Cellulitis

General principles

See the CKS cellulitis guideline

See BNSSG micro guidelines for community management: Antimicrobial (antibiotic) guidelines

Who to admit?

Before admission, consider community IV services eg Sirona SPA and/or discussion with microbiology consultant

• Arrange urgent hospital admission if the person:
  • Has Class IV cellulitis (sepsis or severe life-threatening infection, such as necrotizing fasciitis).
  • Has Class III cellulitis (significant systemic upset, such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable comorbidities, or a limb-threatening infection due to vascular compromise).
  • Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin).
  • Is very young (under 1 year of age) or frail.
  • Is immunocompromised.
  • Has significant lymphoedema.
  • Has facial cellulitis (unless very mild).
  • Has suspected orbital or periorbital cellulitis (admit to ophthalmology).
  • Has Class II cellulitis (systemically unwell or systemically well but with a comorbidity).
    • Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person (check local guidelines).
  • Has symptoms or signs suggesting a more serious illness or condition (such as osteomyelitis, or septic arthritis).
• Consider referring people to hospital, or seek specialist advice, if they:
  • Are severely unwell.
  • Have infection near the eyes or nose (including periorbital cellulitis).
  • Could have uncommon pathogens, for example, after a penetrating injury, exposure to water-borne organisms, or an infection acquired outside the UK.
  • Have spreading infection that is not responding to an oral antibiotic.
  • Have lymphangitis.
  • Cannot take oral antibiotics (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).
• For cellulitis resulting from a wound contaminated with fresh water or sea water:
  • Seek specialist advice from a medical microbiologist.
• Seek specialist advice or consider admission, depending on clinical judgement, if:
  • There is continuing or deteriorating systemic signs, with or without deteriorating local signs, after 2–3 days of treatment.
  • Symptoms are not improving (or are worsening) after 14 days of treatment.
• If a person has recurrent episodes of cellulitis (more than two episodes at the same site within one year), consider routine referral to secondary care for advice on the use of prophylactic antibiotics.

Receiving speciality if patient needs admission:

Guidance below is from North Bristol Trust. Please note there may be differences for the other hospitals due to availability of specialties on site. Call to discuss if unsure.

Location of cellulitis

• pre-septal cellulitis – in the very mildest of pre-septal cellulitis consider PO Coamoxiclav 625mg TDS for 7 days (if penicillin allergy then Cefalexin 500mg tds or if a type 1 allergy Levofloxacin od all for 5 days). Otherwise refer to BEH ED.
• orbital cellulitis – this is an emergency. Refer to BCH ED
• facial cellulitis –  Recent dental procedure/dental pain/dental swelling -> max fax          OR      recent sinusitis -> ENT      OR      no obvious surgical/ENT/dental cause -> discuss with AEC consultant
• hand cellulitis -> plastics (NBT), Orthopaedics on STAU (BRI)
• cellulitis over a joint – > orthopaedics
• mastitis/breast abscess   -> breast surgeons via breastcareadmin@nbt.nhs.uk (if stable ?abscess/mastitis) or surgical hub  if admission needed 01174140700

Contacts

BEH ED 0117 3424613

Plastics, ortho, maxfax SpR – bleep via switch