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Related Terms:  lymphedema, erythema, staph aureus, strep A, gram-negative bacteria,  gangrene, tissue necrosis, septicemia, regional lymphadenopathy, Keflex, Augmentin, penicillins,  pneumococcus, hemophilus influenzae, pasturella multocide, erysipelothrix rhusiopathia, gram negative bacteria 

Cellulitis and Lymphangitis

This is often our worst nightmare and sends us to the hospital more than anything else regarding lymphedema. In this section there are many detailed articles on cellulitis, complications of and treatment for cellulitis and/or lymphangitis.


Discussion Acute Cellulitis 

Acute Cellulitis is one of the complications of
lymphedema. The patient may not be aware of the source of the etiology. Sometimes it may be a cut, mosquito bite, open wound or other infection in the body.

The first sign is increased or different quality of PAIN involving the
lymphedema limb. The patients often describe this as a "flu like symptom or an ache" involving the Lymphedema arm or leg. This is usually followed by sudden onset of ERYTHEMA(redness, red streaks or blotches) on the involved limb. The HYPERTHERMIA(lymphedema limb becomes warm, hot) will follow and the patient may experience the CHILLS and even HIGH FEVER.

The early intervention and treatment with antibiotics will resolve this condition (it usually takes a very minimum ten day course of antibiotics). Only a Medical Doctor will be able to prescribe the Antibiotics, thus a consultation with a Doctor is necessary. Severe Cellulitis may require Inter venous Antibiotic treatment and hospitalization. Again, elevation of the affected limb is important.

During that phase the patient should NOT massage the
lymphedema limb, bandage, apply the pump, wear tight elastic sleeve or exercise excessively. Avoid the blood pressure and blood to be drawn from the involved arm. Keep the limb elevated as much as possible while resting. Once the symptoms dissipate the treatment MLD/CDP should be initiated.

How do we prevent this infection? The patient should be careful with daily activities and take all precautions to protect the skin (wear gloves when gardening, cleaning with detergents, etc... ). If an injury to skin occurs on the
lymphedema limb it is necessary to clean the wound with alcohol or hydrogen peroxide and apply Neosporin/Polysporin antibiotic ointment. If the symptoms progress seek the attention of a physician immediately.

It is so very important to avoid getting cellulitus as it further
destroys the lymphatic system. Allowed to spread or continue it can become systemic and can lead to gangrene, amputation of the limb or even death.


Cellulitis is clinically a spreading infection involving both the dermis and subcutaneous tissues.  Unlike erysipelas, it will not have a clear raised border.  Other features may include red streaking from the infected area, regional lymphadenopathy.


Symptoms include all over body ache, fever, severe pain of the infected area, chills, weakness.  The skin color will be red, warm and very tender to the touch.

Other symptoms may include:


The most common bacteria responsible for cellulitis infections are staph aureus and strep A.  Other less common bacterial agents include Step B, gram-negative bacteria,  and immunocompromised patients pneumococcus. Less common bacteria such as Hemophilus influenzae, Pasturella multocide, and erysipelothrix rhusiopathiae can cause it as well.

Entry foci for the bacteria includes nasal cavities, wound, cuts, scrapes (any type of skin break).  Insect bites (especially spider) can cause the condition.  Cat scratches, animal bites are another source of bacteria.

Risk Factors

Patients with any of the following disorders are more at risk for developing serious and or life threatening cellulitis:

Lymphedema, Diabetes, immunodeficiency (of any type),  Varicella (cellulitis as a complication of), chemo therapy patients, venous insufficiency or venous stasis, chronic steroid users, post surgical patients, individuals with edema and finally age may also be a factor with infants and the elderly more susceptible to infections.


Complications can include septicemia, tissue necrosis, gangrene, amputation of the affected limb, death.  It should be noted also that cellulitis causes further damage to the lymphatics and thereby makes lymphedema worse. Other complications include lymphangitis, skin abcesses.

In compromised patients, physicians must be careful to observe for a complicating gram-negative super infection that can accompany regular gram-positive bacteria.  This can occur asa result of the even further depletion of the body's immune system.


Cellulitis responds well to antibiotic therapy.  Generally, a ten day course of treatment is prescribed.  Antibiotics used to treat cellulitis include Keflex, Augmentin, penicillins.  Unasyn and Vancomycin are standard IV antibiotics.  In situations of a gram negative infection, Gentamicin is used.

