What is the appropriate management for a 27‑year‑old patient with recurrent cellulitis presenting with sepsis, lactic acidosis, and fever?

Management of Recurrent Cellulitis with Sepsis, Lactic Acidosis, and Fever in a 27-Year-Old

Initiate broad-spectrum IV antibiotics within 1 hour of recognition, administer 30 mL/kg crystalloid bolus within 3 hours, start norepinephrine if MAP remains <65 mmHg after fluids, and aggressively search for the source of recurrent infection requiring drainage or debridement. 1

Immediate Actions (Within First Hour)

Antimicrobial Therapy

• Administer IV antibiotics within 60 minutes of sepsis recognition—each hour of delay reduces survival by 7.6% 1, 2
• Start empiric broad-spectrum therapy with meropenem, imipenem/cilastatin, or piperacillin-tazobactam as monotherapy 2
• Add vancomycin empirically given recurrent cellulitis (high risk for MRSA colonization and methicillin-resistant organisms) 3, 2
• If vascular access is delayed, use intraosseous access or intramuscular administration of ceftriaxone or ertapenem to avoid antibiotic delay 3

Obtain Cultures Before Antibiotics (But Do Not Delay >45 Minutes)

• Draw at least 2 sets of blood cultures (aerobic and anaerobic): one percutaneously and one through any vascular device >48 hours old 1
• Culture any wound or cellulitis site 1
• Obtain urine culture if urinary source suspected 1

Fluid Resuscitation

• Give 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion 3, 1, 2
• Use crystalloids (normal saline or lactated Ringer's) rather than colloids—colloids increase renal failure and mortality 3, 2
• Do not use albumin—it provides no survival benefit 3, 2
• Target MAP ≥65 mmHg, urine output ≥0.5 mL/kg/hour, and normalization of lactate 1, 2

Vasopressor Support

• If MAP remains <65 mmHg after initial fluid bolus, start norepinephrine immediately at 0.1–1.3 µg/kg/min 3, 1, 2
• Do not use dopamine—norepinephrine is superior 3

Lactate Measurement and Monitoring

• Measure lactate immediately upon sepsis diagnosis 1
• Elevated lactate >1 mmol/L indicates tissue hypoperfusion and defines severe sepsis 3, 1
• Guide resuscitation to normalize lactate—this is a key endpoint 1

Bicarbonate Therapy for Lactic Acidosis

• Do not administer sodium bicarbonate if pH ≥7.15 despite lactic acidosis 3
• Two randomized trials showed no hemodynamic benefit or reduction in vasopressor requirements with bicarbonate therapy 3
• Bicarbonate causes sodium/fluid overload, increases lactate and PaCO₂, and decreases ionized calcium 3
• The effect of bicarbonate at pH <7.15 is unknown, but the recommendation errs on the side of avoiding it 3

Source Control and Investigation of Recurrent Cellulitis

Identify and Control Infection Source Within 12 Hours

• Recurrent cellulitis in a 27-year-old warrants aggressive search for underlying causes: 1, 4
  • Skin barrier disruption: chronic wounds, pressure ulcers, intertrigo, tinea pedis
  • Venous insufficiency or lymphedema: examine for edema, varicosities
  • Occult abscess or necrotizing infection: palpate for fluctuance, crepitus, or tissue necrosis requiring urgent surgical debridement 1, 4
  • Retained foreign body: piercings, splinters, IV drug use sites
  • Immunocompromise: HIV, diabetes, malignancy, immunosuppressive medications 3
  • Endocarditis: obtain multiple blood cultures and consider echocardiography if no obvious skin source 1

Imaging

• Obtain chest X-ray to exclude pneumonia as alternative/concurrent source 1
• Use ultrasound or CT to evaluate for deep abscess, necrotizing fasciitis, or intra-abdominal source if cellulitis site unclear 1

Surgical Consultation

• Urgent surgical debridement is required if necrotizing fasciitis suspected (pain out of proportion, crepitus, skin necrosis, rapid progression) 1, 4
• Drain any identified abscess promptly 1

Antibiotic De-escalation (After 48–72 Hours)

• Narrow antibiotics once pathogen and sensitivities are known 3, 2
• Discontinue vancomycin if MRSA is ruled out 3
• Transition to targeted therapy based on culture results 3, 2
• Total duration 7–10 days for most serious infections, longer if slow clinical response or S. aureus bacteremia documented 2
• Use procalcitonin levels to support discontinuation if infection resolving 2

Monitoring and Reassessment

• Reassess every 30 minutes if high-risk (NEWS2 ≥7) 1
• Monitor vital signs, mental status, urine output, peripheral perfusion, and lactate clearance continuously 1, 2
• Repeat lactate at 2–4 hours to assess response to resuscitation 1

Critical Pitfalls to Avoid

• Do not delay antibiotics waiting for cultures—survival drops 7.6% per hour 1, 2
• Do not under-resuscitate—ensure full 30 mL/kg crystalloid is given within 3 hours 1
• Do not postpone vasopressors if MAP <65 mmHg persists after fluids 1, 2
• Do not overlook occult sources in recurrent cellulitis: perineal abscesses, dental infections, endocarditis, osteomyelitis 1
• Do not use colloids or albumin for resuscitation 3, 2
• Do not give bicarbonate for lactic acidosis unless pH <7.15 (and even then, benefit is unproven) 3
• Do not miss necrotizing fasciitis—this requires emergency surgical debridement within hours 1, 4

Special Considerations for Recurrent Cellulitis

• After acute management, investigate chronic predisposing factors: venous insufficiency, lymphedema, tinea pedis, obesity, immunodeficiency 4
• Consider suppressive antibiotic prophylaxis (e.g., penicillin or erythromycin) after resolution if ≥3 episodes per year, but only after addressing underlying causes 4
• Screen for MRSA colonization and consider decolonization protocols if positive 3