So how do we treat cellulitis? We use antibiotics. Now remember most of the Staph causes are
methicillin-sensitive Staph aureus, but some of your patients will have methicillin-resistant
Staph aureus or MRSA. There are some risk factors. In the last 6 months has your patient had
MRSA or has a family member had MRSA and do they have a history of recurrent boils,
pustules, "spider bites" and that's in quotes because most often when a patient presents with
what they think is a spider bite it's actually an MRSA or MRSA'l lesion. You need to consider
your patient's comorbidities. Is this a patient that can improve on orals or do they need to be
watched closer in the hospital? And if your patient has an abscess, that needs to be managed
and that's through an I&D or incision and drainage because this abscess pocket is
encapsulated. The oral antibiotics will not cure an abscess, it has to be cut open and this is
usually definitive treatment. The abscess in itself does not require antibiotic therapy unless
the patient also has a surrounding cellulitic infection. You want to carefully inspect the skin
around the abscess. And these conditions are painful so you want to provide your patient with
pain relief and if it's on an extremity they should elevate. So how do we manage cellulitis?
It's important to recognize it early because untreated cellulitis can lead to sepsis and death.
You can use the following guidelines for empiric antibiotic therapy. So if you have an outpatient
and they have non-purulent cellulitis you can empirically treat for beta-hemolytic Strep. Some
clinicians choose an agent that's also effective against Staph aureus. For outpatient
management with purulent cellulitis which means there is a drainage, you're going to cover for
MRSA or methicillini-resistant Staph aureus. Now for unusual exposures, you want to cover for
additional bacterial species that could be involved including if the wound was caused by an
animal bite such as a dog or a cat then the cellulitis would require treatment that would cover
the animal's oral flora. When you're managing cellulitis, you want to have your patients on
your radar. They need close follow-up and this is when you would change treatment as
indicated. You want to do strict teaching about red flags and these are the signs of worsening.
Patients are always wondering when will their cellulitis get better. Well, this can take a few
days and this is an important education point. You can see on day 1 only 50% of patients
started on antibiotics will have a cessation of the spread and improved inflammation and only
40% will have defervescence so improvement of their fever and decreased white blood cell
count. You can see on day 2 more of the patients start to improve but it's not until day 3 that
we see a real improvement. So I'm sure to warn my patients that they won't see any
improvement for 2-3 days. Be sure to give them enough reassurance and close follow-up.
I will call my patients the next day and even the next day, see how they're doing and if I'm
really worried I will invite them back to the clinic so I can look at their wound and also check
their vital signs. So there are complications to cellulitis. Your patient's cellulitic infection
can also form an abscess and remember this requires different treatment. Your patient can
develop necrotizing fasciitis and this is serious. This is a flesh-eating disease that spreads
rapidly. Your patient will develop red and purple skin, severe pain, fever, and vomiting. These
are really sick patients and this requires aggressive surgical debridement and antibiotics.
So, I've had patients present with small cellulitc regions on day 1 and within 12 hours they
have rapidly decompensated. They develop a fever, tachycardia, and signs of shock and
these are the patients with necrotizing fasciitis. They need to go immediately to the hospital
and typically be managed in the operating room with a surgical specialist. If not treated, this
can progress to sepsis and death.