Você está na página 1de 21

the clini

in the clinic

Cellulitis and
Soft-Tissue
Infections
Prevention page ITC1-2

Diagnosis page ITC1-4

Treatment page ITC1-7

Practice Improvement page ITC1-14

CME Questions page ITC1-16

Physician Writers The content of In the Clinic is drawn from the clinical information and
Lawrence J. Eron, MD education resources of the American College of Physicians (ACP), including
PIER (Physicians Information and Education Resource) and MKSAP (Medical
Section Editors Knowledge and Self-Assessment Program). Annals of Internal Medicine
Christine Laine, MD, MPH editors develop In the Clinic from these primary sources in collaboration with
David R. Goldmann, MD the ACPs Medical Education and Publishing Division and with the assistance
Harold C. Sox, MD of science writers and physician writers. Editorial consultants from PIER and
MKSAP provide expert review of the content. Readers who are interested in these
primary resources for more detail can consult http://pier.acponline.org and other
resources referenced in each issue of In the Clinic.

The information contained herein should never be used as a substitute for


clinical judgment.

2008 American College of Physicians


ellulitis is an infection of the skin and underlying tissues. It

C
may fol- low a break in the skin or a surgical wound but may
also occur with- out an obvious inciting event. The
microorganisms most frequently
involved include group A streptococci (Streptococcus pyogenes); groups
B, C, and G -hemolytic streptococci; and Staphylococcus aureus. Over
recent decades, cellulitis has challenged clinicians in several ways. First,
physician visits for cellulitis and soft-tissue infections have increased
from 32 to 48 visits per 1000 population from 1997 to 2005 (1).
Second, necrotizing fasci- itis due to group A streptococci is now
Preventio endemic in the United States. Third, S. aureus, the predominant cause
n of cellulitis accompanied by abscesses or wound drainage, has become
increasingly resistant to methicillin, requiring vancomycin and other,
newer antimicrobial agents. A particular community- acquired
methicillin-resistant S. aureus (CA-MRSA) strain, USA 300, is
replacing nosocomial strains of MRSA in hospitals (2).

4. Parish LC, Jorizzo JL, Breton JJ, et al. Topi- cal


retapamulin oint- ment (1%, wt/wt) twice daily What factors increase the risk
for 5 days versus oral cephalexin twice daily for
10 days in
for cellulitis and soft-tissue
the treatment of sec- ondarily infected der- infections?
matitis: results of a randomized con- trolled trial.
J Am Any injury to the skin may lead
Acad Dermatol. to cellulitis or soft-tissue
2006;55:1003-13. [PMID: 17097398]
infections. Human or animal
bites have an especially high risk
1. Hersh AL, for subsequent infection. Crush
Chambers HF, injuries and open fractures,
Maselli JH, et al.
National trends in particularly those with vascular
ambulatory visits
and antibiotic
injury or gross contamina- tion
prescribing for with soil, are likely to become
skin and soft-tis-
sue infections. infected. Patients with comorbid
Arch Intern Med.
2008;168:1585-
conditions that predispose them
91. [PMID: to infection (see Box) are also at
18663172]
2. King MD, increased risk for cellulitis.
Humphrey BJ,
Wang YF, et al.
Emergence of
A past episode of streptococcal
com- munity- cel- lulitis puts patients at risk for
acquired
methicillin- recur- rences, especially if tinea
resistant
Staphylococcus
pedis is present (3). Recurrent
aureus USA 300 cellulitis is also common in
clone as the
predominant patients with
cause chronic venous insufficiency,
of skin and soft-
tissue infections. radical mastectomy with axillary
Ann Intern Med.
2006;144:309-
lymph node dissection, or a
17. [PMID: coronary artery bypass graft with
16520471]
3. Semel JD, Goldin saphenous vein harvesting.
H. Association of
ath- letes foot
with celluli- tis of How can patients decrease
the lower their chances of developing
extremities:
diagnos- tic value cellulitis and soft-tissue
of bacterial
cultures of
infections? Wounds due to
ipsilateral minor traumatic injuries should
interdigital space
samples. Clin be meticulously cleaned with
Infect Dis.
1996;23:1162-4.
antibacterial soap. Application of
[PMID: 8922818] neomycin (or mupirocin
ointment Although it is not an approved should be inspected for tinea
when indication, retapamulin pedis, which should be
MRSA is ointment is an option when treated if present.
suspected) mupirocin-resistant MRSA is
may be suspected or proven (4).
helpful in Risk Factors for Cellulitis and
patients Major traumatic wounds, Soft-Tissue Infection
with including crush injuries and Trauma (lacerations, burns,
open fractures, should be abrasions, crush injuries, open
comorbid fractures)
conditions cleansed with copious saline
Intravenous drug use
that irrigation and, if necessary, Human or animal bites
predispose surgical debridement with Conditions that predispose to
them to repair of injured vessels. infec- tion (diabetes, arterial
Wounds should be left open insufficiency, chronic venous
infection. insufficiency, lymph- edema,
to heal by secondary intention. chronic renal disease, cirrho- sis,
Antimicrobial prophy- laxis neutropenia, and
should be administered hypogammaglob- ulinemia)
according to recommendations Past streptococcal cellulitis
(especially if tinea pedis is
for the type of injury (5). present)
Radical mastectomy with
Patients with recurrent axillary dissection
lower- extremity cellulitis Saphenous vein harvesting

2008 American College of Physicians ITC1-2 In the Clinic Annals of Internal Medicine 6
January 2009
Which strategies reduce the so for other bites when there is sterile adhesive strips
risk for cellulitis and soft- extensive injury to soft tissue or closed by delayed
tissue infections in patients or when the bite site is near a primary clo- sure. If
with diabetes? joint or bone. For patients sutures are necessary,
Patients with diabetes should allergic to peni- cillin, use then antimicrobial
receive education about proper moxifloxacin plus clin- prophylaxis and close
foot care and should regularly damycin. Doxycycline may follow-up are
inspect their feet to promptly also be used for prophylaxis of indicated.
recognize problem areas. cat bites.
Treatment of super- ficial
A 2001 review of 8 randomized,
plantar ulcers with aggressive
controlled trials compared
cleansing and off-weighting of
antibiotics with placebo or no
the ulcerated area may prevent treatment to prevent infection fol-
subse- quent infection. Plantar lowing mammalian bites. Overall,
calluses should be shaved down. the use of antibiotics was
Multi- disciplinary foot-care associated with a statis- tically
teams may be helpful (6). significant reduction in infection
following human bites but not cat
Which strategies or dog bites. In addition, in analyses
decrease cellulitis and of any mam- malian bite to the
soft-tissue hand, prophylactic antibiotics
infections after mammalian reduced the rate of infection
bites? Bite wounds should be (odds ratio, 0.20 [95% CI, 0.01 to
thoroughly cleansed. Clinicians 0.86]) (7).
should admin- ister amoxicillin
Avoid suturing bite wounds
and clavulanate for prophylaxis
closed except if the wounds
of closed-fist injuries and cat
are on the face. Wound edges
bites and should consider doing
may be approx- imated with
Which interventions decrease the to 10 weeks later while observ- ing Surgical Techniques
risk for cellulitis and soft-tissue for soft-tissue infections. At baseline, that Reduce the
infections associated with 24 (3%) participants were colonized Postoperative
with CA-MRSA and 229 (28%) with Infection Rate
surgical wounds?
Surgical site infections develop in methicillin- sensitive S. aureus (MSSA). Proper skin
Of those with CA-MRSA, 9 (38%) preparation
2% to 5% of all surgical proce- Gentle traction
developed soft-tissue infection
dures. To prevent them, health compared with 8 (3%) with MSSA during surgery
care providers must practice good (relative risk, 10.7 [CI, 4.6 to 25.2]). At Effective
hand hygiene, proper preparation hemostasis
of the patients skin, and good Removal of
devitalized tissues
surgical technique (see Box). Obliteration of dead
space
Proper perioperative Irrigation of
antimicrobial prophylaxis, tissues
administered within 1 hour Fine,
before surgical incision, also nonabsorbable
monofilament
prevents surgical wound infection. suture material
Recommendations are for single- Closed-suction
dose administration or multiple drains
doses to end within 24 hours Wound closure
follow- ing the end of surgery (see without tension
Box) (8).

