CELLULITIS: A BACTERIAL SKIN INFECTION, THEIR CAUSES ...Erysipelas, a superficial cellulitis with...

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Joseph et al. World Journal of Pharmacy and Pharmaceutical Sciences

CELLULITIS: A BACTERIAL SKIN INFECTION, THEIR CAUSES,

DIAGNOSIS AND TREATMENT

Jeeva Joseph*, Sujith Abraham, Arya Soman, Limson K Mathew, Saneesh V Ganga,

Vineetha Vijayan

Mpharma student, Department of pharmaceutics, Nirmala College of pharmacy,

Muvattupuzha, Kerala.

ABSTRACT

Family physicians frequently treat bacterial skin infections in the office

and in the hospital. Common skin infections include cellulitis,

erysipelas, impetigo, folliculitis, and furuncles and carbuncles.

Cellulitis is an infection of the dermis and subcutaneous tissue that has

poorly demarcated borders and is usually caused by Streptococcus or

Staphylococcus species. And that is characterized by warmth, edema,

and advancing borders. Cellulitis commonly occurs near breaks in the

skin, such as surgical wounds, trauma, tinea infections, or ulcerations.

Patients may have a fever and an elevated white blood cell count. The

most common sites of cellulitis were the legs and digits, followed by

the face, feet, hands, torso, neck, and buttocks. For infection in patients without diabetes,

empiric treatment with a penicillinase-resistant penicillin, first-generation cephalosporin,

amoxicillin-clavulanate (Augmentin), macrolide, or fluoroquinolone (adults only) is

appropriate. Limited disease can be treated orally, but more extensive disease requires

parenteral therapy. Antibiotics should be maintained for at least three days after the resolution

of acute inflammation. Adjunctive therapy includes the following: cool com- presses;

appropriate analgesics for pain; tetanus immunization; and immobilization and elevation of

the affected extremity. The patient may also require a plain radiograph of the area or surgical

debridement to evaluate for gas gangrene, osteomyelitis, or necrotizing fasciitis. Recurrent

episodes of cellulitis or undergoing surgery, such as mastectomy with lymph node

dissection.Herbal medicines are also used for cellulitis.

Keywords: Cellulitis, Bacterial skin infection, Dermis, Edema, Antibiotics.

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Article Received on 09 May 2014, Revised on 30 May 2014, Accepted on 20 June 2014

*Correspondence for Author

Jeeva Joseph

Mpharma student, Department

of pharmaceutics, Nirmala

College of pharmacy

Muvattupuzha, Kerala.


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INTRODUCTION

Cellulitis is an acute inflammatory condition of the dermis and subcutaneous tissue usually

found complicating a wound, ulcer or dermatosis. Spreading and pyogenic in nature, it is

characterized by localized pain, erythema, swelling and heat. The involved area, most

commonly on the leg, lacks sharp demarcation from uninvolved skin. Erysipelas, a superficial

cellulitis with prominent lymphatic involvement, does have an indurated, raised border that

demarcates it from normal skin. These distinctive features create what is known as a

“peaud’orange” appearance.[1]

THE SKIN

The skin is the largest organ of the human body. It is made up of three main layers:

the epidermis – the outer surface of skin and an underlying section of cells, which the body

uses to create new skin cells

dermis – the middle layer of skin that contains blood vessels, sweat glands and hair

follicles

subcutis – the bottom layer of skin that consists of a layer of fat and collagen (a tough,

spongy protein), which helps protect the body and regulate temperature.[2]

ETIOLOGY

common causes

Group A β-hemolytic streptococci (Streptococcus pyogenes)

Staphylococcus aureus

Haemophilusinfluenzae (decreasing in frequency)

Group B, C, D, or G β-hemolytic streptococci

Cellulitis may be caused by indigenous flora colonizing the skin and appendages, like

Staphylococcus aureus (S. aureus) and Streptococcus pyogenes (S. pyogenes), or by a wide

variety of exogenous bacteria. Bacteria gain entry into the body in many ways: breaks in the

skin, burns, insect bites, surgical incisions and intravenous (IV) catheters are all potential

pathways. S. aureus cellulitis starts from a central localized infection and spreads from there.

An abscess, folliculitis or infected foreign body, such as a splinter, prosthetic device or IV

catheter, may serve as a possible focus for this condition.

