Cellulitis in Surgery

  • Research Article
  • Siniša Franjić
  • Independent Researcher Croatia.
  • *Corresponding author: Siniša Franjić, Independent Researcher, Croatia. E-mail: sinisa.franjic@gmail.com
  • Received: 01-12-2022; Accepted: 16-12-2022; Published: 20-12-2022.


Cellulitis is a bacterial infection that spreads to the skin and subcutaneous tissue. Cellulitis can be caused by various bacteria, the most common being streptococcus. Streptococci spread rapidly and affect a wide area because they produce enzymes that prevent tissues from limiting infection. Staphylococci, another type of bacteria, can also cause cellulitis, but it is limited to a smaller area. Other bacteria cause cellulite after some types of injuries such as animal bites or skin injuries that occur in freshwater or seawater.

Key words: Cellulitis; Causes; Condition; Pathology; Infections


Cellulitis could be a spreading inflammation of connective tissues [1]. It's generally subcutaneous, but the term might also be applied to pelvic, perinephric, pharyngeal and other connective tissue infections. The common causative agent is that the β-haemolytic group a Streptococcus, although Staphylococcus aureus is usually involved. The invasiveness of the Streptococcus is because of the production of hyaluronidase and streptokinase, which dissolve the intercellular matrix and therefore the fibrin inflammatory barrier respectively.

 Characteristically, the skin is red with local oedema and heat; it blanches on pressure. There is also vesicles and, in severe cases, cutaneous gangrene. Cellulitis is usually accompanied by lymphangitis and lymphadenitis, and there could also be an associated septicaemia.

 It is a non suppurative inflammation spreading along the subcutaneous tissues and connective tissue planes and across intercellular spaces [2]. The term may be a misnomer, because the lesion is one in every of the connective and interstitial tissue and not of the cells. The causative organism is generally the Streptococcus pyogenes, though a range aerobic and anaerobic bacteria may produce cellulitis.


Cellulitis is an contamination of the epidermis and subcutaneous tissues, characterized via way of means of erythema, ache and swelling of the affected portion [3]. It's properly demarcated borders, which often strengthen due to the fact the contamination worsens. The maximum normal motive of cellulitis is trauma, consisting of surgical incisions, despite the fact that ulceration, tinea infections and co-morbid ailment like venous insufficiency, peripheral vascular ailment, or DM, can also bring about cellulitis. In in any other case healthful adults, the isolation of the underlying aetiological elements is regularly difficult. However, sufferers and not using a apparent motive have to be investigated for proof of diabetes. Patients with proof of lymphoedema or impairment of venous go with the drift may have extra enormous issues with cellulitis.

 The most typical organisms worried in cellulitis are the blood group beta-haemolytic streptococci, with S. pyogenes being the most common, with individuals of the staphylococci group additionally prevalent. Rarely Gram-terrible organisms, anaerobes and fungi can purpose cellulitis, however those are commonly in sufferers with diabetes or who're immunocompromised. The presence of gas associated with cellulitis must enhance the suspicion of the presence of C. perfringens.

 Antibiotic therapy for treatment of cellulitis is primarily based totally on the ‘best guess’ of the capability microorganisms, and normally entails treatment inside the preliminary levels with flucloxacillin and penicillin. In sufferers who're in any other case healthy, now no longer systemically unwell, and with constrained signs and symptoms, treatment with oral antibiotics is acceptable. In diabetic sufferers, or people with systemic symptoms, or greater extensive infection, parenteral antibiotics can also be required.

 The evaluation of cellulitis can be aided with the aid of using marking the bounds of the restrict of the erythema, and tracking this for proof of progression. Failure to reply to antibiotic therapy, or speedy development of the volume of ailment have to improve suspicion of necrotising fasciitis and consequently the viable want for pressing surgical intervention, or alteration of antibiotics.


Cellulitis is an acute inflammatory circumstance of the pores and skin that is characterised through localized pain, erythema, swelling, and warmth [4]. Cellulitis may also be resulting from indigenous plants colonizing the pores and skin and appendages (e.g., S. aureus and S. pyogenes) or through a extensive kind of exogenous micro organism. Because the exogenous micro organism concerned in cellulitis occupy particular niches in nature, a radical history (such as epidemiologic data) offers essential clues to etiology. When there may be drainage, an open wound, or a seen portal of entry, Gram's stain and lifestyle offer a definitive diagnosis. inside the absence of these findings, the bacterial etiology of cellulitis is tough to establish, and in a few instances staphylococcal and streptococcal cellulitis might also additionally have comparable features. Even with needle aspiration of the main facet or a punch biopsy of the cellulitis tissue itself, cultures are fantastic in only 20% of instances. This statement indicates that distinctly low numbers of micro organism might also additionally motive cellulitis which the increasing region of erythema inside the pores and skin is likewise an immediate impact of extracellular pollution or of the soluble mediators of infection elicited through the host.

