INSTITUT LATIHAN KEMENTERIAN KESIHATAN

MALAYSIA JOHOR BAHRU

PROGRAM DIPLOMA PEMBANTU PERUBATAN

TAHUN 2 SEMESTER 2

PENEMPATAN WAD SURGIKAL

CASE STUDY

TAJUK TUGASAN:
CELLULITIS

NAMA PELATIH : MOHAMAD NUR HAIRIE BIN

BINDFGDFGDFG KAMAROLZAMAN
NO MATRIK : BPP2019-0176
NO IC : 950415-03-5555
KUMPULAN : JANUARI 2019

UNTUK MEMENUHI KEHENDAK KURIKULUM PROGRAM

DIPLOMA PEMBANTU PERUBATAN
TABLE OF CONTENT

NO TOPICS PAGE
1. Introduction 1
2 Problem statement 2
3. Literature review 3
4 Discussion 5-16
5. Conclusion 17
6. References 18
7. Attachment 19
INTRODUCTION

Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. The

affected skin appears swollen and red and is typically painful and warm to the touch.

Cellulitis usually affects the skin on the lower legs, but it can occur in the face, arms and

other areas. It occurs when a crack or break in your skin allows bacteria to enter.Left

untreated, the infection can spread to your lymph nodes and bloodstream and rapidly become

life-threatening. It isn't usually spread from person to person.

Cellulitis occurs when bacteria, most commonly streptococcus and staphylococcus, enter

through a crack or break in your skin. The incidence of a more serious staphylococcus

infection called methicillin-resistant Staphylococcus aureus (MRSA) is increasing.

Although cellulitis can occur anywhere on your body, the most common location is the lower

leg. Bacteria are most likely to enter disrupted areas of skin, such as where you've had recent

surgery, cuts, puncture wounds, an ulcer, athlete's foot or dermatitis.

Animal bites can cause cellulitis. Bacteria can also enter through areas of dry, flaky skin or

swollen skin.

Although cellulitis may occur anywhere on the body, the lower leg is the most common site

of infection (particularly the shinbone), followed by the arm and then the head and neck areas.

Cellulitis can develop in the abdomen and chest areas as well. Obese people can develop

cellulitis in the abdominal skin. Special types of cellulitis are sometimes designated by the

location of the infection.

1
PROBLEM STATEMENT

Name : -TIDAK PERLU DIISI -

Age : 42 Tahun

Race : Melayu

R/N : 48274

CHIEF COMPLENT :

 Left pedal edema sudden onset for 2 days

2
LITERATURE REVIEW

 Cellulitis is a bacterial infection involving the inner layers of the skin. It specifically affects

the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases

in size over a few days. The borders of the area of redness are generally not sharp and the skin

may be swollen. While the redness often turns white when pressure is applied, this is not always

the case. The area of infection is usually painful. Lymphatic vessels may occasionally be

involved

 Cellulitis is caused by bacteria that enter and infect the tissue through breaks in the skin. Group

A Streptococcus and Staphylococcus are the most common causes of the infection and may be

found on the skin as normal flora in healthy individuals.

 About 80% of cases of Ludwig's angina, or cellulitis of the submandibular space, are caused by

dental infections. Mixed infections, due to both aerobes and anaerobes, are commonly associated

with this type of cellulitis. Typically, this includes alpha-hemolytic streptococci, staphylococci,

and bacteroides' groups.

 Cellulitis is most often a clinical diagnosis, readily identified in many people by history and

physical examination alone, with rapidly spreading areas of cutaneous swelling, redness, and

heat, occasionally associated with inflammation of regional lymph nodes. While classically

distinguished as a separate entity from erysipelas by spreading more deeply to involve the

subcutaneous tissues, many clinicians may classify erysipelas as cellulitis. Both are often treated

similarly, but cellulitis associated with furuncles, carbuncles, or abscesses is usually caused by S.

aureus, which may affect treatment decisions, especially antibiotic selection.