Cellulitis due to S. pyogenes follows a different pattern. It spreads rapidly and diffusely and

is frequently associated with lymphangitis and fever. Recurrent streptococcal cellulitis of the


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lower extremities, seen in conjunction with chronic venous stasis or with saphenous vein

harvest for coronary artery bypass surgery, often comes from organisms of group A, C or G.

Cellulitis is also seen in patients with chronic lymphedema resulting from elephantiasis,

Milroy’s disease or lymph node dissection such as that associated with mastectomy.

Staphylococcal and streptococcal species are also the most common pathogens in bacterial

infections among drug-users [3], and infections that implicate an unusual organism are often

related to a specific drug or drug-use behavior.

Many other bacteria cause cellulitis. Haemophilusinfluenzae was once a major pathogen in

facial cellulitis in young children, but these infections are now rare due to the type B vaccine.

Pasteurellamultocida is the pathogen in cellulitis associated with animal bites, mostly those of

cats. Aeromonashydrophila can cause an aggressive form of cellulitis in a laceration

sustained in fresh water. Pseudomonas aeruginosa is the source of three types of soft tissue

infection: ecthymagangrenosumin neutropenic patients, hot tub folliculitis and cellulitis

following a penetrating wound, like that sustained from stepping on a nail. Gram-negative

bacillary (rod) cellulitis, like P. aeruginosa, is common among hospitalized,

immunocompromised patients and may have multidrug resistance. Culture and sensitivity

tests are very important in this setting. [4, 5]

“Fig. 1”: Patient with cellulitis of the left ankle. This cellulitis was caused by

community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).

contributory or predisposing factors

Break in the skin due to trauma, puncture, laceration, animal bite, or sting

Burns


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Skin lesions caused by furuncle, ulcer, or fungal infection (eg, tineapedis)

Surgical procedure or incision, including lymphadenectomy, saphenous vein stripping, and

mastectomy

Previous cellulitis

Diabetes mellitus (type 1 and type 2)

Lymphatic stasis

Peripheral vascular disease

Chronic steroid use

Intravenous drug addiction

AIDS or other immunodeficiency disorder

Liver disease

Renal failure Occupational exposure: farm workers; gardeners; handlers of fish, shellfish, and

aquariums[6]

EPIDEMIOLOGY

Incidence and prevalence

frequency

Common in the U.S., but because it is a non-reportable infection, exact incidence is not

known.

Demographics

Age

Facial cellulitis usually occurs in adults aged 50 years or above, or children aged 6 months

to 3 years

Perianal cellulitis usually affects children

Gender

Perianal cellulitis is more common in male patients than in female patients

No gender difference for other types of cellulitis

Geography

Cellulitis caused by halophilic Vibrio species occurs in coastal areas (shellfish handlers).


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Socioeconomic status

Immigrant populations who may not have been vaccinated

against Haemophilusinfluenzae type b and tetanus are at increased risk of infection

Overcrowded conditions may also exacerbate infection

Farm, garden, fish, and shellfish workers are at increased risk of infection by rare agents

causing cellulitis[6,7]

GRADES OF CELLULITIS[8, 9]

Class I- Patients have no signs of systemic toxicity, have no comorbidities and can usually

be managed with oral antimicrobials as outpatients.

Class II- Patientsare either systemically ill or systemically well but with a comorbidity

such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which

may complicate or delay resolution of their infection.

Class III- Patients may have a significant systemic upset such as acute confusion,

tachycardia, tachypnoea, or may have unstable comorbidities that may interfere with a

response to therapy, or have a limb-threatening infection due to vascular compromise.

Class IV- Patients have sepsis syndrome or severe life- threatening infection such as

necrotising fasciitis.

“Fig. 2”: Mild cellulitis with a fine lace like pattern of erythema. This lesion was only slightly warm and caused minimal pain.

“Fig.3”: Swelling seen in cellulitis involving the hand. In a situation with hand cellulitis, always rule out deep infection by imaging studies or by obtaining surgical consultation.


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“Fig. 4”: Severe cellulitis of the leg. The cellulitis developed beneath a cast and was

painful and warm to the touch. Significant erythema is evident.

