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CELLULITIS 1.1.pptx presentation slides.

Cellulitis is an acute infection of the skin and soft tissues underneath. It initially affects the epidermis, dermis and spread to the superfacial.

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CELLULITIS HIKMAH D. DAWUD
OUTLINE • INTRODUCTION • EPIDERMIOLOGY • CAUSES • TYPES • RISK FACTORS • PATHOPHYSIOLOGY • CLINICAL PRESENTATIONS • INVESTIGATIONS • COMPLICATIONS • TREATMENT • REFERENCES
INTRODUCTION Cellulitis is an acute infectious process of the skin and soft tissues underneath. It initially affects the epidermis, dermis and may spread to the superficial fascia. There is usually a breach in the skin which acts as a point of entry for microbes; Infected wound or prick, insect bites or cracks between the toes from athlete’s foot. It may affect any part of the body but it mostly affects the legs.
EPIDERMIOLOGY The exact prevalence of the disease is uncertain although it is very common. It affects 1 in 40 people per year. Around 15% of patients will have an episode of cellulitis in their lifetime. There is no difference in the incidence of cellulitis in men and women. Streptococcus pyogenes (27%), and Staphylococcus aureus (51%) are the most common infecting organisms.
CAUSES Microbes implicated are; • Staph aureus • Group A streptococci (Strep. Pyogenes) • Group C streptococci (Strep. Dysgalactiae) Less commonly, Strep. pneumonia and Heam. influenza. Some anaerobes (Bacteroides fragilis, Clostridium species) • Staph. aureus and Strep. pyogenes are the most frequent bacterial causes.
TYPES OF CELLULITIS Simple vrs Complicated • Simple cellulitis: monomicrobic • Complicated cellulitis: polymicrobic Purulent vrs non purulent • Purulent: cellulitis with purulent drainage or exudate in the absence of a drainable abscess (collection of pus within the dermis and deeper skin tissues) • Non purulent Cellulitis without purulent drainage or exudate
NON PRURULENT VS PRURULENT
RISK FACTORS Previous episodes of cellulitis at the same site An injury causing break in the skin Leg ulceration ( a long lasting sore that takes more than 4-6weeks to heal) Fungal infection in adjacent tissue( athlete’s foot/tinea pedis by trichophyton) Skin infection (eg eczema)
PATHOPHYSIOLOGY The skin acts as a primary defense mechanism against infections. Although the skin harbors diverse microbiome of bacteria and fungi, several host factors act together to confer protection against skin infections. • Renewal of epidermal layer resulting in shedding of keratocytes as well as skin bacteria • Sebaceous secretions are hydrolyzed to form free fatty acids that strongly inhibit the growth of many bacteria and fungi
PATHOPHYSIOLOGY Conditions that predispose one to an infection • High concentration of bacteria (more than 105 microbes • Excessive moisture of the skin A break or breach in the skin acts as a point of entry for microbes. The nature and severity of the infection depends on both the type of the organism present and the site of inoculation.
PHYSICAL PRESENTATION • Erythema • Pain • Warm / hot to touch • Swelling • Some systemic features such as fever, chills and malaise may be present. These may suggest severe infections.
PHYSICAL PRESENTATION • Skin infection without underlying drainage or abscess is most likely caused by streptococci; Staph aureus is most likely pathogen when these factors are present • Cellulitis usually must be differentiated from other conditions with similar presentations such as DVT, stasis dermatitis/venous eczema, lipodermatosclerosis.
DIAGNOSIS/INVESTIGATION The Infectious Disease Society of America (IDSA) recommends the following blood tests for patients with skin or soft tissue infection (SSTI) who have signs and symptoms of systemic toxicity: • Blood cultures • CBC • C-reactive protein (CRP) Other tests to consider are as follows: • Creatinine levels help assess baseline renal function and guide antimicrobial dosing
DIAGNOSIS/INVESTIGATION Imaging studies • Ultrasonography • CT imaging • MRI Needle aspiration Dissection of the underlying fascia to assess for necrotizing fasciitis may be determined by surgical consultation Skin biopsy is not routine but may be performed in an attempt to rule out a noninfectious entity
ASSESSING THE SEVERITY OF CELLULITIS Eron classification • Class 1: No systemic toxicity and no co-morbidities. Oral antibiotics are given. Care can be given at the community. • Class 2:May or may not have systemic illness but has a co-morbidity. Initially, IV antibiotics are given at the hospital for 48hours followed by out-patient parenteral antibiotic therapy (OPAT) • Class 3: Significant systemic toxicity plus unstable co-morbidities. IV antibiotics are given • Class 4: Sepsis or necrotising fascitis is present. IV antibiotics are given.
