Skin infections encompass
many specialty groups, ranging from infectious disease and lymphology societies
to wound care specialists and emergency room clinicians, all uniquely aware of
the huge personal and financial cost incurred when infections are not handled
in a prompt and effective manner. The collaborative
management and treatment of cellulitis, an acute and rapidly progressing bacterial
skin infection, is critically important as 2.5% of the general population is
impacted by this disorder and its high level of recurrence when not addressed promptly
and effectively (Nguyen, Rowland & Mounsey, 2014).
Cellulitis is a rapidly spreading
inflammatory skin infection that specifically affects subcutaneous tissues and
is characterized by erythema (redness), swelling and localized tenderness (Goodman &
Fuller, 2009). These authors further
defined a sub-category of cellulitis called erysipelas, a surface cellulitis
that primarily affects the skin and upper dermis, although it may involve
lymphatic vessels with an appearance of redness and sharply defined borders
with occasional red colored streaking. Cellulitis presents as warm and painful
to touch, reddened and edematous in appearance, but with smooth and ill-defined
borders except in severe cases where it may contain pustules or areas of
necrosis (Sambrano, Gordon, Mays, Lapolla & Scheinfeld, 2012). According to
Mortimer and Rockson (2014), cellulitis and erysipelas are among the most
common conditions seen in emergency departments.
Erysipelas, usually caused by group A
Streptococcus, results in the sudden onset of fever, pain and redness (Koster,
Kullberg & Van der Meer, 2007). The typical
scenario that creates a predisposition to infection is the interaction between high
bacteria colonization and circulation of the blood, compounded by increased vulnerability
in moist areas of the body and on the lower extremities (Erbil et al., 2014). The predisposition to cellulitis or erysipelas,
is increased by the presence of skin disruptions or lymphedema, an abnormal
accumulation of fluid in the interstitial space (Koster, Kullberg & Van der
Meer, 2007). This interstitial edema
occurs when the capillary filtration rate exceeds the capability of the lymphatic
drainage mechanism (Trayes, Studdiford, Pickle & Tully, 2013). The lymphatic system tends to be one of the
most poorly understood body systems, however it has been identified as having
three specific functions that include fluid balancing, fatty absorption and
host defense (Mortimer & Rockson, 2014).
Their feeling is the lymphatic system maintains volume homeostasis and
creates an adaptive immunity through its immune surveillance of antigen and
immune cell transport, all important aspects in the maintenance of a healthy
body.
Cellulitis and erysipelas are definitely more
prevalent in patients with lymphedema and skin disruptions, but other risk
factors include diabetes mellitus, chronic venous insufficiency and skin ulcerations
(Perello-Alzamora, Santos-Duran, Sanchex-Barba, Canueto, Marcos & Unamumo,
2012). These authors feel that rendering
a diagnosis of cellulitis is often difficult to provide or problematic in differentiating
from other conditions such as an abscess, as gathering cultures for microbiologic
analysis or isolating a pathogen is not always accessible or available.
When the diagnosis of erysipelas is
rendered, studies have found these bacteria respond well to narrow spectrum penicillins,
such as benylpenicillin (penicillin G), or
to macrolides such as erythromycin, for patients allergic to penicillin (Koster,
Kullberg & Van der Meer, 2007). According
to Ciccone (2013), penicillin G is classified as an anti-infective and falls within
the pharmacologic category of penicillins. The anti-infective mechanism is the occurrence
of cellular death through its binding action to specific enzymes within the
cell wall, making the cellular membrane unable to act as a selective barrier
and unable to handle the high internal osmotic pressure of the bacterial cell
(Ciccone, 2007, p. 504). This anti-infective
mechanism makes it very effective in treating most gram-positive organisms,
some gram-negative organisms and a few anaerobic bacteria and spirochetes (Ciccone,
2013). Ciccone (2013) further states
that Penicillin G, known as a natural occurring penicillin, is particularly
helpful with streptococci and staphylococci, as well as some
penicillin-susceptible strains of N.
gonorrhoeae as it gets widely distributed throughout the body, although
poorly distributed in the central nervous system (CNS).
A
common adverse drug reaction (ADR) for penicillin is the frequency of allergic
reactions that may include hives, skin rashes, itching and difficulty
breathing, although in some cases it may even progress to life-threatening
anaphylactic shock (Ciccone, 2007, p. 505).
