Rosen & Barkin's 5-Minute Emergency Medicine Consult (141 page)

TREATMENT

Airway compromise possible with deep extension of facial or neck cellulitis

• General principles:
  
  • Consider local prevalence of resistant pathogens in addition to usual causes
    
  • In simple cellulitis, periorbital cellulitis, and diabetic patients, need to include CA-MRSA coverage in empiric therapy
    
  • Usual outpatient treatment: 7–10 days
    
  • Cool compresses for comfort
    
  • Analgesics
    
  • Extremity elevation
    
  • Treat predisposing tinea pedis with topical antifungal such as clotrimazole
    
• Simple cellulitis:
  
  • Outpatient:
    
    • Oral Cephalexin + TMP/SMX (to cover CA-MRSA)
      
    • Alternatives to cephalexin: Oral dicloxacillin, macrolide, or levofloxacin
      
    • Alternatives to TMP/SMX: Clindamycin or Doxycycline
      
  • Inpatient:
    
    • IV nafcillin or equivalent, + IV vancomycin (to cover CA-MRSA)
      
• Extremity cellulitis after lymphatic disruption:
  
  • Same as simple cellulitis
    
• Cellulitis in diabetics:
  
  • Outpatient:
    
    • Amoxicillin/clavulanate + TMP/SMX (to cover CA-MRSA), or clindamycin
      
  • Inpatient:
    
    • IV ampicillin/sulbactam or imipenem cilastatin or equivalent; + IV vancomycin (to cover CA-MRSA)
      
• Periorbital cellulitis in adults:
  
  • Outpatient: Oral dicloxacillin or azithromycin; + TMP/SMX (to cover CA-MRSA)
    
  • Inpatient: IV vancomycin
    
• Buccal cellulitis in adults:
  
  • Outpatient: Oral amoxicillin/clavulanate
    
  • Inpatient: IV ceftriaxone
    
  • Odontogenic source:
    
    • Drainage essential
      
    • Coverage for anaerobes: Clindamycin
      
• Facial cellulitis in children:
  
  • IV ceftriaxone
    
• Perianal cellulitis:
  
  • Outpatient: Oral penicillin VK
    
  • Inpatient: IV penicillin G (aqueous)
    
• Animal or human bite:
  
  • Oral amoxicillin/clavulanate
    
• Foot puncture wound:
  
  • Oral or IV ciprofloxacin or IV ceftazidime
    
• MRSA:
  
  • Nosocomial MRSA: IV vancomycin or oral or IV linezolid
    
  • CA-MRSA:
    
    • PO: TMP/SMX, clindamycin or doxycycline
      
    • IV: Vancomycin or clindamycin
      

• Amoxicillin/clavulanate: 500–875 mg (peds: 45 mg/kg/24h) PO BID or 250–500 mg (peds: 40 mg/kg/24h) PO TID
  
• Ampicillin/sulbactam: 1.5–3 g (peds: 100–300 mg/kg/24h up to 40 kg; over 40 kg give adult dose) IV q6h
  
• Azithromycin: (Adults and peds) 10 mg/kg up to 500 mg PO on day 1, followed by 5 mg/kg up to 250 mg PO daily on days 2–5
  
• Ceftazidime: 500–1,000 mg (peds: 150 mg/kg/24h; max. 6 g/24h; use sodium formulation in peds) IV q8h
  
• Ceftriaxone: 1–2 g (peds: 50–75 mg/kg/24h) IV daily
  
• Cephalexin: 500 mg (peds: 50–100 mg/kg/24h) PO QID
  
• Ciprofloxacin: (Adult only) 500–750 mg PO BID or 400 mg IV q8–12h
  
• Clindamycin: 450–900 mg (peds: 20–40 mg/kg/24h) PO or IV q6h
  
• Dicloxacillin: 125–500 mg (peds: 12.5–25 mg/kg/24h) PO q6h
  
• Doxycycline: 100 mg PO BID for adults
  
• Erythromycin base: (Adult) 250–500 mg PO QID
  
• Imipenem cilastatin: 500–1,000 mg (peds: 15–25 mg/kg) IV q6h; max. 4 g/24h or 50 mg/kg/24h, whichever is less
  
