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ABSTRACT
Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections
from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the
importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric
antimicrobial recommendations are suggested, including the most recent recommendations from the
Infectious Disease Society of America.
Published by Elsevier Inc. The American Journal of Medicine (2011) 124, 1113-1122
KEYWORDS: Cellulitis; Community-associated methicillin-resistant Staphylococcus aureus; Necrotizing fasciitis;
Soft tissue infections
Cellulitis is a common form of skin and soft tissue infection resulting in more than 600,000 hospitalizations per
year,1 and along with cutaneous abscess, more than 9
million office visits.2 Traditionally, -hemolytic streptococci and Staphylococcus aureus have been considered
the primary causative agents, and empiric therapy with
-lactam antibiotics has been the mainstay of therapy.
Over the past decade, however, numerous reports have
detailed the widespread emergence of methicillin-resistant S. aureus (MRSA). Previously, MRSA infections
had been limited to hospital-acquired infections or to
community cases with nosocomial exposures. Over the
past decade, however, an increasing proportion of outpatient S. aureus isolates has been found to be methicillinresistant. MRSA infections that occur in outpatients or
within 48 hours of hospitalization and lack nosocomial
exposures such as an indwelling device, recent hospitalization, surgery, dialysis, or residence in a long-term care
facility, have been termed community-acquired or community-associated methicillin-resistant S. aureus (CA-
MRSA).3 Recent studies have concluded that the majority of S. aureus skin and soft tissue infections are now
methicillin-resistant,4 and that CA-MRSA is the most
common isolate from purulent skin and soft tissue infections in the United States.5
Although CA-MRSA has become commonly recognized as a major cause of culturable skin and soft tissue
infections, its role in nonpurulent cases of cellulitis remains uncertain.6,7 Some authors have recommended that
all cases of cellulitis8 be treated for MRSA, while others
have recommended that therapy against CA-MRSA
should be limited to cases that are severely ill or fail
empiric -lactam therapy,7,9 or when local rates of
MRSA are 10% of isolates.10 In February 2011, the
Infectious Disease Society of America (IDSA) published
its first guideline for the treatment of MRSA,6 including
in cellulitis, which, along with the IDSA guideline from
2005 for the management of skin and soft tissue infections,11 forms the basis of the treatment recommendations for this review.
Funding: None.
Conflict of Interest: None.
Authorship: The author is solely responsible for writing this manuscript.
Requests for reprints should be addressed to Craig G. Gunderson, MD,
Department of Internal Medicine, Yale University School of Medicine,
Veterans Administration Health Care System, 950 Campbell Avenue,
West Haven, CT 06516.
E-mail address: craig.gunderson@va.gov
DEFINITIONS
1114
2.
3.
4.
patients with cellulitis appear to support the primary role of streptococci.15-23 Although the reported rates of positive cultures are
low, ranging from 1% to 18%, streptococcal species account for
Cellulitis: any spreading infection involving the dermis and
51% of reported isolates, while S. aureus was isolated in only
subcutaneous tissues.12 Purulent cellulitis is defined as celluli15%. Surprisingly, a broad range of gram-negative organisms
tis with associated purulent drainaccounted for another 25%.
age or exudate in the absence of a
The recent guideline on the
drainable abscess.6 This distincmanagement of infections by
tion is significant because purulent
CLINICAL SIGNIFICANCE
MRSA by the IDSA clarifies the
cases are more likely to be due to
relative contributions of strepto Cellulitis is one of the most common
S. aureus.5,6,13
cocci and S. aureus by emphasinfections seen by primary care and hosErysipelas: a specific type of
izing the distinction between
pital-based physicians.
