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Clinical Practice Guidelines

Cellulitis and other bacterial skin

infections

See also
Antibiotics
Periorbital and orbital cellulitis
Sepsis

Key Points
1. Cellulitis is a spreading infection of the skin extending to
involve the subcutaneous tissues. Many conditions present
similarly to cellulitis — always consider differential
diagnoses
2. The typical presenting features of all skin infections include
soft tissue redness, warmth and swelling, but other features
are variable
3. Allergic reactions and contact dermatitis are frequently
misdiagnosed as cellulitis. If there is itch and no
tenderness, cellulitis is unlikely

Background
Cellulitis

The most common causes are Group A streptococcus

(GAS) and Staphylococcus aureus. Predisposing factors
include skin abrasions, lacerations, burns, eczematous
skin, chickenpox, etc. although the portal of entry of
organisms is often not seen

Impetigo (commonly called "school sores")

Highly contagious infection of the epidermis, particularly

common in young children Causative organisms are GAS
and S. aureus
May be associated with scabies

Staphylococcal scalded skin syndrome (SSSS)

Blistering skin disorder induced by the exfoliative

(epidermolytic) toxins of S. aureus. Primarily affects
neonates and young children

Necrotising fasciitis

Rapidly progressive soft tissue infection characterised by

necrosis of subcutaneous tissue
Causative organisms include GAS, S. aureus, anaerobes
and is often polymicrobial
It causes severe illness with a high mortality rate (~25%)
Recent infection with varicella is a risk factor

Cellulitis associated with water borne organisms

Aeromonas species (fresh or brackish water, and mud)

Mycobacterium marinum (fish tanks)
Vibrio species (salt or brackish water)
S. aureus, including MRSA
GAS (coral cuts)

Infected animal/human bites

Caused by different organisms and often require different

treatment
Other bites are discussed elsewhere, see Snakebite,
Spider bite – big black spider, Spider bite – red-back spider

There are many other forms of skin infection that are not covered
in this guideline

Assessment
Typical presentation of all skin infections

Soft tissue redness

Warmth and swelling
Pain/tenderness

Mild Cellulitis

Features above
No systemic features
No significant co-morbidities

Moderate Cellulitis

Features above with moderate swelling and tenderness

Systemic features (eg fever, tachycardia)

Severe Cellulitis

Features above with severe swelling or tenderness

Large body surface area involved (eg larger than the
patient’s handprint)
Marked systemic features (eg fever or hypothermia,
tachycardia, tachypnoea, altered conscious state, unwell
appearance, hypotension — this is a late sign). See Sepsis

Features suggestive of necrotising fasciitis include:

severe pain out of keeping with apparent severity of

infection
rapid progression
marked systemic features (eg high fever with rigors,
tachycardia, tachypnoea, hypotension, confusion,
vomiting). See Sepsis

Red flags

Abscess or suppuration
Animal or human bite
Deep structure involvement
Foreign body
Immunosuppression
Lymphangitis
MRSA infection
Multiple comorbidities
Periorbital/facial/hand involvement
Varicella associated infection

Differential Diagnosis
Large local reactions to insect bites are a common mimic of
cellulitis. Features include:

a punctum at the site

itch as a prominent feature
redness and induration, but rarely pain

Management
Investigations
Swab for Gram stain (charcoal / gel / bacterial transport
swab and slide) and culture if discharge present
Blood culture is not useful in mild/moderate cellulitis
Consider imaging (eg ultrasound) if abscess, deep infection
or foreign body suspected

Treatment
Manage sepsis if features present
Manage source if identifiable — ie remove foreign body,
drain abscess
For ongoing management refer to flowchart below

Summary of antibiotic therapy

Antimicrobial recommendations may vary according to local
antimicrobial susceptibility patterns; please refer to local guidelines
Cellulitis frequently looks worse after 24 hours of treatment;
consider waiting 48 hours to change therapies
Young, unvaccinated children are at risk of Haemophilus
influenzae type B (Hib)