SYMPTOMS[10]

Symptoms of cellulitis include:

Fever

Pain or tenderness in the affected area

Skin redness or inflammation that gets bigger as the infection spreads

Skin sore or rash that starts suddenly, and grows quickly in the first 24 hours

Tight, glossy, stretched appearance of the skin

Warm skin in the area of redness

Signs of infection:

Chills or shaking

Fatigue

General ill feeling

Muscle aches and pains

Warm skin

Sweating

“Fig. 5”: Symptoms of cellulitis, redness.

Other symptoms that can occur with this disease

Hair loss at the site of infection

Joint stiffness caused by swelling of the tissue over the joint


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Nausea and vomiting

COMPLICATION OF CELLULITIS

Complications of cellulitis can include blood poisoning, abscesses, and meningitis.

blood poisoning

If the bacteria that infect your skin and tissue enter your bloodstream, they can cause blood

poisoning (septicaemia). Symptoms of blood poisoning include:

high temperature (fever) of 38ºC (100.4ºF) or above

rapid heart beat

rapid breathing

low blood pressure, which will make you feel dizzy when you stand up

changes in mental behaviour, such as confusion or disorientation

diarrhoea

reduced urine flow

cold, clammy skin

pale skin

loss of consciousness

Abscess

Some cases of cellulitis can result in an abscess forming near the site of the infection.

An abscess is a swollen, pus-filled lump under the surface of the skin. It is caused by a build-

up of bacteria and dead white blood cells.

In some cases, the antibiotics that are used to treat cellulitis may also help to remove the

abscess. However, if this is not the case, the pus will have to be drained from the abscess

through a small cut in your skin.

Facial cellulitis and meningitis

Facial cellulitis is an uncommon form of cellulitis that develops on the skin of the face. It

accounts for an estimated 8.5% of all cases of cellulitis.

Facial cellulitis is most common in children under three year’s old and older adults above 50.

If facial cellulitis is left untreated in children, the bacteria can potentially spread to the outer

membranes of their brain (the meninges) and trigger a serious brain infection called

meningitis.


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Symptoms of meningitis can differ in adults, but symptoms in babies and children under three

years old include:

becoming floppy and unresponsive, or stiff with jerky movements

becoming irritable and not wanting to be held

unusual crying

vomiting and refusing feeds

pale and blotchy skin

loss of appetite

staring expression

very sleepy and reluctant to wake up

Bacterial meningitis is very serious and should be treated as a medical emergency. If left

untreated, a bacterial infection can cause severe brain damage and infect the blood.

PREVENTING CELLULITIS [2]

Not all cases of cellulitis can be prevented. But you can take steps to reduce the risk of

developing the condition.

These involve steps to prevent skin wounds, and treating wounds properly when they occur.

Treating skin wounds

Make sure that any cuts, grazes or bites are kept clean. Wash the damaged skin under

running tap water and, if necessary, apply an antiseptic cream.

Keep the wound covered with a plaster or dressing. Make sure you change the plaster or

dressing if it becomes wet or dirty. Plasters and dressings will reduce the risk of the wound

being damaged further, and they will help to create a barrier against bacteria entering the

skin.

Hand hygiene

Wash your hands regularly, particularly when treating or touching a wound or skin

condition.

If you have an itchy skin condition, such as atopic eczema or chickenpox, keep your

fingernails clean and short at all timesIf you scratch your skin and your fingernails are short

and clean, the risk of skin damage and infection will be reduced.


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Keep your skin moisturised

If your skin is dry or prone to cracking, keep your skin well moisturised. Cracked skin can

create an entry point for bacteria.

Preventing cellulitis in lymphedema

People with lymphoedema (a condition that causes swelling of the arms and legs) have a

much higher risk of developing cellulitis than others. This is because the swelling of the skin

that is associated with lymphoedema makes it more vulnerable to bacterial infection.

If you are diagnosed with lymphoedema, you may be given a two-week course of

antibiotics to take in case you start having the initial symptoms of cellulitis.

If you have two or more episodes of cellulitis in a year, it is usually recommended that you

begin taking antibiotics on a long-term basis to protect against further infection.