What is the role of surveillance


to identify patients with MRSA Antimicrobial
colonization or infection? Prophylaxis in Surgery
Although MRSA can occur in Cefazolin or cefuroxime
for clean surgical
anyone, athletes, men who have procedures
sex with men, incarcerated (Clindamycin or vanco-
individuals, and people living in mycin for patients with
penicillin allergy)
public housing are at greater risk Cefoxitin, ampicillin/
for MRSA infec- tion than are sulbactam, or
other populations (9). In the metronida-
zole/cefazolin for
United States, 126 000 hos- gastro- intestinal
pitalized patients are infected by surgery (Clindamycin
MRSA each year, and 5000 die as or vanco- mycin plus
aztreonam or
a result. To reduce these ciprofloxacin for
staggering numbers, it would patients with penicillin
seem that clini- cians should allergy)
identify and isolate patients who
are colonized or infected with
MRSA. However,
the connection between coloniza-
tion and infection and the effec- 5. Holtom PD.
tiveness of decolonization in Antibiotic
prophylaxis:
reduc- ing infection are unclear. current
recommendation
The s. J Am Acad
cost-efficacy of active Orthop Surg.
2006;14:S98-
surveillance cultures to identify S100.
MRSA carriers is also [PMID: 17003220]
6. Lipsky BA,
controversial (10). Berendt AR, Deery
HG, et al.
Infectious
A study of 812 U.S. soldiers Diseases Society
evaluated changes over time in of America.
Diagnosis and
community- acquired MRSA treat- ment of
colonization by collecting nasal swabs diabetic foot
infections. Clin
for S. aureus cultures at base- line and 8 Infect Dis.
2004;39:885-910. [PMID: 8. Scottish Intercolle- giate elines/fulltext/10
15472838] Guidelines Net- work. 4/in dex.html on
7. Medeiros I, Saconato H. Antibiotic Antibiotic pro- phylaxis in 11
prophy- laxis for mammalian bites. surgery. Guideline No 104; November 2008.
Cochrane Data- base Syst Rev. 2008. Accessed at
2001:CD001738. [PMID: www.sign.ac.uk/guid
11406003]

6 January Annals of Internal In the ITC1- 2008 American College of


2009 Medicine Clinic 3 Physicians
follow-up, CA-MRSA colonization Although there is evidence that
had decreased to 1.6% without MRSA carriers can be
eradication efforts (11).
decolonized, the net benefit of
In a prospective crossover study in decolonization is uncertain and
which patients were assigned to decolonization through the use
either poly- merase chain reaction of topical antimi- crobials
testing of speci- mens from their
nares or no polymerase chain applied to the nares is not
reaction testing, the incidence of always successful (14). A review
nosocomial MRSA infection was 1.11 addressing eradication strategies
per for MRSA found insufficient
1000 patient-days compared with
9. Diep BA, Chambers evidence to support the use of
HF, Graber CJ, et al. 1.20 in control participants, a
Emer- gence of nonsignificant dif- ference (12). topical or sys- temic
multidrug-
resistant, antimicrobial therapy or
community- A study examining the cost- combinations of these agents for
associated,
methicillin- effectiveness of active surveillance
resistant cultures and barrier precautions for
eradicating nasal or extranasal
Staphylococcus
aureus clone controlling MRSA in neonatal MRSA and identified the
USA300 in men intensive care units of 2 hospitals potential for serious adverse
who have sex with
men. Ann Intern found that identifying colonized events and the development of
Med. patients and implementing
2008;148:249 antimicrobial resistance (15).
-57. [PMID: preventive measures was cost-
18283202] effective (13).
10. Webster J,
Osborne S.
Preoperative
bathing or
showering with
skin antiseptics to Prevention... Prevention of cellulitis and soft-tissue infection is best
prevent surgical
site infection.
accomplished
Cochrane by thorough cleansing of wounds and, when indicated, antimicrobial
Database Syst
Rev.
prophylaxis.
2007:CD00498 In patients with diabetes, examination of the plantar surface of the foot
5. [PMID: and proper early management of lesions prevents the development of
17443562]
11. Ellis MW, infection. Cen- tral principles in the prevention of surgical site infections
Hospenthal DR, are good hand hygiene, good surgical technique, and appropriate use of
Dooley DP, et al.
Natural history of
perioperative antibiotic prophy- laxis. The jury is still out on the net
community- benefits of active surveillance of MRSA carri- ers with identification and
acquired
methicillin-
decolonization.
resistant
Staphylococcus
aureus colonization
and infection in
Diagnosi CLINICAL BOTTOM
soldiers. Clin Infect
Dis.
2004;39:971-9.
s LINE
[PMID:
15472848]
12. Harbarth S,
Fankhauser C,
Schren- zel J, et al.
Universal
screening for methi-
cillin-resistant Staphy- What is the role of the history wounds, or penetrating trauma are
lococcus aureus at
hospital admission
and physical examination in the present (16). Crepitus suggests
and nosocomial infec- diagnosis of cellulitis and soft-
tion in surgical
patients. JAMA. tissue infections? Pathogens Associated With
2008;299:1149-57.
[PMID: 18334690] A careful history is important in Clinical Scenarios
13. Karchmer TB, Durbin
LJ, Simonton BM, et al.
determining the potential cause of Diabetes: Staphylococcus aureus,
Cost-effectiveness of
active surveillance
the infection. See Box for microor- group B streptococci, anaerobes,
gram-negative bacilli
cultures and con- ganisms associated with specific
tact/droplet precau- Cirrhosis: Campylobacter fetus,
tions for ` control of clinical situations. coliforms, Vibrio vulnificus,
methicillin-resistant
Staphylococcus aureus.
Capnocytophaga canimorsus
J Hosp Infect. Skin infection has many causes, and Neutropenia: Pseudomonas
2002;51:126-32. aeruginosa
[PMID: 12090800] other conditions may mimic infec-
14. Simor AE, Phillips E, tion (Table 1). The physical exami- Human bite: Eikenella corrodens
McGeer A, et al. Ran-
Cat bite: Pasteurella multocida
domized controlled nation helps to differentiate celluli-
trial of chlorhexidine Dog bite: P.
gluconate for wash- tis from other diagnoses and to multocida, C.
ing, intranasal
mupirocin, and determine the potential causes if canimorsus
rifampin and doxycy-
cellulitis is present. The absence of Rat bite: Streptobacillus
cline versus no treat-
moniliformis
ment for the eradica-
tion of
drainage or abscess formation Hot tub exposure: P. aeruginosa
methicillin-resistant makes streptococci a likely cause, as Fresh water laceration:
Staphylococcus aureus
colonization. Clin do lymphangitis, a raised indurated Aeromonas hydrophila
Infect Dis.
2007;44:178-85. border, and a peau dorange appear- Fish tank exposure:
[PMID: 17173213] ance of the skin. S. aureus is more Mycobacterium marinum
IV drug use: MRSA, P. aeruginosa
likely when abscess, draining

2008 American College of Physicians ITC1-4 In the Clinic Annals of Internal Medicine 6
January 2009
infection by gas-producing nonlimb-threatening superficial cellulitis, because the former
organisms, such as an anaerobic requires hospitalization whereas outpatient treatment is usually
bacteria or a gram-negative suf- ficient for the latter (17). See Box
bacil- lus. A foul odor may
indicate infec- tion by anaerobic
microorganisms, whereas a
sweet odor may indicate the
presence of Pseudomonas or
clostridial species.

Impetigo is characterized by
blis- ters and sores on the face
or extremities, is due to
streptococci or staphylococci
(S. aureus has become
predominant in recent years),
and usually occurs in chil-
dren. Necrotizing fasciitis
involves deeper tissue planes
(fascia and muscle), whereas
less-severe forms
involve subcutaneous tissue
(celluli- tis) or epidermis and
dermis (erysipelas) (Figure).

