Abscess w/ Surrounding Cellulitis

  • CC: localized painful erythematous swelling/mass at [site]

  • PP: tenderness, fluctuance, purulent drainage, warmth, surrounding erythema/swelling, pustule, progressive pain/swelling, fever/chills

  • PN: crepitus, bullae, necrosis, pain out of proportion, rapidly spreading erythema, deep muscle pain, neurovascular compromise

  • pertinent SHx: tobacco, EtOH, drug use, IVDU

  • Etiology: most commonly S. aureus (MSSA vs MRSA); consider polymicrobial source in diabetic/perineal/bite wounds; entry through skin breakdown/trauma

  • risk factors: DM, immunocompromised state, prior MRSA/abscess, recent antibiotics/hospitalization, skin trauma/breaks, obesity, IVDU

  • initial DATA: CBC, BMP, ESR/CRP, BCx if systemic symptoms, wound culture if drainage/I&D, bedside US for fluid collection, CT if deep infection/unclear anatomy

  • pending DATA: blood cultures, wound/I&D cultures, gram stain, MRSA nares, imaging results

  • MEDS: IV antibiotics (ex: vancomycin ± cefepime), pain control, IV fluids if septic/dehydrated, hold immunosuppressants if indicated

  • COURSE: progressive/stable localized abscess with surrounding cellulitis at [site] x [X days], evaluated for need for I&D and IV antibiotics

Plan:

  • Consult surgery/general surgery for I&D

  • Obtain blood cultures if systemic symptoms/sepsis concern

  • I&D with gram stain and wound cultures

  • Start broad-spectrum antibiotics (ex: vancomycin + cefepime; de-escalate per cultures)

  • Follow wound culture and blood culture results

  • Trend CBC/BMP daily

  • Monitor fever curve and serial skin exams

  • PT/OT when clinically appropriate

  • Elevation of affected extremity and local wound care

Necrotizing Fasciitis Precautions / Red Flags:

  • Monitor closely for severe pain out of proportion, rapidly progressive erythema/swelling, crepitus, bullae, skin discoloration/necrosis, anesthesia over skin, systemic toxicity, hypotension, AMS, elevated lactate

  • Obtain STAT lactate, CRP, CK, repeat CBC/BMP, blood cultures, and CT with contrast if concern for deep soft tissue gas/infection (do not delay surgery for imaging if unstable/high suspicion)

  • Immediate surgical consultation if any concern for necrotizing fasciitis for emergent operative evaluation/debridement