 Bacteria may also benefit get admission to to the dermis thru cracks inside the skin, abrasions, cuts, burns, insect bites, surgical incisions, and intravenous catheters. Cellulitis as a result of S. aureus spreads from a important localized infection, like an abscess, folliculitis, or an inflamed overseas body (e.g., a splinter, a prosthetic device, or an intravenous catheter). In contrast, cellulitis due to S. pyogenes will be a quicker spreading, diffuse system regularly associated with lymphangitis and fever. Recurrent streptococcal cellulitis of the decrease extremities is likewise as a result of organisms of group a, C, or G in affiliation with continual venous stasis or with saphenous venectomy for coronary artery bypass surgery. Streptococci additionally purpose recurrent cellulitis amongst sufferers with continual lymphedema as a consequence of elephantiasis, lymph node dissection, or Milroy's disease. Recurrent staphylococcal cutaneous infections are greater not unusualplace amongst people who've eosinophilia and multiplied serum levels of IgE (Job's syndrome) and amongst nasal providers of staphylococci. Cellulitis as a result of Streptococcus agalactiae (group B Streptococcus) happens normally in aged sufferers and those with DM or peripheral vascular disease. Haemophilus influenzae normally reasons periorbital cellulitis in youngsters in association with sinusitis, otitis, or epiglottitis. it is doubtful whether or not this manner of cellulitis will (like meningitis) subsided not unusualplace as a consequences of the surprising efficacy of the H. influenzae kind B vaccine.

 Many different micro organism additionally reason cellulitis. Fortunately, those organisms arise in such function settings that a very good records offers beneficial clues to the diagnosis. Cellulitis associated with cat bites and, to a lesser degree, with canine bites is frequently resulting from Pasteurella multocida, even though in the latter case Staphylococcus intermedius and Capnocytophaga canimorsus (previously DF-2) have to also be considered. Sites of cellulitis and abscesses associated with canine bites and human bites additionally comprise a range of anaerobic organisms, consisting of Fusobacterium, Bacteroides, cardio and anaerobic streptococci, and Eikenella corrodens. Pasteurella is notoriously evidence in opposition to dicloxacillin and nafcillin however is touchy to all or any different -lactam antimicrobials but on quinolones, tetracycline, and erythromycin. Ampicillin/clavulanate, ampicillin/sulbactam, and cefoxitin are correct alternatives for the treatment of animal or human bite infections. Aeromonas hydrophila reasons competitive cellulitis in tissues surrounding lacerations sustained in clean water (lakes, rivers, and streams). This organism stays touchy to aminoglycosides, fluoroquinolones, chloramphenicol, trimethoprim-sulfamethoxazole, and third-generation cephalosporins; it is evidence in opposition to ampicillin, however.

P. aeruginosa reasons 3 styles of tender tissue infection: ecthyma gangrenosum in neutropenic patients, hot-tub folliculitis, and cellulitis following damage. Maximum typically, P. aeruginosa is added into the deep tissues while a person steps on a nail. Treatment consists of surgical inspection and drainage, in particular if the damage additionally includes bone or joint capsule. Choices for empirical treatment at the same time as antimicrobial susceptibility statistics are awaited consist of an aminoglycoside, a third-generation cephalosporin (ceftazidime, cefoperazone, or cefotaxime), a semisynthetic penicillin (ticarcillin, mezlocillin, or piperacillin), or a fluoroquinolone (even though drugs of the closing magnificence are not indicated for the treatment of kids thirteen years old).


The organism usually gains access through a wound or scratch or following surgical incision [2]. There's wide spread swelling and redness at the area of inflammation, but without definite localization. Initially the positioning of inoculation becomes red. Gradually the skin swells and becomes shiny. In severe infections blebs and bullae form on the skin. Central necrosis may occur at a later stage. The affected part is incredibly much swollen and painful. Diabetic individual often suffers from cellulitis. On examination, the affected part is warm, swollen and tender. There's pitting oedema and brawny induration. the encompassing lymph vessels is also seen as red streaks thanks to lymphangitis. The regional lymph nodes are going to be enlarged and tender with acute lymphadenitis.


