Does recent cellulitis affect pre-operative (pre-op) clearance?

From the Guidelines

Recent cellulitis can significantly affect pre-operative clearance and may require postponement of elective surgery until the infection is fully resolved. Patients with active cellulitis should complete a full course of antibiotics, typically 5-10 days of medications such as cephalexin 500mg four times daily, clindamycin 300-450mg three times daily, or trimethoprim-sulfamethoxazole DS twice daily, and show clinical improvement before proceeding with surgery 1. The surgical site should be free of infection, with resolution of erythema, warmth, swelling, and tenderness. Laboratory markers like white blood cell count, C-reactive protein, and erythrocyte sedimentation rate should return to normal ranges. Active infection increases surgical risks including poor wound healing, surgical site infections, and potential spread of bacteria during the procedure.

Key Considerations

• Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities, as these can increase the risk of recurrent cellulitis 1.
• Administration of prophylactic antibiotics may be considered in patients who have frequent episodes of cellulitis per year despite attempts to treat or control predisposing factors 1.
• For urgent surgeries that cannot be delayed, the patient should be on appropriate antibiotics with coverage continued through the perioperative period.
• The anesthesiologist and surgeon should be informed about the recent infection to make appropriate risk assessments and modifications to the surgical plan.

Management of Recurrent Cellulitis

• Patients with recurrent cellulitis may benefit from prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4–52 weeks, or intramuscular benzathine penicillin every 2–4 weeks 1.
• The duration of therapy is indefinite, and infections may recur once prophylaxis is discontinued 1.

From the Research

Cellulitis and Pre-Op Clearance

• Recent cellulitis may affect pre-op clearance as it is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma 2.
• The diagnosis of cellulitis is based on the history of present illness and physical examination, and lacks a gold standard for diagnosis, which can make it challenging to distinguish from other conditions 3.
• Cellulitis can be treated with oral antibiotics, and the majority of non-purulent, uncomplicated cases are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus 3.
• The route of antibiotic administration (oral vs intravenous) may not affect the outcome of cellulitis treatment, and patients with similar severity of cellulitis may recover regardless of the route of administration 4.
• A thorough history and clinical examination can help narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization, which may be relevant for pre-op clearance 5.

Factors Affecting Pre-Op Clearance

• The severity of cellulitis, as measured by C-reactive protein levels, affected skin surface area, and systemic inflammatory response syndrome score, may influence the decision for pre-op clearance 4.
• Patients with more severe cellulitis may require intravenous antibiotic therapy, which may impact pre-op clearance 4.
• The duration of antibiotic therapy may not be associated with the outcome of cellulitis treatment, but may still be relevant for pre-op clearance 4.