Cellulitis and Erysipelas

L03.0-3/L03.8-9 + (L04.0-3/L04.8-9/B95.0-8) and A46

DESCRIPTION

Skin and subcutaneous infections with pain, swelling, and erythema, usually caused by streptococci and staphylococci, and occasionally other organisms. Regional lymphadenitis may be present. Erysipelas has a raised demarcated border, whilst the border is indistinct in cellulitis.

The presence of areas of necrosis, haemorrhage, or pain out of proportion to the physical signs should raise suspicion of necrotising fasciitis which requires aggressive surgical debridement and broad spectrum antibiotics (e.g. amoxicillin/clavulanic acid) as these infections are often polymicrobial.

GENERAL MEASURES

Elevate the affected limb to reduce swelling and pain.
Hydrate.

MEDICINE TREATMENT

LoE I [2]

For pain:

  • NSAID, oral: e.g.
    • Ibuprofen, oral, 400 mg 8 hourly with meals.

OR

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4 g in 24 hours.

Antibiotic therapy

  • Cefalexin, oral, 500 mg 6 hourly for 5 days.

OR

  • Flucloxacillin, oral, 500 mg 6 hourly for 5 days.

Severe penicillin allergy: (Z88.0)

  • Macrolide, e.g.:
    • Azithromycin, oral, 500 mg daily for 3 days.

Severe cases may require parenteral antibiotics.


Severe infection

If intravenous antibiotics are given initially, patients should be switched to oral agents as soon as there is clinical improvement.

If there is a rapid progression of erythema, intravenous antibiotics are preferred.

The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period.

LoE III [3]

  • Cefazolin, IV, 1 g 8 hourly.

LoEII [4]

When there is clinical improvement, change to:

  • Flucloxacillin, oral, 500 mg 6 hourly.

Severe penicillin allergy: (Z88.0)

  • Clindamycin, IV, 600 mg 8 hourly.

When there is clinical improvement, change to:

  • Clindamycin, oral, 450 mg 8 hourly.

If patient is admitted and bed-bound with lower limb cellulitis, consider deep venous thrombosis prophylaxis. See Venous thrombo-embolism.

If Taenia pedis is suspected to be the pre-disposing cause, treat accordingly. See Fungal infections

REFERRAL

Urgent

  • For debridement if necrotising fasciitis is suspected, i.e. gangrene, gas in the tissues or haemorrhagic bullae.

Non-urgent

  • To surgeon for non-response.
  • Cellulitis involving wounds in aquatic environment, (salt or brackish water), fresh water or lack of response to treatment, refer for further investigation with an option for a biopsy.