How common are insect bites and stings. What are the best ways to identify and treat insect bites. When should you seek medical attention for insect bites and stings. What antibiotics are used for insect bite infections.

The Prevalence and Impact of Insect Bites and Stings

Insect bites and stings are a common occurrence, particularly during the warmer months when insects are most active. Studies indicate that between 56% and 94% of people experience at least one sting from insects like bees, wasps, or ants in their lifetime. In the United Kingdom, insect stings rank as the second most frequent cause of anaphylaxis outside of medical settings.

The impact of insect bites extends beyond mere discomfort. In Germany, for instance, large local reactions affect up to 25% of the population, while 3.5% develop potentially life-threatening IgE-mediated anaphylaxis. Tragically, this results in approximately 20 fatalities annually in Germany alone.

Identifying Insect Bites: Key Characteristics and Challenges

Identifying the culprit behind an insect bite can be straightforward in some cases, particularly when the insect remains attached (as with ticks) or is highly visible (like mosquitoes or black flies). However, diagnosis becomes more challenging when dealing with nocturnal biters or those that cause minimal immediate pain.

Typical bite characteristics include:

• Single or grouped pruritic erythematous papules
• Possible central punctum
• Occasional bullous presentation

In cases involving fleas or bedbugs, a distinctive pattern known as the ‘breakfast, lunch, and dinner’ sign may be observed. This manifests as three or more pruritic, erythematous-oedematous papules arranged linearly or triangularly, spaced a few centimeters apart.

General Treatment Approaches for Insect Bites and Stings

When dealing with insect bites and stings, several general treatment measures can be employed:

1. Prompt removal of visible stingers by scraping sideways with a fingernail or card
2. Cleansing of the affected area
3. Application of cold compresses to alleviate pain and swelling
4. Emphasis on good hygiene practices to prevent secondary infections
5. Use of simple pain relief medications like paracetamol or ibuprofen
6. Consideration of oral antihistamines or topical corticosteroids to reduce itching

When to Seek Immediate Medical Attention

While most insect bites and stings can be managed at home, certain situations warrant immediate medical attention. These include:

• Systemic hypersensitivity or toxic reactions
• Previous systemic allergic reactions to similar bites or stings
• Severely immunocompromised individuals showing signs of infection
• Stings to the mouth, throat, or tongue risking airway obstruction
• Stings around the eyes potentially compromising vision
• Cellulitis with systemic effects or worsening despite treatment
• Fever or persistent lesions associated with bites or stings from tropical regions
• Bites or stings from unusual or tropical insects

Antibiotic Treatment for Insect Bite Infections

Do all insect bites require antibiotic treatment? The answer is no. Most insect bites or stings do not necessitate antibiotics. However, when secondary bacterial infections develop, antibiotic therapy may be warranted.

First-Line Antibiotic Choices:

• Flucloxacillin is typically the first-choice antibiotic
• For penicillin allergies or when flucloxacillin is unsuitable, alternatives include clarithromycin, erythromycin, or doxycycline
• In cases of infection near the eyes or nose, co-amoxiclav is the preferred option (specialist advice may be necessary)

Prevention Strategies for Insect Bites and Stings

How can one reduce the risk of insect bites and stings? Implementing effective prevention strategies is crucial:

• Use insect repellents containing DEET, picaridin, or oil of lemon eucalyptus
• Wear long-sleeved clothing and pants when outdoors, especially during peak insect activity times
• Avoid wearing strong perfumes or scented products that may attract insects
• Keep food covered when dining outdoors
• Eliminate standing water around your property to reduce mosquito breeding grounds
• Use bed nets when sleeping in areas with high insect populations

Complications of Insect Bites and Stings: Beyond the Initial Reaction

While most insect bites and stings result in minor, localized reactions, it’s important to be aware of potential complications that may arise. These can range from moderate to severe and may include:

Allergic Reactions

In some individuals, insect bites or stings can trigger allergic responses ranging from mild to life-threatening. Anaphylaxis, a severe systemic allergic reaction, is a particular concern with certain insect stings, such as those from bees or wasps.

Secondary Infections

Bacterial infections can develop at the site of an insect bite or sting, especially if the area is scratched excessively. Cellulitis, a common skin infection, may occur and can spread if left untreated.