cellulitis involving more superpurulent and nonpurulent types.6
ficial dermal structures distin Cellulitis that is associated with puruCiting a large study of purulent
guished clinically by raised
lent drainage is most commonly due to
soft tissue infections in emergency
borders and clear demarcation
departments across the US, which
Staphylococcus aureus, including combetween involved and uninfound that 76% of cases were due
munity-associated methicillin-resistant
volved skin.11 The distinction
to S. aureus, including 59% by
S. aureus (CA-MRSA). Empiric antimicrois significant because erysipeCA-MRSA,5 the guideline states
bial therapy in these cases should be
las is thought to be predothat in cases with purulence, therdirected against CA-MRSA, and modified
minantly due to -hemolytic
apy should be directed at CAbased on cultures.
streptococci.11
MRSA. In cases of nonpurulent
Abscess: any collection of pus
More commonly, cellulitis is nonpurucellulitis, on the other hand, the
within the dermis or subcutaguideline cites a recent study that
lent. Antimicrobial therapy in such caneous tissues. 11 Clinically,
assessed for evidence of streptoses should be directed at -hemolytic
patients present with nodules
cocci using acute and convalesstreptococci and methicillin-sensitive
with surrounding erythema and
cent serologies of antistreptolysin
S. aureus.
fluctuance. The distinction beO and anti-DNase-B antibodies.7
tween abscess and cellulitis is
This study found that 73% of
significant because abscesses
cases of nonpurulent cellulitis had
are more likely to be due to S.
positive serology, supporting the traditional teaching of the
13
aureus, and are treated primarily by incision and drainage.
predominant streptococcal origin for nonpurulent cellulitis.
Necrotizing soft tissue infections: a necrotizing infection involving any of the soft tissue layers, including the dermis,
subcutaneous tissue, superficial or deep fascia, and muscle.14
CLINICAL PRESENTATION
ETIOLOGY
As noted in the 2005 guideline from the IDSA, traditional
teaching is that most cases of cellulitis are due to -hemolytic
streptococci, often group A, but also groups B, C, or G. S.
aureus also is noted to cause cellulitis, especially when associated with furuncles, carbuncles, or abscesses.11 Nevertheless,
the exact frequency of specific pathogens and the relative
proportion of streptococci and S. aureus remain uncertain,
largely because of the difficulty in culturing most cases of
cellulitis. Potential sources for culture include peripheral
blood, needle aspirates, skin biopsies, and surgical specimens
in cases with purulence, abscess, or necrosis. Unfortunately,
cultures from blood, needle aspirate, and skin biopsy have a
relatively low yield, and many cases of cellulitis are
nonpurulent.7
A recent review of studies of cellulitis that used needle aspiration or punch biopsy for diagnosis questions the traditional
teaching that most cases of cellulitis are due to streptococci. These
authors found that S. aureus accounted for 51% of positive cultures, compared with only 27% from group A streptococcus.8 On
the other hand, studies reporting the results of blood cultures in
Gunderson
Cellulitis
Table 1
1115
Risk Factors for Associated Pathogens in Cellulitis5,10,13
DIFFERENTIAL DIAGNOSIS
A broad range of conditions may masquerade as cellulitis,
including infections such as necrotizing fasciitis, varicella
zoster, herpetic whitlow, and erythema migrans; inflammatory conditions such as acute arthritis, gout, or bursitis; or
dermatologic conditions such as contact dermatitis, hypersensitivity reaction, fixed drug reaction, and venous stasis
disease33 (Table 2). As previously described, cutaneous
abscesses are important to distinguish from cellulitis because of the necessity of drainage.
One common practice for patients with lower-extremity
cellulitis is to rule out deep venous thrombosis with duplex
ultrasound. Data on this practice are mixed, however.
