Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?

 

The great cellulitis mimic: Stasis Dermatitis

• Similar in appearance to cellulitis
• Often bilateral (where cellulitis is usually unilateral)
• Risk factors include venous stasis, lymphedema
• Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation

Treatment

• Many recommendations out there, many of them consensus, opinion or based on weak data
• Elevation
• Compression if the patient can tolerate it
• Wet dressings if there is crusting and exudative eczema
• Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
• If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)

 

Admit or go home?

• Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
• No validated decision instruments regarding admission or discharge
• 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis  found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
• Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
• Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
• A nice review of the admit or discharge cellulitis question can be found here

  Single or double antibiotic coverage

Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235

• 500 patients with cellulitis
• Treated cephalexin alone or cephalexin plus TMP/Sulfa
• No significant difference in outcome

Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080

• 150 patients with cellulitis
• Treated cephalexin alone or cephalexin plus TMP/Sulfa
• No significant difference in outcome

Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin

 

Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation.   References

• Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
• Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
• Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
• Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
• Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
• Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
• Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
• Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
• Original Kings of County Analysis of Admit or Discharge Cellulitis