3
 It is important to evaluate for co-existent abscess, as this finding usually requires surgical

drainage as opposed to antibiotic therapy alone. Physicians' clinical assessment for abscess may

be limited, especially in cases with extensive overlying induration, but use of bedside

ultrasonography performed by an experienced practitioner readily discriminates between abscess

and cellulitis and may change management in up to 56% of cases.

 Use of ultrasound for abscess identification may also be indicated in cases of antibiotic failure.

Cellulitis has a characteristic "cobblestoned" appearance indicative of subcutaneous edema

without a defined hypoechoic, heterogeneous fluid collection that would indicate abscess

 Misdiagnosis can occur in up to 30% of people with suspected lower-extremity cellulitis, leading

to 50,000 to 130,000 unnecessary hospitalization and $195 to $515 million in avoidable

healthcare spending annually in the United States.

 Other conditions that may mimic cellulitis include deep vein thrombosis, which can be diagnosed

with a compression leg ultrasound, and stasis dermatitis, which is inflammation of the skin from

poor blood flow. Signs of a more severe infection such as necrotizing fasciitis or gas

gangrene that would require prompt surgical intervention include purple bullae, skin sloughing,

subcutaneous edema, and systemic toxicity

4
DISCUSSION

Cellulitis is a common and sometimes painful bacterial skin infection. It may first appear as a

red, swollen area that feels hot and tender to the touch. The redness and swelling can spread

quickly.

It most often affects the skin of the lower legs, although the infection can occur anywhere on

a person’s body or face.

Etiology

The most common bacteria that cause cellulitis are beta-hemolytic streptococci (groups A, B,

C, G, and F). In addition, a form of rather superficial cellulitis caused by streptococcus is

called erysipelas and is characterized by a spreading hot, bright red circumscribed area on the

skin with a sharp, raised border. Erysipelas is more prevalent in young children. A strain of

streptococcal bacteria can sometimes rapidly destroy tissues beneath the skin.

There is a growing incidence of community-acquired infections due to MRSA, a particularly

dangerous form of staphylococcal bacteria that is resistant to many antibiotics and is

therefore more difficult to treat.

Many other bacteria can cause cellulitis. In young children, H  influenzae (H flu) bacteria can

cause cellulitis, especially on the face and arms. Cellulitis from a dog or cat bite or scratch

may be caused by the Pasteurella multocida bacterium, which has a very short incubation

period of only 4 to 24 hours. Cellulitis can also be caused by Aeromonas hydrophila, Vibrio

vulnificus, and other bacteria after exposure to freshwater or saltwater. Pseudomonas

aeruginosa is another type of bacterium that can cause cellulitis, typically after a puncture

wound.

5
Signs and Symptoms

There are four signs and symptoms associated with cellulitis: erythema, pain, swelling, and

warmth. The categories are as follows.

Uncomplicated cases of cellulitis: In these cases, the skin infection is without underlying

drainage, penetrating trauma, or abscess and is most likely caused by a streptococcus or S

aureus. There is limited area of involvement with minimal pain. This category includes

conditions with no systemic signs of illness (e.g., fever, altered mental status, tachypnea,

tachycardia, hypotension) and no risk factors for serious illness (e.g., extremes of age, general

debility, immunocompromised health).

Severe and complicated cases of cellulitis: These cases involve malaise, chills, fever, and

toxicity; lymphangitic spread (red lines streaking away from the area of infection);

circumferential cellulitis; and pain disproportionate to examination findings.

Emergent surgical evaluation: These cases include violaceous bullae, cutaneous hemorrhage,

skin sloughing, skin anesthesia, rapid progression, and gas in the tissue.

Risk Factors

Often, cellulitis develops in the area of a break in the skin, such as a cut, small puncture

wound, or insect bite. In some cases, cellulitis develops due to microscopic cracks in the skin

that are inflamed or irritated. It can also occur around surgical wounds.

Cellulitis can develop where there is no skin break at all, such as a chronic leg swelling.

