Ovid: 5-Minute Sports Medicine Consult, The

Kenneth Barnes
Shane Hudnall
An inflammation of the skin and underlying subcutaneous tissues (specifically the dermal and subcutaneous fat layers) caused by a spreading infiltration of bacteria through the skin surface
  • Typically results from entry of bacteria through a break in the skin, from a contiguous foci (abscess), or from metastatic dissemination via bacteremia
  • Most commonly involves the lower extremities where venous stasis predisposes to infection
  • Can occur anywhere on the body, including periorbital area, upper extremities, and abdominal wall
  • Gram positives (beta-hemolytic streptococcus, strep pyogenes especially, and Staphylococcus aureus) comprise >80% of the organisms responsible.
  • Methicillin-resistant Staphylococcus aureus (MRSA) is a concern due to increasing prevalence in the community setting.
1 case per 500 patient years (1)
Risk Factors
  • Disruption of skin from trauma or scratching
  • Eczema or other inflammation
  • Underlying skin infections (ie, tinea pedis)
  • Elderly (thrombophlebitis)
  • IV drug use
  • Human or animal bites
  • Edema (related to venous insufficiency)
  • Surgeries
  • MRSA risk factors:
    • Recent antibiotics
    • Recent hospitalization
    • Homelessness
    • Previous MRSA infection
    • IV drug abuse
    • Contact sports (2,3)
Commonly Associated Conditions
Consider treating for the specific organisms identified in these populations (2):
  • Diabetes: Anaerobes and gram negatives
  • Neutropenia: Pseudomonas
  • Human bite: Eikenella corrodens, Fusobacterium species
  • Cat bite: Pasteurella multocida
  • Dog bite: Pasteurella multocida, Capnocytophaga canimorsus
  • Hot tub: Pseudomonas
  • Fresh water: Aeromonas hydrophila
  • Salt water: Vibrio species
  • IV drug abuse: MRSA, Pseudomonas
  • Immunocompromised: Cryptococcus neoformans
  • Breakdown in normal skin barriers almost always precedes this infection.
  • Preexisting venous stasis alone may predispose to cellulitis.
Physical Exam
  • Area of involvement denoted by spreading erythema, warmth, and swelling with ill-defined margins
  • Associated pain and tenderness
  • Streaks of erythema and tenderness indicative of lymphatic spread
  • Bullae may develop, but generally rash is not raised.
  • Fever, sweats, shaking chills common, but bacteremia infrequent
  • Regional lymphadenopathy
  • Look for evidence of predisposing factors: Lower extremity venous stasis, tinea infection, IV drug abuse track marks, eczema, radiation (irritation and thinning of skin)
  • Use of pen/marker to demarcate the leading edge of cellulitis is helpful in monitoring during follow-up.
Diagnostic Tests & Interpretation
  • Current recommendations are to culture all wounds for bacterial identification and antimicrobial sensitivity testing.
  • Blood cultures rarely helpful (<5%) (3,4)
  • Needle aspiration of abscess or bullae most likely to be helpful if present
  • Culture of overlying intact skin is not helpful and recommended against.
Generally, imaging not recommended unless concerned about osteomyelitis, gas gangrene, underlying abscess, or other conditions in differential (ie, deep vein thrombosis)
Differential Diagnosis
  • Erysipelas (infection of the superficial layers of the skin, usually caused by group A streptococci)
  • Fasciitis/necrotizing fasciitis
  • Myonecrosis/gas gangrene
  • Toxic epidermal necrolysis
  • Osteomyelitis
  • Cutaneous candidal infection
  • Septic arthritis
  • Gout
  • Zoster
  • Erythema migrans
  • Contact dermatitis
  • Eczema
  • Deep venous thrombosis
  • Ruptured baker's cyst
  • Drug rash
  • Insect bite
Ongoing Care
Patient Education
  • Early identification is important.
  • If infection considered contagious, must not participate in contact or collision sports
  • MRSA becoming more prevalent in locker rooms as well as in the community.
  • Do not share towels, razors, other products.
  • Frequent skin inspections
  • Cover all wounds.
  • Disinfect all shared athletic equipment and whirlpools.
  • Education and posters recommended in all training rooms and locker rooms
  • Liberal use of antibacterial soap or alcohol-based hand sanitizer
  • Return to play:
    • Mild to moderate skin lesions: 72 hr after initiation of therapy, with clinical improvement and no new lesions for 48 hr
    • Before and during sports participation: Cover completely with occlusive dressing.
    • Multiple wound checks: If leakage, remove athlete, cleanse skin with soap and water, apply new dressing
    • Removal of dressing once firm, adherent crust develops (7,8)
1. McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota. Mayo Clin Proc. 2007;82:817–821.
2. Eron LJ, Laine C, Goldmann DR, Sox HC. Cellulitis and soft-tissue infections. Ann Intern Med. 2009;150:ITC1–1.
3. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373–1406.
4. Perl B, Gottehrer NP, Raveh D, et al. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999;29:1483–1488.
5. Gilbert DN, Moellering RC Jr, Sande MA, eds. The Sanford guide to antimicrobial therapy 2000, 30th ed. Hyde Park, VT: Antimicrobial Therapy, 2000.
6. Melzer M, Eykyn SJ, Gransden WR, et al. Is methicillin-resistant Staphylococcus aureus more virulent than methicillin-susceptible S. aureus? A comparative cohort study of British patients with nosocomial infection and bacteremia. Clin Infect Dis. 2003;37:1453–1460.
7. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation. Pediatrics. 2008;121:841–848.
8. Minooee A, Arezou, Rickmans LS, et al. Transmission of infectious diseases during sports. In: Schlossberg D, ed. Infections of leisure, 2nd ed. Washington, DC: American Society for Microbiology, 1999.
Additional Reading
Benjamin HJ, Nikore V, Takagishi J. Practical management: community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA): the latest sports epidemic. Clin J Sport Med. 2007;17(5):393–397.
Reese RE, Betts RF, eds. A practical approach to infectious diseases, 4th ed. Boston: Little Brown, 1996.
Stevens DL. Cellulitis, pyoderma, and other skin and subcutaneous infections. In: Armstrong D, Cohen J, eds. Infectious diseases. Vol. 1. Mosby/Harcourt Publishers, 1999:2.2.6–2.2.8.
Swartz NN. Cellulitis and subcutaneous tissue. In: Mandell GL, Bennet JE, Dolin R, eds. Mandell, Douglas, and Bennetts principles and practice of infectious disease, 5th ed. Vol. 1. Philadelphia: Churchill Livingstone, 2000.
  • 682.2 Cellulitis and abscess of trunk
  • 682.3 Cellulitis and abscess of upper arm and forearm
  • 682.9 Cellulitis and abscess of unspecified sites

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