14 July 2022 at 15:06:02
Assess for systemic and joint sepsis. Take obs (BP, HR, temp etc), take bloods (FBC, U&Es, CRP)
Refer to oncall ortho team for severe cellulitis that require IV antibiotics
Clinical presentation
Patients often present with redness of the skin which can become painful to touch. It may occur spontaneously or following skin penetration injury / inset bites. Cellulitis can present from a spectrum from mild to severe. When severe, it can be associated with systemic sepsis.
Clinical assessment
Important focused history include:
duration and onset of cellulitis (acute, chronic, recurrent?)
preceding event (e.g. skin abrasion, insect bite, medical devises)
treatment history so far (antibiotic treatment given so far)
systemic symptoms
significant co-morbidities (e.g. diabetes, immunosuppressed, vascular disease, IVDU, renal/liver failure, history of MRSA) - these may interfere with antibiotic treatment and require closer monitoring
Examination
heat, redness and swelling (use marker to mark the outline of cellulitis)
skin necrosis and blistering are signs of severe cellulitis
examine joint above and below for signs of septic arthritis
for hand cellulitis - look for signs of flexor sheath infection and deep palm infection
neurovascular status
XR of limb if suspected retained foreign body
Investigation
Bloods (FBC, U&Es, CRP), blood cultures / blood gas + lactate (if unwell)
uncomplicated cellulitis - systemically well patients with no significant co-morbidities (see above)
complicated cellulitis - systemically unwell, presence of significant co-morbidities, severe cellulitis (rapid spread, skin necrosis, bullae), failed oral antibiotic treatment
A&E management
uncomplicated cellulitis
these patients may be suitable for oral antibiotics without orthopaedic input
If IV antibiotics is required, please refer to ortho-oncall (these patients may be suitable for daily IV antibiotics with orthopaedic review in AEC)
complicated cellulitis
follow sepsis 6 guidelines if patient shows signs of sepsis
refer to ortho on-call to consider in-patient IV antibiotics treatment
for admission with strict elevation (bradford sling) and antibiotics
antibiotics - See MTW hospital antibiotic guidelines
mild uncomplicated cellulitis - oral flucloxacillin 1g QDS (or Doxycycline 200mg OD if penicillin allergy) for 5 days
severe cellulitis - IV benzylpenicillin 2.4g QDS plus flucloxacillin 2g QDS (or Teicoplanin plus oral sodium fusidate 500mg TDS if penicillin allergy) for 5 days IV