Athlete’s foot or impetigo can also predispose a person to develop cellulitis. Other diseases

conditions such as eczema and psoriasis or skin damage caused by radiation therapy can lead

to cellulitis.

6
People with diabetes or those receiving chemotherapy or drugs that suppress the immune

system are particularly prone to developing cellulitis. Conditions that reduce the circulation

of blood in the veins or reduce circulation of the lymphatic fluid also increase the risk of

developing cellulitis.

Tattoos usually are not considered risky procedures (an estimated 45 million people in the

United States have at least one), but they do entail risk for infection with both typical

bacterial pathogens and less common organisms. If infected, patients first complain of

pruritic pustules in newly tattooed skin.

Tattoo infections are widely underreported, and nontuberculous mycobacterial infections may

be far more common than it is believed. This diagnosis is unlikely to be made without

mycobacterial cultures of skin-biopsy specimens, and in many cases drug resistance is very

common among these organisms.

Cellulitis is not contagious because it is an infection of the skin’s deeper layers (the dermis

and subcutaneous tissue), and the skin’s top layer (the epidermis) provides a cover over the

infection. In this regard, cellulitis is different from impetigo, in which there is a very

superficial skin infection that can be contagious.

Diagnosis

It is important first to establish that the inflammation is due to an infection. Past medical

history and a physical examination can provide more information. Elevated white blood cell

count and a culture of bacteria may also be of high value in diagnosis. However, in many

cases of cellulitis, the concentration of bacteria may be low and cultures may fail to

demonstrate the causative organism.

When it is difficult or impossible to distinguish whether or not the inflammation is due to an

infection, clinicians treat the patient with antibiotics just to be sure. If the condition is not

7
resolved, the inflammation may not be due to an infection, and different methods dealing

with types of inflammation may be applied. For example, if the inflammation is thought to be

due to an autoimmune disorder, treatment with corticosteroids may be warranted.

First, antibiotics, such as penicillin derivatives or other types of antibiotics, are used to treat

cellulitis. If the bacterium turns out to be resistant to the chosen antibiotics or patients allergic

to penicillin, other appropriate antibiotics can be substituted. In some cases, oral antibiotics

may not always provide sufficient penetration of the inflamed tissues to be effective, and in

these instances antibiotics will be administered in a hospital setting or at home.

The method of treatment is based on many factors, including the location and extent of the

infection, the type of bacterium causing the infection, and the overall health status of the

patient

Cellulitis can be prevented by proper hygiene, treating chronic swelling of tissues (edema),

and care of wounds. It is preventable in a healthy person with a healthy immune system, but

in people with predisposing conditions and/or weakened immune systems, cellulitis may not

always be avoidable.

Blood Tests and Culture

The following blood tests are recommended for patients with soft-tissue infection who have

signs and symptoms of systemic toxicity: CBC with differential; levels of creatinine,

bicarbonate, creatine phosphokinase, and C-reactive protein; and blood cultures.3 Blood

cultures should be done in moderate-to-severe disease (e.g., cellulitis with complicating

lymphedema); in cellulitis of specific anatomical sites (e.g., facial and especially ocular

areas); and in patients with a history of contact with potentially contaminated water.

Additional tests that may be warranted include mycologic investigation if recurrent episodes

8
of cellulitis are suspected to be secondary to tinea pedis or onychomycosis, and serum

creatinine levels to help assess baseline renal function and guide antimicrobial dosing.

Imaging Studies

If necrotizing fasciitis is a concern, CT imaging is typically used to examine stable patients.

Ultrasonography may play a role in the detection of occult abscess and the direction of

medical care, while ultrasonographic-guided aspiration of pus can shorten hospital stay and

fever duration in children with cellulitis. If there is a strong clinical suspicion of necrotizing

fasciitis, surgical consultation should be initiated without delay.

