Cellulitis and necrotising fasciitis

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of patients presenting to the Emergency Department with cellulitis or necrotising fasciitis.

Assessment

There is often an obvious injury to the skin (laceration, abrasion) which has served as a point of entry for infection.

Investigations

The majority of children have mild disease and require no investigations.
Indicated only if systemic symptoms, suspicion of underlying infection or in immunocompromised patient.
FBC, CRP and blood cultures are indicated in the unwell child who appears septic.
X-Ray if cellulitis in close proximity to bone (osteomyelitis, septic arthritis).
Swab microculture & sensitivity (MC&S) if discharge.
o Consider HSV PCR test if suggestive of herpes.
o Consider biopsy in the immunocompromised patient or if the infection is subacute or chronic.

Management

Cellulitis
Cellulitis, erysipelas or soft tissue infection <1 month of age This includes neonates with periumbilical cellulitis (omphalitis) or those with suspected staphylococcal scalded skin syndrome All neonates with cellulitis should be admitted for a septic work-up and IV antibiotics Discuss patient with Infectious diseases or Clinical Microbiology services.
Mild cellulitis or erysipelas ≥1 month of age Usually *Staphylococcus aureus* or *Streprococcus pyogenes* Bacteraemia is unlikely Oral antibiotics as an outpatient Oral cefalexin or flucloxacillin (cotrimoxazole if known or suspected MRSA) Refer to ChAMP Guideline Skin, Soft Tissue and Orthopaedic Infections (PDF 375KB) for dosing and management of patient with antibiotic allergy.
Moderate cellulitis, erysipelas or soft tissue infection ≥ 1 month of age Admit IV Flucloxacillin (add cotrimoxazole if known or suspected MRSA) Refer to ChAMP Guideline Skin, Soft Tissue and Orthopaedic Infections (PDF 375KB) for dosing and management of patient with antibiotic allergy.
Severe skin and soft tissue infection (rapidly progressive cellulitis, cellulitis with persisting fever or tachycardia despite 24 hours of therapy) Admit Surgical review to consider / exclude necrotising fasciitis or deeper infection IV Flucloxacillin IV Vancomycin Add IV Clindamcyn in severe cellulitis with shock Refer to ChAMP Guideline Skin, Soft Tissue and Orthopaedic Infections (PDF 375KB) for dosing and management of patient with antibiotic allergy.
Periorbital/orbital cellulitis Refer to ED Guidelines: Cellulitis Periorbital and Orbital.

Suspected or proven necrotising fasciitis
Uncommon but very serious rapidly progressive soft tissue infection Characterised by extreme tenderness of the soft tissue infection There may be subcutaneous gas resulting in palpable crepitus General surgery review is required in all cases suspected of necrotising fasciitis (fasciotomy / debridement may be indicated) Admit Discuss patient with Infectious Diseases or Clinical Microbiology Patients need aggressive broad spectrum antibiotics: IV Meropenem IV Vancomycin IV Clindamycin Refer to ChAMP Guideline: Skin, Soft Tissue and Orthopaedic Infections (PDF 375KB) for dosing and management of patient with antibiotic allergy.

Suspected or proven necrotising fasciitis

Uncommon but very serious rapidly progressive soft tissue infection
Characterised by extreme tenderness of the soft tissue infection
There may be subcutaneous gas resulting in palpable crepitus
General surgery review is required in all cases suspected of necrotising fasciitis (fasciotomy / debridement may be indicated)
Admit
Discuss patient with Infectious Diseases or Clinical Microbiology
Patients need aggressive broad spectrum antibiotics:
- IV Meropenem
- IV Vancomycin
- IV Clindamycin
Refer to ChAMP Guideline: Skin, Soft Tissue and Orthopaedic Infections (PDF 375KB) for dosing and management of patient with antibiotic allergy.

Nursing

Apply lidocaine (lignocaine) 2.5% with prilocaine 2.5% cream or lidocaine (lignocaine) 4% cream if patient condition is suggestive of requiring intravenous antibiotics as above.

Monitoring

Baseline observations include heart rate, blood pressure, respiratory rate, oxygen saturations, temperature and neurovascular observations (if circumferential or significant swelling).
Minimum of hourly observations should be recorded whilst in the emergency department.
Any significant changes should be reported immediately to the medical team.

Bibliography

Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Nelson Textbook of Pediatrics: 20th Edition, 2015. Elsevier

Endorsed by:	Director, Emergency Department	Date:	Dec 2019
		Review date:	Oct 2022

This document can be made available in alternative formats on request for a person with a disability.