Other ADRs mentioned were the possibility of seizures, with some milder gastrointestinal
side effects like colitis, nausea, vomiting and diarrhea, as well as nephritis,
eosinophilia and leukopenia.
In the presence of an allergic sensitivity
to penicillin, a macrolide antibiotic such as erythromycin is the alternative
of choice for treatment of erysipelas and cellulitis (Koster, Kullberg &
Van der Meer, 2007). The role of the macrolide
antibiotic is to corrupt the peptide bonding between adjacent amino acids thus
disrupting structural and functional features at specific areas of the
ribosomes, resulting in the inhibition of bacterial synthesis (Sothiselvam et
al., 2014).
As with penicillin, erythromycin is an
anti-infective that is very effective with gram-positive streptococci and
staphylococci, and gets widely distributed throughout the body, although poorly
perfused throughout the CNS (Ciccone, 2013).
According to this author there are several strong ADRs that include
ventricular arrhythmias, QT prolongation characterized by palpitations,
seizures or syncope, as well as pseudomembranous colitis. Other side effects mentioned were
gastrointestinal issues like nausea, vomiting, cramping and diarrhea, as well
as rashes, drug induced hepatitis and on rare occasion, drug induced
pancreatitis. Both penicillin and
erythromycin cross the placenta and enters into the breast milk (Ciccone, 2013).
The diagnosis of cellulitis tends to be
based mainly on clinical findings versus microbiologic results from needle
aspirations due to an issue of unreliable accuracy with organism identification
that is common in healthy hosts (Sambrano, Gordon, Mays, Lapolla &
Scheinfeld, 2012). These authors found
the most common cause of cellulitis was S. aureus
and streptococci, treated initially with beta-lactam, administered
intravenously in severe cases. Ciccone
(2007) characterizes beta-lactam antibiotics as cephalosporin drugs that
utilize a penicillin-like anti-infective mechanism to adversely impact the
integrity of cellular membrane (p. 505).
He states that cephalosporin is commonly used as an alternative for
patient’s having difficulty tolerating penicillins, although it should not be
used in those having allergic reactions to penicillin.
The treatment of cellulitis varies in
response to the specific causative agent, as methicillin-resistant S. aureus (MRSA) will typically require interventions
with vancomycin, linezolid or daptomycin (Sambrano, Gordon, Mays, Lapolla &
Scheinfeld, 2012). These authors feel
that vancomycin should be used with MRSA cellulitis, especially in the presence
of a penicillin allergy, but promptly switched to linezolid, an oxazolidinone, if
there is a vancomycin-resistant infection. But they all believe that
cellulitis, especially those atypical in nature or in the presence of MRSA,
should be treated in an empirical manner utilizing patient history, anatomic
site and clinical presentation for the most appropriate antibiotic choice.
Vancomycin,
an anti-infective, also has an action of binding to the cell wall, resulting in
cell
death (Ciccone,
2013). He highlighted the most severe
ADRs as being hypersensitivity and anaphylaxis, with lesser side effects being
ototoxicity, hypotension, nausea, rash, chills and neck or back pain. This author feels vancomycin is also widely
distributed throughout the body and crosses the placenta, but it also allows
some permeation into the cerebral spinal fluid (CSF).
Linezolid, an oxazolidinone, has an anti-infective
action that inhibits bacterial protein synthesis at the ribosomal level
(Ciccone, 2013). This author feels it
serves as a very effective treatment against streptococci, as well as having a
bacteriostatic action against staphylococci.
Side effects of linezolid include headache, insomnia, diarrhea, nausea,
lactic acidosis, thrombocytopenia, as well as optic and peripheral neuropathies
(Ciccone, 2013).
Recurrent episodes of cellulitis or
erysipelas manifest in spite of antibiotic treatment, whether curative or
preventive in nature. An analysis by
Koster, Kullberg and Van der Meer (2007) reported patient noncompliance,
incorrect selection of antibiotics, insufficient dosages or antibiotic
concentrations, as well as the possibility of other causative agents as reason
for recurrence. According to Cox (2005),
40% of cellulitis cases currently have recurrences. However, in a study summary
by Nguyen, Rowland and Mounsey ( 2014), they found the prophylactic use of
lower dose penicillin effective in reducing recurrence of leg cellulitis, but
feel that more trials are needed to determine if this lower recurrence rate
persists upon its discontinuation.