Aspiration and Biopsy

Needle aspiration should be performed only in selected patients or in unusual cases, such as

in patients who have diabetes, are immunocompromised, are neutropenic, are not responding

to empirical therapy, or have a history of animal bites. Gram stain and culture following

incision and drainage of an abscess yield positive results in more than 90% of cases. Skin

biopsy is not routine but may be performed in an attempt to rule out a noninfectious entity.

Cellulitis Treatment

Oral Antibiotics

 If lymphadenopathy, fever and other constitutional signs are not present [eg White blood cell

(WBC) <15,000], then may typically treat patient with oral antibiotics on an outpatient basis

o Given for uncomplicated cellulitis

 If symptoms do not improve or if disease progresses significantly within the first 24-48 hours,

parenteral therapy may be needed

Parenteral Antibiotics

 Should be considered in the presence of the following:

9
 o Presence of signs of toxicity (fever >100.5°F/38°C, tachycardia, hypotension)

o Rapid progression of erythema

o Unresponsive/intolerant to oral antibiotic therapy with significant disease progression

after 2 days of initiation

o Presence of indwelling medical device (eg prosthesis, stents)

 Considered in patients with complicated cellulitis and comorbidities [eg diabetes mellitus

(DM), peripheral vascular diseases]

 Consider switching to oral therapy after 48 hours if possible

Choice of Antibiotic

 Tailored according to known pathogen, comorbid condition (eg DM), and special situations

like water (salt or freshwater) exposure or animal bites

o Treatment should also address underlying predisposing conditions

 Empiric therapy may be started pending culture results

o For patients with purulent cellulitis, treatment is directed towards Methicillin-

resistant S aureus (MRSA) since it is the dominant pathogen in this type of cellulitis;

therapy for beta-hemolytic streptococci is likely not needed

o For patients with nonpurulent cellulitis, treatment is directed towards Methicillin-

sensitive S aureus (MSSA) and beta-hemolytic streptococci

 Empiric therapy for MRSA may be needed if patient has signs of systemic

infection, is unresponsive to initial therapy, has recurrent infection, has a

previous episode of or is at high risk for MRSA infection, or with indwelling

medical device in close proximity to the location of the lesion

Pharmacotherapy

Penicillins (Beta-lactamase Resistant)

10
  Eg Dicloxacillin, Flucloxacillin, Nafcillin, Oxacillin

 Recommended therapy for patients with erysipelas, moderate nonpurulent and purulent

cellulitis, and MRSA infection

 Recommended antibiotics against mild nonpurulent cellulitis caused by group

A Streptococcus or S aureus

o Some authorities recommend antistaphylococcal penicillin alone while others

advocate antistaphylococcal penicillin + Penicillin or Amoxicillin

o Combination may increase adverse effects

 Recommended for initial treatment of neonates with moderate to severe cellulitis

 Also recommended for recurrent cellulitis

Penicillin G [Intravenous (IV)]

 Used for erysipelas and moderate nonpurulent uncomplicated cellulitis

 Treatment option for patients with recurrent cellulitis

 Usually sufficient for uncomplicated cellulitis of an extremity caused by streptococci

Aminopenicillin/Beta-lactamase Inhibitors

 Eg Amoxicillin/clavulanic acid, Ampicillin 

 Recommended 1st-line therapy for patients with cellulitis or erysipelas near the eyes or nose

 Considered 2nd-line alternative for patients with severe infection

 Effective and especially useful in the presence of bone or joint infection

Cephalosporins - 1st Generation

 Eg Cefadroxil, Cefalexin, Cefazolin 

 Usually sufficient for mild nonpurulent uncomplicated cellulitis and treatment option for

erysipelas

11
  Active against streptococci and methicillin-sensitive S aureus (MSSA)

 Cefalexin may be used in patients with erysipelas with beta-lactam allergy

Cephalosporins - 2nd and 3rd Generation (Parenteral)

 Eg Ceftriaxone, Cefuroxime 

 Treatment alternative for patients with moderate nonpurulent cellulitis

 Usually used empirically in diabetes mellitus (DM) patients who have early mild cellulitis