COMPLICATIONS  Myositis  Osteomyelitis  Septic arthritis  Bacteremia  Septicemia  endocarditis
TREATMENT Goals of therapy • to relieve pain • to control and eradicate the infection • To prevent complications Non pharmacological management of Cellulitis • Rest and elevate the affected part if possible • Use cool sterile, saline dressings to help decrease pain
DRUG THERAPY FOR TYPICAL CELLULITIS( CREST) Class First Line Second line Class 1 Flucloxacillin 500mg qds po Clarithromycin 500mg bd po Class 2 Flucloxacillin 2g qds IV or Ceftriaxone 1g od IV(OPAT) Clarithromycin 500mg bd IV or Clindamycin 300-600mg tds IV Class 3 Flucloxacillin 2g qds IV Clindamycin 900mg tds IV Class 4 Benzylpenicillin 2.4g 2- 4 hourly IV+Ciprofloxacin 400mg bd IV + Clindamycin 900mg tds IV
DRUG THERAPY FOR ATYPICAL CELLULITIS (CREST) Risk Factor First line Penicillin allergy Human bite Co-amoxiclav 625mg tds po Clarithromycin 500mg bd po OR Doxycycline AND Metronidazole 400mg tds po Cat /Dog Bite Co-amoxiclav 625mg tds po Doxycycline 100mg bd po AND Metronidazole 400 mg tds po Exposure to fresh water at site of skin break Ciprofloxacin 750mg bd po AND Flucloxacillin 500mg qds po Ciprofloxacin 750mg bd po AND Clarithromycin 500mg bd po
TREATMENT FOR PURULENT CELLULITIS Mild • incision and drainage of abscess, antibiotics aren’t usually necessary Moderate • incision and drainage, oral antibiotics to cover for MRSA; Co- trimoxazole, Doxycycline Severe • incision and drainage, IV antibiotics to cover for MRSA ; Linezolid, Vancomycin
TREATMENT FOR NON PURULENT CELLULITIS Mild non purulent (antibiotics to cover streptococci): Penicillin V K, Clindamycin Moderate non purulent: Penicillin, Ceftriaxone, Clindamycin Severe non purulent. Vancomycin + Piperacillin-Tezobactam/ Meropenem • To cover methicillin resistant strains and streptococci: Co- trimoxazole/ Doxycycline + Penicillin/Amoxicillin, Vancomycin, linezolid, ceftaroline
REFERENCES • Chan M. (2017) Role of outpatient parenteral antibiotic therapy in the treatment of community acquired skin and soft tissue infections. BMC Infect Dis. 2017; 17:474 doi:10.1186/s12879- 017-2569-4. • CREST (Clinical Resource Efficiency Support Team) guidelines on the management of cellulitis in adults, 2005. • Davis CP (1996) Normal Flora. Medical Microbiology. 4th edition. Galverston (TX): University of Texas Medical Branch at Galverston; Chapter 6. • Ellis Simonsen SM, Hatch BE (2006) Cellulitis incidence in a defined population. Epidemiol Infect. April 2006. 134(2): 293-9
REFERENCES • Ministry of Health (2017) Standard Treatment Guidelines, 7th Edition. Yamens Press Ltd. Page 604-607 • McNamara DR Berbari EF (2007) Incidence of lower extremity cellulitis: a population-based study in Olmsted County, Minneesota. Mayo Clin Proc.July 2007. 82(7): 817-21 • National Institute for Care and Health Excellence (NICE)Guidelines (2019). Cellulitis and erysipelas; Antimicrobial Prescribing.