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