Clinicians must differentiate


limb- threatening infection,
such as necrotizing fasciitis,
from
Table 1. Other Conditions to chills, or reddened skin. Hemodynamic instability
Consider in the Differential with pulmonary embolism.
Diagnosis of Cellulitis and Soft- Septic arthritis Fever. Exquisitely painful range of motion.
Tissue Infection Olecranon bursa infection Redness, tenderness, fluctuance, nonpainful
range of motion.
Disease
Characteristics Toxic epidermal necrolysis Mucous membrane and diffuse cutaneous
involvement.
Myositis due to viruses or Mild-
Bullae and sloughing of skin. History of drug
to-moderate fever. Severe, diffuse pain
and little to parasites no exposure. Hypersensitivity reaction Usually localized. Insect bite might
localized pain. Mild systemic toxicity. be present.
No gas in tis- Contact dermatitis Look for unusual patterns of distribution.
sues. No There is no fever, but pruritis is present.
obvious Exposure to irritant.
portal of
entry. Pyoderma gangrenosum Usually on the anterior shin. Frequently acute
bluish- black discoloration. Ragged ulcers
Deep venous thrombophlebitis Deep with undermined edges. Often underlying
pain, inflammatory bowel disease.
usually
in the Herpetic whitlow Vesicles on digits with associated pain, redness,
calf. and swelling; frequently accompanied by
Not lymphangitic streak- ing. Sometimes occupational
usually (for example, dental hygien- ist, anesthesiologist).
associa Erythema migrans (Lyme disease) Resembles erysipelas, but is not painful and
ted progresses slowly, and fever is less marked.
with Early herpes zoster (before Pain and erythematous papules precede vesicle
fever, formation. vesicles appear)

15. Loeb M, Main C,


Hair follicle Sebaceou Walker-Dilks C, et
s gland al. Antimicrobial
Bulla drugs for treating
e methi- cillin-
Cru Vesicl
st e resistant
Staphylococcus
aureus
Stratum colonization.
corneum Erysipel
as Cochrane
Database Syst
Strat Rev.
um 2003:CD0033
germinativ 40. [PMID:
um 14583969]
Cellulitis 16. Stevens DL, Bisno
Dermal AL, Chambers HF,
papillae et al. Infectious
Dis- eases Society
Post capillary of America.
venule Practice
guidelines for the
diagnosis and
man- agement of
skin and soft-
Subcutaneous tissue infections.
fat Clin Infect Dis.
2005;41:1373-
406. [PMID:
Deep fascia 16231249]
17. Bisno AL,
Lymphatic Cockerill
channel FR 3rd, Bermudez
CT. The initial
Vein outpa- tient-
physician
Artery encounter in group
A streptococcal
necrotizing fasciitis.
Bone Clin Infect Dis.
2000;31:607-8.
[PMID: 10987730]
18. Anaya DA, Dellinger
EP. Necrotizing soft-
tissue infection:
diagnosis and man-
agement. Clin Infect
Dis. 2007;44:705-
Figure. Anatomy of Skin and Soft Tissues and Different Types of Skin and Soft-Tissue 10. [PMID:
17278065]
Infections.

6 January Annals of Internal In the ITC1- 2008 American College of


2009 Medicine Clinic 5 Physicians
Table 2. Laboratory and Other Studies for Evaluating Cellulitis and Soft-Tissue
Physical Examination Infection
Findings that Suggest Test Notes
Necrotizing Fasciitis
CBC, differential, and Elevated leukocyte count with marked left shift suggests
Rapid increase in size of platelet count deep-seated or systemic infection. Decreased platelet count
the infected area suggests bacteremia, the toxic shock syndrome, or gas
Evolution of violaceous bullae gangrene. Leukemoid reaction (>50 000) and
A reddish-purple discoloration hemoconcentration (rising hematocrit, frequently
of the skin >60) suggests Clostridium sordellii infection. Low hematocrit,
Woody induration of the increased
infected area LDH, and intravascular hemolysis suggest C. perfringens
A pale appearance of the infection. Serum creatinine Elevated creatinine concentration suggests group
infected area rather than A streptococcal or
erythema clostridial myonecrosis or the toxic shock syndrome.
Pain or severe tenderness Serum glucose Elevated glucose level suggests underlying diabetes mellitus.
out of proportion to the
appearance of the cellulitis Serum CPK Elevated CPK concentration suggests rhabdomyolysis,
clostridial or streptococcal myonecrosis, or necrotizing
Severe systemic toxicity fasciitis.
Sepsis syndrome
Serum bicarbonate Low serum bicarbonate concentration suggests metabolic
acidosis and septic shock. Alternatively, in a patient with
diabetes, metabolic acidosis associated with any soft-tissue
infection suggests an aggressive process.
Serum albumin A low or decreasing albumin level suggests a diffuse
capillary leak syndrome. Subsequent soft-tissue swelling,
third spacing, and pulmonary edema may result.
Serum calcium A low serum calcium level suggests staphylococcal or
streptococcal toxic shock syndrome or necrotizing fasciitis.
Radiography Useful to detect gas in tissue and may also show underlying
fracture, osteomyelitis, or foreign body.
CT or MRI May be useful to localize the site, discern the extent of
disease, and provide for early diagnosis of necrotizing
infections.
Ultrasonography With necrotizing fasciitis caused by group A streptococcus,
distortion or thickening of the fascia with fluid accumulation
can occur in children. In adults, CT is better than
ultrasonography at defining the extent of disease.
Culture and sensitivity The definitive test for identification of the cause of
infection. testing

CBC = complete blood count; CPK = creatine phosphokinase; CT = computed tomography;


LDH = lactic dehydrogenase; MRI = magnetic resonance imaging.

21. Zahar JR, Goveia J, Lesprit P, et al. Severe soft


tissue infections of the extremities in for physical examination clues
patients admitted to an intensive care unit. Clin
Microbiol to necrotizing fasciitis.
Infect. 2005;11:79-82. [PMID: 15649312]
What is the role of laboratory
testing in the diagnosis of
cellulitis and soft-tissue
19. Arslan A, Pierre-
infections? Laboratory testing is
Jerome C, useful to judge the severity of
Borthne A.
Necrotizing infection and to
fasci- itis:
unreliable MRI guide therapy (Table 2).
findings in the
pre- operative
Appropri- ate laboratory tests
diagnosis. Eur J include blood cultures; complete
Radiol.
2000;36:139- blood count with differential; and
43. [PMID:
11091013] chemistries, includ- ing a
20. Eron LJ, Lipsky
BA.
creatinine, blood urea nitro- gen,
Use of cultures in
cellulitis: when,
creatine phosphokinase, glu- cose,
how, and why? electrolytes (especially the
[Editorial]. Eur J
Clin Microbiol bicarbonate), and calcium.
Infect Dis.
2006;25:615- Patients with lower extremity
7. [PMID:
16896821]
cellulitis
shoul tissue. Magnetic resonance patients with strep- tococcal toxic
d imaging is more sensitive than shock syndrome, 60% have
also CT for detecting edema but positive blood cultures (21).
be may be less useful in
evalu differentiating between cel- Although bullae and vesicles
ated lulitis and necrotizing fasciitis due to streptococcal toxic shock
for because of their low specificity syndrome may yield positive
tinea (18,19). cultures, those
pedis
. Results of wound and blood
cul- tures may guide antibiotic
Computed choices but are positive in less
tomography than 5% of cases (16, 20).
(CT) is Aspiration or punch biopsies
more sensitive are reported to yield posi- tive
and specific cultures in 2% to 40% of cases
than plain (21), with the lower figure
radiographs in being closer to most clinical
identifying experience. However, among
gas in

2008 American College of Physicians ITC1-6 In the Clinic Annals of Internal Medicine 6
January 2009
Types of Necrotizing Fasciitis
viability of underlying Necrotizing fasciitis type 1:
due to nonnecrotizing infection musculature. Diagnostic Mild- to-moderate fever and
by streptococci are sterile. incisions can be extended to systemic toxicity. Little to no
Streptococcal infection, although perform radical debridement, diffuse pain and mild-to-
highly inflam- matory, is moderate localized pain. Mild-
should necrotizing infection be to-moderate gas in tis- sues.
paucibacterial. In the future, visible. Other signs suggesting Portal of entry usually obvi-
polymerase chain reaction the need for surgical ous. Higher risk with diabetes
technology may permit rapid intervention include drainage,
(S. aureus, group B
iden- tification of pathogens that streptococci, anaerobes, and
thrombosed vessels, and lack of gram-negative bacilli).
are dif- ficult to culture. resistance to finger dissection in Necrotizing fasciitis type 2
normally adherent tissues (18). (flesh-eating strep):
When should clinicians consult Moderate- to-severe fever.
an interventional radiologist or Interventional radiologists can Little to no diffuse pain and
severe localized pain. Severe
surgeon during the evaluation use diagnostic imaging to locate, systemic toxicity. No gas in
of cellulitis and soft-tissue biopsy, and aspirate deep tissues. Portal of entry not
infection? Patients with collections or masses for
obvious in 50% of cases
(commonly strep- tococci).
necrotizing fasciitis require diagnostic purposes as well as Necrotizing fasciitis type 3
early surgical inspection of the for therapeutic drainage but (gas gangrene): Moderate
deep tissues through a small cannot inspect wounds fever. Little to no diffuse pain
incision that allows evaluation macroscopi- cally or debride and severe local- ized pain.
Severe systemic toxicity. Severe
of the condition of the fascia devitalized tissue. gas in tissues. Portal of
and the entry usually obvious
(clostridial species).