DIAGNOSIS

Generally, no workup is required in uncomplicated cases of cellulitis that meet the following

criteria:

Limited area of involvement

Minimal pain

No systemic signs of illness (eg, fever, altered mental status, tachypnea, tachycardia,

hypotension)

No risk factors for serious illness (eg, extremes of age, general debility,

immunocompromise)

The Infectious Disease Society of America (IDSA) recommends the following blood tests for

patients with soft-tissue infection who have signs and symptoms of systemic toxicity:[11]

Blood cultures

CBC with differential

levels of creatinine, bicarbonate, creatine phosphokinase, and C-reactive protein (CRP)

Blood cultures should also be done in the following circumstances:[11]

Moderate to severe disease[11] (eg, cellulitis complicating lymphedema[12] )

Cellulitis of specific anatomic sites (eg, facial and especially ocular areas)

Patients with a history of contact with potentially contaminated water[13]

Other tests to consider are as follows:


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Mycologic investigations are advisable if recurrent episodes of cellulitis are suspected to be

secondary to tineapedis or onychomycosis

Creatinine levels help assess baseline renal function and guide antimicrobial dosing.

Imaging studies

Ultrasonography may play a role in the detection of occult abscess and direction of care[14]

Ultrasonographic-guided aspiration of pus can shorten hospital stay and fever duration in

children with cellulitis[15]

If necrotizing fasciitis is a concern, CT imaging is typically used in stable patients; MRI

can be performed,[16] but MRI typically takes much longer than CT scanning

Strong clinical suspicion of necrotizing fasciitis should prompt surgical consultation

without delay for imaging.

Aspiration, dissection, and biopsy

Needle aspiration should be performed only in selected patients or in unusual cases, such as

in cases of cellulitis with bullae or in patients who have diabetes, are immunocompromised,

are neutropenic, are not responding to empiric therapy, or have a history of animal bites or

immersion injury[17,18,19]

Aspiration or punch biopsy of the inflamed area may have a culture yield of 2-40% and is

of limited clinical value in most cases[20]

Gram stain of aspiration or biopsy specimens has a low yield and is unnecessary in most

cases, unless purulent material is draining or bullae or abscess is present; however, Gram

stain and culture following incision and drainage of an abscess yields positive results in more

than 90% of cases[11]

Dissection of the underlying fascia to assess for necrotizing fasciitis may be determined by

surgical consultation or indicated following initial evaluation and imaging studies[21]

Skin biopsy is not routine but may be performed in an attempt to rule out a noninfectious

entity.

Hospital admission

The IDSA recommends considering inpatient admission in patients with hypotension and/or

the following laboratory findings:[11]

Elevated creatinine level

Elevated creatine phosphokinase level (2-3 times the upper limit of normal)


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CRP level >13 mg/L (123.8 mmol/L)

Low serum bicarbonate level

Marked left shift on the CBC with differential

DRUG THERAPYAND TREATMENT

Class I patients can usually be managed with oral antimicrobials on an outpatient basis.

Class II patients are suitable for short-term (up to 48 hours) hospitalisation and discharge

on outpatient parenteral antimicrobial therapy (OPAT), where this service is available.

Class III and Class IV patients require hospitalisation until the infected area is clinically

improving, systemic signs of infection are resolving and any co-morbidities are stabilised.

Patients with suspected necrotising infection require urgent surgical assessment and extensive

debridement of the affected area.

Table1: Suitable Drug Therapy for Typical Cellulitis

* Must not be used in penicillin anaphylaxis

Rationale

The vast majority of cases of cellulitis are caused by beta-haemolytic streptococci or

S.aureus. Empiric antimicrobial therapy should therefore provide adequate cover for these

micro-organisms.

Flucloxacillin exerts a bactericidal effect on streptococci as well as staphylococci and for this

reason has been suggested as monotherapy orally for Class I infections and initially

First line Second line

Class 1

Flucloxacillin 500mg qdspo

Penicillin allergy: Clarithromycin 500mg bdpo

Class 2 Flucloxacillin 2g qds IV Or *Ceftriaxone 1g od IV

Penicillin allergy Clarithromycin 500mg bd IV Or Clindamycin 600mg tds IV

Class 3 Flucloxacillin 2g qds IV Penicillin allergy: Clarithromycin 500mg bd IV or Clindamycin 900mg tds IV

Class 4 Benzylpenicillin 2.4g 2-4 hourly IV + Ciprofloxacin 400mg bd IV + Clindamycin 900mg tds IV (If allergic to penicillin use Ciprofloxacin and Clindamycin only) NB Discuss with local Medical Microbiology Service


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intravenously for Class II and Class III infections. Custom and practice has traditionally

combined the use of benzylpenicillin and flucloxacillin in the management of hospitalised

patients with cellulitis. The short half-life of benzylpenicillin necessitates administration at

least four hourly and when combined with intravenous flucloxacillin results in ten doses of an

antimicrobial agent over a twenty-four hour period. In most cases this is not seen as practical

or necessary. If a recognised pathogen is isolated from blood cultures seek specific advice

from a Medical Microbiologist.

