Cellulitis

This vignette includes possible findings for a complicated presentation.

40 y/o African American male with h/o peripheral arterial disease, ESRD requiring dialysis, DM with peripheral neuropathy, immunocompromised state, alcohol abuse presents with acute onset painful lower extremity redness and swelling. Reports recent hot tub use, athletic activity, and trauma at infection site. ROS positive for anorexia, vomiting. Fever, tachycardia, obesity, lymphedema, lymphedema, intravascular port on exam. Skin infection site reveals skin break surrounded by erythema, warmth, edema, induration, and tenderness to palpation. No bullous lesions, crepitus noted.

• Systemic s/sx symptoms of infectious spread (anorexia, vomiting, abnormal vitals) in an immunocompromised patient despite initial oral antibiotics: Admit for inpatient management

• Labs

  • Obtain CBC, CMP, CRP

  • S/sx of systemic involvement: Obtain blood cultures

  • Immunocompromised state and/or sepsis/lymphangitis on exam: Obtain wound cultures

• Adult patient: Wound ultrasound not indicated

• Antibiotic coverage

  • Uncomplicated, i.e. erythema/warmth/edema at site but no concerning risk factors or indications for hospitalization

    • Non-purulent: Cephalexin (Keflex) 500 mg 4x daily

    • Purulent infection concerning for MRSA: Doxycycline 100 mg BID

  • Hospitalized

    • Non-purulent: Ceftriaxone 1g IV qd

    • Purulent infection concerning for MRSA: Vancomycin 15 mg/kg q8h, maximum dose 2g; obtain trough before 4th dose with goal 10-15 if not septic