 Active against streptococci and MSSA

 Aminoglycosides may be added if needed

Cephalosporins - Other Generations

 Eg Ceftaroline, Ceftobiprole

 May be considered for patients with methicillin-resistant S aureus (MRSA) infections

Macrolides

 Eg Clarithromycin, Erythromycin, Roxithromycin

 May be used if patient is allergic to Penicillin

 Macrolide resistance among Group A Streptococci has increased and has become a concern in

some countries

 Erythromycin is the main macrolide used unless Erythromycin resistance is widespread in the

community

 Alternative therapy for patients with cellulitis or erysipelas near the eyes or nose

 Also used for prophylactic treatment against recurrent cellulitis

 Studies showed that the efficacy of Roxithromycin for erysipelas was comparable to that of

Benzylpenicillin

Oxazolidinones

12
  Eg Linezolid, Tidezolid

 May be used in patients allergic to Penicillin and for complicated cellulitis and erysipelas, or

MRSA infections

Quinolones

 Eg Ciprofloxacin, Delafloxacin, Levofloxacin, Moxifloxacin, Ofloxacin

 Those that have enhanced activity against Gram-positive bacteria have been shown to be

effective

 Used for cellulitis caused by Vibrio vulnificus

 Used in combination with other antibiotics for MRSA and other Gram-positive or Gram-

negative organisms and anaerobes

Tetracyclines

 Eg Doxycycline, Minocycline, Omadacycline, Tigecycline

 May be considered for moderate-severe purulent cellulitis, MSSA, and MRSA infections

 Tigecycline may be used for treatment of complicated skin infections

o Clinical efficacy is comparable with standard treatment

Other Antibiotics

 Clindamycin

o Used in patients allergic to Penicillin and cephalosporins

o Alternative therapy for patients with nonpurulent or purulent cellulitis caused by

MSSA or MRSA infection

 Co-trimoxazole

o Used for nonpurulent cellulitis and moderate purulent cellulitis

13
 o Treatment option for patients with erysipelas with beta-lactam allergy

o Has very good activity against community-acquired MRSA but not to streptococci

 Dalbavancin, Oritavancin, Telavancin

o Lipoglycopeptide antibacterials with properties similar to Vancomycin that may be

considered for complicated cellulitis caused by gram-positive organisms including

MRSA 

 Vancomycin

o Treatment option for patients allergic to Penicillin

o Combination with Ampicillin/sulbactam, Piperacillin/tazobactam,

Ticarcillin/clavulanate, or Ceftriaxone/Ciprofloxacin/Levofloxacin plus

Metronidazole is recommended for patients with purulent cellulitis caused by MRSA

infection and other Gram-positive or Gram-negative organisms and anaerobes

o Combination with Cefotaxime or Gentamicin is recommended as 1st-line parenteral

treatment for neonates with MRSA infections

o Also used for patients with penetrating trauma, nasal colonization with MRSA, and

intravenous drug use

o Daptomycin is an alternative option if Vancomycin is unavailable

 Teicoplanin

o Alternative to Vancomycin for patients with cellulitis caused by gram-positive

organisms including MRSA

Length of Therapy

Uncomplicated/Purulent/Nonpurulent Cellulitis and Erysipelas

14
  Patient may be treated with antibiotics for 5 to 14 days depending on clinical response

Complicated Cellulitis

 It is typically recommended that once erythema, warmth and edema have subsided

significantly, patient may be treated for an additional 10 days with oral antibiotics