In a study by Morgan and McGuckin (2013),
they found that collaboration between dermatology and lymphedema services created
a multi-specialist approach that provided prompt and effective management of
cellulitis. The treatment plan they
identified began with intravenous antibiotics that progressed to oral
antibiotics for 14 days, or until the cellulitis resolved, topical steroids and
wound dressings/soaks, if needed, followed by compression. From there they
highlighted the progression to multilayer compression wrapping using short
stretch bandages, followed by thorough instruction in self-care strategies for
good nutrition, hydration, proper skin care and manual lymphatic drainage
techniques. The final phase of this treatment plan was the progression to
custom or over-the-counter compression garments and the incorporation of appropriate
self-care strategies.
Physical therapists treating patients with
lymphedema must always be aware of the potential for cellulitis or erysipelas, carefully
monitoring the skin on a daily basis.
Once cellulitis is diagnosed it is important to monitor the involved area
of redness, either by measurement or photography, observing the impact and
effectiveness of the empiric antibiotic. Those therapists specialized in
complex lymphedema management will work with bandaging, skin care, compression
garments, manual lymphatic drainage and exercises. However, caution must be
utilized during the performance of an active physical therapy (PT) program as
these antibiotics possess ADRs ranging
from anaphylaxis
and seizures to pseudomembranous colitis
(Ciccone, 2013). Side effects may include
nausea, fatigue, hypotension and neuropathies to name just a few, but all
require astute clinical observation for safety while attending the PT
appointment (Ciccone, 2013).
In conclusion, the benefits of the collaborative
management of cellulitis are clearly presented in many studies similar to
Morgan and McGuckin (2013), with the education of healthcare professionals
being an essential aspect to insuring early antibiotic intervention or early referral
to appropriate dermatology or lymphedema services. Early intervention provides
significant patient benefits by limiting tissue damage and medical complications,
as well as significant cost savings through shorter hospital stays and less
frequent recurrences.
References
Ciccone, C. D. (2007). Pharmacology in rehabilitation (4th ed).
Philadelphia, PA: F. A. Davis
Company.
Ciccone, C. D. (2013). Drug guide for rehabilitation professionals.
Philadelphia, PA: F. A.
Davis Company.
Cox, N. H. (2006). Oedema
as a risk factor for multiple episodes of cellulitis/erysipelas of the
lower leg: a series with community
follow-up. Br J Dermatol, 155(5), 947-50.
Erbil, B., Ersoy, G.,
Ozkutuk, A., Akarca, F. K., Korkmaz, T., Demir, O. F. & Kiyan, S. (2014).
The effects of oral antibiotics on
infection prophylaxis in traumatic wounds. Ulus
Travma
Acil Cerrahi Derg, 20(4),
231-235.
Koster, J. B.,
Kullberg, B. J. & Van der Meer, J. W. M. (2007). Recurrent erysipelas despite
antibiotic prophylaxis: An analysis from case studies. The
Netherlands Journal of
Medicine, 65(3),
89-94.
Mortimer, P. S. &
Rockson, S. G. (2014). New developments in clinical aspects of lymphatic
disease. The Journal of Clinical Investigation, 124(3), 915-921.
Nguyen, L., Rowland, K.
& Mounsey, A. (2014). Low dose penicillin for recurrent cellulitis?
The
Journal of Family Practice, 63(1), E10-E12.
Perello-Alzamora, M.
R., Santos-Duran, J. C., Sanchex-Barba, M., Canueto, J., Marcos, M. &
Unamumo, P. ( 2012). Clinical and
epidemiological characteristics of adult patients
hospitalized for erysipelas and
cellulitis. Eur J Clin Microbiol Infect
Dis, 31, 2147-2152.
DOI 10.1007/s10096-012-1549-2
Sambrano, V., Gordon, R., Mays, R., Lapolla, W. &
Scheinfeld, N. ( 2012). Intravenous
antibiotics used in dermatology. Dermatologic Therapy, 25, 70-81.
Sothiselvam, S., Liu,
B., Han, W., Ramu, H., Klepacki, D., Atkinson,
G. C.,.….
Mankin, A. S. (2014 ). Macrolide
antibiotics allosterically predispose the ribosome for
translation arrest. PNAS, 11(27), 9804-9808.
10.1073/pnas.1403586111
Trayes, K. P.,. Studdiford,
J. S., Pickle, S. & Tully, A. S. (2013). Edema: Diagnosis and
Management. Am Fam Physician, 88(2), 102-110.
