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Cellulitis

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Updated 2024 ESCMID guidelines for laboratory testing and antimicrobial stewardship in cellulitis and erysipelas in the emergency department.

Background

Overview

Definition
Cellulitis is an acute bacterial infection of the deep dermis and subcutaneous tissue.
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Pathophysiology
Cellulitis is primarily caused by β-hemolytic Streptococci and S. aureus.
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Epidemiology
The incidence of non-purulent lower extremity cellulitis is 176.6 per 100,000 persons in the US.
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Disease course
After a breach in the skin causes the entry of pathogens into the dermis, the release of bacterial toxins and other inflammatory mediators results in dermal edema, lymphatic dilation, bulla formation and regional lymphadenopathy. Untreated infection may progress to bacteremia and systemic inflammatory response syndrome.
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Prognosis and risk of recurrence
Approximately 17% of patients with acute cellulitis are unresponsive to initial treatment, and the risk of treatment failure is highest in obese patients. Recurrence of cellulitis occurs in approximately 14% and 45% cases within 1 year and 3 years, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of cellulitis are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2024), the European Society for Microbiology and Infectious Diseases (ESCMID 2024), the American College of Radiology (ACR 2022), the American College of Physicians (ACP 2021), the Surgical Infection Society Europe (SIS-E/WSES 2018), the ...
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Diagnostic investigations

Clinical assessment: as per SIS-E/WSES 2018 guidelines, assess the following independently to classify patients with SSTIs:
character of the infection (necrotizing or non-necrotizing)
purulence (purulent or nonpurulent)
anatomical extension
patient's clinical condition.
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  • Blood and skin cultures

  • MRSA PCR

  • Diagnostic imaging

Medical management

Setting of care: as per AAFP 2015 guidelines, hospitalize patients with any of the following:
uncontrolled SSTI despite adequate oral antibiotic therapy
inability to tolerate oral antibiotics
indications for surgery
initial severe or complicated SSTI
underlying unstable comorbidity or signs of sepsis.
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  • Management of underlying conditions

  • Antibiotic therapy (initial empiric therapy)

  • Antibiotic therapy (duration)

  • Antibiotic therapy (MRSA coverage)

  • Adjunctive corticosteroids

Nonpharmacologic interventions

Elevation of the affected area: as per KDA/KOA/KSC/KSID 2017 guidelines, consider elevating the lesion area to shorten the progression of cellulitis.
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Surgical interventions

Incision and drainage: as per KDA/KOA/KSC/KSID 2017 guidelines, perform incision and drainage for the treatment of purulent SSTIs.
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Specific circumstances

Pediatric patients: as per IDSA 2011 guidelines, administer vancomycin in hospitalized children with complicated SSTIs.
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  • Immunocompromised patients (evaluation)

  • Immunocompromised patients (management)

  • Patients with cellular immunodeficiency

  • Patients with febrile neutropenia (evaluation)

  • Patients with febrile neutropenia (management)

  • Patients with febrile neutropenia (persistent/recurrent episodes)

  • Patients with Vibrio vulnificus infection

Follow-up and surveillance

Repeat microbiological testing: as per IDSA 2011 guidelines, obtain cultures from purulent SSTIs in patients treated with antibiotic therapy, not responding adequately to initial treatment, and if there is a concern for a cluster or outbreak.
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  • Management of recurrent cellulitis (predisposing conditions)

  • Management of recurrent cellulitis (hygiene practices)

  • Management of recurrent cellulitis (prophylactic antibiotics)

  • Management of recurrent cellulitis (decolonization strategies)