For special at risk patients, blood work may also be indicated to assure the infection has not become systemic.

This group, which includes lymphedema patients may need extended IV antibiotic therapy. 


With early diagnosis and subsequent rapid treatment the outcome is actually excellant with the overwhelming number of patients making full recovery.  In special risk groups however, there is a heightened risk of complication and morbidity.


This article is taken from the Spring 2002 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members

Watch point: The Importance of Antibiotics for Cellulitis

By Professor Peter Mortimer

Antibiotics are often recommended on a long term basis in patients who have recurrent attacks of cellulitis. The reason is quite simply because nothing else works (unless there has been a substantial improvement in the swelling following decongestive lymphatic therapy). Cellulitis results from the compromised local immunity within the swollen region (but not your overall body).

Treating with antibiotics as and when each attack of cellulitis occurs is a bit like 'shutting the stable door after the horse has bolted'! Each attack of cellulitis can not only make you ill but tends to cause a deterioration in the swelling and make the tissues (skin and underlying fat layer) harder (fibrotic). This does not help the long term control of the lymphoedema. Experience has shown that the best way of controlling recurrent attacks of cellulitis is with a low dose of antibiotic taken every day (usually penicillin or erythromycin). Unfortunately this approach, nor any other for that matter, may not necessarily cure the infection and an attack could start immediately if you inadvertently stop the antibiotic. Therefore please only comply with the recommendations made by your GP or lymphoedema therapist.

There is no reason to believe that long term antibiotics are harmful or affect your whole body's immunity. For decades penicillin has been given life long without a problem to patients who have had their spleen removed. Therefore safety seems assured providing you are not allergic.


Treatment of Cellulitis

Shared discussion between Bill and Bob from

In discussing the treatment of cellulitis, international lymphedema expert

Bruno Chikly, M.D. writes:

Treatment: The therapist should be able to work with a medical team. It is imperative to check with a physician if there is any suspicion of secondary infection, and scrupulously treat any infection. Hands-on lymphatic drainage and medical compression (bandages, garments) should be interrupted until the condition is under control (at least 48 to 72 hours, up to 8 days). The signs of infections (edema, erythema, warmth, aching, etc.) should have clearly

Antibiotic therapy: Bacterial infection calls for immediate antibiotic therapy. The sensitivity of the bacteria to antibiotics (regular penicillin G)is generally good.

Suggested treatment (quoting expert W. L. Olszewski M.D.): first episode: 3 months of antibiotic therapy. If there are more than two episodes, one year's antibiotic therapy may be indicated. Check for the few adverse effects of prolonged antibiotic therapy: change in intestinal flora, gastro-intestinal disorders, damage to liver, kidneys and bones, allergic reactions, etc. Where the patient is allergic to penicillin, erythromycin usually works well. After one
episode of infection, it may be wise for lymphedema patients to carry a supply of antibiotics or a prescription with them, especially when traveling away from home.

(Published with permission from the author of Silent Waves Theory And
Practice Of Lymph Drainage Therapy (Ldt) With Applications For Lymphedema, Chronic Pain And Inflammation Author: Bruno Chikly, M.D.2000 Publisher: I.H.H.
Publishing, Arizona. Isbn Hard Cover = 0-9700530-5-3 Part 3, Chapter 9, page 209-210 )



By Mayo Clinic staff

March 15, 2004


Cellulitis (sel-u-LI-tis) is a potentially serious bacterial infection of your skin. It appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly.

Skin on the lower legs or face is most commonly affected by this infection, though cellulitis can occur on any part of your skin. The infection may only be superficial, but it may also affect the tissues underlying your skin and can spread to your lymph nodes and bloodstream.

Left untreated, the spreading bacterial infection may rapidly turn into a life-threatening condition. That's why it's important to recognize the signs and symptoms of cellulitis and to seek immediate medical attention if they occur.

Signs and symptoms

Cellulitis may result in skin that is:

The changes in your skin may be accompanied by a fever. Over time, the area of redness tends to expand. Small red spots may appear on top of the reddened skin, and less commonly, small blisters may form and burst.


Cellulitis occurs when one or more types of bacteria enter through a crack or break in your skin. The two most common types of bacteria that cause cellulitis are streptococcus and staphylococcus.

Although cellulitis can occur anywhere on your body, the most common location is the legs, especially near your shins and ankles. Disrupted areas of skin, such as where you've had recent surgery, cuts, puncture wounds, an ulcer, athlete's foot or dermatitis, serve as the most likely areas for bacteria to enter.

