Paediatric Pathways

Cellulitis pathway for children presenting to hospital

(for periorbital/orbital cellulitis, see separate pathway)

DIAGNOSIS

Presentation of cellulitis:
Erythematous, hot, tender spreading rash. May be associated with swelling and systemic features. For guidance on infected bites (human or animal), see NICE guidelines.

Consider differentials:

  • Allergic/contact dermatitis: if itchy and non-tender, cellulitis unlikely
  • Impetigo: well defined lesions, often crusting/discharging, systemically well
  • In a young infant with erythema over a joint or bone, consider septic arthritis or osteomyelitis1
  • Staph scalded skin syndrome: blistering, exfoliative rash; more common in neonates and young children
  • Necrotising fasciitis: serious infection, rapidly progressing, red/purple colour, extreme pain over site of erythema often disproportionate to the extent of the rash2

INVESTIGATIONS

Cellulitis is diagnosed clinically; investigations are rarely useful in the child presenting with uncomplicated cellulitis#.3

  • Consider dental/maxfax review and/or odontogram in children presenting with facial or submandibular cellulitis; >50% of facial cellulitis is of odontogenic origin and may require tooth extraction
  • Send skin swab for MC+S if skin broken, esp. if risk of unusual organism
  • In children with complex cellulitis#, consider full blood count, CRP and blood culture.

# Features of complex cellulitis include:

  • Severe infection (see Melbourne ASSET score)
  • Significant immunosuppression
  • Associated with VZV
  • Post-burn

ASSESSING SEVERITY

All children with cellulitis require treatment with systemic antibiotics. The severity of infection determines the route of administration (IV versus oral). Consider using Melbourne ASSET score to stratify severity of infection. In addition, consider lower threshold for starting IVAbx if features of complex cellulitis#

Melbourne ASSET score:4
Area: <1% BSA=0; >1% BSA=1 (size of child’s palm = 1%)
Systemic features: No=0, Yes=1
Swelling: None=0, Mild=1, Mod/severe=2
Eye: Not involved=0, Involved=1
Tenderness: None=0, Mild=1, Mod/severe=2

MANAGEMENT

MILD/MOD if score <4.
Treat with oral antibiotics

Choice of oral Abx as per local / national guidelines
Total duration of treatment 5-7 days5-8
Provide verbal and written safety netting information

In MILD infection, only consider IVAbx if:

  • Oral Abx not tolerated or absorbed
  • Worsening of cellulitis despite adequate oral Abx (check dose and adherence)
  • Associated with VZV
  • Post-burn
  • Facial cellulitis
  • Significant immunosuppression

MANAGEMENT

SEVERE if score ≥4
Initial management with IVAbx as per local / national guidelines

Consider ambulation8 on IVAbx from ED / assessment unit (admission avoidance or reduced inpatient stay) unless:

  • Clinical risk factors: haemodynamically unstable or evidence of toxin mediated disease
  • Social / caregiver risk factors
  • Lower threshold for admission prior to ambulation if features of complex cellulitis#
  • Choice of IVAbx as per local / national guidelines

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information

IV to oral switch when:

  • Clinically improving and apyrexial +- improving inflammatory markers
  • Choice of oral Abx as per local / national guidelines. Total duration of treatment (IV+oral) = 5-7 days5-8.
  • Seek ID/micro advice if complex infection

If clinically deteriorating despite IVAbx, consider:

  • Deep seated infection requiring source control; consider imaging / surgical review
  • Resistant organism – check risk factors and microbiology results
  • Non-infective pathology

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Faust SN, Clark J, Pallett A, et al. Managing bone and joint infection in children. Archives of Disease in Childhood 2012;97:545-553.
  2. Diab J, Bannan A, Pollitt T. Necrotising fasciitis. BMJ. 2020 Apr27;369:m1428. doi: 10.1136/bmj.m1428. PMID: 32341079.
  3. Malone JR, Durica SR, Thompson DM et al. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics 2013; 132: 454-9.
  4. Ibrahim LF, Hopper SM, Donath S et al. Development and Validation of a Cellulitis Risk Score: The Melbourne ASSET Score. Pediatrics 2019; 143.
  5. Ibrahim LF, Hopper SM, Orsini F et al. Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial. Lancet Infect Dis 2019; 19: 477-86.
  6. NICE (National Centre for Health and Care Excellence). Cellulitis and erysipelas: antimicrobial prescribing. NICE Guideline [NG141]. Available at https://www.nice.org.uk/guidance/ng141. 2019.
  7. McMullan BJ, Andresen D, Blyth CC et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis 2016; 16: e139-52.
  8. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.