We read with interest the article by Pheonix et al on the diagnosis and management of cellulitis.1 As Infectious Diseases physicians, interestingly not mentioned on the list of specialists who treat cellulitis given in the article, we wish to point out some important areas where we disagree with the authors, some of which are errors.
1) Clostridium perfringens classically causes so-called “gas gangrene”, a rapidly progressive infection often associated with vascular compromise due to severe penetrating trauma or crush injuries.2 Necrotising fasciitis is often polymicrobial, with common causes including group A streptococci, Staphylococcus aureus and anaerobes. Rare causes, often in the immunocompromised, include Aeromonas hydrophilia and Vibrio vulnificus.2
2) Clinically distinguishing between streptococcal and staphylococcal cellulitis is often impossible. Recommending different treatment based on this distinction is not helpful in clinical practice. All cases of cellulitis should be treated with an antibiotic with anti-staphylococcal activity, thus amoxicillin would be inappropriate therapy. This is supported by both CREST and IDSA guidelines,2,3 in contrast to the authors’ incorrect statement that amoxicillin is recommended empirical treatment in the CREST guidance.
3) Ciprofloxacin appears to have been misspelled "ciprofloxacillin".
4) Confirmed erysipeloid (caused by Erysipelothrix rhusiopathiae) should be treated with a penicillin, such as amoxicillin, as opposed to ciprofloxacin.2
5) Cross-sectional imaging is not essential in the diagnosis of necrotising fasciitis, which is mainly clinical. Delays in obtaining imaging may lead to significant deterioration and delay in definitive surgical treatment.2,3
References
1] Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ 2012;345:e4955.
2] Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJC, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clin Infect Dis. 2005; 41:1373–406
3] DHSS Northern Ireland. CREST (Clinical Resource Efficiency Support Team) Guidelines on the Management of Cellulitis In Adults. 2005; 1–31.
Rapid Response:
Re: Diagnosis and management of cellulitis
We read with interest the article by Pheonix et al on the diagnosis and management of cellulitis.1 As Infectious Diseases physicians, interestingly not mentioned on the list of specialists who treat cellulitis given in the article, we wish to point out some important areas where we disagree with the authors, some of which are errors.
1) Clostridium perfringens classically causes so-called “gas gangrene”, a rapidly progressive infection often associated with vascular compromise due to severe penetrating trauma or crush injuries.2 Necrotising fasciitis is often polymicrobial, with common causes including group A streptococci, Staphylococcus aureus and anaerobes. Rare causes, often in the immunocompromised, include Aeromonas hydrophilia and Vibrio vulnificus.2
2) Clinically distinguishing between streptococcal and staphylococcal cellulitis is often impossible. Recommending different treatment based on this distinction is not helpful in clinical practice. All cases of cellulitis should be treated with an antibiotic with anti-staphylococcal activity, thus amoxicillin would be inappropriate therapy. This is supported by both CREST and IDSA guidelines,2,3 in contrast to the authors’ incorrect statement that amoxicillin is recommended empirical treatment in the CREST guidance.
3) Ciprofloxacin appears to have been misspelled "ciprofloxacillin".
4) Confirmed erysipeloid (caused by Erysipelothrix rhusiopathiae) should be treated with a penicillin, such as amoxicillin, as opposed to ciprofloxacin.2
5) Cross-sectional imaging is not essential in the diagnosis of necrotising fasciitis, which is mainly clinical. Delays in obtaining imaging may lead to significant deterioration and delay in definitive surgical treatment.2,3
References
1] Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ 2012;345:e4955.
2] Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJC, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clin Infect Dis. 2005; 41:1373–406
3] DHSS Northern Ireland. CREST (Clinical Resource Efficiency Support Team) Guidelines on the Management of Cellulitis In Adults. 2005; 1–31.
Competing interests: No competing interests