Certain types of insect or spider bites also can transmit the bacteria that start the infection. Areas of dry, flaky skin also can be an entry point for bacteria, as can swollen skin.

Risk factors

Several factors can place you at greater risk of developing cellulitis:

When to seek medical advice

If you have a rash that's red, swollen, tender and warm — and it's expanding — try to see your doctor the same day. If a fever or pain accompanies the rash, or the rash is changing rapidly, seek emergency care. It's important to identify and treat cellulitis early because the condition can cause a serious infection to spread rapidly throughout your body.

Screening and diagnosis

The appearance of your skin will help your doctor make a diagnosis. Your doctor may also suggest blood tests, a wound culture or other tests to help rule out a blood clot deep in the veins of your legs. Cellulitis in the lower leg is characterized by signs and symptoms that may be similar to those of a clot occurring deep in the veins, such as warmth, pain and swelling.


This reddened skin or rash may signal a deeper, more serious infection of the inner layers of skin. Once below the skin, the bacteria can spread rapidly, entering the lymph nodes and the bloodstream and spreading throughout your body.

In rare cases, the infection can spread to the deep layer of tissue called the fascial lining. Flesh-eating strep, also called necrotizing fasciitis, is an example of a deep-layer infection. It represents an extreme emergency.


Your doctor may prescribe an oral antibiotic to treat cellulitis. You'll likely recheck with your doctor one to two days after starting an antibiotic, and take it for about 10 days. In most cases, signs and symptoms of cellulitis disappear after a few days. If they don't clear up, if they're extensive or if you have a high fever, you may need to be hospitalized and receive antibiotics through your veins (intravenously).

Usually, doctors prescribe a drug that's effective against both streptococci and staphylococci. An example is cephalexin (Keflex, Keftab). Your doctor will choose an antibiotic depending on your circumstances.


To help prevent cellulitis and other infections, follow these measures any time you have a skin wound:

People with diabetes and those with poor circulation need to take extra precautions to prevent skin wounds and treat any cuts or cracks in the skin promptly. Good skin care measures include:


Cellulitis is a superficial infection of the skin. But if severe or if left untreated, it can spread into your lymph nodes and bloodstream.

By Mayo Clinic staff

© 1998-2004 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.  A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "," "Mayo Clinic Health Information," "Reliable information for a healthier life" and the triple-shield Mayo logo are


Morton N. Swartz, M.D.

Clinical Practice

Volume 350:904-912 February 26, 2004 Number 9
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.


An otherwise healthy 40-year-old man felt feverish and noted pain and redness over the dorsum of his foot. Tender edema and erythema extended up the pretibial area. Fissures were present between the toes. What diagnostic procedures and treatment are indicated?

The Clinical Problem

Cellulitis is an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, usually complicating a wound, ulcer, or dermatosis. The area, usually on the leg, is tender, warm, erythematous, and swollen. It lacks sharp demarcation from uninvolved skin. Erysipelas is a superficial cellulitis with prominent lymphatic involvement, presenting with an indurated, "peau d'orange" appearance with a raised border that is demarcated from normal skin. The distinctive features, including the anatomical location of cellulitis and the patient's medical and exposure history, should guide appropriate antibiotic therapy (Table 1).

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Table 1. Specific Anatomical Variants of Cellulitis and Causes of Predisposition to the Condition.


Anatomical Features

Periorbital cellulitis involves the eyelid and periocular tissues anterior to the orbital septum. Periorbital cellulitis should be distinguished from orbital cellulitis because of the potential complications of the latter: decreased ocular motility, decreased visual acuity, and cavernous-sinus thrombosis.

Before young children began to be immunized with conjugated Haemophilus influenzae type b vaccine, buccal cellulitis due to H. influenzae type b was responsible for up to 25 percent of cases of facial cellulitis in children 3 to 24 months of age; now such cellulitis is rare. Infection originates in the upper respiratory tract.

Perianal cellulitis occurs mainly in young children and is generally caused by group A streptococci.1 Manifestations include perianal pruritus and erythema, anal fissures, purulent secretions, and rectal bleeding.