The method by which mixed aerobic and anaerobic bacteria cause infections is known with some certainty [5]. After initial inoculation into the deeper tissues, the facultative S. milleri group organisms can synthesize hyaluronidase, which allows the infecting organisms to spread through connective tissues, initiating a cellulitis kind of infection. Metabolic by-products from the streptococci then create a positive environment for the expansion of anaerobes: the release of essential nutrients, lowered pH within the tissues, and consumption of local oxygen supplies. The anaerobic bacteria are then ready to grow, and because the local oxidation-reduction potential is lowered further, the anaerobic bacteria predominate and cause liquefaction necrosis of tissues by their synthesis of collagenases. As collagen is broken down and invading white blood cells necrose and lyse, micro abscesses form and should coalesce into a clinically recognizable abscess. Within the abscess stage, the anaerobic bacteria predominate and will eventually become the only organisms found in culture. Early infections appearing initially as a cellulitis could also be characterized as aerobic streptococcal infections, and late, chronic abscesses is also characterized as anaerobic infections.

 Clinically, this progression of the infecting flora from aerobic to anaerobic seems to correlate with the sort of swelling that may be found within the infected region. Thus, odontogenic infections seem to submit to four stages. within the first 3 days of symptoms, a soft, mildly tender, doughy swelling represents the inoculation stage, within which the invading streptococci are just setting out to colonize the host. After 3 to five days, the swelling becomes hard, red, and acutely tender because the infecting mixed flora stimulates the intense inflammatory response of the cellulitis stage. At 5 to 7 days after the onset of swelling, the anaerobes begin to predominate, causing a liquefied abscess within the center of the swollen area. this can be the abscess stage. Finally, when the abscess drains spontaneously through skin or mucosa or it's surgically drained, the resolution stage begins because the immune system destroys the infecting bacteria and therefore the processes of healing and repair ensue.

 Infections arise maximum in the main 5–6 days post-operatively, however may also be eventually than that [6]. Up to 90% of all post-operative infections arise inside 30 days postoperatively. Superfcial and deep wound infections gift with tenderness, erythema, oedema, and there may also be drainage of purulent fuid from the wound. The affected person might also additionally moreover have leukocytosis and fever. Preoperative antibiotics need to have a tendency for prophylaxis in clean-infected procedures, and for healing intentions in infected and grimy procedures. Clean-infected wounds are frequently closed mostly after a wound wash. Contaminated and grimy wounds is likewise transformed to a clean-infected one after extensive debridement and copious wound irrigation and be taken into consideration for number one closure. However, way to the excessive chance of wound contamination, frequently behind schedule number one closure or recovery with the aid of using secondary purpose is suggested. A wound contamination deeper than superfcial cellulitis need to be opened to allow drainage and controlled as a grimy wound. Negative stress dressings, if available, can expedite the technique of recovery with the aid of using secondary purpose.


After the physical examination, the practitioner should begin to own a way of the stage of the presenting infection [5]. Very soft, mildly tender, edematous swellings indicate the inoculation stage, whereas an indurated swelling indicates the cellulitis stage, and central fluctuance indicates an abscess. Soft tissue infections within the inoculation stage is also cured by removal of the odontogenic cause with or without supportive antibiotics, and infections within the cellulitis or abscess stages require removal of the dental explanation for infection plus incision and drainage and antibiotics.

 Distinctions between the inoculation, cellulitis, and abscess stages are typically in duration, pain, size, peripheral definition, and consistency on palpation, presence of purulence, infecting bacteria, and potential danger. The duration of cellulitis is sometimes thought to be acute and is that the most severe presentation of the infection. An abscess, however, may be a sign of increasing host resistance to the infection. Cellulitis is typically described as more painful than an abscess, which can be the results of its acute onset and distention of tissues.

 Edema, the hallmark of the inoculation stage, is usually diffuse and jellylike, with minimal tenderness to palpation. The dimensions of a cellulitis is often larger and more widespread than that of an abscess or edema. The periphery of a cellulitis is sometimes indistinct, with a diffuse border that creates it difficult to work out where the swelling begins or ends. The abscess usually has distinct and well-defined borders. Consistency to palpation is one among the first distinctions among the stages of infection. When palpated, edema are often very soft or doughy; a severe cellulitis is sort of always described as indurated or perhaps as being "boardlike." The severity of the cellulitis increases as its firmness to palpation increases. On palpation, an abscess feels fluctuant because it's a pus-filled cavity within the tissue. Thus an infection may appear innocuous in its early stages and intensely dangerous in its more advanced, indurated, rapidly spreading stages. A localized abscess is often less dangerous, because it's more chronic and less aggressive.

