Cellulitis 1.

0 Introduction Cellulitis is a spreading, acute inflammation of the dermis and subcutaneous tissue and it also sometimes involving muscle. There is considerable overlap in presentation between various skin and soft tissue infections and many have a cellulitic component. According to Clinical Key, Hallmarks are erythema, edema, tenderness, and warmth. Erysipelas, a streptococcal infection involving the superficial layers of the dermis is characterized by a well-demarcated raised area of vivid erythema which is the more common appearance of cellulitis is one of varying degrees of erythema and poorly defined margins. The degree of associated systemic illness is variable. Besides, Cellulitis can occur among children and adult. It is most frequently occurs on the head and neck of children and the lower extremities in adults. It is also found on the scalp, the perianal area, or complicating surgical incisions, sites of chronic or traumatic wounds, burns or bites inflicted by animals or humans including closed fist wounds. Patients most likely to develop cellulitis are those with diabetes, immunodeficiency diseases, previous cellulitis, venous and lymphatic compromise, alcoholism, intravenous drug abuse and peripheral vascular disease. In addition, according to National Institute of Allergy and Infectious Diseases (NIH), Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. There are various symptoms that can cause Cellulitis. It includes fever and chills, swollen glands or lymph nodes and a rash with painful, red, tender skin. The skin also may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (through the vein) for more severe cases. Meanwhile, according to Medscape, the term cellulitis is commonly used to indicate a non-necrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection. Cellulitis usually follows a breach in the skin, although a portal of

entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain bacteria. 2.0 Causes of Cellulitis There are several causes of Cellulitis for instance, age, gender, geography and socioeconomic status. In age aspect, facial cellulitis usually occurs in adults aged 50 years or above, or children aged 6 months to 3 years while Perianal cellulitis usually affects children. In aspect of gender, Perianal cellulitis is more common in male patients than in female patients while there is no gender difference for other types of cellulitis. Next, in aspect of geography, Cellulitis caused by halophilic Vibrio species occurs in coastal areas (shellfish handlers). Meanwhile, in socioeconomic status aspect, immigrant populations who may not have been vaccinated against Haemophilus influenzae type b and tetanus are at increased risk of infection and overcrowded conditions may also exacerbate infection. Farm, garden, fish, and shellfish workers also are at increased risk of infection by rare agents causing cellulitis. 3.0 Signs and Symptoms Sign or symptom of non-purulent cellulitis is associated with the 4 cardinal signs of infection which are Erythema, pain, swelling and warmth. Physical examination findings that suggest the most likely pathogen include the following such as skin infection without underlying drainage, penetrating trauma, eschar or abscess is most likely caused by streptococci; Staphylococcus aureus, often community-acquired MRSA, is the most likely pathogen when these factors are present . Meanwhile, Violaceous color and bullae suggest more serious or systemic infection with organisms such as Vibrio vulnificus or Streptococcus pneumonia. Besides that, the following findings suggest severe infections such as Malaise, chills, fever, and toxicity, Lymphangitic spread (red lines streaking away from the area of infection), Circumferential cellulitis and pain disproportionate to examination findings. There are indications for emergent surgical evaluation which are as follows, Violaceous

bullae, Cutaneous hemorrhage, Skin sloughing, Skin anesthesia, Rapid progression and Gas in the tissue. 4.0 Investigation Generally, no workup is required in uncomplicated cases of cellulitis that meet the following criteria such as limited area of involvement, minimal pain, no systemic signs of illness for instance, fever, altered mental status, tachypnea, tachycardia, and hypotension and no risk factors for serious illness such as extremes of age, general debility and immunocompromised. The Infectious Disease Society of America (IDSA), recommends the following blood tests for patients with soft-tissue infection who have signs and symptoms of systemic toxicity. They are Blood cultures, CBC with differential and levels of creatinine, bicarbonate, creatine phosphokinase, and C-reactive protein (CRP). Firstly, Blood cultures should also be done in the following circumstances for instance, moderate to severe disease such as cellulitis complicating lymphedema, Cellulitis of specific anatomic sites such as facial and especially ocular areas, Patients with a history of contact with potentially contaminated water. There are also several other tests to be considered such as Mycologic investigations which are advisable if recurrent episodes of cellulitis are suspected to be secondary to tinea pedis or onychomycosis and also Creatinine levels which help to assess baseline renal function and guide antimicrobial dosing. Secondly, Imaging studies can be use through Ultrasonography which play a role in the detection of occult abscess and direction of care. Ultrasonographic-guided aspiration of pus can shorten hospital stay and fever duration in children with cellulitis. If necrotizing fasciitis is a concern, CT imaging is typically used in stable patients. Besides, MRI also can be performed but MRI typically takes much longer than CT scanning. Strong clinical suspicion of necrotizing fasciitis should prompt surgical consultation without delay for imaging. Apart from that, Aspiration, Dissection and Biopsy. Needle aspiration should be performed only in selected patients or in unusual cases such as in cases of cellulitis