Types of Exposure That Predispose Patients to Cellulitis

Severe bacterial cellulitis has been known to occur as a complication of liposuction. The subcutaneous injection of illicit drugs ("skin popping") can result in cellulitis due to unusual bacterial species.2,3

A distinctive form of cellulitis, sometimes recurrent, may occur weeks to months after breast surgery for cancer. Cellulitis in the ipsilateral arm has been well described after radical mastectomy,4 where it occurs because of associated lymphedema; cellulitis in the ipsilateral breast is more common now, occurring after breast-conservation therapy.5,6 Local lymphedema from the combination of partial mastectomy, axillary lymph-node dissection, and breast irradiation is a predisposing factor.

Cellulitis also occurs in the legs of patients whose saphenous veins have been harvested for coronary-artery bypass.7 Lymphatic disruption and edema occur on the removal of the vein.

Unusual Manifestations of Cellulitis

Crepitant cellulitis is produced by either clostridia or non–spore-forming anaerobes (bacteroides species, peptostreptococci, and peptococci) — either alone or mixed with facultative bacteria, particularly Escherichia coli, klebsiella, and aeromonas.

Gangrenous cellulitis produces necrosis of the subcutaneous tissues and overlying skin. Skin necrosis may complicate conventional cellulitis or may occur with distinctive clinical features (including necrotizing cutaneous mucormycosis in immunocompromised patients).

Initiating Sources of Infection

Identifying the source of cellulitis — whether it is cutaneous, subjacent, or bacteremic — can provide clues as to the causative microorganism and the identity of a process that requires additional intervention. Most commonly, the source is skin trauma or an underlying lesion (an ulcer or fissured toe webs, for example). Animal or human bites can cause cellulitis due to the skin flora of the recipient of the bite or the oral flora of the biter (Figure 1). Specific pathogens are suggested when infection follows exposure to seawater (Vibrio vulnificus), fresh water (Aeromonas hydrophila), or aquacultured fish (Streptococcus iniae).

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Figure 1. Cellulitis Due to Pasteurella multocida after a Cat Bite.

Bite marks are evident, as are adjacent swelling and edema.


Edema predisposes patients to cellulitis (Figure 2). Some lymphedema persists after recovery from cellulitis or erysipelas and predisposes patients to recurrences,8 which may be of longer duration than the initial inflammation.9

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Figure 2. Cellulitis Due to Group A Beta-Hemolytic Streptococci in Leg (Previously Mildly Edematous) of a Patient with Paraplegia.

Some of the superficial skin is eroded. The initiating event was an abrasion on the lower leg.


Occasionally, cellulitis may be caused by the spread of subjacent osteomyelitis. Rarely, infection may emerge as apparent cellulitis, sometimes distant from the initial site. Crepitant cellulitis on the left thigh, for instance, might be a manifestation of a colonic diverticular abscess.

Cellulitis infrequently occurs as a result of bacteremia. Uncommonly, pneumococcal cellulitis occurs on the face or limbs in patients with diabetes mellitus, alcohol abuse, systemic lupus erythematosus, the nephrotic syndrome, or a hematologic cancer.10 Meningococcal cellulitis occurs rarely, although it can affect both children (periorbital cellulitis) and adults (cellulitis on an extremity).11 Bacteremic cellulitis due to V. vulnificus with prominent hemorrhagic bullae may follow the ingestion of raw oysters by patients with cirrhosis, hemochromatosis, or thalassemia.12,13 Cellulitis caused by other gram-negative organisms (e.g., E. coli) usually occurs through a cutaneous source in an immunocompromised patient but can also develop through bacteremia14; it sometimes follows Pseudomonas aeruginosa bacteremia in patients with neutropenia. In immunocompromised persons, less common opportunistic pathogens (e.g., Helicobacter cinaedi in patients with human immunodeficiency virus infection; Cryptococcus neoformans; and fusarium, proteus, and pseudomonas species) have also been associated with bloodborne cellulitis.15,16,17

Differential Diagnosis

The differential diagnosis of cellulitis is summarized in Table 2. Soft-tissue infections that resemble cellulitis must be distinguished from it, since the management of necrotizing fasciitis or gas gangrene requires extensive débridement. The diagnosis of necrotizing fasciitis can be established definitively only by direct examination on surgery or by biopsy with frozen section.23,24

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Table 2. Important Processes to Be Distinguished from Cellulitis.


