Top 10 Myths Regarding the Diagnosis and Treatment of Cellulitis

McCreary EK, Heim ME, Schulz LT, Hoffman R, Pothof J, Fox B. J Emerg Med. 2017 Jul 3

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Top 10 Myths Regarding the Diagnosis and Treatment of Cellulitis.

McCreary EK, Heim ME, Schulz LT, Hoffman R, Pothof J, Fox B. J Emerg Med. 2017 Jul 3.

BACKGROUND:

Cellulitis is commonly treated in the emergency department (ED). Patients who present with cellulitis incur significant health care costs and may be overtreated with antibiotics. The accurate diagnosis and treatment of cellulitis plays an important role in cost-effective, high-quality medical care, as well as appropriate antibiotic utilization.

OBJECTIVE:

We aim to describe common fallacies regarding cellulitis. We present 10 myths that result in misdiagnosis, overtreatment, or inappropriate empiric management of cellulitis. Clinical presentation, including swelling and redness, is explored in depth, along with incidence of community-acquired methicillin-resistance Staphylococcus aureus, management of tick bites, and effective antibiotic therapy for cellulitis.

DISCUSSION:

Patients are often treated for cellulitis unnecessarily or inappropriately. Awareness of these myths will help guide providers in clinical decision making in order to effectively tailor treatment for these infections.

CONCLUSIONS:

Cellulitis is not as simple as it might seem, and is commonly misdiagnosed in the ED. Noninfectious causes of local symptoms, including lymphedema, venous stasis, and deep vein thrombosis need to be considered. Cellulitis should be treated with empiric antimicrobial therapy based on patient risk factors and regional susceptibility patterns. This review will assist providers in managing cellulitis and avoiding treatment errors that lead to high costs, unwanted side effects for patients, and overuse of antibiotics.

Main findings

  • Myth 1: Skin that is red and swollen is definitely cellulitis.
  • Myth 2: My patient has bilateral lower-extremity swelling and redness; my patient has bilateral cellulitis.

Lesson 2: Bilateral lower-extremity cellulitis is exceedingly rare.

  • Myth 3: All skin and soft-tissue infections need antibiotic treatment.

Lesson 3: Some skin and soft-tissue infections do not require antibiotic treatment.

  • Myth 4: With the increased prevalence of methicillin resistant Staphylococcus aureus (MRSA) in the community, all clinically stable, community-dwelling patients presenting to the ED with cellulitis should be treated with an antibiotic that has activity against MRSA.

Lesson 4: The antibiotic spectrum decision should be based on several factors, including presence or absence of purulence, severity of illness, patient-specific risk factors for MRSA, and local bacteria ecology.

  • Myth 5: My patient requires hospitalization for cellulitis, therefore, my patient has a MRSA infection and requires MRSA targeted anti-infective therapy.
  • Myth 6: Clindamycin is an effective empiric antibiotic for MRSA.

Lesson 6: Clindamycin should only be used for the treatment of cellulitis when other alternative agents are contraindicated.

  • Myth 7: Because one cannot tell whether cellulitis is caused by Streptococcus spp., MSSA, MRSA, Gramnegative or anaerobic pathogens, each patient needs to be treated with broad-spectrum antibiotic therapy.

Lesson 7: Antibiotic therapy should be selected based on the characteristics of the infection, severity of illness, and patient-specific risk factors for different organisms. Most cases of uncomplicated cellulitis without abscess or purulence will not need combination therapy with a b-lactam and anti-MRSA antibiotic. Gramnegative and anaerobic coverage is generally unnecessary

  • Myth 8: If the redness extends beyond the drawn wound margin in a patient with cellulitis, the patient is getting worse.

Lesson 8: Because of the subacute spread of redness, edema, or induration in some patients at the time of presentation with cellulitis, the lesion may continue to spread for the first 48 h after administration of antibacterial drug therapy.

  • Myth 9: Patients should never have another skin infection if they are taking antibiotic prophylaxis for recurrent skin infections.

Lesson 9: Antibiotic prophylaxis has been shown to be effective in suppressing infection and decreasing rates of recurrence, but recurrence may occur despite adherence to therapy. Treatment of causes of infection and optimization of treatment of other disease states may decrease the risk of recurrence.

  • Myth 10: All patients with tick bites and surrounding redness have cellulitis.

Lesson 10: Local tick bite reactions are predictable and do not indicate that a patient has cellulitis. These reactions are usually no more than a few centimeters in size.