Cellulitis (DERM) Flashcards

1
Q

Define cellulitis.

A

Acute spreading infection of the skin with visually distinct borders, that involves the deep dermis and subcutaneous tissue

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2
Q

What is the difference between cellulitis and erysipelas?

A
  • cellulitis - involves deep dermis and subcutaneous tissue
  • erysipelas - distinct form of superficial cellulitis involving only the upper dermis and superficial lymphatics –> raised and sharply demarcated from uninvolved skin
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3
Q

What is cellulitis characterised by?

A

Redness, swelling, heat and tenderness, and commonly occurs in an extremity

(Immunocompromised patients may present with atypical infections)

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4
Q

How does cellulitis develop?

A
  • when microorganisms gain entry into dermal and subcutaneous tissues via disruptions in cutaneous barrier e.g. minor skin injury
  • often results from: penetrating injury, local lesions (e.g. insect bites), fissuring (e.g. anal fissures)
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5
Q

What are the most common causative bacteria of cellulitis? (2)

A
  • Staphylococcus aureus (catalase +ve)
  • Streptococcus pyogenes (catalase -ve)
  • beware of MRSA
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6
Q

What is orbital cellulitis usually caused by?

A

Haemophilus influenzae

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7
Q

What are the clinical features of cellulitis? (5)

A
  • acute onset of red, painful, hot, swollen skin
  • poorly defined (not well demarcated) lesions - compared to erysipelas –> well-demarcated, bright red raised skin
  • most commonly occurs on shins
  • Hx of cut/scratch/injury
  • systemic symptoms - fever, chills, nausea, headache
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8
Q

What systemic symptoms can be seen in cellulitis? (4)

A
  • fever
  • chills
  • nausea
  • headache
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9
Q

How does erysipelas differ clinically to cellulitis?

A
  • more superficial, limited version of cellulitis
  • causes well-defined lesions + bright red raised skin
  • caused by Streptococcus pyogenes
  • treated with flucloxacillin
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10
Q

How does periorbital cellulitis present?

A

Painful swollen red skin AROUND the eye

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11
Q

How does orbital cellulitis present?

A

Painful or limited eye movements, VISUAL IMPAIRMENT

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12
Q

What might you see on examination of cellulitis?

A
  • lesion: erythema, oedema, warm tender indistinct margins
    • pyrexia - may suggest systemic spread
    • NB exclude the presence of an abscess - aspirate if pus suspected
  • orange-peel appearance, blistering, bleeding, lymphangitis (red line that spreads proximally along lymphatics towards lymph nodes)
  • unilateral
  • toe-to-web abnormalities (evidence of fungal infection AKA tinea may reveal the point of bacterial entry)
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13
Q

What are some risk factors for cellulitis?

A

DOOVE + skin break

  • diabetes (–> poor vascularisation)
  • obesity
  • oedema (& lymphoedema)
  • venous insufficiency (–> poor vascularisation)
  • eczema
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14
Q

What observations show septic signs of cellulitis? (5)

A
  • high HR
  • high RR
  • low BP
  • confusion (low GCS)
  • fever
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15
Q

What is a sign of systemic illness in cellulitis?

A

Pyrexia

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16
Q

How do we usually diagnose cellulitis?

A

Clinical diagnosis - only request further tests if there are signs of systemic illness or septicaemia

  • acute, red, hot, swollen skin
  • Hx trauma/cracked skin/scratch/injury
  • Hx lymphoedema/poor vascularisation
17
Q

What are the 1st-line investigations for cellulitis? (1 + 6)

A
  • clinical diagnosis
  • FBC
  • ESR
  • CRP
  • U&Es
  • blood culture and sensitivities - if patient needs admission
  • skin swab/aspirate
18
Q

What would bloods show for cellulitis?

A

High WCC and CRP/ESR

19
Q

How can we identify the causative pathogen and know which Abx to use for cellulitis?

A

Blood MC&S and skin swab

20
Q

When do we admit patients with cellulitis?

A

If septicaemia suspected, or if significant systemic upset and/or comorbidities

21
Q

What do we do after admitting a patient with cellulitis?

A

Blood MC&S to identify pathogen and test antibiotic sensitivity - do before giving Abx

22
Q

What imaging could we do for cellulitis? (2)

A
  • XR - if osteomyelitis or necrotising fasciitis
  • CT/MRI - if orbital cellulitis is suspected to check if infection has spread posteriorly to brain
23
Q

What are some differentials for cellulitis?

A
  • necrotising fasciitis - marked pain, necrotic bullous, crepitus, surgical exploration
  • thrombophlebitis - tender palpable cord along affected vein
  • DVT - prolonged immobility, tender vein
  • gout
  • Lyme disease
  • contact dermatitis
  • insect bites and stings
  • fixed drug eruptions
  • eosinophilic cellulitis
  • sweet syndrome
  • inflammatory carcinoma
  • calciphylaxis
  • lipodermatosclerosis (venous insufficiency)
24
Q

What is the first thing you do with patients with cellulitis?

A

Exclude sepsis!!

  • fever
  • tachycardic
  • hypotensive
  • low O2 sats
  • high respiratory rate
25
What is the 1st line treatment for cellulitis? (Mild/moderate vs severe)
- **flucloxacillin** (oral if mild/mod, IV if severe) - clarithromycin if allergic - secondary option: amoxicillin/clavulanate
26
What do we do for severe systemic cellulitis e.g. septic signs, tachycardic + hypotensive?
Hospital admission + IV co-amoxiclav/cefuroxime/clindamycin/ceftriaxone
27
What do we give for cellulitis if penicillin allergy?
Clarithromycin / erythromycin (in pregnancy) / doxycycline
28
What do we give for cellulitis if near eye/nose?
Co-amoxiclav (or clarithromycin+metronidazole)
29
What do we give for cellulitis if MRSA suspicion?
Flucloxacillin + vancomycin/teicoplanin/linezolid
30
What do we give for cellulitis if Aeromonas hydrophila (freshwater exposure)?
Flucloxacillin + ciprofloxacin/doxycycline/trimethoprim
31
What do we give for cellulitis if Vibrio vulnificus (softwater exposure)?
Flucloxacillin + doxycycline
32
How do we manage periorbital cellulitis?
Incision, drainage and culture of peri-ocular abscess, possible antifungal therapy
33
How do we manage orbital cellulitis?
Nasal decongestant, possible antifungal therapy, possible lateral canthotomy and cantholysis, possible orbitotomy and surgical drainage of orbital abscess
34
What is 1st line treatment for erysipelas (cellulitis)?
Flucloxacillin
35
What are some complications of cellulitis? (4)
- sepsis - cellulitis caused by Vibrio vulnificus after salt water exposure, usually occurs in patients with pre-existing liver disease - chronic oedema (in affected extremity) - necrotising fasciitis - periorbital/orbital cellulitis
36
Describe the prognosis of cellulitis.
Excellent - most episodes resolve with therapy and major sequelae are absent