What is the management of a patient with cellulitis presenting with hypotension?

From the Guidelines

For a patient with cellulitis who is hypotensive, immediate intervention is required as this likely represents sepsis, and the most recent guidelines from 2018 suggest starting with fluid resuscitation using crystalloids and broad-spectrum antibiotics 1. The patient should receive fluid resuscitation using crystalloids (normal saline or lactated Ringer's) at a dose that is typically in the range of 30 mL/kg within the first 3 hours, but the exact dose may need to be adjusted based on the patient's response and other factors such as cardiac function. Simultaneously, obtain blood cultures and begin broad-spectrum antibiotics within 1 hour. For empiric coverage, use vancomycin 15-20 mg/kg IV (actual body weight) plus either piperacillin-tazobactam 4.5g IV q6h, cefepime 2g IV q8h, or meropenem 1g IV q8h, as these combinations are effective against the typical pathogens that cause cellulitis, including streptococci and staphylococci, and are recommended by recent guidelines 1. Some key points to consider in the management of cellulitis include:

• The importance of early recognition and treatment of sepsis, as delayed treatment can lead to worse outcomes 1.
• The need to consider the patient's underlying health status and other factors that may affect their response to treatment, such as renal function and allergy history.
• The potential for MRSA to be a cause of cellulitis, particularly in patients with certain risk factors such as recent hospitalization or antibiotic use, and the need to consider this when selecting empiric antibiotics 1.
• The importance of monitoring the patient's response to treatment and adjusting the antibiotic regimen as needed based on culture and susceptibility results. If the patient remains hypotensive despite adequate fluid resuscitation (MAP < 65 mmHg), start vasopressors, with norepinephrine as the first-line agent (starting at 0.1-0.2 mcg/kg/min, titrated to effect) 1. Monitor vital signs, urine output, lactate levels, and other markers of perfusion. The hypotension in this scenario is likely due to systemic inflammatory response and vasodilation from bacterial toxins entering the bloodstream from the cellulitis infection site. Addressing both the underlying infection and supporting hemodynamics are essential for preventing progression to septic shock and multi-organ failure. It is also important to consider the potential for other complications, such as abscess formation or necrotizing fasciitis, and to monitor the patient closely for signs of these conditions. Overall, the management of cellulitis requires a comprehensive approach that takes into account the patient's underlying health status, the severity of their illness, and the potential for complications, and that is guided by the most recent and highest-quality evidence available.

From the Research

Patient Presentation

• The patient presents with cellulitis and is hypotensive, indicating a potential severe infection [(2,3,4,5,6)].
• Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma 2.
• The condition classically presents with erythema, swelling, warmth, and tenderness over the affected area [(2,4,5)].

Diagnostic Considerations

• The diagnosis of cellulitis is clinical, based on the history of present illness and physical examination, and lacks a gold standard for diagnosis 4.
• Cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers [(2,4,6)].
• A holistic patient assessment, skin assessment, and thorough clinical history are important in the diagnosis of cellulitis 6.

Management

• Most patients with cellulitis can be treated as outpatients with oral antibiotics 2.
• The choice of antibiotic should be based on the suspected causative organism, with β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus being common causes 4.
• However, the patient's hypotensive state may indicate a more severe infection, requiring closer monitoring and potentially more aggressive treatment [(3,5)].