Glover and Bendick34 reviewed 241 patients with a clinical
diagnosis of cellulitis who were referred for ultrasound, and
found no cases of proximal deep venous thrombosis (2 cases
had isolated calf thrombosis). On the other hand, Rabuka et
al35 retrospectively reviewed all duplex scans ordered in the
emergency department with the question of cellulitis versus
deep venous thrombosis. In this study, 17% had a deep
venous thrombosis.35 Based on these studies, it seems that
the yield for routine lower extremity ultrasound in patients
with readily apparent cellulitis is very low, but for patients
1116
Infectious
Necrotizing fasciitis
Erysipelas
Cutaneous abscess
Herpetic whitlow
Erythema migrans
Inflammatory
Acute arthritis (gout, septic)
Acute bursitis
Dermatologic
Stasis dermatitis
Hypersensitivity reaction
Fixed drug reaction
Miscellaneous
Deep venous thrombosis
Rare
Familial Mediterranean fever
Pyoderma gangrenosa
Sweets syndrome
Gunderson
Cellulitis
1117
more sensitive at showing soft tissue gas, and may additionally show deep fascial thickening or associated deep
tissue abscesses.38 Magnetic resonance imaging has been
touted as the imaging study of choice for differentiating
necrotizing infections from cellulitis.39-41 Reported findings
include deep fascial involvement with thickening and inflammation, and the absence of gadolinium contrast enhancement on T1-weighted images, which may reflect tissue necrosis.42 Because studies of diagnostic imaging for
necrotizing fasciitis have generally been retrospective case
series that have lacked meaningful comparison groups,14
data on sensitivity and specificity are unknown.11
Ultimately, the only way to definitively diagnose necrotizing soft tissue infections is by surgical exploration, which
is recommended urgently for any case with substantial concern. Operative findings diagnostic of necrotizing soft tissue
infection include the presence of necrotic fascia, lack of
resistance of normally adherent muscular fascia to blunt
DIAGNOSTIC STUDIES
Most cases of cellulitis are managed empirically. According
to the IDSA guideline, cultures of blood, needle aspirates,
and skin biopsies are optional. Given the relatively low
yield in culturing cellulitis and risk of contaminants, cultures are generally not pursued other than the common
practice of obtaining blood cultures for admitted patients.
Purulent infections, on the other hand, should be debrided
and cultured.
The IDSA does recommend that needle aspiration or skin
biopsies should be considered in patients who are immunocompromised or have an abnormal exposure history, such as
bite wounds. These tests also should be considered in pa-
1118
tients who fail to improve with empiric antibiotics.11 Various methods have been described for needle aspiration,43-45
but the most common is using a 22-gauge needle to aspirate
fluid from the advancing edge of the cellulitis after the area
is cleaned with povidone-iodine solution. The average microbiologic yield reported in studies using needle aspiration
or skin biopsy for culture is 24%,8 although rates have
varied from 0-40%. An alternative to needle aspirate is
using a punch biopsy for culture, although it is unclear
whether this increases diagnostic yield.46
Studies of patients with cellulitis with associated open
wounds or ulcers that have used swabs for culture have
reported high yields of potential pathogens, but distinguishing between causative agents and contaminants may be
difficult.47
A summary of possible diagnostic tests to consider in
patients with cellulitis is found in Table 3.
TREATMENT
Traditionally, cellulitis has been managed empirically with
antibiotics chosen to cover -hemolytic streptococci and
methicillin-sensitive S. aureus. Over the past decade, with
the widespread emergence of CA-MRSA as a potential
pathogen, many clinicians have chosen to treat cellulitis
Table 3
with therapy directed at MRSA. A recent study from Denver, for example, reported that 85% of hospitalized patients
with cellulitis were treated with vancomycin or other antiMRSA therapy, whereas only 20% were treated with cefazolin and 8% with nafcillin. At discharge, 48% were discharged on trimethoprim-sulfamethoxazole, compared with
only 6% on cephalexin and 3% on dicloxacillin.48
The recent guideline from the IDSA on the treatment of
MRSA substantially changes prior recommendations about
the treatment of cellulitis. For outpatients with purulent
cellulitis, empiric therapy for CA-MRSA is now recommended, pending culture results. Empiric therapy for -hemolytic streptococci is considered unnecessary (class A-II
recommendation). Listed options include clindamycin, trimethoprim-sulfamethoxazole (TMP-SMZ), a tetracycline
such as doxycycline or minocycline, or linezolid (Table 4).
