BẢN TIẾNG ANH

Cellulitis
Description
■Cellulitis is an infection of the dermis and subcutaneous tissues characterized by fever,
erythema, edema, and pain.
History
Localized pain and tenderness occur for a few days before presentation.
The most susceptible populations are people with diabetes, cirrhosis, poor lymphatic
circulation (i.e., postmastectomy), renal failure, malnourishment, and HIV. Patients who
have cancer and are on chemotherapy or who abuse intravenous drugs and alcohol are
also at increased risk.
Cellulitis typically occurs near surgical wounds and trauma sites (e.g., bites, burns,
abrasions, lacerations, and ulcers).
It may develop in apparently normal skin or at sites of other dermatoses.
Recurrent episodes occur with local anatomic abnormalities that compromise the venous
or lymphatic circulation (e.g.. chronic stasis dermatitis).
The pinna and lower legs are particularly susceptible to recurrence.
Picking skin and transfer of bacteria from fingernails into minor skin abrasions may be an
important source.
Skin Findings
A pre-existing lesion, such as an ulcer or erosion, may act as a portal of entry for the
infecting organism.
Athlete's foot may be a common predisposing condition for cellulitis of the lower
extremities.
An expanding red. swollen, tender, or painful plaque with an indefinite border may cover
a small or wide area. Skin appears tight. Patient may have nausea chills. Shaking.
Palpation produces pain, but rarely crepitus
Vesicles, blisters, hemorrhage, necrosis, or abscesses may occur.
Regional lymphadenopathy sometimes occurs: lymphangitis and adenitis are common
with infection with S. pyogenes
Repeated attacks on the legs can impair lymphatic drainage, leading to chronically
swollen legs.
The end stage of repeated infection of the leg includes dermal fibrosis, lymphedema, and
epidermal thickening. This is known as elephantiasis nostras.
Laboratory
Mild to moderate leukocytosis and a mildly elevated erythrocyte sedimentation rate may
be present.
Cellulitis without abscess is most often caused by a group A streptococcus. Many other
bacteria, including S. aureus, can cause cellulitis. Less common causative organisms
include Erysipelothrix rhusiopathiae (erysipeloid) in fish, poultry, meat, or hide handlers:
Aeromonas hydrophila after swimming in fresh water: Vibrio species after swimming in
salt water or exposure to raw seafood drippings: Pasteurella multocida from an animal
bite or scratch.
Culture of the lesion is a more predictable source of information than needle-aspirate
cultures.
Differential Diagnosis
Stasis dermatitis
Thrombophlebitis
Deep venous thrombosis
Contact dermatitis
Erythema nodosum
Treatment
 Elevation of the affected limb assists with drainage and will hasten recovery. Rest with
elevation of the affected limb is advised.
 Empiric treatment with antibiotics aimed ar staphylococcal and streptococcal organisms
is appropriate because it is difficult clinically to distinguish between streptococcal and
staphylococcal infections.
 MRSA and macrolide or erythromycin-resistant S. pyogenes can complicate
management.
 If the case is not severe and there are no signs of systemic infection, treat with a
semisynthetic penicillin (dicloxacillin 500-1000 mg orally every 6 hours, amoxicillin-
clavulanate 875/125 mg twice daily or 500/125 mg three times daily), a cephalosporin
(cephalexin 500 mg four times daily), or clindamycin 300 mg orally four times a daily.
Reserve fluoroquinolone (levofloxacin) use for gram-negative organisms documented by
culture.
 Cellulitis adjacent to an abscess has a high risk for MRSA strains. Most CA-MRSA
strains are sensitive to trimethoprim-sulfam ethoxazole, doxycycline 100 mg two times a
day, and clindamycin 300 mg by mouth three to four doses daily..
 The mean time for healing after treatment is initiated is 12 days.
 Most cases improve when the patient is on simple oral antibiotic therapy for 5 days.
Nonresponding cases require re-evaluation. consideration of infectious disease
consultation, and intravenous antibiotics.
 Severe infections may require hospitalization and intravenous antibiotics. Intravenous
empiric therapy with coverage for group A streptococci and S. aureus is cefazolin 1 g
every 8 hours or nafcillin 2 g every 4 to 6 hours.
 Abscesses require drainage.
Secondary Bacterial Cellulitis From Pre-existing Wounds, Trauma, or Skin
Lesions
 In eczema and lacerations, infecting organisms are typically S. aureus or group A
streptococci.
