Clinical update

Management of cellulitis – new guidance includes antimicrobial prescribing strategy

Timely treatment of cellulitis is essential to avoid the development of sepsis

Timely treatment of cellulitis is essential to avoid the development of sepsis

Cellulitis can become serious and lead to sepsis if untreated. Picture: SPL

Essential information

Cellulitis and erysipelas are infections of the tissues under the skin which usually result from contamination of a break in the skin.

Cellulitis needs to be treated swiftly with antibiotics, as it can become serious and lead to sepsis if untreated. It most commonly affects the hands, feet and legs.

Research suggests rates of cellulitis are increasing the in UK. In 2008-09 there were more than 82,000 hospital admissions in England and Wales relating to cellulitis.

What’s new?

Prescribing advice to treat cellulitis and erysipelas while reducing antibiotic resistance has been published by the National Institute for Health and Care Excellence (NICE). It sets out an antimicrobial prescribing strategy for adults, young people, children and babies aged 72 hours and over. The guidance calls for oral antibiotics to be used if possible, and encourages healthcare staff to not offer antibiotic prophylaxis routinely to prevent recurrent cellulitis or erysipelas. It also provides guidance on when patients should be referred to hospital.

Signs and symptoms

Both cellulitis and erysipelas are characterised by acute localised inflammation and oedema. Lesions are more superficial in erysipelas and with a well-defined, raised margin. People can also present with swollen, painful glands.

Causes and risk factors

Cellulitis is usually caused by a bacterial infection that gets through broken skin. People are more at risk if they have poor circulation to limbs. This will include people who have:

  • Mobility problems.
  • A weakened immune system due to chemotherapy treatment or diabetes.
  • Pressure ulcers.
  • Lymphoedema.
  • A surgical wound.
  • A history of cellulitis.

It will also affect people who are overweight or who have injected drugs.

How you can help your patient

  • Offer an antibiotic treatment based on prescribing guidance from NICE.
  • Consider marking the extent of infection with a single-use surgical marker pen.
  • Consider a swab for microbiological testing, but only if the skin is broken and there is a risk of an uncommon pathogen.
  • Manage underlying conditions such as diabetes, venous insufficiency, eczema and oedema.
  • Refer the patient to hospital if there are symptoms or signs of a more serious illness or condition such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis.
  • Consider making a referral or seeking specialist advice if the person is severely unwell or has lymphangitis, has an infection near the eyes or nose, has spreading infection that does not respond to oral antibiotics or they are unable to take them, or they are suspected of being infected with uncommon pathogens.

More essential clinical updates

Expert comment

Caitriona O’Neill is director of community services at Accelerate, a London-based community interest company providing wound and lymphoedema care

‘The patient will be significantly affected when cellulitis or erysipelas is present, and they will have a risk of sepsis. Early recognition of cellulitis with prompt treatment and regular review is essential.

'Cellulitis episodes and admissions have a significant financial impact on the health economy. A focus on skin care and self-monitoring is essential for high-risk groups.  All nurses need to be aware of the symptoms and presentation of cellulitis and the fact that it will be more prevalent in those with lymphoedema and chronic oedema. Managing swelling by using compression along with skin care is essential to avoid reoccurrence.

‘The National Institute for Health and Care Excellence guidance provides a framework for healthcare professionals as a minimum standard and aims to reduce the risk of sepsis for people who have episodes of cellulitis.’


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