Although co-amoxiclav also exerts a bactericidal effect on streptococci and staphylococci this

antibiotic has a considerably broader spectrum of activity including Gram-negative organisms

and anaerobes and is therefore unnecessary in this situation.

Penicillin allergy: It is essential to obtain a detailed history of a patient’s reaction to penicillin

as this may allow a clinician to exclude allergy. The vast majority of patients with a history of

penicillin rash tolerate cephalosporins without significant reaction.[22] If the patient has

experienced an anaphylactic reaction or immediate urticarial rash to a penicillin, this class of

drug must be avoided. Macrolide antibiotics or clindamycin are suitable alternatives.

Clindamycin suppresses toxin production by group A streptococci, C. prefringens and S.

aureus. It is for this reason that it is used in the management of necrotizing fasciitis. It has

been associated with cases of Clostridium difficilediarrhoea and in non-life threatening

infection the development of diarrhoea should prompt discontinuation.

In the past, it has been standard practice to hospitalize Class II patients with serious soft

tissue infections, such as cellulitis. However, those of Class II severity can be treated safely

and effectively with OPAT followed by transition to oral agents as the infection resolves.

Ceftriaxone has been listed for the management of Class II infections. This agent is

administered once daily making it a suitable agent if OPAT is locally available and

considered appropriate. Its safety and efficacy in this situation is well established. [23, 24, 25]

Non- responders

There may be an increase in erythema in the first 24-48 hours of treatment possibly related to

toxin release. Further deterioration should prompt consultation with the local Medical

Microbiology/Dermatology/Tissue Viability Service or Surgical Team as appropriate.


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Oral Antimicrobial switch and hospital discharge

Although criteria for the switch from parenteral to oral antibiotics for patients with

community acquired pneumonia have been studied, [26, 27] there is less information in relation

to cellulitis. It has been suggested that patients can be switched safely to oral antibiotics

within 3.5 days of therapy for uncomplicated cellulitis. [28]

Use of IV therapy for longer than 3-4 days does not correlate with better outcomes. [29]

Delay of discharge until complete resolution of fever and all signs of inflammation is usually

unnecessary. [30,31]

Suggested criteria for oral switch and/or discharge

Pyrexia settling

Co-morbidities stable

Less intense erythema

Falling inflammatory markers

Suitable agents for oral switch therapy

Flucloxacillin 500mg qds

If penicillin allergy-

Clarithromycin 500mg bd

Clindamycin 300mg qds

If an oral preparation of the parenteral drug is available this will, on most occasions, be

the most appropriate oral switch agent.

Clarithromycin and clindamycin are suitable agents in the penicillin allergic patient.

Table 2: Suitable Drug Therapy for Atypical Cellulitis

Risk factor First line Penicillin allergy

Human bite Co-amoxiclav 625mg tdspo Clarithromycin 500mg bdpo or Doxycycline 100mg bdpo and Metronidazole 400mg tdspo

Cat/Dog bite Co-amoxiclav 625mg tdspo Doxycycline 100mg bdpo and Metronidazole 400mg tdspo

Exposure to fresh water at site of skin break

Ciprofloxacin 750mg bdpo and Flucloxacillin 500mg qdspo

Ciprofloxacin 750mg bdpo And Clarithromycin 500mg bdpo


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Discontinuation of antibiotics

The duration of antimicrobial therapy for cellulitis has not been extensively studied. Most

cases of uncomplicated cellulitis can be successfully treated with 1-2 weeks of therapy

although complicated cases may require more prolonged therapy.

The bacterial aetiology of cellulitis associated with bites or non-chlorinated water is more

diverse than “simple” cellulitis.

