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Welcome to <a href="Pathophysiology of Complex Patient Problems">PT 635 Pathophysiology of Complex Patient Problems</a> This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

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Definition/Description

Cellulitis

Prevalence

• 650,000 hospital admissions per year in the United States are due to Cellulitis.⁴
• When hospitalized, patients with recurrent cellulitis require longer hospitalizations relative to nonrelapsing Cellulitis patients.⁴
• From 1998-2006, 10% of all infectious-disease hospitalizations were related to Cellulitis⁴
• 22-49% of patients who have cellulitis report at least one previous episode⁴
• Recurrences, typically in the same location, occur approximately 14% of cellulitis cases within 1 year and in 45% of cases within 3 years⁴
  
  

Characteristics/Clinical Presentation

Typical symptoms include acute poorly demarcated and spreading erythema along with pain, swelling, and warmth of the lower extremity but can occur on any area of skin or underlying subcutaneous tissue.^2,3  Additional symptoms may include fever, nausea, vomiting, and rigors.^3,10 Other features include proximal dilated and edematous skin lymphatics and bulla formation.³ Cellulitis predominantly has a unilateral presentation.³

Associated Co-morbidities

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Medications

Cephalexin, Dicloxacillin, Penicillin VK, Amoxicillin, and Clindamycin are typical Antistreptococcal Antimicrobial agents for the treatment of typical cellulits that is considered mild and does not show signs of systemic involvement.³  Figure 1 states which medications would be appropriate based on the severity of symptoms and the risk of Methicillin-resistant Staphylococcus aureus (MRSA).⁴

Clinical Presentation	Appropriate Antibiotic Treatment
Routine Cellulitis with low suspicion of MRSA	Dicloxacillin, Cephalexin, Nafcillin, or Cefazolin
High suspicion of MRSA or Penicillin allergy	Doxycycline, Clindamycin, Trimethoprim-sulfamethoxazole
High suspicion of MRSA with signs and symptoms of severe infection or did not respond to initial routine treatment	Vancomycin*, Linezolid

• Vancomycin is the drug of choice for infections resulting from MRSA⁴

Diagnostic Tests/Lab Tests/Lab Values

Cellulitis is most commonly diagnosed by history and physical examination alone. Certain laboratory tests can indicate the presence of infection, but are not specific to cellulitis alone. Elevated white blood cell count, C-reactive protein, and erythrocyte sedimentation rate are the most common laboratory results in people with cellulitis, though the prevalence of these results varies widely on a case by case basis. Imaging studies can identify more severe infections to differentiate from cellulitis, but are not a reliable diagnostic tool for cellulitis itself. (3)

Cultures are typically not beneficial in making a cellulitis diagnosis. Identification of the cause of the infection through blood, needle aspiration or punch biopsy are not recommended unless the patient has a complication or abnormal exposure history. This would include immunosuppressants, a diagnoses of chronic liver disease, aquatic soft tissue injury, animal and human bites, or being in contact with various bacteria.3 If a biopsy and culture is warranted, a histopathologic evaluation will be performed on the sample. Hematoxylin-and-eosin and certain stainings for organisms, bacteria, fungi, and microbacteria will be included. 8

Etiology/Causes

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Systemic Involvement

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Medical Management (current best evidence)

Currently, there are no published national guidelines for the treatment of cellulitis.⁵ Most common management of the infection is administration of antibiotics. In more severe cases of cellulitis, intravenous antibiotics can be used.⁸ Elevation and compression of the affected area promotes drainage of edema and can reduce inflammation, speeding up recovery.⁸

For those with recurrent cellulitis, prophylactic antibiotic therapy is an option. Recent studies show that antibiotic prophylaxis substantially reduced the number or recurrences experienced by patients while actively taking the medication. Although there is reduction during the antibiotic therapy, there is no evidence of persistent protect effect after it has ceased.¹

In regards to those patients with recurrent cellulitis due to lymphedema, decongestive therapy including manipulation of the lymphatic system through massage, has shown to reduce the recurrence of cellulitis.⁹

This flow chart is a treatment algorithm based on the type of cellulitis a patient is diagnosed with from: Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-37.
http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/935437/

Physical Therapy Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

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References

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