Cellulitis / Reading and Sharing

Cellulitis -a diffuse inflammation of the deep dermal and subcutaneous tissue that results from an infectious process, characterized by erythema, warmth, and tenderness of the involved tissues (Ferri, 2018). This can occur anywhere in the body where there is any break in the skin. The skin and subcutaneous tissue respond to a bacterial infection by an inflammatory response; there’s an increase in vascular permeability of the microcirculation of the skin that allows protein-rich fluids to leak into the interstitial tissue causing inflammation (Dunphy et al., 2015). Vasodilation also occurs causing the erythema of the tissue involved. Leukocytes accumulate at the site of injury and engulf particulate material such as the bacteria, cellular debris, and antigen-antibody complexes. In most cases, bacterial burden in cellulitis is low unless there’s an abscess or skin ulcer is present (Dunphy et al., 2015). 

Cellulitis caused by infection with group A beta-hemolytic streptococci, Staphylocossus aureus, Haemophilus influenzae, or other organisms. Cellulitis occurs most frequently in diabetics, immunocompromised hosts, and patients with venous and lymphatic compromise (Ferri, 2018). It’s most frequently found near breaks of skin, but it can also manifest in edema, bites, osteomyelitis, or bacteremia. Skin and soft-tissue infections account for more than 650,000 hospital admissions per year. They account for over 14 million outpatient visits per year and $3.7 billion in ambulatory care costs (Ferri, 2018). 

Physical assessment and examination would include a thorough viewing of the affected tissue; most patients will complain of pain, warmth, and redness to an area of skin. Most often times, there will be a site of entry for bacteria such as a bug bite or cut that got infected. The provider should be looking for areas of macerated or peeling skin on toes if it’s assosciated with lower extremities. The area will be warm to the touch and bright red; the borders of redness are flat and diffused. We should also be looking for symptoms of a systemic infection which include fever, hypotension, tachycardia, leukocytosis, and lymphangitis (Dunphy et al., 2015). 

Diagnostic studies may include cultures of the open area, blood cultures if systemic symptoms are present, CBC, and a CT or MRI to determine abscess or necrotizing fasciitis (Ferri, 2018). Cellulitis is often times misdiagnosed causing unnecessary hospitalizations and costs, so it’s important to assess the situation and skin to determine of other diagnoses can be made (Moran & Talan, 2017). In a study conducted by Moran & Talen (2017), 79 out of 259 patients that were hospitalized for cellulitis actually didn’t have it. 

Some cellulitis is treated different than others due to the type of person, how severe it is, where it is, and how recurrent it is. Patients with diabetes or are immunocompromised should be treated aggressively with antibiotics. Cellulitis if the hands, feet, and face should also be treated aggressively to prevent loss of function. If the celluitis is caused by a animal or human bite should be taken into special account as well; those are more likely to have higher bacterial incidence causing a more severe infection. Most often, dicloxacillin or cephalexin for 10-14 days can be used as outpatient therapy (Dunphy et al., 2015). Patients who have a fever, chills, or are not getting better with oral antibiotics after 48 hours, they may need to be hospitalized for IV antibiotics; there’s always a chance that the brewing bacteria is MRSA. It’s important to educate your patients as a clinic provider to go to ER if fever is present or if symptoms worsen after antibiotic initiation. Follow-up for oral antibiotics should be 2-3 days to make sure it is getting better (Dunphy et al., 2015). 

References: 

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company.

Ferri, F. F. (2018). Ferri’s clinical advisor 2018. Philadelphia, PA: Elsevier.

Moran, G. J., & Talan, D. A. (2017). Cellulitis: Commonly misdiagnosed or just misunderstood?. Jama, 317(7), 760-761. doi:10.1001/jama.2016.15921