In the case of human bites cover for mouth anaerobes as well as staphylococci and

streptococci is essential and provided with co-amoxiclavmonotherapy. Combination therapy

is recommended in cases of penicillin allergy. In animal bites co-amoxiclav also provides

cover for other common Gram-negative pathogens such as Pasturellamultocida. In cases of

penicillin allergy clarithromycin does not provide this Gram-negative cover and doxycycline

is recommended.

LOCALMANAGEMENT OF CELLULITIS

Management of the locally affected area should include the following:

Adequate analgesia to ensure pain relief

Monitoring and management of any pyrexia

Consider hydration – intravenous/oral

Recording of the site and/or limb affected

Mark off the extent of erythema present on admission

If applicable:

Measurement of the limb

Elevation of the limb

Use of a bed cradle

Blistering

In some instances cellulitis may lead to the skin blistering and subsequent breakdown of the

skin.

Where there is potential for blisters to burst spontaneously, proactive management is

advocated. This includes aseptic aspiration and/or deroofing of the blister. If in doubt, seek

specialist advice.


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Broken and Exudating Skin

The impact of the cellulitis on the skin is to cause tension and swelling which in some cases

leads to ulceration and subsequent loss of large amounts of exudate.

Products normally used for management of wound exudate should be considered and

selection of these will depend on the site and size of area to be covered.

Topical antibiotics should not be used in the management of cellulitis.

Compression Bandages

Once the critical stage of swelling and redness has subsided and the patient is reasonably pain

free, the patient should be assessed for compression bandaging.

Lymphoedema

Patients with lymphoedema require referral to appropriate lymphoedema services.

RISK OF RECURRENCE OF CELLULITIS AND NEED FOR PROPHYLAXIS

Studies on recurrence rates for cellulitis show that 29% of patients who have previously been

admitted to hospital with cellulitis develop a recurrence within a mean of 3 years. [32] Other

reported studies show 17% recurrences but no defined follow-up time [33] and a 12%

recurrence after a follow-up of only 6 months.[34]Strobart 1985 [35] demonstrated a recurrence

rate of 34% in 103 patients who had 2 episodes of erysipelas followed for a mean of 3.3

years. Venous insufficiency has been reported to be the commonest predisposing

factor.[32]Other studies show that lymphoedema is the most important risk factor in the

development of recurrent cellulitis.[36] As lymphoedema and venous insufficiency are often

associated, it would clearly be best to combine these two as the main risk factors for recurrent

cellulitis. Each episode of cellulitis adds to the lymphatic damage. Therefore, prophylaxis

should be considered for patients with recurrent episodes.

Long-term Prophylaxis

Cellulitis is presumed to be caused mainly by streptococci. However in more than 80% of

cases a pathogen is not identified and the pathogenesis of recurrent episodes of cellulitis is

poorly understood. Although there is weak and inconclusive evidence on whether long-term

antibacterial prophylactic therapy prevents recurrent cellulitis, it may be worth trying for 1 –

2 years in patients with predisposing conditions who have had at least 2 episodes of cellulitis

at the same site [42, 43] Antibiotic prophylaxis for recurrent cellulitis is purely empirical and

optimal treatment and prophylaxis in these patients remains to be determined.[36] Prophylaxis


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may be more effective in patients without predisposing factors. [44] Early patient initiated

treatment rather than long-term prophylaxis may be preferable. [45]

Small series have reported benefit from prophylaxis with low dose Penicillin V or

Erythromycin (both typically 250mg bd) or with intermittent IM depot Penicillin[37, 38, 39, 40,and

41]. However it is not proven whether a prolonged course of antibiotics after a single acute

episode will prevent future recurrences.

Prophylaxis for Recurrent Cellulitis

• 2 or more episodes at the same site

• Penicillin V 250mg bd or Erythromycin 250mg bd for up to 2 years.

CONCLUSION

The majority of bacterial skin infections are caused by the gram-positivebacteria

Staphylococcus and Streptococcus species. Antibiotics are used empirically with

consideration for resistance patterns. Current antibiotic recommendations include

penicillinase-resistant penicillins, first-generation cephalosporins, azithromycin,

clarithromycin, amoxicillin- clavulanic acid, or a second-generation fluoroquinolone in the

skeletally mature patient. Gram-negative coverage with a second-, third, or fourth-generation

cephalosporin is usually indicated in children under three years and in patients with diabetes

or who are immunocompromised.

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