cellulitis_erysipelas%20(pediatric)
CELLULITIS/ERYSIPELAS (PEDIATRIC)
Cellulitis is an acute spreading skin infection that may go deep, involving the subcutaneous tissues.
It typically occurs in areas where the skin integrity has been compromised.
May result from blood-borne spread of infection to the skin and subcutaneous tissues.
It is commonly caused by beta-hemolytic streptococci and Staphylococcus aureus in adults and Haemophilus influenzae type B in patients <3 year of age.

Diagnosis

  • Diagnosis is usually made by clinical presentation w/ or w/o Gram stain & culture
  • Clinical response is usually evident w/in 24-48 hours
  • Disease progression despite receipt of oral antibiotics suggests infection w/ resistant microbes, an underlying condition or presence of a deeper, more serious infection
  • In patients who become increasingly ill or experience increasing toxicity, an aggressive evaluation should be initiated, & antibiotic treatment modified on the basis of Gram stain results, culture results & antimicrobial susceptibilities of organisms obtained from surgical specimens

Classification

Uncomplicated cellulitis

  • Area involved is erythematous, warm to the touch, swollen & is distinguished from erysipelas by non-elevated, ill-defined margins
  • Primarily involves the subcutaneous tissues & dermis
  • Erysipelas is more common among infants & young children
  • Local tenderness & regional adenopathy are usually present
  • Constitutional signs & symptoms are usually present (eg fever, chills & malaise)

Complicated cellulitis

  • Cellulitis in patients w/ diabetes mellitus (DM)
  • Facial cellulitis, as meningitis may occur
  • Presence of comorbidities (eg peripheral vascular disease, chronic venous insufficiency, morbid obesity)
  • Presence of significant systemic symptoms (eg irritability, tachycardia, tachypnea, hypotension)
  • Signs of potentially severe deep soft-tissue infection (eg violaceous bullae, cutaneous hemorrhage, skin sloughing, gas in the tissue)

Purulent Cellulitis

  • Presence of purulent exudate or drainage w/o a drainable abscess

Nonpurulent Cellulitis

  • Absence of purulent exudate or drainage & no abscess

Recurrent Cellulitis

  • Cellulitis occurring 3-4 times/year even w/ pharmacological prophylaxis & control of predisposing factors

Laboratory Tests

Gram stain, Culture & Sensitivity

  • Cellulitis in a neonate should prompt a full sepsis evaluation
  • Etiology of cellulitis remains unidentified in most patients & empiric treatment may be based on clinical presentation
  • Lesion culture
    • Cultures of aspirate, biopsy & swabs identify causative organism in ~25% of cases
    • If a specimen can be taken from the site of origin of the cellulitis, positive culture can be obtained in about 1/3 of patients
    • Essential only for those w/ history of malignancy, systemic complications (eg pyrexia, hypotension), predisposing factors (eg immersion injury, animal bites, neutropenia)
  • Blood cultures (BC)
    • Useful only in patients w/ significant leukocytosis, neutropenia, acute onset & high fever, animal bites, immersion injuries, in immunocompromised or in a toxic-appearing patient 
  • Lumbar puncture should be done if H influenzae facial cellulitis is suspected, or if there are signs of systemic toxicity

Imaging

  • Unnecessary in most cases
  • Computed tomography (CT) or magnetic resonance imaging (MRI) scan for suspected necrotizing fasciitis
  • Radiographic exams may be used to rule out osteomyelitis
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