 A cellulitis is an acute, painful infection with more swelling and diffuse borders. Cellulitis includes a hard consistency on palpation and contains no pus. Cellulitis is also a rapidly spreading process in serious infections. An acute abscess could be a more mature infection with more localized pain, less swelling, and well-circumscribed borders. The abscess is fluctuant on palpation because it's a pus-filled tissue cavity. A chronic abscess is sometimes slow growing and fewer serious than a cellulitis, especially if it's drained spontaneously to the external environment.


Although the diagnosis of cellulitis is normally pretty straightforward, it is able to now and again be hard in sufferers with persistent decrease extremity edema, particularly in the ones which might be afebrile and feature continual discoloration [7]. One hardship of persistent decrease extremity edema is lipodermatosclerosis (i.e., infection observed with the aid of using fibrosis of subcutaneous fat), that is visible acutely as erythema, warmth, and tenderness and is actually harassed with cellulitis. The pores and skin above the medial malleolus is normally the initial site of involvement for lipodermatosclerosis, however the infection can increase onto the shin and calf. The persistent segment of lipodermatosclerosis is characterised with the aid of using induration, a everlasting brown-red to violet discoloration of the pores and skin, and an “inverted wine bottle” look of the distal cease of the decrease extremity. it is vital for the clinician to recognize that during sufferers with persistent lipodermatosclerosis and superimposed cellulitis, the pores and skin will in no way go back to the shade of uninvolved pores and skin, even after good enough antibiotic therapy.

 Unless there is an related bacteremia, the analysis of cellulitis is often clinical. In immunocompromised hosts, a saline injection observed via way of means of aspiration and subculture can be helpful. Histologically, cellulitis is characterised via way of means of an infiltrate of neutrophils inside the dermis. Skin biopsy can exclude problems with a purpose to be pressured with cellulitis, like dermatitis, erythema migrans, inflammatory carcinoma, poisonous erythema of chemotherapy, and Wells syndrome (an idiopathic disease inside which eosinophils infiltrate the dermis).


An abscess could be a localised collection of pus [8]. Symptoms include rubor (redness), dolor (pain), calor (warmth) and functio laesa (loss of function) if the pus is in an interior space, together with a swinging pyrexia and general malaise. After drainage it's essential to make sure that continued drainage is allowed. Deep abscesses will require drains, whilst superficial abscesses need deroofing to permit healing by secondary intention. Antibiotics aren't required unless there's surrounding cellulitis.

Deep-seated abscesses could also be primary (e.g. pyogenic liver abscess) or secondary, e.g. after surgery for peritonitis. The latter patients could also be difficult to diagnose and need repeated imaging to seek out the source of the sepsis. Investigations most typically used are ultrasound, CT scan and white cell scan. Increasingly, percutaneous drainage under ultrasound- or CT-guided control is being employed rather than open surgical approaches.

Cellulitis is inflammation of the tissues without suppuration. It's commonly seen within the lower limb but may occur deep within the retroperitoneum. There could also be associated lymphangitis. The organisms most typically found are Streptococcus or Staphylococcus. a mix of flucloxacillin and penicillin intravenously should lean until appropriate cultures and sensitivities are found. Adequate analgesia, bed rest and exclusion of diabetes are essential.

Streptococcal infections are sensitive to penicillins and these are the firstline choice for cellulitis. Staphylococcal infections are an increasingly common problem in hospitals and also the community, especially if they're methicillin-resistant. Hand-washing policies are now operative throughout hospitals within the UK and with political backing hygiene measures are strictly enforced to cut back this problem. Hospital policies include isolation, barrier nursing, topical mupirocin (similar to vancomycin), regular screening to work out if the infection has been eradicated, with IV vancomycin for serious infections. New agents active against MRSA (e.g. linezolid), which can be administered orally, are now available.

Nearly each affected person with a peri-rectal abscess will gift with ache [9]. A retrospective have a look at of sufferers with a peri-rectal abscess who offered to the emergency room determined that 99% of them had a prime complaint of ache. The ache is regularly defined as consistent and throbbing in nature. Swelling changed into much less not unusualplace and positioned best in 46% of sufferers. About 25% had energetic drainage or a fever. A bit over one third had a previous abscess. Patients with peri-rectal abscesses predictably report worsening of ache with bowel movements.

