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what are some skin and soft tissue infections?
- cellulitis
- necrotising fasciitis
what is cellulitis
Cellulitis is a bacterial infection that affects the dermis and the deeper subcutaneous tissues.
features cellulitis
Erythema (red discolouration)
Warm or hot to touch
Tense
Thickened
Oedematous
Bullae (fluid-filled blisters)
A golden-yellow crust can be present and indicate a staphylococcus aureus infection
commonly occurs on the shins
usually unilateral - bilateral cellulitis is rare and suggests an alternative diagnosis
systemic upset
fever
malaise
nausea
most common causative agent cellulitis
Streptococcus pyogenes
or less commonly Staphylococcus aureus
what classification is used to guide management of patients with cellulitis
Eron classification
Eron classification of cellulitis
I There are no signs of systemic toxicity and the person has no uncontrolled co-morbidities
II The person is either systemically unwell or systemically well but with a co-morbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection
III The person has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize
IV The person has sepsis syndrome or a severe life-threatening infection such as necrotizing fasciitis
who should be admitted with cellulitis
Has Eron Class III or Class IV cellulitis.
Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin).
Is very young (under 1 year of age) or frail.
Is immunocompromised.
Has significant lymphoedema.
Has facial cellulitis (unless very mild) or periorbital cellulitis.
how to manage eron class 2 cellulitis
Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines.
how to manage eron class 1 cellulitis
oral antibiotics
- oral flucloxacillin as first-line treatment for mild/moderate cellulitis
oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin
how to manage class 3 and 4 cellulitis
admit usually for IV abx
oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone
Pre-septal vs septal cellulitis
Preseptal cellulitis is sometimes also referred to as periorbital cellulitis. It is an infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit.
This is in contrast to orbital cellulitis, which is an infection of the soft tissues behind the orbital septum, and is a much more serious infection.
Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be absent in preseptal cellulitis - their presence would indicate orbital cellulitis
epidemiology preseptal celulitis
- Preseptal cellulitis occurs most commonly in children - 80% of patients are under 10 and the median age of presentation is 21 months
- It is more common in the winter due to the increased prevalence of respiratory tract infections.
orbital cellulitis - Mean age of hospitalisation 7-12 years
Management of preseptal and of orbital cellulitis
- Refer to secondary care, orbital is much more time critical
- CT with contrast to differentiate between
+ FBC, blood culture, swab of any discharge
Periorbital: often oral co-amoxiclav and observation
Orbital: IV abx
what often precedes periorbital/orbital cellulitis
sinus infection, facial infection, insect bite
most common causative organisms preseptal/orbital cellulitis
Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria
