Medical School – Cellulitis

Hey this is Dr. K from imedicalschool and
today lets talk about cellulitis. We will rev iew the causes of cellulitis, the differential
diagnoses , as well as, the management of cellulitis. First we need to understand what exactly is
cellulitis. Cellulitis is an infection that involves the skin and soft tissues. The parts
of the skin that are involved include the Dermis,a s well as, the subcutaneous tissues.
In addition to an infection of the tissue an abscess amy be present. An abscess is a
walled off collection of pus that are generally resistant to antibiotics unless they are incised
and drained. Now what organisms are commonly responsible for cellulitis. Well remember
that your skin is the first line of defense for your body from outside pathogens. When
you have breaks in your skin from cuts or trauma bacteria are able to enter into the
deeper layers of tissue. As a result the most common organisms involved in cellulitis are
really the organisms that are constantly present on your skin. These organisms include beta
hemolytic strep and staphylococcus aureus. More recently methiccilin resistant staphylococcal
aureus, otherwise known as MRSA has become significantly more prevalent within the community
and should especially be considered when an abscess is present. Now besides cellulitis are there other skin
infections that can appear similar to cellulitis. Well the first one we will talk about is erysipelas.
Erysipelas is an superficial cellullitis that has a defined raised border, which is key.
Erysipelas is cause by the bacteria beta-hemolytic strep. The reason it is important to differentiate
erysipelas from cellulitis is that the antibiotics used are slightly different because in erysipelas
we are really trying to tagret beta-hemolytic streptococcus. In add-on to erysipelas we
should always be mindful of necrotizing infection. Necrotizing infection lead to significant
cell death. Many organisms can be responsible but what is so scary about necortizing infections
is that they can threaten the limb and if severe enough can lead to limb amputation
so it is always best to catch necrotizing infections early when all they may need is
some localized debridement. Now what are the risk factors that may predispose
individuals to cellulitis. If we know what risk factors predispose people to cellulitis
we will be better able to identify and possible prevent cellulitis in these groups of patients.
First off obesity is a known risk factor for cellulitlits as it has many associated problems
like increased venous congestion and gthe development of a greater number of skin folds
where bacteria can grow if not properly cleaned. The presence of edema or prior radiation therapy
increases your risk of cellulitis. Hospitalizations increase your risk of celluliitis and can
increase your risk of developing MRSA cellulitis. If walk down the hospital hallway it is clear
to see how many rooms are on contact isolation because someone has an MRSA infection or their
skin is colonized with MRSA. Of course intravenous drug abuse predisposes people to cellulitis
as they are breaking the skin barrier with many times dirty needles and introducing bacteria
into the deeper tissues. Finally the last two risk factor include being diabetic and
immunocompromised because both of these groups are unable to mount an appropriate immune
response. Diabetics are prone to cellulitis because they can develop neuropathy or chronic
numbness from their diabetes and they may not be able to feel that minor cuts they receive
are becoming infected. This is the reason that all diabetics should do daily foot care
to identify of any scrapes ro cuts are infected on their feet. THis is one of the major reasons
why many uncontrolled diabetics undergo leg amputations which is really sad to see. Now what are the keys to the physical exam?
Well it is really important to identify the areas affected by cellulitis. You really should
take a marker and outline the edge of the area affected. Drawing a border will help
you and other health care providers to see if the cellulitis is improving or worsening
on their antibiotic therapy. In addition because necrotizing infections are so severe it is
important to try to identify necrotising fascists early. On physical exam when you press on
the affected area if you feel or here a crackling or popping sensation this may represent subcutaneous
gas produced by a bacteria in a necrotizing infection. if this were present he patient
would need urgent surgical evaluation. Most of the time though subcutaneous gas will be
better appreciated on X-ray or MRI. of the affected area. In addition make sure to identify
if the skin infection is plain old cellulitis versus erysipelas with the demarcated raised
borders. Other consideration would be to consider if the patient has osteomyelitis. Osteomyelitis
i an infection of the bone. As infection penetrate the skin the can progress to deeper tissues,
so they can affect muscles, tendons, and if they get deep enough even bone. Usually a
significant wound is present if a patient is at risk for osteomyelitis. If a patient
has osteomyelitis do not swab the skiing to identify the bacteria involved because all
the bugs on the skin flora will grow out but rather have a bone culture performed to identify
what is causing the osteomyelitis. In terms of workup I would always start with
a CBC with a differential to help identify if a leukocytosis is present. In addition
obtain an ESR and CRP. ESR is the erythrocyte sedimentation rate and CRP is c-reactive protein.
Bothe these labs are indicators of inflammation within the body but are not specific to any
particular cause for the inflammation. ESR and CRP will not tell you what type of infection
is occurring but may indicate to you the severity of the infection based on how high these lab
values are. In addition you could follow these labs through treatment to see if there is
a decrease in inflammation with antibiotic treatment to figure out if your treatment
is working. Generally I do not follow ESR and CRP but in rare cases where for some reason
it is difficult to tell if the cellulitis is improving I may consider repeating the
CRP and ESR several days after admission. Given that we want to assess the severity
of the skin infection it is important to obtain blood cultures as the blood cultures will
identify a bactaremia that means whether the bacteria that is infecting the skin has been
able to start growing in the blood, which would indicate a severe infection and changes
the course and rout of antibiotics that you need. If a patient is bactaremic they must
be treated with IV antibiotics and not oral antibiotic.s. Also consider if imaging needs
to be performed. Imaging studies can help you identify necrotizing infections as well
as osteomyelitis. IF you are suspecting osteomyelitis make sure to obtain above culture. In someone with cellulitis it is important
to keep in mind a broad differential because you do not want to miss any of the mimics
of cellulitis and get the diagnosis wrong. As i have mentioned previously make sure a
patient does not have necrotizing fascitiis. in addition a infection that can mimic cellullitis
is called herpetic whitlow. Herpetic whitlow is an infection by herpes zoster, the bug
that causes chicken pox, of a inter. You will see small vesicles with underlying red skin.
Keep in mind this is a viral infection and not a bacterial infection so antibiotics will
not help this. A patient with herpetic whitlow will likely need antiviral therapy. In addition
make sure your patient does not have a hypersensitivity reaction which means an allergy. Allergic
responses can mimic a cellulitis picture. Finally make sure the patient does not have
a clot or DVT in the legs or arms. A blood clot can present with swelling and redness
of their underlying skin. A detailed history and physical should point your clinical suspicion
towards or away from cellulitis. Now lets talk about the treatment of cellulitis.
Cellulitis can be treated on an outpatient basis if not severe. The key finding that
dictates treatment is whether the cellulitis is purulent, producing pus, or not. if the
area affected is purulent there is a concern for MRSA so think about using clindaymycin
or TMP.Sx; if they are penicillin allergic you could consider doxycycline. Linezolid
is another outpatient agent that can be sussed that would also cover MRSA. If the cellulitis
is non purulent then consider cephalexin, dicloxacillin, or clindamycin. THese antibiotics
are mainly pointed at streptococcus. Finally lets talk about inpatient treatment.
In the Inpatient setting for patients that are very sick I would consider starting with
vancomycin as it will cover all your gram positive organisms, as well as, MRSA. Now
if someone has a chronic diabetic wound I would consider adding antipseudomonal coverage
so you could consider an antibiotic like piperacillin tazobactam, otherwise known as Zosyn. always
remember the key rule is to tailor antibiotics based on the culture data to decrease the
risk of bacteria developing resistance and your patient from developing complications.
Eventually you should be able to wean to oral medications after significant improvement.
Well that is a brief review of cellullitis. I hope you liked this video. If you did like
this video make sure to share this video with your friends on Facebook and twitter, please
give this video a like. If you have any questions or suggestions for any future videos place
them down below, and most importantly subscribe. THis is Dr. K and I will see you next time.

12 thoughts on “Medical School – Cellulitis

  1. Good video, but in order to make it more helpful and to make it more interesting I would definitely include some pictures! Xx

  2. the hand that is writing the letters kinda makes me dizzy and motion sick, so i could only listen to the audio.  good video, but consider a less distracting way of getting the text on the screen. thx.

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