In addition to eliciting a records related to the suspicion of a peri-rectal abscess, it is critical to additionally decide the patient's baseline continence repute to gas, liquid, and strong stools. A records of earlier anorectal pathology or strategies ought to be sought, along with obstetric tears. Prior anamnesis that shows an impaired immunologic reaction ought to be determined. On evaluation of symptoms, it is critical to invite approximately urinary retention seeing that to be able to be an illustration of a extra intense contamination regarding for pelvic sepsis.

The majority of peri-rectal abscesses are frequently detected on outside anal bodily examination, with handiest a minority (approximately 10%) located completely on inner virtual rectal examination findings. Typical findings encompass uneven swelling, tenderness, warmth, cellulitis and fluctuance. Spontaneous drainage may also be present. A affected person with a perirectal abscess is not going to tolerate anoscopy and it is typically unrevealing.

Patients with a complex abscess must be tired inside the identical way as people with easy abscesses with a few modifications. Within the case of a recurrent abscess (in particular one with a short interval to recurrence like but a month) or an abscess that looks to contain pretty one peri-rectal space, it is prudent to get imaging to higher decide the places of the fluid collections and facilitate whole drainage. If imaging indicates a supralevator collection, the supply of the collection ought to be decided when you consider that supralevator collections is due to both descending pelvic methods like a tubo-ovarian abscess or diverticulitis or due to an ascending peri-rectal system like an intersphincteric abscess. Supralevator abscesses which are derived from pelvic methods are higher served with an interventional radiology-located drain, while supralevator abscesses that originate from a peri-rectal abscess are regularly tired thru the perineum.


Thrombosis in the deep veins can arise at any web website online in the frame even though it is maximum not unusualplace in the deep calf veins of the decrease limb, in part due to their shape and consequently the results of gravity [10]. Thrombosis in the upper limb, neck, subclavian veins, or vena cava most usually happens whilst an intravascular device is inserted (e.g., a subclavian or inner jugular venous get right of entry to line) main to venous obstruction or following infusion of fluids irritant to the vein walls. In those situations, the threat of thrombosis is extra not unusualplace with the extended length of placement of the tool or infusion.

 Deep venous thrombosis (DVT) typically refers to thrombosis of the deep calf, thigh, and iliac veins, and those may be the inferior vena cava. In general, the occurrence of DVT is of the calf > thigh > iliac; however, the hazard of pulmonary thromboembolism (PTE), and therefore the relative chance of tremendous sequelae consisting of death, is that the opposite with iliac > thigh > calf. However, calf DVT can be the thigh, and so as to iliac veins, forming an oversized clot all through component or all the decrease limb venous system. the hazard of PTE will increase due to the fact the DVT extends greater proximally into large vessels. Pelvic surgery, particularly hip and gynecological surgery, is associated with an expanded hazard of iliac DVT and PTE. DVT constrained to the calf of itself incorporates a espresso hazard of PTE; however, hazard of extension to contain the thigh vessels is that the principle indication for treatment.

 DVT has an annual prevalence of approximately 160 per 100,000 population, and masses of of these are beneath the knee; however, whilst the thigh veins are involved, danger of PTE increases. one of the maximum sequelae of DVT is persistent venous congestion or insufficiency. This arises from harm to the valves in the veins and improvement of superficial varicose veins, chronic venous congestion, and chronic pores and skin changes, together with recurrent ulceration chronic edema, terrible recuperation after injury, chronic pain, and recurrent cellulitis. These sequelae are frequently very enormous economically and socially, inflicting readmission to sanatorium with lots of bed-days. the cost of DVT is considerable for plenty western countries and additionally for plenty much less advanced regions. In Australia, for instance, it is predicted to price over A$200 M yearly or approximately A$10 M (US$12 M) per person. Effective prophylaxis is one method of reducing this enormous price burden.


Cellulitis most often develops on the legs. Usually the infection occurs after damage to the skin by some injury, ulcers or dermatitis. The most sensitive areas of the skin are those where there is the most water. Cellulite recurs in or near scars after surgery. However, cellulite can also occur on skin that has not been injured. The infection can spread quickly and can affect the lymph vessels and enter the bloodstream. When this happens, the infection can spread throughout the body.


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