Strategies and Evidence

Diagnostic Studies

            Cultures of Aspirates and Lesions

The diagnosis of cellulitis is generally based on the morphologic features of the lesion and the clinical setting. Culture of needle aspirates is not indicated in routine care. However, data from five series using needle aspiration have elucidated common pathogens. Among 284 patients, a likely pathogen was identified in 29 percent.25,26,27,28,29,30 Of 86 isolates, only 3 represented mixed cultures. Gram-positive microorganisms (mainly Staphylococcus aureus, group A or B streptococci, viridans streptococci, and Enterococcus faecalis) accounted for 79 percent of cases; the remainder were caused by gram-negative bacilli (Enterobacteriaceae, H. influenzae, Pasteurella multocida, P. aeruginosa, and acinetobacter species). A small study in children demonstrated higher yields when needle aspirates were obtained from the point of maximal inflammation than when they were obtained from the leading edge.30

In two small studies, the yield of punch biopsies was slightly better than that of needle aspirates,27,29 and the biopsies revealed the presence of gram-positive bacteria in all but one case (S. aureus alone in 50 percent of cases, and either group A streptococi alone or S. aureus with other gram-positive organisms in most of the remainder). Cultures of ulcers and abrasions in areas contiguous to those with cellulitis have similarly revealed the presence of S. aureus, group A streptococci, or both in the majority of cases.28 These data indicate that antimicrobial therapy for cellulitis in immunocompetent hosts should be focused primarily on gram-positive cocci.

Broader coverage is warranted in patients with diabetes. Among 96 leg-threatening foot infections (including cellulitis) in patients with diabetes, the main potential pathogens recovered from deep wounds or débrided tissue were gram-positive aerobes including S. aureus, enterococci, and streptococci (in 56 percent of cases); gram-negative aerobes including proteus, E. coli, klebsiella, enterobacter, acinetobacter, and P. aeruginosa (in 22 percent); and anaerobes including bacteroides and peptococcus (in 22 percent).31 This broad range of microorganisms should also be considered as potential pathogens in cellulitis that occurs as a complication of decubitus ulcers.

            Blood Cultures

Bacteremia is uncommon in cellulitis: among 272 patients, initial blood cultures were positive in 4 percent.25,26,28,29,30 Two thirds of the isolates were either group A streptococci or S. aureus, and the remainder were either H. influenzae or P. multocida. A retrospective study of blood cultures in 553 patients with community-acquired cellulitis found a relevant isolate, mainly group A or group G streptococci (but also S. aureus and V. vulnificus), in only 2 percent,32 indicating that blood cultures were not likely to be cost effective for most patients with cellulitis.

In contrast, blood cultures are indicated in patients who have cellulitis superimposed on lymphedema. In a study involving 10 such patients, 3 had positive blood cultures (all non–group A streptococci).9 This high prevalence of bacteremia may be attributable to the preexisting lymphedema and the infecting bacterial species. Blood cultures are also warranted in patients with buccal or periorbital cellulitis, in patients in whom a salt-water or fresh-water source of infection is likely (Table 3), and in patients with chills and high fever, which suggest bacteremia.

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Table 3. Initial Treatment for Cellulitis at Specific Sites or with Particular Exposures.



Radiologic examination is unnecessary in most cases of cellulitis. Plain-film radiography and computed tomography (CT) are of value, however, when the clinical setting suggests a subjacent osteomyelitis. When it is difficult to differentiate cellulitis from necrotizing fasciitis, magnetic resonance imaging (MRI) may be helpful, although surgical exploration for a definitive diagnosis should not be delayed when the latter condition is suspected.24 In a study involving 17 patients with suspected necrotizing fasciitis, 11 cases were ultimately confirmed to be necrotizing fasciitis (at surgery or, in 1 case, on autopsy), and 6 were confirmed to be cellulitis on the basis of the clinical course33; on MRI, all 11 cases of necrotizing fasciitis were identified (100 percent sensitivity), but 1 of the 6 cases of cellulitis was misdiagnosed (for a specificity of 86 percent). The criteria for identifying necrotizing fasciitis on MRI include the involvement of deep fasciae, as evidenced by fluid collection, thickening, and enhancement with contrast material.