For outpatients with nonpurulent cellulitis, on the other
hand, empirical therapy for infection due to -hemolytic
streptococci and methicillin-sensitive S. aureus is still recommended (A-II), whereas therapy for CA-MRSA is reserved for patients who fail -lactam therapy or who are
severely ill. Listed options include cephalexin, dicloxacillin,
and clindamycin. If therapy for both CA-MRSA and -hemolytic streptococci is desired, options include a -lactam
Laboratory tests:
CBC, chemistries, ESR, CRP
CK
Imaging:
Plain films
Ultrasound
CT
MRI
Bacterial cultures:
Blood cultures
Associated wounds or ulcers
Needle aspiration
Culture from punch biopsy
Culture from fluid-filled bullae
Culture of drainage
CBC complete blood count; CK creatine kinase; CRP C-reactive protein; CT computed tomography;
ESR erythrocyte sedimentation rate; LRINEC Laboratory Risk Indicator for Necrotizing Fasciitis; MRI magnetic
resonance imaging.
Gunderson
Table 4
Cellulitis
1119
Erysipelas
Penicillin
Outpatient purulent cellulitis
Clindamycin
A-I*
A-II
TMP-SMZ
A-II
Doxycycline
Linezolid
A-II
A-II
A-II
A-II
A-II
See above.
Highly effective against both HS and CA-MRSA. Recommended for
patients who fail -lactam therapy and may be considered in all with
systemic toxicity.
See above. Recommended for patients who fail -lactam therapy and
may be considered in all with systemic toxicity.
A-II
A-I
Linezolid
Daptomycin
A-I
A-I
Telavancin
Clindamycin
Nafcillin or oxacillin
A-I
A-III
A-II
Cefazolin
A-II
A-III
Pathogen directed.
A-II
HS beta-hemolytic streptococci; CA-MRSA community-acquired S. aureus; MSSA methicillin-susceptible S. aureus; MRSA methicillin-resistant
S. aureus; SSTI skin and soft-tissue infection; TMP-SMZ trimethoprim-sulfamethoxazole.
*All grading of recommendations per the Infectious Disease Society of America (IDSA) guidelines.6,11 Grade A Good evidence to support a
recommendation for use; should always be offered. Quality of evidence I Evidence from at least one randomized, controlled trial; II Evidence from at
least one well-designed nonrandomized clinical trial or cohort or case-controlled study, or multiple time-series, or from substantial results from
uncontrolled experiments; III Evidence from opinions of respected authorities.
1120
therapy for CA-MRSA should be considered pending culture data. Listed options include vancomycin, linezolid,
daptomycin, and telavancin (all A-I). Clindamycin also is
listed as an option, but with a lower level of evidence
(A-III). For hospitalized patients with nonpurulent cellulitis,
however, the IDSA guideline states that -lactam therapy
remains an acceptable option, with reservation of MRSAactive therapy for patients who fail to respond.
Of note, the IDSA does not recommend different antibiotics for diabetics with cellulitis than it does for nondiabetics, except in cases of chronic diabetic foot infections.28
Antimicrobial medications based on IDSA recommendations, including for necrotizing soft tissue infections, are
listed in Table 4. The overall approach to cellulitis is shown
in Figure 2.
Gunderson
Cellulitis
CONCLUSIONS
Cellulitis is a common cause of infection for adult patients.
Until the past decade, empiric treatment using -lactam
antibiotics has been standard. Specific microbiologic diagnosis was rarely pursued or found. Over the past decade,
however, community isolates of S. aureus have been found
to be increasingly resistant to even extended-spectrum
-lactams. Studies of skin and soft tissue infections during
this time, particularly purulent infections, have found a
large proportion to be due to CA-MRSA. It remains unknown, however, how much of nonpurulent cases are due to
CA-MRSA. High-quality randomized, controlled trials
comparing different antibiotic regimens for nonpurulent cellulitis are needed. Lastly, studies to evaluate duration of
therapy and preventive strategies also are overdue.
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