Cellulitis Management

Diagnosis

Examination of interdigital toe spaces for fissuring, scaling, or maceration is important for identifying predisposing factors, as recommended by the Infectious Diseases Society of America 1
Patients with cellulitis should be evaluated for warning signs of deeper infection, including pain disproportionate to physical findings, and laboratory tests such as complete blood count with differential and C-reactive protein levels, particularly in those with buccal space and facial inflammation, as stated by the IDSA 2
Assess for warning signs of orbital involvement, including proptosis, pain with eye movements, restriction of extraocular movements/diplopia, vision changes, and severe eyelid swelling with pain and erythema, and same-day ophthalmology referral is recommended for any signs of orbital involvement, as per the Society for Immunotherapy of Cancer guidelines and the American Academy of Ophthalmology 3

For mild, non-purulent cellulitis, antibiotics active against streptococci are recommended, with a duration of 5 days that can be extended if no improvement is seen, according to the Infectious Diseases Society of America 1
For moderate to severe cellulitis with systemic signs, adding coverage for MRSA is recommended if risk factors are present, and broad-spectrum coverage with vancomycin plus piperacillin-tazobactam or a carbapenem may be necessary for severe infections or immunocompromised patients 1
The recommended treatment for uncomplicated cellulitis is a 5-6 day course of antibiotics active against streptococci, with options including cephalexin, penicillins, or clindamycin for non-purulent cellulitis, and MRSA coverage should be added for purulent cellulitis or in patients with specific risk factors, as recommended by the American College of Physicians and the IDSA 4, 5, 6
For patients requiring MRSA coverage, treatment options include TMP-SMX, Clindamycin, Doxycycline or minocycline, and Linezolid 6
Shingles with secondary cellulitis requires prompt treatment with antiviral therapy and antibiotics, with recommended antiviral therapy options including Famciclovir, Valacyclovir, or Acyclovir, and antibiotic options including Clindamycin, Doxycycline, and Minocycline, as recommended by the American Academy of Pediatrics and the IDSA 7, 2, 8, 6

Treatment duration should be extended beyond 5 days if clinical improvement is slow, according to the Infectious Diseases Society of America 1
Typical duration of treatment is 5-10 days for uncomplicated cellulitis, and treatment should be extended for slow clinical response, severe initial infection, immunocompromised patients, or presence of complicating factors, as suggested by the IDSA 6

Maintaining good personal hygiene, keeping draining wounds covered with clean, dry bandages, and avoiding reusing or sharing personal items can prevent non-purulent cellulitis, as recommended by the IDSA 9
Implementing environmental hygiene measures can help prevent recurrent skin and soft tissue infections (SSTI), and for patients with recurrent cellulitis, prophylactic antibiotics may be considered, and addressing underlying conditions such as edema, obesity, eczema, and venous insufficiency is crucial in preventing recurrent cellulitis, as recommended by the IDSA 8, 9, 1

Children under 8 years should avoid tetracyclines, and hospitalized children can be treated with Vancomycin IV or clindamycin, as recommended by the IDSA 6
Linezolid dosing for children under 12 years is 10 mg/kg/dose PO/IV every 8 hours, according to the IDSA 6

The wound should be cleansed with sterile saline or a mild antiseptic solution, and debridement of necrotic tissue should be performed if present, with consideration of topical antimicrobials for mildly infected open wounds with minimal cellulitis, as suggested by the IDSA 10

Daily follow-up is recommended until definite improvement is noted, with monitoring for skin lesions developing firm, adherent crusts with no discharge, no new lesions appearing in the preceding 48 hours, resolution of cellulitis, and no evidence of systemic symptoms, as recommended by the American Academy of Pediatrics 7
Monitor patients for signs of anaphylaxis, including difficulty breathing, tongue or throat swelling, lightheadedness, vomiting, and disseminated hives, as recommended by the American Heart Association 11

Hospitalization should be considered for patients with uncomplicated cellulitis if there is concern for deeper or necrotizing infection, poor adherence to therapy, severe immunocompromisation, failing outpatient treatment, signs of systemic inflammatory response syndrome (SIRS), or altered mental status or hemodynamic instability 8
Hospitalization is recommended for patients with no improvement within 24-48 hours of outpatient therapy, progressive infection, presence of proptosis, impaired visual acuity, or impaired/painful extraocular mobility, systemic toxicity, immunocompromised state, or significant comorbidities, as stated by the American Academy of Pediatrics 12