Does a patient with cellulitis and bullae require a computed tomography (CT) scan and surgical consultation?

From the Guidelines

Diagnosis and Management of Cellulitis with Bullae

A patient with cellulitis and bullae requires immediate evaluation for potential necrotizing fasciitis, and a computed tomography (CT) scan is recommended to rule out underlying abscesses or necrotizing fasciitis, particularly if there are signs of severe infection, such as fever, tachycardia, or significant pain 1.

• The presence of bullae is a significant indicator of potential necrotizing fasciitis, as outlined in the practice guidelines for the diagnosis and management of skin and soft tissue infections 1.
• A surgical consult is also strongly advised to assess the need for potential debridement or drainage of any identified collections, as imaging studies should not delay surgical consultation and intervention 1.
• Initial empiric antibiotic therapy with intravenous ceftriaxone 1-2 grams every 12-24 hours or cefepime 1-2 grams every 8-12 hours, in combination with vancomycin 1 gram every 12 hours, should be considered pending culture and sensitivity results, with treatment duration typically ranging from 7-14 days depending on clinical response.
• The Laboratory Risk Indicator for Necrotizing infection (LRINEC) score may be used to predict the presence of necrotizing soft tissue infections, but its sensitivity and specificity are limited, and clinical judgment remains the most important element in diagnosis 1.
• CT scans have a higher sensitivity than plain radiography in identifying early necrotizing soft tissue infections, and findings consistent with necrotizing infections include fat stranding, fluid and gas collections that dissect along fascial planes, and gas in the involved soft tissues 1.

From the Research

Cellulitis and Bullae Management

• The presence of bullae in a patient with cellulitis may indicate a more severe infection, potentially requiring closer monitoring and more aggressive treatment 2.
• Computed Tomography (CT) scans can be useful in diagnosing necrotizing soft tissue infections, which can present with similar symptoms to cellulitis, including bullae 2.
• A study found that IV contrast-enhanced CT scans had a sensitivity of 100% and a specificity of 98% in identifying necrotizing soft tissue infections, suggesting that a negative CT scan can reliably rule out the need for surgical intervention 2.

Surgical Consultation

• Surgical consultation may be necessary for patients with cellulitis and bullae, especially if there is suspicion of an underlying necrotizing soft tissue infection or abscess 2.
• A study found that patients with necrotizing soft tissue infections often require surgical exploration and debridement, highlighting the importance of early recognition and referral to surgery 2.

Diagnostic Approaches

• Thermal imaging has been explored as a potential tool for tracking the progression of cellulitis and monitoring response to treatment, with studies showing promising results 3.
• Clinical evaluation and physical examination remain the primary methods for diagnosing cellulitis, with laboratory tests and imaging studies used to support the diagnosis and guide treatment 4.

Treatment Considerations

• The management of cellulitis typically involves antibiotic therapy, with the choice of antibiotic and duration of treatment depending on the severity of the infection and the presence of any underlying conditions 5, 6.
• Patients with cellulitis and bullae may require closer monitoring and more aggressive treatment, including potential surgical consultation and intervention 2.