Diagnosis... Clinicians must use the medical history, physical


examination, and laboratory testing to identify probable pathogens.
Culture identification of the pathogen should lead to changes from
initial broad-spectrum antimicrobial agents to more narrow-spectrum
regimens to avoid the emergence of resistance. Unfor- tunately, positive
cultures are infrequent in patients with nonpurulent cellulitis. Rapid
expansion of the infected area, violaceous bullae or reddish-purple
discol- oration of the skin, severe pain, or systemic toxicity suggest
necrotizing fasciitis, a condition that requires urgent surgical
evaluation.

CLINICAL
BOTTOM LINE

Treatment
Which adjuvant measures are When is topical
helpful in the treatment of antimicrobial therapy
patients with cellulitis and appropriate?
soft- tissue infection? Topical mupirocin is an option
Compression dressings in for impetigo with limited
patients with chronic venous lesions, but it is expensive and 22. Stevens DL,
Bryant AE,
insufficiency or pedal edema some staphylococci are Adams K, et al.
Evaluation of
promote resolution of cellulitis. resistant. Oral therapy with ther- apy with
Negative pressure dressings for penicillinase-resistant hyperbaric
oxygen for
large, exudative penicillins or first-generation experi- mental
infection with
wounds reduce proteolytic cephalosporins is preferred (16). Clostridium per-
enzymes and other substances fringens. Clin
Infect Dis.
that retard wound healing. How should clinicians 1993;17:231-7.
[PMID: 8399871]
Remediation of lymphedema or determine whether to 23. Eron LJ, Lipsky
BA, Low DE, et al.
compromised vascular supply prescribe oral or parenteral Expert panel on
may improve deliv- ery of antimicrobials? managing skin
and soft tissue
oxygen and antimicrobials High bioavailability makes par- infections.
Managing skin
to the site of infection. There is enteral administration of and soft tissue
insufficient evidence about the antimicro- bials largely infections: expert
panel
benefits of hyperbaric oxygen for unnecessary for mild, recommenda-
tions on key deci-
infected diabetic foot ulcers and uncomplicated cellulitis. sion points. J
Antimi- crob
gas gangrene (23). Parenteral therapy is usually Chemother.
2003;52 Suppl 1:i3-
reserved for mod- erate-to- 17. [PMID:
severe infections that may 14662806]

require hospitalization.
However,

6 January Annals of Internal In the ITC1- 2008 American College of


2009 Medicine Clinic 7 Physicians
Doxycycline or minocycline follow-up. Scand J Infect
Dis.
Oral Antimicrobials for Mild Trimethoprimsulfamethoxazole 1998;30:206-7.
[PMID: 9730318]
Infections Caused by Linezolid (very expensive) 26. Dall L, Peterson S,
Streptococci, MSSA, and Advanced fluoroquinolones Simmons T, et al. Rapid
moxifloxacin and levofloxacin resolution of cellulitis in
MRSA patients managed with
com- bination antibiotic
Streptococci only and anti-inflamma- tory
Phenoxymethyl penicillin 24. Bergkvist PI, Sjbeck K. therapy. Cutis.
Antibiotic and 2005;75:177-80.
Amoxicillin prednisolone ther- apy [PMID: 15839362]
of erysipelas: a 27. Lee MC, Rios AM, Aten
Streptococci or MSSA randomized, double MF, et al. Man- agement
Amoxicillinclavulanate blind, placebo-con- and out- come of
trolled study. Scand children with skin and
Cloxacillin, J Infect Dis. soft tissue abscesses
dicloxacillin, 1997;29:377-82. caused by commu- nity-
cephalexin [PMID: 9360253] acquired methi- cillin-
25. Bergkvist PI, Sjbeck K. resistant Staphylococcus
Clindamycin or a macrolide Relapse of erysipelas aureus. Pediatr Infect Dis
(if allergic to penicillins; and following treatment J. 2004;23:123-7. [PMID:
with prednisolone or 14872177]
if sen- sitive) placebo in addition to 28. Ruhe JJ, Menon A.
MSSA or MRSA antibiotics: a 1- year Tetracyclines as an oral
treatment option for
Clindamycin (if sensitive)
patients with
community parenteral agents may also be of group A streptococci are
onset skin and
soft tissue administered to outpatients if resist- ant to clindamycin.
infections
the patient is stable and has a
caused by Purulence is more often present
methi- cillin- social sit- uation that enables
resistant in staphylococcal cellulitis.
Staphylococcu out-patient therapy.
s aureus. Specimens from wounds,
Antimicrob Classification schemes
carbuncles, or furun- cles may
Agents
have been proposed to assist in
Chemother. reveal gram-positive
2007;51:3298- these treatment decisions (16,
303. [PMID: cocci in clusters, consistent with
17576834] 23).
S. aureus. Clinicians must judge
In some patients, cutaneous whether MRSA or MSSA is
inflam- mation worsens during likely. Appropriate choices for
the initial the oral
24 hours of antimicrobial treat-
ment. This is not necessarily a
sign of treatment failure and
may merely represent an
inflammatory response to release
of bacterial antigens.
Anti-inflammatory agents may
accelerate the resolution of the
clinical signs of inflammation
(24-
26). When patients do not
improve when receiving what
should be adequate
antimicrobials, it could also
represent antimicrobial resist-
ance; a deeper, undrained
collec- tion; or complicating
comorbid conditions.

One study suggests that


abscesses less than 5 cm in
diameter may be effectively
treated by incision and
drainage without systemic
antimi- crobial therapy (27),
but other studies show no
correlation between the size of
abscesses and
the need for antibiotic therapy
(28).

In patients for whom oral


therapy is appropriate, how
should clinicians choose a
specific antimicrobial agent?
Generally, streptococci usually
cause cellulitis without
purulence. Phenoxymethyl
penicillin, amoxi- cillin, or (for
penicillin-allergic patients)
clindamycin are all appro- priate
antibiotic choices (Box).
However, a small number
(<10%)
treatment of MSSA administered antimicrobials methoxazole should not be used
include cloxacillin; adequately tested in for cellulitis without purulence
dicloxacillin; cephalexin; comparative trials with because these drugs have
and, for penicillin-allergic parenteral vancomycin. relatively poor activity against
patients, clindamycin or a Clindamycin may be a very streptococci (31). In one
macrolide (eryth- romycin, good alternative, if the comparative trial, cures were
clarithromycin, or S. aureus (MRSA or MSSA) obtained in 37 of 42 patients
azithromycin). However, is susceptible. However, treated with orally
patients treated with resistance is becoming administered trimethoprim
cephalexin should be increasingly prevalent among sulfamethoxazole and 57 of 58
observed for treatment S. aureus. Advanced fluoro- patients treated with
failure, as some studies quinolones, such as vancomycin, suggesting
have reported high failure moxifloxacin and levofloxacin, equivalence between these 2
rates in adults (29), may also be used, but only if drugs in the treat- ment of mild
possibly due to poor patients cannot tolerate any cellulitis (32). A study comparing
absorption (30). other choices. trimethoprimsulfa-
methoxazole with doxycycline
Appropriate orally Trimethoprim sug- gested no statistically
administered choices for sulfamethoxazole is a significant difference between
the treatment of MRSA reasonable initial choice for these 2 antimi- crobials in the
include trimethoprim the treatment of mild, treatment of celluli- tis and soft-
sulfa- methoxazole, uncomplicated cellulitis. tissue infections caused by
doxycycline, minocy- cline, However, some experts feel MRSA (33). The use of clin-
or linezolid. Linezolid is that trimethoprimsulfa- damycin and tetracyclines to
one of the few orally treat