 Cellulitis with an abscess or furuncle, or in postsurgical patients, should prompt
antimicrobial coverage including MRSA. pending culture.
 Infected decubitus ulcers are often malodorous and necrotic and are complicated by
increasing tenderness and fever. Organisms most commonly present are mixed bowel
flora (gram-negative organisms, streptococci, anaerobes).
 Infection of burns is most commonly due to Pseudomonas aeruginosa, other gram-
negative organisms. S. aureus, and Candida species.
 Postsurgical cellulitis may be due to gram-negative organisms and can be complicated
by wound dehiscence and sepsis. Treat for MRSA, group A streptococci, and gram-
negative bacilli.
 Gangrenous cellulitis involves extensive necrosis of subcutaneous tissue and overlying
skin and is a rapidly progressive form of cellulitis most commonly caused by group A
streptococci. Such streptococcal gangrene most commonly occurs at the site of trauma.
Painful erythema is followed by edema, bullae, and necrosis and may be complicated by
rapid development of bacteremia and septic shock. Prompt management is critical.
 Infections in diabetic patients with leg ulcers need broader spectrum coverage and are
often polymicrobial. Coverage should be for gram-positive, gram-negative, and
anaerobic organisms.
 Treat infections from dog and cat bites with oral amoxicillin-clavulanic acid 875 mg/175
mg twice daily for 7 to 10 days. If the patient is allergic to penicillin. use a
fluoroquinolone plus clindamycin or trimethoprim-sulfamethoxazole. Cephalosporins
are less effective.
Pearls
 Interdigital athlete's foot may be a predisposing condition for cellulitis of the
lower extremity. Cultures from the interdigital spaces may yield the pathogenic
bacteria.
Cellulitis is characterized by erythema, edema, and pain. Patients with cellulitis of the leg
often have a pre-existing lesion, such as an ulcer or erosion, that acts as a portal of entry
for the infecting organism.
Empiric therapy of cellulitis must give good coverage for S. pyogenes, if no purulence is
present, streptococcal infection is most likely, and trimethoprim sulfamethoxazole or
tetracyclines may not give adequate streptococcal coverage and should not be first
choice. In the case of cellulitis with abscess, treat for CA-MRSA.
Treat aquatic punctures and lacerations for common gram-positive and gram-negative
aquatic bacteria (freshwater-a fluoroquinolone, saltwater-doxycycline and ceftazidime or
a fluoroquinolone).
Cellulitis of the pinna may result from infection with Pseudomonas species or with
staphylococci and streptococci. The lymphatics may be permanently damaged during an
attack, predisposing the patient to recurrent episodes of streptococcal erysipelas of the
pinna. Recurrent attacks are brought on by manipulation, or even by the slightest trauma.
Pediatric Considerations
Perianal cellulitis due to group A beta-hemolytic streptococci can be misdiagnosed as
candidiasis. Children develop moist, edematous, pink skin around the anus and frequently
complain of itch and pain with bowel movements.
Cellulitis can complicate any cutaneous wound. Some children with varicella are at risk
for acquiring invasive forms of group A beta-hemolytic streptococcus (necrotizing
fasciitis)-return of fever. tachycardia, and severe skin tenderness are signs that should
prompt immediate evaluation for invasive group A streptococcus. Necrotizing fasciitis is
a complication of group A beta strep infection; the patient may present with flu-like
symptoms.
Fig. 6.13 Cellulitis with erythema, edema, and tenderness of the ear.
Fig. 6.14 Sharp demarcation of cellulitis of the arm. The area affected is tender, warm,
and swollen. Marking the area is a good way to monitor the expected resolut on when
receiving treatment.
Fig. 6.15 Cellulitis of the leg. There is often a predisposing skin lesion, such as an
abrasion, erosion, or fissure, that allows for bacteria to break the skin berrier and gain
entry to cause infection.
Fig. 6.16 An early case of cellulitis with diffuse erythema and minimal swelling. Pain
was el cited with palpation.
Fig. 6.17 Perianal cellulitis. Cellulitis (group A beta-hemolytic streptococci) around the
anal orifice is often misdiagnosed as candidiasis. It occurs more frequently in children.
They are not systemically ill. Culture confirms the diagnosis. Systemic therapy is
required.
Fig. 6.16 An early case of cellulitis with diffuse erythema and minimal swelling. Pain
was el cited with palpation.