,,
Aseptic aspiration/ deroofing of blisters Blisters contains fluid that is a good culture medium. Therefore removal of blisters is advisable. Aseptic aspiration/ deroofing of blisters
Blisters contains fluid that is a good culture medium. Therefore removal of blisters is advisable.
Compression bandaging Once the acute stage has subsided the patient should be assessed for applying compression bandages to reduce limb edema. , Compression bandaging
Once the acute stage has subsided the patient should be assessed for applying compression bandages to reduce limb edema. ,

Management - Specific

Fact Explanation
Flucloxacillin Cellulitis is commonly caused by beta-haemolytic streptococci or S.aureus. Flucloxacillin is a bactericidal to both types. It can be combined with benzylpenicillin while Ceftriaxone an alternative drug. ,, Flucloxacillin
Cellulitis is commonly caused by beta-haemolytic streptococci or S.aureus. Flucloxacillin is a bactericidal to both types. It can be combined with benzylpenicillin while Ceftriaxone an alternative drug. ,,
Clarythromycin/Clindamycin (iv) Used in patients with a penicillin allergy.
Clindamycin inhibits toxin production by group A streptococci, C. prefringens and S.
aureus.
Clarythromycin/Clindamycin (iv)
Used in patients with a penicillin allergy.
Clindamycin inhibits toxin production by group A streptococci, C. prefringens and S.
aureus.
Benzylpenicillin (IV)+ciprofloxacin+clindamycin(IV) This regime is used in patients with class IV(With shock) cellulitis. Benzylpenicillin (IV)+ciprofloxacin+clindamycin(IV)
This regime is used in patients with class IV(With shock) cellulitis.
Co-amoxiclav, Doxycycline and Metronidazole In atypical cellulitis due to human/animal bite.These antibiotics provide cover against Gram negative organisms. Co-amoxiclav, Doxycycline and Metronidazole
In atypical cellulitis due to human/animal bite.These antibiotics provide cover against Gram negative organisms.
Surgical management Indicated only in chronic ulcers, underlying abscesses or necrotising fasciitis. Surgical management
Indicated only in chronic ulcers, underlying abscesses or necrotising fasciitis.
Propyhlaxis for recurrent cellulitis For patients who have had 2 or more episodes of cellulitis at the same site should receive prophylaxis with: Penicillin 250mg bd or Erythromycin 250mg bd for up to 2 years. , Propyhlaxis for recurrent cellulitis
For patients who have had 2 or more episodes of cellulitis at the same site should receive prophylaxis with: Penicillin 250mg bd or Erythromycin 250mg bd for up to 2 years. ,

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  1. BARRETT Kim E, BOITANO, Scott, BARMAN Susan M, BROOKS Heddwen L ed. Ganong’s Review of Medical Physiology. 23rd edition. New York. McGraw Hill. 2010.
  2. BARRETT Kim E, BOITANO, Scott, BARMAN Susan M, BROOKS Heddwen L ed. Ganong’s Review of Medical Physiology. 23rd edition. New York. McGraw Hill. 2010.
  3. Consensus document on the Management of Cellulitis in Lymphedema. Revised Cellulitis Guidelines. British Lymphology Society. 2013. Available from: http://www.lymphoedema.org/Menu3/Revised%20Cellulitis%20Consensus%202013.pdf
  4. Definition and diagnosis of Diabetes Mellitus and intermediate hyperglycemia -Report of a WHO/ IDF consultation. World Health Organization. 2006. [Viewed 17 April 2014] Available from:http://www.who.int/diabetes/publications/Definition%20and%20diagnosis%20of%20diabetes_new.pdf
  5. FOWLER MJ. Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes [ONLINE]. 2008;26(2):77-82.[viewed 17 April 2104] Available from: http://clinical.diabetesjournals.org/content/26/2/77.long
  6. Guidelines on Management of Cellulitis in Adults. Clinical Resource Efficiency Support Team (CREST) Guidelines. 2005. Available from: www.acutemed.co.uk/docs/Cellulitis%20guidelines,%20CREST,%2005.pdf
  7. KUMAR Vinay, ABBAS Abul K, ASTER Jon.ed. Robbins Basic Pathology. 9th edition. Philadelphia. Saunders Elsevier. 2012.
  8. KUMAR Vinay, ABBAS Abul K, ASTER Jon.ed. Robbins Basic Pathology. 9th edition. Philadelphia. Saunders Elsevier. 2012.
  9. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. [Online] 2012;54(12):e132-73.[viewed 17 April 2014]. doi: 10.1056/NEJM199710303371801
  10. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. [Online] 2012;54(12):e132-73.[viewed 17 April 2014]. doi: 10.1056/NEJM199710303371801
  11. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. [Online] 2012;54(12):e132-73.[viewed 17 April 2014]. doi: 10.1056/NEJM199710303371801
  12. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Infectious Diseases Society of America. 2005. Available from: http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/idsasst05.pdf
  13. SONTHEIMER Daniel L. Peripheral Vascular Disease: Diagnosis and Treatment. Am Fam Physician. [online] 2006 Jun 1;73(11):1971-1976. [viewed 4 April 2014] Available from: http://www.aafp.org/afp/2006/0601/p1971.html
  14. The management of Type 2 Diabetes. Clinical Guideline 66 .National Institute for Health and Clinical Excellence. 2009. [viewed 17 April 2014]. Available from: http://www.nice.org.uk/nicemedia/pdf/CG87NICEGuideline.pdf
  15. Understanding cellulitis of lower limb. Wound Essentials Vol-2 2007. Available from: www.woundsinternational.com/pdf/content_183.pdf