Ultrasonography and CT are of less value in distinguishing necrotizing fasciitis from cellulitis, but ultrasonography can be helpful in detecting the subcutaneous accumulation of pus as a complication of cellulitis and can aid in guiding aspiration.34 Gallium-67 scintillography may aid in the detection of cellulitis superimposed on recently increasing, chronic lymphedema of a limb.35

Antimicrobial Treatment

Because most cases of cellulitis are caused by streptococci and S. aureus, beta-lactam antibiotics with activity against penicillinase-producing S. aureus are the usual drugs of choice. Initial treatment should be given by the intravenous route in the hospital if the lesion is spreading rapidly, if the systemic response is prominent (e.g., chills and a fever, with temperatures of 100.5°F [37.8°C] or higher), or if there are clinically significant coexisting conditions (such as immunocompromise, neutropenia, asplenia, preexisting edema, cirrhosis, cardiac failure, or renal insufficiency) (Table 4). Specially tailored treatment for other bacterial causes is warranted when cellulitis occurs after an unusual exposure (a human or animal bite or exposure to salt or fresh water), in patients with certain underlying conditions (neutropenia, splenectomy, or immunocompromise), or in the presence of bullae (Table 3). Diabetic foot infections involve multiple potential pathogens, and broad antimicrobial coverage is required.31 Ampicillin–sulbactam and imipenem–cilastatin were shown in a randomized, double-blind trial to have similar cure rates in this setting (81 percent vs. 85 percent), but the former combination was more cost effective.38

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Table 4. Antimicrobial Treatment for a Usual Case of Cellulitis.


Several trials have evaluated newer antibiotics. In a multicenter, double-blind trial involving 461 patients, oral ciprofloxacin (750 mg every 12 hours) was as safe and effective as parenteral cefotaxime (overall failure rate, 2 percent vs. 8 percent; P=0.008) in the treatment of various skin and skin-structure infections.39 The evaluation of these results must be tempered by the facts that most of the skin infections studied were infected ulcers and abscesses rather than cellulitis and that, since the time of the study, the fluoroquinolone resistance of S. aureus, the predominant pathogen isolated, has increased. More recently, oral moxifloxacin (400 mg once daily) has been shown to be as effective (84 percent) as oral cephalexin (500 mg three times a day) in the treatment of uncomplicated skin and soft-tissue infections.40

In a randomized, open-label trial of treatment of "complicated" skin and skin-structure infections in which high-dose levofloxacin (750 mg intravenously once daily) was compared with ticarcillin–clavulanate (3.1 g intravenously every four to six hours), therapeutic equivalence was demonstrated (success rates of 84 percent and 80 percent, respectively).41 However, cellulitis (as a complication of preexisting skin lesions, immunosuppression, or vascular insufficiency) accounted for only 7 percent of the 399 skin infections. Linezolid (600 mg intravenously every 12 hours) has been compared with oxacillin (2 g intravenously every 6 hours) in a randomized, double-blind trial of treatment of complicated skin and soft-tissue infections in 819 hospitalized adults,42 44 percent of whom had cellulitis. The cure rates were 89 percent for linezolid and 86 percent for oxacillin. Clinically relevant pathogens isolated from contiguous sites included S. aureus (in 35 percent), group A streptococci (in 11 percent), and group B streptococci (in 27 percent), but infections due to methicillin-resistant S. aureus were excluded. A trial comparing linezolid and vancomycin in the treatment of adults with methicillin-resistant S. aureus infections, including 175 skin and soft-tissue infections,43 found similar cure rates (79 percent with linezolid and 73 percent with vancomycin), but cellulitis accounted for only 13 percent of these infections.

Ancillary Measures

The local care of cellulitis involves the elevation and immobilization of the involved limb to reduce swelling and cool sterile saline dressings to remove purulence from any open lesion. Interdigital dermatophytic infections should be treated with a topical antifungal agent until they have been cleared. Such lesions may provide ingress for infecting bacteria. Several classes of topical antifungal agents are effective in clearing up fungal infection when applied one to two times daily; these include imidazoles (clotrimazole and miconazole), allylamines (terbinafine), and substituted pyridones (ciclopirox olamine).44 Observational data suggest that after the successful treatment of such dermatophytic infections, the subsequent prompt use of topical antifungal agents at the earliest evidence of recurrence (or prophylactic application once or twice per week) will reduce the risk of recurrences of cellulitis.

Patients with peripheral edema are predisposed to recurrent cellulitis. Support stockings, good skin hygiene, and prompt treatment of tinea pedis can prevent recurrences. In patients who, despite these measures, continue to have frequent episodes of cellulitis or erysipelas, the prophylactic use of penicillin G (250 to 500 mg orally twice daily) may prevent additional episodes; if the patient is allergic to penicillin, erythromycin (250 mg orally once or twice daily) may be used.

