Erysipelas is a clinical variant of cellulitis, is characterized by
well-demarcated erythema, tenderness, and swelling, & discrete raised
border. Erysipelas usually affects the face, or the extremities.
Facial Cellullitis & Erysipelas is suggested by a well-demarcated
raised border cellulitis of the face. Both preseptal & orbital
cellulitis cause marked eyelid inflammation & swelling. However,
decreased visual acuity, decreased extraoccular eye movement, marked chemosis,
pain on eye movement, or significant axial proptosis indicates orbital
cellulitis, which can permanently damage the optic nerve as well as
extend centrally and cause cavernous sinus thrombosis.
Necrotizing Cellulitis is a subset of soft-tissue infections marked
by frank cutaneous & subcutaneous necrosis yet lacking involvement of
fascial planes. Its systemic toxicity is less than that of its more
lethal cousin necrotizing fasciitis.
In immunocompetent hosts, GAS, Clostridium (gas forming anaerobes), Vibrio
(seawater injury or seafood), Aeromonas spp. (outdoor freshwater injuries)
may be the pathogens. Gas-forming anaerobes, such as clostridia,
Bacteroides, and peptostreptococci; Klebsiella & E.Coli can also produce
a crepitant cellulitis.
In immunocompromised patients Pseudomonas aeruginosa can cause a cellulitis
that may have a necrotizing component, ecthyma gangrenosum (EG).
It is marked by redness, tenderness, swelling, and a poorly defined border.
Fever, leukocytosis, lymphangitis, regional lymphadenopathy, hematogenous
dissemination, and focal abscesses or bullae may accompany these infections.
Overall, Group A beta-hemolytic streptococci (GAS), Strep. pyogenes, and
Staphyloccal aureus account for most cellulitis. Less common pathogens
include group B, C, & G streptococci, Strep.pneumoniae, H.influenze,
& Yersinia enterocolitica. Other pathogens include enteric
Gram-negative rods, Pseudomonas spp., & anaerobes.
For possible or proven MRSA Cellulitis:
PO Clindamycin 300-450 mg q6-8h, Trimethoprim-sulfamethoxazole
(Bactrim/Septra-DS) 1 tab bid, or doxycycline (Vibramycin) or Minocycline
100 mg bid.
Rifampin has excellent activity against MRSA (not to be used alone due to
rapid development of resistance) and may be used in combination with the
* Fluoroquinolones should NOT be used to treat skin & soft tissue infections
due to MRSA due to frequent resistant to Ciprofloxacin.
IV Vancomycin 30 mg/kg/24 hour in 2 divided doses (max not to exceed 2 g/24h).
IV Linezolid 600 mg q12h or daptomycin 4 mg/kg once daily.
For Nonfacial Cellulitis & Erysipelas:
Incise & drain any abscess, and send the pus for Gram stain and
PO dicloxacillin or cephalexin (Keflex) for 7-10 days with or
without a single dose of IV Cefazolin (Ancef).
IV Cefazolin (Ancef) single dose as outpatient, followed by daily
home parenterial ceftriaxone (Rocephin) 50 mg/kg per day until significant
improvement is noted, then completion of Rx with the above PO antibiotics.
For Facial Cellulitis & Erysipelas:
All pts with moderate to severe nonperiocular facial cellulitis should
initially be hospitalized to monitor for progression to a necrotizing
infection, which if not managed urgently by surgical debridement may
result in significant facial disfigurement and dysfunction. Obviously
facial erysipelas should be treated with parenteral penicillin G 2 million
units q4h. Once the pts is afebrile for 24 hours, oral penicillin
VK 500 mg q6h for 7-10 days will complete the Rx.
Adults with established facial cellulitis should receive a parenteral
semisynthetic penicillin as Nafcillin 1-1.5 g q4h or Cefazolin 1 g q8h
until significant clinical improvement is noted; completion of Rx should
include 7-10 days of oral dicloxacillin or cephalexin.
Periocular soft tissue infections require thorough opthalmologic evaluation
to distinguish preseptal from orbital cellulitis. Moderate to severe
preseptal cellulitis in older children & adults can progress to a necrotizing
infection that requires urgent surgical debridement; these pts should
initially be treated with a parenteral semisynthetic penicillin as Nafcillin
1-1.5 g q4h or Cefazolin 1 g q8h until significant clinical improvement
Orbital cellulitis, a medical emergency,
should be managed initially with a parenteral semisynthetic penicillin as
Nafcillin 1-1.5 g q4h and ceftriaxone (Rocephin).
Clindamycin may be substituted for the penicllin if anaerobic
infection is suspected. Orbital collections of pus must be drained
immediately. Otorhinoloryngologic consultation is indicated to help
search for underlying sinusitis, which must be drained. Close
ophthalmologic follow-up is necessary to assess the response to treatment.
For Hand Cellulitis:
Mild cellulitis be treated with arm elevation, splinting, and oral dicloxacillin
or cephalexin; penicillin, clindamycin, or metronidazole should be
added if anaerobic on-infection is suspected.
Severe hand cellulitis should be initially treated with parenteral nafcillin,
oxacillin or cefazolin, arm elevation & observation until significant
clinical improvement is noted. All pus collections must be drained.
For human & animal bite infections of the hand, additional coverage
against mouth anaerobes, Haemophilus & Pasteurella multocida, should
For Necrotizing Soft-Tissue Infections:
Tissue necrosis mandates hospitalization and immediate surgical consultation
for early complete debridement of necrotic tissue. Bacteriologic evaluation
of wound exudate, bulla fluid, excised tissue, and blood is essential.
Empiric parenteral vancomycin, gentamicin, and either metronidazole or
clindamycin constitute an effective initial regimen. Penicillin
G at least 20 million units/day either alone or in combination with
clindamycin or chloramphenicol should be instituted when crepitance
or Gram stain indicates clostridial infection.
Current Therapy in Adult Medicine 4th Ed, 1997 - Jerome Kassierer & Harry