with bullae or in patients who have diabetes, are immunocompromised, are neutropenic, are not responding to empiric therapy, or have a history of animal bites or immersion injury. Aspiration or punch biopsy of the inflamed area may have a culture yield of 240% and is of limited clinical value in most cases. Gram stain of aspiration or biopsy specimens has a low yield and is unnecessary in most cases, unless purulent material is draining or bullae or abscess is present; however, Gram stain and culture following incision and drainage of an abscess yields positive results in more than 90% of cases. Dissection of the underlying fascia to assess for necrotizing fasciitis may be determined by surgical consultation or indicated following initial evaluation and imaging studies. Skin biopsy is not routine but may be performed in an attempt to rule out a noninfectious entity. Finally, hospital admission where The IDSA recommends considering inpatient admission in patients with hypotension or the with following laboratory findings such as Elevated creatinine level, elevated creatine phosphokinase level (2-3 times the upper limit of normal), CRP level >13 mg/L (123.8 mmol/L), low serum bicarbonate level and marked left shift on the CBC with differential. 5.0 Management There are several treatments for Cellulitis. The treatments of cellulitis are Antibiotic regimens which are effective in more than 90% of patients. All but the smallest of abscesses require drainage for resolution regardless of the pathogen. Drainage only without antibiotics, may suffice if the abscess is relatively isolated with little surrounding tissue involvement. In cases of cellulitis without draining wounds or abscess, streptococci continue to be the likely etiology and beta-lactam antibiotics are appropriate therapy as noted in the following cases. In mild cases of cellulitis treated on an outpatient basis use Dicloxacillin, amoxicillin, or cephalexin. In cases of patients who are allergic to penicillin Clindamycin or a macrolide (clarithromycin or azithromycin) are used. An initial dose of parenteral antibiotic with a long half-life like ceftriaxone followed by an oral agent.

Furthermore, the treatment of recurrent disease which usually related to venous or lymphatic obstruction is as follows. The cellulitis is most often due

to Streptococcus species, and penicillin G or amoxicillin (250 mg bid) or erythromycin (250 mg qd or bid) may be effective. If tinea pedis is suspected to be the predisposing cause, treat with topical or systemic antifungals. Meanwhile, patients with severe cellulitis require parenteral therapy such as Cefazolin, cefuroxime, ceftriaxone, nafcillin, or oxacillin for presumed staphylococcal or streptococcal infection, Clindamycin or vancomycin for penicillin-allergic patients, Broad gram-positive, gram-negative, and anaerobic coverage for cases associated with diabetic ulcers and coverage for MRSA, until culture and sensitivity information become available, for severe cellulitis apparently related to a furuncle or an abscess. Instead of that, for cellulitis involving wounds sustained in an aquatic environment, recommended antibiotic regimens vary with the type of water involved, such as saltwater or brackish water which known as Doxycycline and ceftazidime, or a fluoroquinolone, freshwater which is a third or fourth generation cephalosporin for instance, ceftazidime and cefepime or a fluoroquinolone like ciprofloxacin or

levofloxacin. Lack of response to an appropriate antibiotic regimen should raise suspicion for Mycobacterium marinum infection and suggest wound biopsy for mycobacterial stains and culture.