2008 American College of Physicians ITC1-8 In the Clinic Annals of Internal Medicine 6
January 2009
MRSA is supported only by vancomycin in compara- tive Parenteral Antibiotic
obser- vational studies (34, 35). trials. Some studies reported Therapy
more rapid resolution of Ceftriaxone, cefazolin,
In patients for whom clinical signs of inflammation and cefuroxime (for
streptococci and MSSA
parenteral therapy is in patients receiving infections)
appropriate, how should daptomycin compared with a Ertapenem, cefepime,
clinicians choose a specific matched cohort of patients ceftazidime (for gram-
antimicrobial regimen? negative bacillary
receiving vancomycin (36, 37). infection)
The choices for parenteral
Daptomycin and vancomycin
antibi- otics for cellulitis For outpatient parenteral (for
probably caused by treatment of MRSA, MRSA infections)
streptococci, as well as soft-tis- daptomycin has certain Clindamycin (for
sue infection due to MSSA, advantages when compared streptococci, MSSA,
and MRSA infection,
include semisynthetic penicillins with vancomycin. Daptomycin if sensitive)
(nafcillin and oxacillin), pharma- cokinetics allow once- Aminoglycosides (for
cephalosporins (cefa- zolin, daily adminis- tration in resistant gram-negative
bacillary infection)
cefuroxime, or ceftriaxone), patients with healthy renal
clindamycin (for penicillin- function. Rapid administration
allergic patients and if the does not cause red-man
pathogen is shown to be syndrome as
sensitive). If MRSA is
suspected, vancomycin, dapto-
mycin, tigecycline, and linezolid
are appropriate choices for
moder- ate-to-severe infections. Antimicrobials Commonly
The newer agents have been Used for Outpatient
shown to be non- inferior to
happens with vancomycin, and it antigen tests, or imaging studies Treatment of Human and
is not necessary to monitor are crucial. Empiri- cal therapy Animal Bites
dapto- mycin levels. should be quickly initi- ated and Oral treatment
guided by patient-specific Human bite:
A new antimicrobial agent, clinical parameters and the most amoxicillin/clavu- lanate
dalba- vancin, is awaiting Animal bite:
likely pathogens. For example, amoxicillin/clavulanate
approval by the U.S. Food and the most likely pathogens during
Drug Administra- tion. Its Parenteral treatment
the Human bite: ampicillin/sulbactram
pharmacokinetics allow once-
Animal bite: ampicillin/sulbactam
weekly administration, mak- ing
Penicillin allergy
it attractive for outpatient par-
Human bite: moxifloxacin
enteral treatment. Dalbavancin plus clindamycin,
has been compared with trimethoprim/
linezolid and shows similar sulfamethoxazole plus
metronidazole
efficacy (38) (Table Animal bite: doxycycline or
3). Other parenteral agents active moxi- floxacin or
against MRSA and pending trimethoprim/sul-
famethoxazole with either
release include telavancin, clin- damyciin or
ceftobiprole, cef- taroline, and metronidazole
iclaprim.
What is appropriate 29. Madaras-Kelly
KJ, Arbogast R,
antimicrobial therapy for Jue S. Increased
therapeu- tic
infections associated with failure for
human or animal bites? cephalexin
versus
See Box for suggested comparator
antibi- otics in
antimicrobial treatment following the treat- ment
bite wounds. The microorganisms of uncompli-
cated
involved in human bites are most outpatient
cellulitis.
commonly Eikenella corrodens, Pharma-
cotherapy.
anaerobes, and viridans 2000;20:199-
streptococci. Animal bites are 205. [PMID:
10678298]
commonly caused by a mixture of 30. Madaras-Kelly
KJ, Remington
bacteria, including Pasteurella RE, Oliphant CM,
mutocida, Streptococcus et al. Efficacy of
oral beta-
intermedius, anaerobes, and S. lactam versus
non- beta-
aureus. A rare cause of infection lactam treat-
ment of
following dog bites is uncomplicated
Capnocytophaga canimorsus, which cel- lulitis. Am J
Med.
causes severe sepsis syn- drome 2008;121:41
9-25. [PMID:
with disseminated intravas- cular 18456038]
coagulation but is susceptible to 31. Daum RS.
Clinical
penicillins. practice. Skin
and soft-tissue
infections
Are there special considerations caused by
methi- cillin-
for antimicrobial selection in resistant
immunocompromised patients Staphylococcus
aureus. N Engl J
with cellulitis and soft-tissue Med.
2007;357:380-
infection? The clinical signs of 90. [PMID:
17652653]
infection in 32. Markowitz N,
the immunocompromised patient Quinn EL,
Saravolatz LD.
may be subtle or absent due to Trimethoprim-
sul-
decreased inflammatory response. famethoxazole
Because of the extremely broad com- pared with
van- comycin
range of opportunistic pathogens for the treatment
of Staphy-
in this patient population, lococcus aureus
infection. Ann
attempts to definitively identify Intern Med.
pathogens with cultures, biopsies, 1992;117:390-
8. [PMID: 1503330] famethoxazole or aureus.
33. Cenizal MJ, Skiest D, doxycycline for out- Antimicrob
Luber S, et al. patient skin and soft Agents
Prospective random- tissue infections in Chemother.
ized trial of empiric an area of high 2007;51:262
therapy with prevalence of methi- 8-30. [PMID:
trimethoprim-sul- cillin-resistant 17502411]
Staphylococcus

6 January Annals of Internal In the ITC1- 2008 American College of


2009 Medicine Clinic 9 Physicians
Table 3. Drug Treatment for Cellulitis and Soft-Tissue Infections
Agent Dosage Side Effects Notes
-lactams
Penicillin G Low: 0.61.2 million IU/d, Hypersensitivity Benzathine useful only for impetigo due
IM (benzathine); High: >20 to Staphylococcus pyogenes or syphilis.
million IU/d, IV (crystalline) Crystalline useful for mild-to-moderate
streptococcal and clostridial infections and
bite wounds
Nafcillin 1.02.0 g, q4h IV or IM Hypersensitivity; reversible neutropenia; Useful for staphylococcal infections
interstitial nephritis; peripheral IV irritating except MRSA
Oxacillin 1.02.0 g, q4h IV or IM Hypersensitivity; hepatic dysfunction with Useful for staphylococcal infections
>12 g/d; interstitial nephritis except MRSA
Dicloxacillin 0.1250.5 g, q6h PO Hypersensitivity Useful for minor infections with Staphylo-
coccus except MRSA and Streptococcus
Amoxicillin 0.5 g, q8h PO; 0.875 g, q12h Hypersensitivity Useful for Pasteurella and minor strepto-
coccal infections
Ampicillin 0.250.5 g, q6h PO; 150200 Hypersensitivity Useful for Pasteurella and minor
mg/kgper day, IV streptococcal infections
Ampicillin 1.03.0 g, q68h IV Hypersensitivity Improved spectrum to Staphylococcus
sulbactam aureus and Bacteroides fragilis
Piperacillin 2.254.5 g, q6h Excellent gram-negative spectrum, including
tazobactam Pseudomonas species
Macrolides
Erythromycin 0.250.5 g, q6h PO; 1520 Hypersensitivity, nausea, vomiting, Erythromycin resistance in S. aureus and
mg/kg per day, IV diarrhea; phlebitis when given IV; group A streptococcus
cholestatic hepatitis (erythromycin estolate)
Clarithromycin 0.5 g, q12h PO GI intolerance (4%); reversible dose-related
hearing loss
Azithromycin 0.5 g PO on day 1, then 0.25 GI intolerance (4%); reversible dose-related
g/d PO on days 25; 0.5 g/d IV hearing loss
Cephalosporins
Cefazolin 1.02.0 g, q8h IV or IM Hypersensitivity Useful for both staphylococcal and strepto-
coccal infections
Cefuroxime 0.751.5 g, q6h IV or IM Hypersensitivity More stable than cefazolin against Staphy-
lococcus -lactamase. Useful for staphylo-
coccal and streptococcal infections.
Cefoxitin 1.0 g, q8h; 2.0 g, q4h IV Hypersensitivity Reasonable activity against anaerobes
Ceftriaxone 0.5 g, q12h; 2.0 g, qd (total Hypersensitivity; cholelithiasis Useful for outpatient prescription due to
<4 g/d) IV or IM once-a-day dosing
Cefpodoxime 100200 mg, q12h PO Hypersensitivity
Ceftobiprole 500 mg, q8h IV Active against MRSA, VISA, VRSA, gram-
negative bacilli
Ceftaroline 600 mg, q12h IV Active against MRSA, VISA, VRSA, gram-
negative bacilli
Fluoroquinolones
Ciprofloxacin 500750 mg, bid PO; CNS and GI disturbances; avoid caffeine; Excellent activity against gram-negative
200400 mg, q12h IV not for use during pregnancy and if age bacteria, including Pseudomonas
<18 y; Achilles tendon rupture
Levofloxacin 500750 mg, q24h IV or PO CNS and GI disturbances; avoid caffeine; Improved gram-positive spectrum against
not for use during pregnancy and if age Staphylococcus aureus and Streptococcus
<18 y; Achilles tendon rupture species
Moxifloxacin 400 mg, q24h PO CNS and GI disturbances; avoid caffeine; Improved gram-positive spectrum against
not for use during pregnancy and if age S. aureus and Streptococcus species
<18 y; Achilles tendon rupture
Gatifloxacin 200400 mg, q24h IV or PO Hypoglycemia; CNS and GI disturbances; Improved gram-positive spectrum against
avoid caffeine; not for use during pregnancy Staphylococcus aureus and Streptococcus
and if age <18 y; Achilles tendon rupture; species. Contraindicated in diabetes. Use
rarely used due to toxicity risk cautiously in the elderly and if renal insuffi
ciency is present
Aminoglycosides (rarely used due to toxicity risk)
Gentamicin 2 mg/kg load, then 1.5 mg/kg, Ototoxicity and nephrotoxicity Good spectrum of activity against resistant
q8h; 5.0 mg/kg (if critically ill, gram-negative bacteria. Follow levels to
7.0 mg/kg), q24h load guide dosing