• Levofloxacin: (Adult only) 500–750 mg PO or IV daily
  
• Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/24h div. q8h)
  
• Nafcillin: 1–2 g IV q4h (peds: 50–100 mg/kg/24h divided q6h); max. 12 g/24h
  
• Penicillin VK: 250–500 mg (peds: 25–50 mg/kg/24h) PO q6h
  
• Penicillin G (aqueous): 4 mU (peds: 100,000–400,000 U/kg/24h) IV q4h
  
• Trimethoprim/sulfamethoxazole (TMP/SMX): 2 DS tabs PO q12h (peds: 6–10 mg/kg/24h TMP div. q12h)
  
• Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h; dosing adjustments required younger than age 5 yr); check serum levels
  

FOLLOW-UP

• Toxic appearing
  
• Tissue necrosis
  
• History of immune suppression
  
• Concurrent chronic medical illnesses
  
• Unable to take oral medications
  
• Unreliable patients
  

• Mild infection in a nontoxic-appearing patient
  
• Able to take oral antibiotics
  
• No history of immune suppression or concurrent medical problems
  
• No hand or face involvement
  
• Has adequate follow-up within 24–48 hr
  

• Follow-up within 24–48 hr
  
• Sooner if worsening symptoms, including new or worsening lymphangitis, increasing area of redness, worsening fever
  
• Outline the border of erythema before discharge to aid in assessing response to therapy
  

• Strep and staph are most common causes
  
• CA-MRSA now significant cause of cellulitis, frequent enough to warrant including coverage in empiric treatment
  
• Clinicians not accurate at identifying MRSA at the bedside
  
• A deep abscess may be misclassified as cellulitis
  
• Use clinical suspicion and ultrasound to avoid missing an abscess
  

• Abrahamian FM, Talan DA, Moran GJ. Management of skin and soft-tissue infections in the emergency department.
  Infect Dis Clin North Am
  . 2008;22:89–116.
  
• Gunderson CG. Cellulitis: Definition, etiology, and clinical features.
  Am J Med.
  2011;124:1113–1122.
  
• Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.
  Clin Infect Dis.
  2011;52:1–38.
  
• Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis and subcutaneous tissue infections. In: Mandell GL, Bennett JE, Dolin R, eds.
  Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases
  . 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:1289–1312.
  
• Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis.
  BMJ
  . 2012;345:e4955.
  
• Swartz MN. Cellulitis.
  New Engl J Med
  . 2004;350:904–912.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abscess, Skin/Soft Tissue
  
• Lymphadenitis
  
• Lymphangitis
  
• MRSA
  
• Necrotizing Fasciitis
  

CODES

• 682.3 Cellulitis and abscess of upper arm and forearm
  
• 682.6 Cellulitis and abscess of leg, except foot
  
• 682.9 Cellulitis and abscess of unspecified sites
  

BASICS

• Obstruction of the central retinal artery associated with sudden painless loss of vision
  
• Usually occurs in persons 50–70 yr of age
  
• Ophthalmic artery is 1st branch of carotid.
  
• Risk factors include HTN, atherosclerotic disease, sickle cell disease, vasculitis, valvular heart disease, lupus, trauma, and coronary artery disease.
  
• Incidence of 1–10/100,000
  
• Often described as a “stroke of the eye”
  

• Embolic:
  
  • Occlusion by intravascular material from a proximal source:
    
    • Atherosclerotic disease (majority)
      
    • Carotid artery stenosis
      
    • Valvular heart disease (cardiogenic emboli)
      
    • Atrial myxoma
      
    • Dissection of the ophthalmic artery
      
    • Carotid artery dissection
      
• Thrombotic:
  
  • Obstruction of flow from the rupture of a pre-existing intravascular atherosclerotic plaque
    
  • Hypercoagulable states (sickle cell)
    
• Inflammatory:
  
  • Due to temporal arteritis, lupus, vasculitis
    
• Arterial spasm:
  
  • Associated with migraine headaches
    
• Decreased perfusion:
  
  • Low-flow conditions such as in severe hypotension or high-pressure situations seen in acute angle-closure glaucoma or retrobulbar hemorrhage