Diagnosis Antibiotic Total Comments

duration

Impetigo Topical Mupirocin 2% ointment 5 days

or cream to crusted areas
tds OR

Cefalexin 33 mg/kg (max 500

mg) oral bd if widespread or
large lesions

Mild cellulitis Cefalexin 33 mg/kg (max 500 5 days

mg) oral tds

Moderate A trial of high-dose oral 5–10 days If oral

cellulitis antibiotics with close review antibiotics not
may be considered: tolerated or
Cefalexin 33 mg/kg (max 1 g) no
oral tds improvement
after 48
Consider Ambulatory/Hospital-
hours,
in-the-Home (HITH) if
manage as
available:
per severe
Ceftriaxone 50 mg/kg (max 2g)
cellulitis
IV daily
When
Cefazolin 50 mg/kg (max 2g)
improving,
IV bd
switch to oral
antibiotics as
per mild
cellulitis

Severe Flucloxacillin 50 mg/kg (max 2 5–10 days Consider

cellulitis g) IV 6H early
or (if rapidly progressive consider discharge to
Staphylococcal adding Clindamycin 10 mg/kg HITH once
scalded skin (max 600 mg) IV 6H) stable. When
syndrome improving,
switch to oral
antibiotics as
per mild
cellulitis

Necrotising Vancomycin and Meropenem Urgent

Fasciitis 20 mg/kg IV (max 1 g) 8H referral to
AND surgical team
Clindamycin 10 mg/kg (max for
600 mg) IV 6H debridement
Seek
specialist
advice for
antibiotics
Consider IVIg

Mammalian Often do not need prophylactic 5 days

bites antibiotics. When indicated*:
(uninfected / Amoxicillin/Clavulanate
prophylactic) 80 mg/mL amoxicillin oral
liquid (7:1)
22.5 mg/kg (max 875 mg) oral
bd

Animal/human Amoxicillin/Clavulanate 5 days Seek

bites 80 mg/mL amoxicillin oral (extend if specialist
(established liquid (7:1) severe, advice
infection) 22.5 mg/kg (max 875 mg) oral penetrating,
bd involving
If unable to tolerate oral deep
antibiotics: tissues)
25 mg/kg (max 1g) IV 6–8H

Waterborne Cefalexin 33 mg/kg (max 1 g) 5–10 days Clean and

skin infections oral tds and Ciprofloxacin 10 debride
– seawater or mg/kg (max 500 mg) oral bd wound as
fresh water OR needed
Trimethoprim/sulfamethoxazole Prophylactic
8/40 mg/kg (max 320/1600 mg) antibiotics are
oral bd not
recommended

*Indications for prophylactic antibiotics in a animal/human bite

Presentation delayed by >8 hours

Puncture wound unable to be adequately debrided
Bite on hands, feet, face
Involves deep tissues (eg bones, joints, tendons)
Involves an open fracture
Immunocompromised patient
Cat bites

Suggested antibiotic therapy where MRSA is suspected

Antimicrobial recommendations may vary according to local

antimicrobial susceptibility patterns; please refer to local guidelines

Diagnosis Antibiotic Total Comments

duration

Mild cellulitis Trimethoprim/sulfamethoxazole 5 days

8/40 mg/kg (max 320/1600 mg)
oral bd

OR
Clindamycin 10 mg/kg (max
450 mg) oral qid

Moderate A trial of oral antibiotics with When

cellulitis close review may be improving,
considered switch to
OR oral
Vancomycin IV antibiotics
as per mild
cellulitis

Severe Vancomycin IV When

cellulitis OR improving,
or Clindamycin 10 mg/kg (max switch to
Staphylococcal 600 mg) IV 6H oral
scalded skin antibiotics
syndrome as per
mild
cellulitis

Risk factors for MRSA infection

Residence in an area with high prevalence of MRSA, eg

Northern Territory, remote communities in northern
Queensland
Previous colonisation or infection with MRSA (particularly
recent)
Aboriginal and Torres Strait Islander or Pacific Islander child

Consider consultation with local

paediatric team when
No improvement or deterioration after 24–48 hours of
therapy
Deep abscess or necrotising fasciitis suspected — consider
surgical opinion

Consider transfer when

Child requires care above the level of comfort of local hospital

For emergency advice and paediatric or neonatal ICU transfers,

see Retrieval Services

Consider discharge when

Able to tolerate oral antibiotics

Parent Information
Cellulitis
Impetigo
Staphylococcal infections
Bleach Baths

Last Updated March 2020

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