2008 American College of Physicians ITC1-10 In the Clinic Annals of Internal Medicine 6 January 2009
Table 3. Drug Treatment for Cellulitis and Soft-Tissue Infections (continued)
Agent Dosage Side Effects Notes
Tobramycin 2 mg/kg load, then 1.5 mg/kg, Ototoxicity and nephrotoxicity Good spectrum of activity against resistant
q8h; 5.0 mg/kg (if critically gram-negative bacteria. Follow levels to
ill, 7.0 mg/kg), q24h load guide dosing
Amikacin 15 mg/kg per day
Glycopeptides
Vancomycin 15 mg/kg, q12h IV. Follow Can cause nephrotoxicity and the red-man Used primarily against MRSA
serum levels syndrome with rapid infusion.
Dalbavancin 1 g, IV followed 1 week later Active against MRSA, VRE (Van B and Van C
by 500 mg, IV strains only). Use for outpatient therapy
once weekly
Lincosamides
Clindamycin 0.150.45 g, q6h PO; 1.2 g, Pseudomembranous colitis Useful for severe group A streptococcal
IV q12h infections and gas gangrene caused by
Clostridium species; inhibits bacterial toxin
production; use for oral or dental infections
Tetracyclines
Doxycycline 100 mg, bid Liver toxicity; photosensitivity; tooth Option for penicillin-allergic patients
discoloration in children
Minocycline 100 mg, qd or bid Dizziness
Tigecycline 100 mg, IV load, 50 mg, q12h Nausea and vomiting Active against MRSA, streptococci, anaerobic
IV thereafter organisms, and gram-negative bacilli except
Pseudomonas species
Penems
Imipenemcilastatin 0.51.0 g, q6h IV Superinfection; allergic reactions; phlebitis; Broadly active against aerobes, anaerobes,
hepatotoxicity; seizures; renal failure gram-positives, and gram-negatives
Meropenem 12 g, q6h IV Diarrhea (5%); nausea, headache
Doripenem 500 mg, q8h IV Headaches 2- to 4-fold lower MIC for Pseudomonas
aeruginosa
Ertapenem 1 g, q24h Nausea, diarrhea, rash Use for outpatient therapy once daily
Oxazolidinone
Linezolid 600 mg, q12h IV or PO Nausea, diarrhea, thrombocytopenia with Active against MRSA and VRE, but also
prolonged treatment (>2 wk), peripheral against other gram-positive bacteria; should
neuropathy, optic neuritis not be used when alternatives are available
Lipopeptides
Daptomycin 46 mg/kg per day CPK elevation; rhabdomyolysis at high dosage Use for outpatient therapy once daily, use
for bacteremia due to MRSA, as it is rapidly
bactericidal
Telavancin 7.5 mg/kg, q24h IV Taste disturbance, headache Rapidly bactericidal with a long postantibi-
otic effect. Active against MRSA, GISA,
VRSA, VRE (including Van A strains), may
have a reduced potential for development of
resistance

bid = twice daily; CNS = central nervous system; DNA = deoxyribonucleic acid; GI = gastrointestinal; GISA = glycopeptide intermediate-resistant
Staphylococcus aureus; IM = intramuscular; IV = intravenous; PO = oral; qd = once daily; MIC = minimal inhibitory concentration; MRSA =
methicillin- resistant Staphylococcus aureus; VISA = vancomycin intermediate-resistant Staphylococcus aureus; VRE = vancomycin-resistant
enterococci;
VRSA = vancomycin-resistant Staphylococcus aureus.

first week of postchemotherapy antimicrobial therapy for cellulitis


neu- tropenia are gram-positive in immunocompromised patients 34. Martnez-Aguilar G,
organ- isms, such as staphylococci, should include coverage Hammerman WA,
Mason EO Jr, et al.
viridans streptococci, enterococci, of both gram-positive and gram- Clindamycin treat-
ment of invasive
and gram- positive bacilli, such as negative microorganisms infections caused by
community-
Corynebac- terium, Clostridia, and (ceftazidime, cefepime, acquired, methicillin-
Bacillus piperacillin tazobactam, resistant and methi-
cillin-susceptible
species. During the second week of meropenem, dori- penem, or Staphylococcus
aureus in children.
neutropenia, antibiotic-resistant imipenem). Penicillin- allergic Pediatr Infect Dis J.
2003;22:593-8.
bacteria and fungi (Aspergillus, patients should receive [PMID: 12867833]
Candida, and Rhizopus and Mucor fluoroquinolones (such as
species) become prominent. Initial ciprofloxacin) or aztreonam.