Areas of Uncertainty

A variety of antimicrobial agents have been used to treat cellulitis because of their spectrum of action against likely causative organisms and have been approved by the Food and Drug Administration for use in skin and soft-tissue infections. However, such approval is often based on clinical studies of heterogeneous collections of cutaneous infections (including infected ulcers, abscesses, and wound infections); in some studies, cellulitis accounts for a minority of the infections.39,43

Most studies of cellulitis have involved patients with serious infections. Studies are needed to determine specific criteria that define the types of mild cases that are highly likely to respond to oral antibiotics administered at home. Penicillinase-resistant penicillins and cephalosporins have been used because most community-acquired pathogens causing cellulitis (streptococci and S. aureus) are susceptible to methicillin. However, the rate of community-acquired methicillin-resistant S. aureus infections in patients without identified risk factors appears to be increasing. In a rural Native American community, 55 percent of 112 isolates of S. aureus were methicillin-resistant, and 74 percent of these cases were community-acquired; the risk factors did not differ from those in patients with community-acquired methicillin-susceptible strains.45 It remains uncertain how this change in resistance patterns will affect the management of cellulitis.46

Although there is a rationale for the empirical prophylactic use of penicillin to prevent recurrences of cellulitis in patients with multiple previous episodes, the results of efficacy studies have been conflicting. In a study of prophylaxis with monthly intramuscular doses of penicillin G benzathine (1.2 million units) after treatment for an acute episode of streptococcal cellulitis in the lower leg, such prophylaxis reduced the rate of recurrence from 17 percent to 0 (0 of 11) among patients who did not have predisposing factors, but it failed to prevent recurrence in those who had such predisposing factors as lymphedema (4 of 20 cases).47 Whether it would be more effective to shorten the interval between doses to two or three weeks or to increase the dose is not known. Long-term erythromycin therapy (250 mg orally twice daily for 18 months) has been used to prevent recurrences in patients with a history of two or more episodes of cellulitis or erysipelas.48 Episodes did not occur in 16 treated patients, whereas 8 of 16 controls had one or more recurrences.


Guidelines for the treatment of skin and soft-tissue infections (including cellulitis) are being prepared by the Infectious Diseases Society of America.

Summary and Recommendations

Cellulitis is a clinical diagnosis based on the spreading involvement of skin and subcutaneous tissues with erythema, swelling, and local tenderness, accompanied by fever and malaise. The approach to therapy involves the identification of the likely source as either local (secondary to abrasion or ulcer or due to another exposure, such as an animal bite or seawater, which implicates particular bacterial species — P. multocida and V. vulnificus, respectively) or an uncommon bacteremic spread of infection. Distinctive features of the patient (such as the presence of diabetes or immunocompromise) or anatomical sites should also be considered in treatment decisions. Streptococci (groups A, G, and B) and S. aureus are the most frequently isolated bacterial species.

Initial empirical antimicrobial treatment for moderate or severe cellulitis in a patient such as the one described in the vignette would thus consist of an intravenous cephalosporin (cefazolin or ceftriaxone) or nafcillin (vancomycin in patients with an allergy to penicillin), followed by dicloxacillin or an oral cephalosporin, generally for a course of 7 to 14 days. In patients with recurrent cellulitis of the leg, any fissures in the interdigital spaces caused by epidermophytosis should be treated with topical antifungal agents in order to prevent recurrences. Daily prophylaxis with oral penicillin G (or amoxicillin) should be considered for patients who have had more than two episodes of cellulitis at the same site

Source Information

From the Division of Infectious Disease and the Jackson Firm, Massachusetts General Hospital and Harvard Medical School, Boston.

Address reprint requests to Dr. Swartz at the Division of Infectious Disease, Massachusetts General Hospital, Boston, MA 02114, or at


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*** Recommended Sites:***


Comprehensive site on the bacterial infection called cellulitis.
Information will include causes, complications, treatment and prevention.

