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Cellulitis A Review

Adam B. Raff, MD, PhD1; Daniela Kroshinsky, MD, MPH1
[+] Author Affiliations
1Harvard Medical School, Massachusetts General Hospital, Boston
JAMA. 2016;316(3):325-337. doi:10.1001/jama.2016.8825.
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Published online

Importance  Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650 000 admissions per year in the United States alone.

Observations  In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S aureus, with expansion for methicillin-resistant S aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence.

Conclusions and Relevance  The diagnosis of cellulitis is based primarily on history and physical examination. Treatment of uncomplicated cellulitis should be directed against Streptococcus and methicillin-sensitive S aureus. Failure to improve with appropriate first-line antibiotics should prompt consideration for resistant organisms, secondary conditions that mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic liver disease, or chronic kidney disease.

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Figure 1.
Clinical Presentation of Conditions That Mimic Cellulitis and True Cellulitis

The image in panel A provided courtesy of Daniel Sugai, MD, Massachusetts General Hospital Dermatology, Boston. The image in panel B provided courtesy of Anthony Cukras, MD, PhD, Beth Israel Deaconess Medical Center Dermatology, Boston.

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Figure 2.
Treatment Algorithm for Nonpurulent Cellulitis

SIRS indicates systemic inflammatory response syndrome; HR, heart rate; RR, respiratory rate; WBC, white blood cells; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus. This algorithm is based on studies that used a prior definition for SIRS. SIRS is no longer included in the new definition of sepsis.93 Antibiotics are ordered by preference with first choice listed on top. Adjust antibiotic selection based on culture results, local resistance patterns, and clinical response after 24-48 hours. If unresponsive after 24-48 hours, consider possible pseudocellulitis or resistant or atypical organisms.

aTrue penicillin allergy as per published criteria.94,95 For organisms not susceptible to clindamycin, azithromycin 500 mg orally once, then 250 mg/d for 4 days, or levofloxacin, 500 mg/d orally.

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Place holder to copy figure label and caption
Figure 3.
Treatment Algorithm for Purulent Cellulitis

SIRS indicates systemic inflammatory response syndrome; HR, heart rate; RR, respiratory rate; WBC, white blood cells; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus. This algorithm is based on studies that used a prior definition for SIRS. SIRS is no longer included in the new definition of sepsis.93 Antibiotics are ordered by preference with first choice listed on top. Adjust antibiotic selection based on culture results, local resistance patterns, and clinical response after 24-48 hours. If unresponsive after 24-48 hours, consider possible pseudocellulitis or resistant or atypical organisms.

aTrue penicillin allergy as per published criteria.94,95 For organisms not susceptible to clindamycin, azithromycin 500 mg orally once, then 250 mg/d for 4 days, or levofloxacin, 500 mg/d orally.

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