6 January 2009 Annals of Internal Medicine In the Clinic


ITC1-11 2008 American College of Physicians
Monotherapy of Pseudomonas infec- Because necrotizing fasciitis is asso-
Risk Factors for MRSA
tions seems at least equal to if not ciated with shock and organ failure,
Recent antibiotic use
superior to dual therapy, in view of with a mortality rate ranging from
Recent hospitalization
Recurrent needle
the toxicity associated with the 30% to 70% (16), these patients
sticks (IV drug use, addition of an aminoglycoside require hospitalization for surgical
hemo- dialysis, or (39). Reasons for initiating amino- debridement, prompt antibiotic
insulin- requiring
diabetic patients) glycosides for empirical treatment treatment, and monitoring. When
Homelessness, include a high level of anti- the diagnosis is in doubt, in-hospi-
incarceration microbial resistance within an tal observation is appropriate until
Contact sports institution. the clinical course becomes clear.
(football, wrestling) See Box for conditions that may
Previous MRSA infection
or colonization
If patients remain febrile and cul- require hospitalization.
tures remain negative, the empiri-
cal addition of vancomycin or Generally, hospitalized patients
Indications for daptomycin for MRSA coverage with cellulitis or soft-tissue infec-
Hospitalization of and addition of amphotericin or an tion can be discharged when no
Patients with Cellulitis echinocandin (caspofungin, mica- longer febrile, when the cellulitis is
and Soft Tissue fungin, or anidulafungin) or a tria- no longer spreading, and when the
Infections zole (voriconazole) are warranted leukocyte count is trending toward
Necrotizing fasciitis for antifungal coverage. Patients normal.
Toxic shock syndrome or with deficiencies of cell-mediated
multiorgan failure When should clinicians consider
Limb- immunity (such as those with consulting infectious disease
threatening lymphoma, or HIV infection or experts?
infection organ transplant recipients) are
Need for surgical Involvement of an infectious
debride- ment or beyond the scope of this article disease expert may result in more
drainage (16). appropri- ate and cost-effective use
Gas in tissue of antimi- crobial agents and may
Inadequate home situa- When should clinicians consider
tion or patient at risk for coverage of MRSA when treating be helpful when patients are
nonadherence immunocompro- mised, have severe
patients with cellulitis and soft-
infection, or do not improve on
tissue infections?
initial therapy.
Although MRSA should be con-
sidered in all cases of cellulitis or In one study, more-appropriate treatment
35. Ruhe JJ, Monson T, soft-tissue infection (because of its was ordered initially by a consulting
Bradsher RW, et al.
Use of long-acting widespread prevalence), particular infec- tious disease specialist (78%) than
tetracyclines for populations are at higher risk than without such consultation (54%).
methicillin-
resistant others (see Box). MRSA and Following the availability of culture
Staphylococcus
aureus infections: MSSA should be suspected in results, appropriate treatment increased
case series and to 97% and 89%, respectively (40).
review of the patients with purulent cellulitis,
litera- ture. Clin
Infect Dis.
although streptococci can also What should clinicians consider
2005;40:1429- cause purulent cellulitis. in managing patients with
34. [PMID:
15844065] necrotizing fasciitis?
36. Davis SL, McKinnon When should clinicians
PS, Hall LM, et al. Type 1 necrotizing fasciitis is usu-
Daptomycin versus hospitalize a patient with
vancomycin for ally a polymicrobial infection due to
complicated skin cellulitis and soft- tissue
and skin structure S. aureus, group B streptococci,
infection?
infections: clinical anaerobic organisms, and gram-
and economic out- Mild, uncomplicated cellulitis may
comes. Pharma- negative bacilli. Management
cotherapy. be treated out of the hospital with includes broad-spectrum antimicro-
2007;27:1611-8.
[PMID: oral antibiotics. Although surgical bials, surgical debridement, vascular
18041881]
37. Krige JE, Lindfield K, drainage may be required in some evaluation, off-weighting of the
Friedrich L, et al.
Effectiveness and
cases, this can also be done on an lower extremity, and
duration of dapto- outpatient basis. Moderate-to- normalization of blood glucose
mycin therapy in
resolving clinical severe cellulitis, however, may levels.
symptoms in the
treatment of compli- require hospitalization for observa-
cated skin and skin
structure infections.
tion, control of comorbid condi- Type 2 necrotizing fasciitis is
Curr Med Res Opin. tions, and administration of par- known colloquially as flesh-eating
2007;23:2147-
56. [PMID: enteral antimicrobial agents. strep, because it is caused most
17669231]
frequently
2008 American College of Physicians ITC1-12 In the Clinic Annals of Internal Medicine 6 January 2009
by streptococci. Occasionally, requires debridement, which should
staphylococci and gram-negative be continued until viable tissue is
bacilli, such as Vibrio vulnificus, are reached. Multiple debridements are
isolated from necrotizing soft-tis- often required for patients with
sue infections. For streptococcal necrotizing fasciitis or myonecrosis.
38. Billeter M, Zervos MJ,
Chen AY, et al.
necrotizing fasciitis, the antimicro- Delay of surgical debridement Dalbavancin: a novel
once-weekly lipogly-
bial agent of choice is clindamycin increases mortality. copeptide antibiotic.
Clin Infect Dis.
combined with penicillin or other 2008;46:577-83.
-lactam antibiotic. As 5% of How long should patients remain on [PMID: 18199045]
39. Paul M, Silbiger I,
streptococci are resistant to clin- antimicrobial therapy for cellulitis Grozinsky S, et al.
Beta lactam antibi-
damycin, penicillin is added to and soft-tissue infection? otic monotherapy
clindamycin in case of resistance When treating moderate-to-severe versus beta lactam-
aminoglycoside
(16). Linezolid is an expensive but cellulitis, it is appropriate to switch antibiotic combina-
tion therapy for sep-
appropriate choice for from parenteral to oral antibiotics sis. Cochrane Data-
base Syst Rev.
staphylococcal necrotizing fasciitis in when the infection is stabilized and 2006:CD003344.
penicillin- allergic patients (16). the patient is able to tolerate oral [PMID: 16437452]
40. Byl B, Clevenbergh P,
However, in cases of intolerance to therapy. Many antimicrobials exhibit Jacobs F, et al.
Impact of infectious
linezolid, dap- tomycin is an option. complete oral bioavailability and diseases specialists
and microbiological
comparative trials have shown the data on the appro-
Type 3 necrotizing fasciitis is equivalence between parenteral and priateness of antimi-
crobial therapy for
charac- terized by severe toxicity orally administered antimicrobials in bacteremia. Clin
and gas in tissues due to infection the treatment of soft-tissue Infect Dis.
1999;29:60-6; discus-
with clostridial species. Penicillin infections (44, 45). There may be no sion 67-8.
[PMID: 10433566]
plus clindamycin with debridement advantage in administering parenteral 41. Stevens DL. Dilem-
is the therapy of choice (16). antibi- otics in patients who have
mas in the treat-
ment of invasive
Streptococcus pyo-
infections susceptible to oral
What are the indications for genes infections [Edi-
therapies and no symptoms, such as torial]. Clin Infect Dis.
surgical debridement of cellulitis 2003;37:341-3.
nausea and vomit- ing, that would [PMID: 12884157]
and soft-tissue infection? 42. Kaul R, McGeer A,
complicate oral ther- apy. Patients Norrby-Teglund A, et
Evidence of gangrenous or necro- al. Intravenous
with cellulitis and soft- tissue
tizing infection requires immediate immunoglobulin
infection often receive antimicrobial therapy for strepto-
and thorough debridement. This is coccal toxic shock
therapy for 10 to 14 days or until syndrome-a com-
especially true of streptococcal parative observa-
inflammation resolves. This practice
necrotizing fasciitis. Expert consen- tional study. The
assumes that inflamma- tion Canadian Strepto-
sus favors the use of intravenous coccal Study Group.
indicates surviving organisms, Clin Infect Dis.
immunoglobulin to treat strepto- 1999;28:800-7.
but after several days of antimicro- [PMID: 10825042]
coccal necrotizing fasciitis, 43. Darenberg J,
bials, inflammation may be due to
although studies are conflicting Ihendyane N, Sjlin
antigens released from dead J, et al. StreptIg
(41-43). Friable fascia and dark Study Group. Intra-
bacteria. Clinical trial evidence venous
muscle that do not bleed or twitch immunoglobulin G
shows similar outcomes in patients therapy in strepto-
treated for 5 days and 10 days (46).
Treatment... Treat cellulitis and soft-tissue infections empirically with anti- coccal toxic shock
syndrome: a Euro-
microbials that target the suspected pathogen. Topical treatment is an option for pean randomized,
mild impetigo. Patients with mild, uncomplicated cellulitis who are not at high double-blind,
placebo-controlled
risk for MRSA should receive oral antibiotics active against both staphylococci and trial. Clin Infect Dis.
streptococci. Abscesses require drainage. Oral antibiotics are sufficient to treat 2003;37:333-40.
mild MRSA infection. Patients unable to tolerate oral antibiotics or those with [PMID: 12884156]
44.Gentry LO, Ramirez-
severe cellulitis and systemic toxicity who are at risk for MRSA should receive par- Ronda CH,
enteral antibiotics active against MRSA and streptococci. Patients at risk for Rodriguez-Noriega
E, et al. Oral
MRSA should receive coverage for MRSA and streptococci. Antimicrobials should ciprofloxacin vs par-
be adjusted to focus on culture-identified pathogens. Prompt surgical enteral cefotaxime
in the treatment of
evaluation is indicated for patients with evidence of necrotizing fasciitis. difficult skin and
skin structure infec-
tions. A multicenter
trial. Arch Intern
CLINICAL BOTTOM LINE Med. 1989;149:2579-
83. [PMID: 2684078]
6 January 2009 Annals of Internal Medicine In the ITC1-13 2008 American College of Physicians
Clinic

Practice
Improvement What factors do U.S. stakeholders
surgical incision and discontinued
within 24 hours of the end of
use to evaluate the quality of care surgery).
for soft-tissue infection and
cellulitis? What do professional
The Center for Medicare & Med- organizations recommend
icaid Services (CMS) has devel-
45. Weigelt J, Itani K,
Stevens D, et.al. oped measures of quality of care to regarding the care of patients
Line- zolid versus
van- comycin in use in the Physician Quality with cellulitis and soft-tissue
treat- ment of
Reporting Initiative. None of these infection?
complicated skin
and soft tissue infec- measures relates to the treatment of In 2005, the Infectious Disease
tions. Antimicrob
Agents Chemother. cellulitis and soft-tissue infection. Society of America (IDSA)
2005;49:2260-6.
[PMID: 15917519] However, several measures focus on released guidelines on the manage-
46. Hepburn MJ. Dooley
DP, Skidmore PJ, et.
the antibiotic prophylaxis to pre- ment of cellulitis and soft-tissue
Al Comparison of vent surgical wound infections. infection (16). This review largely
short course (5
days) and standard These measures focus on the reflects the IDSA recommenda-

c
(10 days) treatment
for uncomplicated appropriate timing and selection of tions. See the Toolkit for other
cel- lulitis. Arch
Intern Med. 2004;
antibiotic prophylaxis (started guidelines related to the prevention
164:1669-74. [PMID: within 1 hour [2 hours for fluoro- and treatment of soft-tissue
15302637]).
quinolone or vancomycin] before infections.

