Facial cellulitis

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Background

Risk Factors

Clinical Features

Differential Diagnosis

Facial cellulitis

Infectious

Trauma

  • Soft tissue contusion
  • Burn

Inflammatory

Immunologic

Skin and Soft Tissue Infection

Look-A-Likes

Evaluation

  • Diagnosis is clinical
  • Consider labs, blood culture if patient is immunocompromised, risk factors, renal dysfunction
  • Bedside ultrasound to identify abscess
  • CT can identify deep, extensive infection that involve soft tissues of neck or pharynx

Management

  1. Analgesics
  2. Remove foreign bodies from affected area if possible
  3. Abscesses should be drained
  4. Antibiotics (see below)

Antibiotics

Tailor antibiotics by regional antibiogram[1]

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS[2]

  • 5 day treatment duration, unless symptoms do not improve within that timeframe[2]
    • Cephalexin 500mg PO q6hrs OR
      • Add TMP/SMX 1DS PO BID[3] if MRSA is suspected
      • Most cases of non-purulent cellulitis are thought caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.[4]
    • Clindamycin 450mg PO TID
    • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis, due to high rates of Strep resistance[5]

Inpatient

Saltwater related cellulitis

coverage extended for Vibrio vulnificus

Freshwater related cellulitis

coverage extended for Aeromonas sp

Disposition

  • Most patients can be treated with oral antibiotics as outpatient

Consider admission for:

  • systemic signs of sepsis
  • antibiotic intolerance
  • immunosuppression
  • extensive areas of erythema or induration
  • foreign bodies that cannot be removed in ED
  • failure of outpatient therapy

See Also

External Links

References

  1. Stevens D, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52
  2. 2.0 2.1 Stevens D, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52
  3. Cadena J, et al. Dose of trimethoprim-sulfamethoxazole to treat skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus. Antimicrobial agents and chemotherapy 55.12 (2011): 5430-5432.
  4. Pallin D, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 56.12 (2013): 1754-1762
  5. Traub, W and Leonhard, B. Comparative susceptibility of clinical group A, B, C, F, and G beta-hemolytic streptococcal isolates to 24 antimicrobial drugs. Chemotherapy 43.1 (1997):10-20.