 Patients with peripheral vascular disease, chronic venous stasis, diabetes mellitus or alcoholic

cirrhosis may take 1-2 weeks to improve and often require 3-4 weeks of treatment

Adjunct Therapy

Corticosteroids

 Eg Prednisolone, Prednisone

 Studies showed that when used in combination with antibiotics, healing time of lesions are

reduced

 Should be considered in nondiabetic patients

Non-Pharmacological Therapy

 Immobilization and elevation of affected limb

o Effects: May help to decrease swelling and pain especially if used early in the course

of treatment, and may also shorten time to recovery

 Dressings

o Cool sterile saline dressing may be applied

o Effects: Removes purulent exudate from ulcers or infected abrasions, may help

decrease local pain

15
  Compression stockings

o May help with edema

Patient Education

 Advise on good personal hygiene and wound care

 Cover draining wounds with clean bandage

 Regularly bathe and wash hands after coming in contact with a wound

 Avoid sharing or reusing items that came in contact with infected skin

 Inspect interdigital toe spaces regularly especially if with lower extremity cellulitis

16
CONCLUSION

Cellulitis is an acute inflammatory condition of the dermis and subcutaneous tissue usually

found complicating a wound, ulcer or dermatosis. Spreading and pyogenic in nature, it is

characterized by localized pain, erythema, swelling and heat. The involved area, most

commonly on the leg, lacks sharp demarcation from uninvolved skin. Erysipelas, a superficial

cellulitis with prominent lymphatic involvement, does have an indurated, raised border that

demarcates it from normal skin. These distinctive features create what is known as a “peau

d’orange” appearance

17
REFERENCES

Vary, JC; O'Connor, KM (May 2014). "Common Dermatologic Conditions". Medical Clinics

of North America. 98 (3): 445–85. 

Dhingra, PL; Dhingra, Shruti (2010) [1992]. Nasim, Shabina (ed.). Diseases of Ear, Nose and
Throat. Dhingra, Deeksha (5th ed.). New Delhi: Elsevier. pp. 277–78. ISBN 978-81-312-
2364-2.

Stevens, Dennis L (2014-06-18). "Practice Guidelines for the Diagnosis and Management of Skin and
Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America". Clinical
Infectious Diseases. 59 (2): 147–59. doi:10.1093/cid/ciu296. ISSN 1058-4838. PMID 24947530

Singer, Adam J.; Talan, David A. (2014-03-13). "Management of Skin Abscesses in the Era of
Methicillin-Resistant Staphylococcus aureus". New England Journal of Medicine. 370 (11): 1039–
1047. doi:10.1056/NEJMra1212788. ISSN 0028-4793. PMID 24620867.

Bornemann, Paul; Rao, Victor; Hoppmann, Richard (2015-05-04). "Ambulatory Ultrasound". In

Mayeaux, E.J. (ed.). The Essential Guide to Primary Care Procedures. Lippincott Williams &
Wilkins. ISBN 9781496318718. Archived from the original on 2016-05-06.

Mistry, RD (Oct 2013). "Skin and soft tissue infections". Pediatric Clinics of North America. 60 (5):
1063–82. doi:10.1016/j.pcl.2013.06.011. PMID 24093896.

18
 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE STUDY

Nama Pelatih: ………………………………………… No. Matrik: ………….……….

Tahun: …… Semester: ……… Kawasan Penempatan: ...…………………………

Bil. Perkara Wajaran Skor Catatan

Pengenalan dan penyataan
1 10
masalah yang jelas
Pencarian literatur yang lengkap
2 20
dan relevan
Perbincangan & hujah yang
3 jelas, kukuh serta menunjukkan 40
keaslian
Rumusan yang padat dan
4 10
konklusif
Sumber rujukan yang sesuai dan
5 10
mencukupi

Format:
2
- Kulit pakej yang jelas
2
- Bilangan perkataan seperti
ditetapkan
2
- Cetakan yang jelas dan bersih
6 - Penjilidan yang kemas
2
- Format mengikut yang
2
ditetapkan

Demerit:
- Kesilapan ejaan > 20 perkataan
-5
JUMLAH

Nota:
Kelewatan penghantaran tugasan akan diperiksa berdasarkan wajaran 80%.

Tandatangan Pemeriksa : ……………………………….……………

Nama : …………………………….………………

19
Tarikh : ………………………………….…………

20