PIER Modules
in the clinic www.pier.acponline.org
Access the following PIER module: Cellulitis and Soft Tissue Infections. PIER

Tool Kit
modules provide evidence-based, updated information on prevention, diagnosis,
and treatment in an electronic format designed for rapid access at the point of care.

Patient Education Resources

lin
ec i
www.annals.org/intheclinic/toolkit-cellulitis.html

Cellulitis and Access the Patient Information material that appears on the following page for
duplication and distribution to patients.

Soft-Tissue www.nlm.nih.gov/medlineplus/cellulitis.html
Medline Plus
Infections www3.niaid.nih.gov/topics/streptococcal/
National Institute of Allergy and Infectious Diseases

www.healthsystem.virginia.edu/uvahealth/adult_derm/cell.cfm
Patient information developed at University of Virginia (available in English
and Spanish).

Guidelines

in
www.journals.uchicago.edu/doi/pdf/10.1086/497143

ht
Infectious Diseases Society of America: Practice Guidelines for the Diagnosis and
Management of Skin and Soft Tissue Infections

www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Centers for Disease Control and Prevention: Guidelines for the Management of
Multi-drug Resistant Organisms in Healthcare Settings

www.shea-online.org/Assets/files/position_papers/SHEA_hand.pdf Healthcare
Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force: Guideline for
Hand Hygiene in Healthcare Settings

www.shea-online.org/Assets/files/position_papers/SHEA_MRSA_VRE.pdf
Society for Healthcare Epidemiology of America
2008 American College of Physicians ITC1-14 In the Clinic Annals of Internal Medicine 6 January 2009

THINGS PEOPLE SHOULD In the Clinic


Annals of Internal Medicine
KNOW ABOUT CELLULITIS AND annals.org
SOFT-TISSUE INFECTION
What is cellultis?

Cellulitis is an infection that involves the skin or the


muscles and other body tissues directly under the skin.
Symptoms can include redness, pain, and fever.

Who gets cellulitis?


Cellulitis can happen after an injury to the skin,
an animal bite, or a surgical wound, but
sometimes there is no obvious cause.
Conditions that increase the chances of cel-
lulitis include diabetes, circulatory problems,
past surgery or radiation treatment of the arms Patients with diabetes should talk to their
or legs, and chronic athletes foot. doctors about proper foot care to prevent
infection.
What is the treatment for cellulitis? Keep skin moisturized to prevent cracks.
Treatment usually involves cleaning the injury or If you have athletes foot, treat it.
wound, if present, and antibiotics.
Cellulitis can be an emergency. See a doctor if
If the infection is severe, then hospitalization for

Information
you notice:
intravenous antibiotics may be necessary.
Sometimes surgery is needed to clean and a very large area of red, inflamed skin
drain the infected area. fever
affected area of skin is numb, tingling, or in
Can you prevent cellulitis?
severe pain
Look out for early signs of infection. skin seems black, purple, or has blisters
Clean any skin injuries very well. redness or swelling around the eye(s) or
See a doctor if you have an animal bite. behind the ear(s).

For More Information


Medline Plus
www.nlm.nih.gov/medlineplus/cellulitis.html

National Institute of Allergy and


Patient
Infectious Diseases
www3.niaid.nih.gov/topics/streptococcal/

University of Virginia
(information in English and Spanish)
www.healthsystem.virginia.edu/uvahealth/adult_derm/cell.cfm
CME Questions
1. A 20-year-old college wrestler has a 3. An 83-year-old woman is brought to the emergency department physician pre-
painful lesion on his upper back. He first emergency department with redness and scribed warm packs to the area and a
noted a small painful area 7 days ago, swelling of her right lower leg of several course of dicloxacillin. The patient
and the lesion has since enlarged and days duration and a 12-hour history of returns to the emergency department 2
became more red. Other members of his nausea, vomiting, and diarrhea. The days later. The patch is larger and more
wrestling team have developed similar patient has type 2 diabetes mellitus and tender but is still not fluctuant. He is
lesions. His history is otherwise coronary artery disease. Medications slightly ill but does not seem toxic. The
uneventful. Examination of the upper include glyburide, an angiotensin-con- emergency department physician
back reveals a 1 1 cm2 red, raised pus- verting enzyme inhibitor; a -blocker; a changes the antibiotic to cephalexin,
tule that is tender to palpation, with a 4 statin; and low-dose aspirin. but the patient continues to become
2
4 cm area of surrounding erythema. somewhat worse over the next 2 days.
On physical examination, temperature is
The remainder of the physical examina-
38.9C (102F), pulse rate is 102/min, Which of the following is the most
tion is normal. The lesion is incised,
respiration rate is 20/min, and blood likely cause of this patients
drained, and cultured.
pressure is 92/64 mm Hg. Profuse crack- clinical deterioration?
Which of the following is the most les are heard at both lung bases. A. Lyme disease
appropriate empiric treatment? Cardiac examination discloses a regular B. An abscess
A. Levofloxacin rhythm and no audible murmurs; there C. Fasciitis
B. Doxycycline is a prominent 3
S . The right leg is more D. A -lactamresistant organism
C. Dicloxacillin swollen than the left and is erythema-
D. Cephalexin tous with tenderness to the knee. There 5. A 53-year-old man underwent open
are no open lesions, and no inguinal reduction and internal fixation of a
2. A 32-year-old man has a 1-week history lymphadenopathy is noted. Hemoglobin fractured tibia. The patient has diabetes
of worsening erythema and pruritus level is 11.4 g/dL (114 g/L); hematocrit mellitus and end-stage renal disease
of both axillae. He is otherwise is and requires hemodialysis by means of
asymptomatic. 34%; leukocyte count is 19.8 109/L an arteriovenous graft in the left-upper
On physical examination, temperature is with 80% neutrophils, 15% lympho- extremity. Three weeks postoperatively,
37.1C (98.8F), pulse rate is 72/min, cytes, and 5% monocytes; platelet count his surgical incision became inflamed,
9
respiration rate is 16/min, and blood is 281 10 /L; blood urea nitrogen is 34 with an open section and drainage of
pressure level is 128/62 mm Hg. Both mg/dL (12.14 mmol/L); serum creatinine cloudy yellow fluid. Culture of the dis-
axillae show marked erythema, minimal level is 2.2 mg/dL (194.52 mol/L); and charge grew methicillin-resistant
tenderness, and several small nonpustu- serum electrolytes and liver chemisty Staphylococcus aureus (MRSA) that was
lar vesicles. There is no erythema adja- studies are normal. resistant to erythromycin, clindamycin,
cent to the axillae and no palpable The patient is hospitalized. Blood cul- and tetracycline but was sensitive to
lym- phadenopathy. Hemoglobin level is tures obtained on admission show no vancomycin and trimethoprim
15 g/dL (150 g/L); hematocrit is 47%; growth at 2 days. sulfamethoxazole. The patient was
leukocyte count is 5.3 109/L with Which of the following organisms is
treated intermittently with vancomycin,
72% neutrophils, 18% lymphocytes, 2% 500 mg intravenously. Two months later,
most likely causing this patients current
monocytes, 8% eosinophils; and platelet the surgical incision is unchanged. Cul-
findings?
9
count is 310 10 /L. Cultures of the ture of the discharge now grows
axillae grow several coagulase-negative A. Escherichia coli Entero- coccus faecalis in addition to
staphylococci, Propionibacterium acnes, B. Clostridium tetani MRSA.
and rare Escherichia coli. C. Staphylococcus aureus Both pathogens are resistant to van-
D. Bacillus cereus comycin. Polymerase chain reaction
Which diagnosis is most likely? 4.
shows that the MRSA is vanA ligase
A. Streptococcal cellulitis An 18-year-old male basketball player positive.
B. Staphylococcal cellulitis came to the emergency department in
February because of a red patch on his Which of the following is the most
C. Pasteurella multocida cellulitis
left forearm. He had been well the day appropriate antibiotic agent?
D. Contact dermatitis
E. Hidradenitis suppurativa before, but woke up with a painful area A. Linezolid
measuring about 6 9 cm2 on the B. Trimethoprimsulfamethoxazole
volar surface of the forearm. The area C. Clindamycin
was tender to touch, erythematous, D. Imipenem
and raised but was not fluctuant. The E. Quinupristindalfopristin

Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/
to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

2008 American College of Physicians ITC1-16 In the Clinic Annals of Internal Medicine 6 January 2009

Você também pode gostar