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Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
CELLULITIS
• Definition • Resistant Organisms
• The Cellulitis / Abscess Clinical Pathway • Personal Hygiene
• Admission Guidelines • Education
• Infection Control • Other discharge information
• Assessment • Referral to Community District Nursing
• Teams & Referrals Service
• Investigations • Referral to Community Services
• Treatment Flow Chart
• Antibiotics
Definition
Cellulitis is a diffuse inflammation of the soft tissue or connective tissue due to infection.
A child with cellulitis will have a red, warm and tender area of skin.
There may be associated fever, chills and sweats, regional lymph node involvement and proximal
red streaking. Cellulitis may lead to ulceration and abscess.
Periorbital cellulitis is swelling and erythema in the soft tissues around the eye. These children
can be managed on the pathway.
Children with orbital cellulitis have clinical evidence of exophthalmos, pain on eye movement, or
limitation of eye movement OR radiographic evidence of subperiosteal or orbital abscess. Urgent
ophthalmology review is mandatory for these patients and they should NOT be managed according
to the pathway.
CELLULITIS
Admission Guidelines
Admit ALL children who:
• are toxic,
• have peri-orbital cellulitis,
• have not responded to oral antibiotics within 48hrs,
• have families unable to cope with the illness at home,
• require IV antibiotic therapy.
Admit MOST children who:
• are systemically unwell,
• have another serious systemic illness (e.g.diabetes),
• have facial cellulitis / abscess,
• are young infants,
• have failed a trial of appropriate oral antibiotics (not tolerated or compliance problems).
Consider a trial of a different antibiotic if the child is stable and there was intolerance or an
inappropriate antibiotic used in the first instance. It is also worth checking the dose of the antibiotic
prescribed to see that it was adequate.
There are certain issues that will influence the decision made whether to discharge or admit a
child. These may not reflect the state of illness but some of the following should be considered:
Infection Control
The mode of transmission is through direct contact with a person who has a purulent lesion.
Hands are the main vehicle for transmitting infection. Washing and drying your hands is the most
important means in preventing the spread of infection.
CELLULITIS
Assessment
Abscess
If the child has a fluctuant lump, the child is to be referred to the surgical team for consultation/
incision and drainage.
Cellulitis
Remember to ask about:
In periorbital cellulitis always examine for signs of orbital involvement (exophthalmos, pain on eye
movement, or limitation of eye movement) & meningitis.
All patients with cellulitis should be examined at least daily to check for abscess development. If
fluctuance develops referral should be made to the appropriate surgical team (depending on the
location of the infection).
CELLULITIS
Investigations
Investigations are not routinely required in most children with cellulitis/abscess.
Blood Culture
Rarely indicated as of little diagnostic value even in the presence of systemic symptoms. Many
children will have been on antibiotics prior to presentation. Consider blood cultures if:
• Temperature >38.5º
• Not on oral antibiotics at time of presentation
• Underlying skin lesions such as varicella or eczema
• +/- facial cellulitis
Wound/Pus Swabs
Not routine. May be done if you are considering a resistant organism e.g. MRSA (however often
results are not available until after the patient is discharged).
A swab for AFB (acid fast bacilli) should be taken where nontuberculous mycobacteria is
suspected.
X-Rays
Not routine. Performed only after discussion with the Orthopaedic team.
CT Scan.
Children must have a CT scan (brain, orbits and sinuses) if there is clinical evidence of orbital
cellulitis. Note: children need not wait in CED until the CT scan has been undertaken but can be
transferred to the ward.
Lumbar Puncture
A lumbar puncture is usually indicated in patients with orbital cellulitis.
It is only considered in patients with peri-orbital cellulitis (or cellulitis involving other sites), if the
patient has any signs suggestive of meningitis (e.g. photophobia, meningism etc.)
CELLULITIS
Consider Yes
Abscess
Surgical
Present?
Intervention
No
Penicillin
Allergic?
Yes
No
Site of
Cellulitis
No IV IV IV
antibiotic antibiotic No antibiotic No
required? required? required?
IV IV IV
Flucloxacillin Amoxicillin + Erythromycin
Clavulanic acid
Oral
Flucloxacillin
capsules
Child unable to
take capsules
Yes
Oral Oral Oral
Amoxycillin + Amoxicillin + Erythromycin
Clavulanic acid Clavulanic acid tabs/suspension
suspension tabs/suspension
CELLULITIS
Antibiotics
Choose the appropriate antibiotic according to site of cellulitis, etiology, presence or absence of
penicillin allergy, and ability of child to swallow tablets (see flow chart).
• Flucloxacillin.
Very effective against S.aureus and has adequate cover for S.pyogenes.
Use for IV therapy and oral therapy for children able to ingest capsules for torso and limb
cellulitis. As flucloxacillin is not palatable in the liquid form, amoxycillin and clavulanic acid may
be a more suitable alternative in a child requiring a syrup.
• Erythromycin.
The drug of choice when there is penicillin allergy.
If there is penicillin allergy (immediate allergic reaction, anaphylaxis or widespread urticaria) then refer to
paediatric immunology non acutely.
Resistant Organisms
If there is deterioration on the recommended Intravenous antibiotics or no improvement within 48
hours, consider resistant organisms (e.g. MRSA, resistant Streptococcus)
CELLULITIS
Personal Hygiene
Parents should be reminded to;
• avoid sharing towels and bedding at home,
• wash linen and clothing regularly,
• maintain children’s short / clean fingernails to avoid skin breaks from scratching,
• examine their child’s skin and clean breaks in the skin,
• see their GP early if redness develops,
• encourage all family members to wash and dry hands properly,
• avoid sharing bath, swimming, and cleaning water when the child has an infected wound,
• restrict their child from swimming in unclean water when they have an open wound.
Education
• Parents / caregivers are to be given the ‘Skin Infections’ handout. This handout is to be
explained to parents/ caregivers.
Medications
Antibiotics
• Parents should be well informed regarding the use of the antibiotics prescribed.
• In particular they should be informed of the importance to complete the course given to the
child, and not to share the course of antibiotics among the family members.
• Parents should be aware of possible adverse effect.
Insect Bites
Parents should;
• be educated to inspect child regularly, to identify insect bites early, so that bites can be treated
early,
• be informed that insect bites have the potential to lead to a more serious situation through
scratching,
• be advised to visit the G.P. early in the disease process.
Recurrent cellulitis/abscess
CELLULITIS