From the Guidelines
Patients with cellulitis and bullae require prompt evaluation and management to rule out underlying necrotizing fasciitis or abscesses. A computed tomography (CT) scan is recommended to assess the extent of the infection and identify potential complications, such as gas in the soft tissues or fascial necrosis 1. Additionally, a surgical consultation is advised to evaluate the need for potential debridement or drainage of any identified collections 1.
- Key findings that suggest severe infection and warrant further evaluation include:
- Severe pain disproportionate to the clinical findings
- Failure to respond to initial antibiotic therapy
- Systemic toxicity, such as fever, tachycardia, or hypotension
- Edema or tenderness extending beyond the area of apparent skin involvement
- Crepitus, indicating gas in the tissues
- Bullous lesions or skin necrosis
- Initial empiric antibiotic therapy should cover common causes of skin and soft-tissue infections, including methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pyogenes 1. A combination of intravenous ceftriaxone 1-2 grams every 12-24 hours or cefepime 1-2 grams every 8-12 hours, along with vancomycin 1 gram every 12 hours, is a reasonable choice pending culture and sensitivity results 1.
- Treatment duration typically ranges from 7-14 days, depending on the clinical response and the presence of any underlying complications 1.
- Imaging studies, such as CT or MRI, should not delay surgical consultation and intervention, as prompt surgical evaluation is crucial for both diagnostic and therapeutic purposes in cases of suspected necrotizing fasciitis 1.
From the Research
Cellulitis and Bullae Diagnosis
- The presence of bullae in a patient with cellulitis may indicate a more severe infection, such as necrotizing soft tissue infection (NSTI) 2.
- Computed tomography (CT) scans can be useful in diagnosing NSTI, with a sensitivity of 100% and a specificity of 98% 2.
- A negative CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI 2.
Treatment and Management
- The treatment of cellulitis typically involves antibiotic therapy, with the optimal time to clinical reassessment being between 2 and 4 days 3.
- Clinical and operational factors, such as age, peak C-reactive protein, and frequency of medical assessments, can influence the duration of intravenous antibiotic therapy 4.
- Senior clinicians may prescribe shorter courses of follow-on oral antibiotics, and IV to oral conversion is more likely to occur on the first day of the work week 4.
Surgical Consultation
- Surgical consultation may be necessary in cases of suspected NSTI or other complications, such as abscesses or necrotic tissue 2.
- The presence of bullae and other clinical factors, such as severe pain, swelling, and redness, may indicate the need for surgical evaluation 5, 2.
- A CT scan can help identify patients who require surgical intervention, and a negative scan can help rule out the need for surgery 2.