A guide to the Tx of cellulitis and other soft-tissue infections

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doi:10.12788/jfp.0198

Applied Evidence

A guide to the Tx of cellulitis and other soft-tissue infections

J Fam Pract. 2021 June;70(5):214-219 | 10.12788/jfp.0198

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References

1. Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316:325-337.

2. Collazos J, de la Fuente B, García A, et al. Cellulitis in adult patients: a large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment. PLoS One. 2018;13:e0204036.

3. Chira S, Miller LG. Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review. Epidemiol Infect. 2010;138:313-317.

4. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64:148-155.

5. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:147-159.

6. Jain A, Rubin PA. Orbital cellulitis in children. Int Ophthalmol Clin. 2001;41:71-86.

7. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127:e566-e572.

8. Nageswaran S, Woods CR, Benjamin DK, et al. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25:695-699.

9. Bonnetblanc J-M, Bédane C. Erysipelas. Am J Clin Dermatol. 2003;4:157-163.

10. Jorup-Rönström C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection. 1987;15:105-106.

11. Clebak KT, Malone MA. Skin Infections. Prim Care. 2018;45:433-454.

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14. Akaza N, Akamatsu H, Sasaki Y, et al. Malassezia folliculitis is caused by cutaneous resident Malassezia species. Med Mycol. 2009;47:618-624.

15. Berger RS, Seifert MR. Whirlpool folliculitis: a review of its cause, treatment, and prevention. Cutis. 1990;45:97-98.

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17. Meislin HW, Lerner SA, Graves MH, et al. Cutaneous abscesses: anaerobic and aerobic bacteriology and outpatient management. Ann Intern Med. 1977;87:145-149.

18. Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013;20:545-553.

19. Gaspari RJ, Resop D, Mendoza M, et al. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2011;57:483-491.

20. Fernandez R, Griffiths R, Ussia C. Water for wound cleansing. Cochrane Database Syst Rev. 2002: CD003861.

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22. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med. 2016;374:823-832.

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Incision and drainage first. Ultrasound-guided needle aspiration, however, has not improved treatment efficacy compared with incision and drainage,¹⁹ the mainstay approach for abscesses.¹⁷ The procedure to drain a furuncle, carbuncle, or abscess should include the expression of all purulent material and the removal of all loculations if possible. Wound culture is recommended during incision and drainage per current guidelines.⁵ Simple dry dressings are convenient and effective, although some wounds may require packing. Tap water (that is potable) is suitable for wound cleansing. However, there is no strong evidence that irrigating wounds increases healing or reduces infection.²⁰

Routine use of antibiotics is not recommended for simple cutaneous abscesses.^5,17,21 Evidence has been conflicting regarding empiric antibiotic coverage of MRSA following incision and drainage.^22-25 Guidelines recommend considering the initiation of antibiotics if there are multiple abscesses, gangrene, surrounding cellulitis, or systemic signs of infection, or if the host is immunocompromised.⁵

If MRSA is suspected, recommended antibiotic coverage includes trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline.⁵ If MRSA is identified, treatment options include dicloxacillin or cephalexin. For severe infections persisting after incision and drainage, in addition to oral antibiotic therapy, consider intravenous antibiotic options for MRSA: cefazolin, clindamycin, linezolid, nafcillin, telavancin, or vancomycin.⁵

Necrotizing fasciitis

Necrotizing fasciitis is a rare but potentially deadly infection of the skin and soft tissue. It progresses rapidly and spreads along fascial planes, leading to the necrosis of the superficial fascia. The infection often is more extensive than is indicated by superficial signs. Prompt diagnosis is imperative as necrotizing fasciitis is a surgical emergency.^5,26 In the United States, 500 to 1500 cases of necrotizing fasciitis occur each year.²⁷ Risk factors for necrotizing fasciitis include diabetes, peripheral vascular disease, malignancy, obesity, cirrhosis, renal failure, injection drug use, chronic corticosteroid therapy, alcohol abuse, malnutrition, and iatrogenic immunosuppression.^26,28

Monomicrobial infections, which account for 20% to 30% of cases of necrotizing fasciitis, are community acquired.

Necrotizing fasciitis may be polymicrobial or monomicrobial. Polymicrobial infection, also referred to as type I, is often due to multiple bacteria that originate from the bowel flora, typically including a mix of anaerobic and aerobic organisms. On average, there can be 5 infecting organisms identified per wound, although in some cases up to 15 organisms have been identified in a single wound.⁵ Type I infection is often associated with tissue injury, abscess, or abdominal surgery. The majority of cases of necrotizing fasciitis are polymicrobial.^27,28

Continue to: Monomicrobial infection...