Cellulitis Cellulitis is an infection that occurs in the subcutaneous tissues. Multiple bacteria can cause it, but we will focus on cellulitis caused by Streptococcus pyogenes , which, as noted above, is also called group A streptococcus (group A strep). Cellulitis affects structures that are deeper than areas affected by impetigo or erysipelas. As a result, the affected skin usually has a pinkish hue with a less defined border, compared to erysipelas, which presents with well-demarcated borders and bright red color. Local signs of inflammation (warmth, erythema, and pain) are present in most cellulitis cases. In severe cases, systematic symptoms such as fever, chills, and malaise may be present and can be accompanied by lymphangitis and, less frequently, bacteremia. An elevated white blood cell count may also be present (CDC, 2022a). Disruption of the cutaneous barrier, such as the presence of ulcers, wounds, or fungal skin infections (e.g., athlete’s foot), is a risk factor for developing cellulitis. Previous history of cellulitis; venous insufficiency, presence of chronic edema, or impaired lymphatic drainage of the limbs; obesity; and injection drug use have also been identified as risk factors for cellulitis. For typical Case study #2 A 65-year-old male with a medical history of diabetes and poor circulation was admitted to the hospital for cellulitis of the right leg. The patient initially presented with symptoms that included redness, warmth, and tenderness in the affected leg, along with localized pain and swelling. Additionally, the patient reported feeling unwell with symptoms such as fatigue, fever, and chills. Upon examination, it was observed that the affected area was tender and had an erythematous appearance, with signs of inflammation and swelling. The skin was warm to the touch, and the area felt firm and indurated. It is believed that the cellulitis was caused by a break in the skin, which occurred after the patient accidentally scraped his leg while gardening. Question What would be appropriate treatment strategies for this patient? Discussion The healthcare provider ordered a CBC and differential, a blood culture, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The patient was started on intravenous antibiotics, including vancomycin and cefepime. Figure 11. Cellulitis
cases of nonpurulent cellulitis, the Infectious Diseases Society of America (IDSA) recommends treatment with an antibiotic that is active against streptococci (CDC, 2022a). Due to the difficulty of determining the causative pathogen for most cellulitis cases, clinicians may select antibiotics that cover S taphylococcus aureus and group A strep. Group A strep remains susceptible to beta-lactam antibiotics. Mild cellulitis can be treated with oral antibiotics, including penicillin, cephalosporins (e.g., cephalexin), dicloxacillin, or clindamycin. If signs of systemic infection are present, intravenous antibiotics such as penicillin, ceftriaxone, cefazolin, or clindamycin can be considered. The recommended duration of antibiotic treatment for most cellulitis cases is 5 days. Cases that have not improved during this period may require longer treatment durations (CDC, 2022a). Certain comorbidities (i.e., diabetes, cancer, HIV) increase the risk of systemic complications. In addition to antibiotics and possible wound care, the elevation of the affected area and treating predisposing factors (e.g., edema, underlying skin disorders) is recommended to reduce the risk of recurrent infection.
From ColmAnderson. (2006). Cellulitis Left Leg. https://commons.wiki - media.org/wiki/Category:Cellulitis. CC BY-SA 2.5 (ColmAnderson, 2006)
NP Consideration: Methicillin-Resistant Staphylococcus Aureus (MRSA) Studies suggest that most patients with cellulitis do not need MRSA coverage. A randomized trial of adults with nonpurulent cellulitis in five emergency departments in the U.S. noted similar clinical cure rates among those treated with cephalexin plus trimethoprim-sulfamethoxazole and those treated with cephalexin plus placebo. In the per-protocol analysis, 182 (84%) of 218 individuals in the cephalexin plus TMP-SMX group achieved cure versus 165 (86%) of 193 in the cephalexin group (difference: –2%, 95%; Confidence Interval –9.7% to 5.7%). The modified intention-to-treat analysis suggested a possible trend favoring the cephalexin plus TMP-SMX group. However, those results are difficult to interpret due to the large number of patients in both groups who did not complete the full course of therapy. Another randomized trial of 153 patients with cellulitis without abscess noted comparable cure rates among those treated with cephalexin and TMP-SMX (85%) and those treated with cephalexin and placebo (82 percent; difference: 2.7%, 95%; CI: –9.3% to 15%). Indications for MRSA Coverage Empiric coverage for MRSA is indicated for patients with MRSA risk factors and those with increased morbidity if suboptimal antibiotics are administered. Conditions that warrant MRSA coverage include the following. ● Systemic signs of toxicity (fever >100.5°F [38°C], hypotension, tachycardia) ● Cellulitis with purulent drainage or exudate ● Immunocompromising condition ● Presence of risk factor(s) for MRSA infection (previous MRSA infection, healthcare exposure, antibiotic use, intravenous drug use)
Tinea Ringworm, also called tinea or dermatophytosis, is a common infection of the epidermis (skin, hair, or nails) caused by dermatophyte molds. Tinea can be acquired through direct skin contact with infected individuals and animals. Individuals can also acquire ringworm by sharing personal items (e.g., towels,
clothing, bedding) or through contact with surfaces found in moist areas (e.g., shower stalls, locker room floors, pool areas). Tinea can also spread from one body part to another (CDC, 2022d).
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