Bacterial Infections

Resource guide for bacterial infections, causes, treatment, prevention, research


Cellulitis Staphylococcal



Last Updated: January 11, 2002

Author: Danny Lee Curtis, MD, Consulting Staff, Department of Emergency Medicine, Community Hospital of New Port Richey



Medline Plus





New Zealand Derm Net



Last Updated: October 20, 2003

Synonyms and related keywords: gram-positive bacteria, group A beta-hemolytic Streptococcus, GABHS, Staphylococcus aureus, S aureus, Streptococcus pyogenes, S pyogenes, systemic toxins, bacteremia, sepsis, buccal cellulitis, Haemophilus influenzae type B, HIB, facial cellulitis, perianal cellulitis, group B Streptococcus cellulitis, Pseudomonas osteomyelitis, septic arthritis, thrombophlebitis, Pasteurella multocida, P multocida, Vibrio vulnificus, V vulnificus, Aeromonas species, Clostridium perfringens, C perfringens, crepitus, crepitation, Escherichia coli cellulitis, E coli

Author: Dennis Cunningham, MD, Assistant Professor of Clinical Pediatrics, Section of Infectious Diseases, Children's Hospital



The Merck Manual



An inflammation of one or more lymphatic vessels, often resulting from an acute streptococcal infection. Fine red streaks may extend from the infected area to the armpit of groin. Other signs are fever, chills, headache, over all body ache, or muscle ache. The infection may spread to the blood system, thereby becoming septic.

Treatment includes extensive antibiotic therapy.



Last Updated: July 1, 2003

Synonyms and related keywords: lymphangeitis, lymphangiitis

Author: Raymond D Pitetti, MD, MPH, Medical Director of Fast Track, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine


Acute lymphangitis


Acute Lymphangitis


Lymphadenitis and lymphangitis


Staphylococcal Lymphangitis

Allrefer Health

Includes images


Lymphadenitis and lymphangitis

Medline Plus

Alternative names  

Lymph node infection; Lymph gland infection; Localized lymphadenopathy


Lymphadenitis and lymphangitis are infection of the lymph nodes (also called lymph glands) and lymph channels, respectively.

Causes, incidence, and risk factors    

The lymphatic system is a network of vessels (channels), nodes (glands) and organs. It functions as part of the immune system to protect against and fight infection, inflammation, and cancers. It also functions in the transport of fluids, fats, proteins, and other substances within the body.

The lymph glands, or nodes, are small structures that filter the lymph fluid. There are many white blood cells in the lymph nodes to help fight infection.

Lymphadenitis and lymphangitis are common complications of bacterial infections.

Lymphadenitis involves inflammation of the lymph glands. It may occur if the glands are overwhelmed by bacteria, virus, fungi, or other organisms and infection develops within the glands. It may also occur as a result of circulating cancer cells or other inflammatory conditions.

The location of the affected gland(s) is usually associated with the site of the underlying infection, tumor, or inflammation. It commonly is a result of a cellulitis or other bacteria infection (usually infection by streptococci or staphylococci).

Lymphangitis involves the lymph vessels/channels, with inflammation of the channel and resultant pain and systemic and localized symptoms. It commonly results from an acute streptococcal or staphylococcal infection of the skin (cellulitis), or from an abscess in the skin or soft tissues.

Lymphangitis may suggest that an infection is progressing, and should raise concerns of spread of bacteria to the bloodstream, which can cause life-threatening infections. Lymphangitis may be confused with a clot in a vein (thrombophlebitis).



Signs and tests

An examination shows affected lymph nodes and/or lymph vessels and may indicate the cause. The health care provider may look for evidence of trauma around enlarged or swollen nodes.

A biopsy and culture of the affected area or node may reveal the cause of the inflammation. Blood cultures may reveal spread of infection to the bloodstream.


Lymphadenitis and lymphangitis may spread within hours. Treatment should begin promptly.

Specific antibiotics are used to control infection, when this is diagnosed as the underlying cause of lymphadenitis. Analgesics may be needed to control pain with lymphangitis.

Anti-inflammatory medications may help reduce inflammation and swelling. Aspirin may be recommended as an analgesic, anti-inflammatory, and fever reducer. (Consult the health care provider before giving aspirin to children!)

An abscess may require surgical drainage. Hot moist compresses may help to reduce inflammation and pain.

Expectations (prognosis)    

Prompt treatment with antibiotics may result in complete recovery, though it may take weeks, or even months, for swelling to disappear. The amount of time until recovery occurs will vary depending on the underlying cause.


Calling your health care provider    

Call your health care provider or go to the emergency room if symptoms indicate lymphadenitis or lymphangitis.


Good general health and hygiene are helpful in the prevention of any infection.

Update Date: 8/15/2003


See Also:

Deep Venous Thrombosis


Immunodificient Limb


Pleural Effusions



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