Vector-Borne Diseases

Some insects serve as vectors for various diseases. For example:

• Mosquitoes can transmit malaria, dengue fever, and Zika virus
• Ticks may carry Lyme disease or Rocky Mountain spotted fever
• Sandflies can spread leishmaniasis

Psychological Impact

Repeated exposure to insect bites, particularly in cases of infestations (e.g., bed bugs), can lead to psychological distress, anxiety, and insomnia in some individuals.

Emerging Research and Future Directions in Insect Bite Management

The field of insect bite and sting management is continuously evolving. Recent research has focused on several promising areas:

Improved Diagnostic Tools

Scientists are developing more accurate methods to identify specific insect bites, which could lead to more targeted treatments. These include advanced imaging techniques and molecular diagnostics that can detect insect-specific proteins or DNA in bite wounds.

Novel Treatment Approaches

Researchers are exploring new therapeutic options, including:

• Targeted immunotherapies to reduce allergic reactions to insect venom
• Topical treatments that combine anti-inflammatory and antimicrobial properties
• Nanotechnology-based drug delivery systems for enhanced efficacy of topical treatments

Eco-Friendly Insect Repellents

There is growing interest in developing effective, environmentally friendly insect repellents. These include plant-based formulations and synthetic compounds designed to mimic natural repellents found in certain plants or animals.

Genetic Approaches to Vector Control

Genetic modification techniques, such as CRISPR-Cas9, are being explored as potential tools to control insect populations that pose significant health risks. This includes efforts to reduce the ability of mosquitoes to transmit diseases like malaria.

As research in these areas progresses, we can anticipate more effective prevention strategies and treatment options for insect bites and stings in the future.

Global Perspectives on Insect Bite Management

The approach to managing insect bites and stings varies significantly across different regions of the world, influenced by factors such as local insect species, prevalent diseases, and available healthcare resources.

Tropical and Subtropical Regions

In these areas, the focus is often on preventing and treating vector-borne diseases. Strategies include:

• Mass distribution of insecticide-treated bed nets
• Indoor residual spraying programs
• Community education initiatives on disease prevention

Developed Countries

In more temperate climates and developed nations, management tends to center on:

• Treating allergic reactions to stings
• Managing local reactions and preventing secondary infections
• Surveillance and control of invasive insect species

Global Health Initiatives

International organizations play a crucial role in addressing insect-related health issues globally. The World Health Organization, for instance, leads efforts to combat vector-borne diseases through initiatives like the Global Vector Control Response 2017-2030.

These varied approaches highlight the need for tailored strategies that consider local environmental factors, insect populations, and healthcare infrastructure when addressing insect bite and sting management on a global scale.

The Role of Climate Change in Insect Bite Patterns

Climate change is increasingly recognized as a significant factor influencing insect populations and, consequently, the prevalence and distribution of insect bites and stings. This global phenomenon is altering ecosystems in ways that can impact human-insect interactions:

Expanding Insect Habitats

Rising temperatures are allowing certain insect species to survive in regions previously too cold for them. This expansion of habitats can expose new populations to unfamiliar insect-related health risks.

Changes in Insect Behavior and Life Cycles

Warmer temperatures can accelerate insect life cycles and increase their reproductive rates. This may lead to larger insect populations and potentially more frequent human-insect encounters.

Impact on Vector-Borne Diseases

Climate change can affect the transmission of vector-borne diseases by:

• Altering the geographic range of disease-carrying insects
• Extending the seasons during which disease transmission is possible
• Influencing the replication rates of pathogens within insect vectors

Adaptation and Mitigation Strategies

In response to these changes, public health strategies are evolving to include:

• Enhanced surveillance systems to monitor changes in insect populations and disease patterns
• Development of predictive models to forecast potential outbreaks
• Implementation of adaptive pest management strategies
• Increased public education on emerging insect-related health risks

Understanding and addressing the impacts of climate change on insect populations is crucial for developing effective long-term strategies for managing insect bites and stings and their associated health risks.

Insect Bites and Stings: Treatment and Management | Doctor

Insect Bites and Stings

In this article

• How common are insect bites?
• How to identify an insect bite
• What is the treatment for insect bites and stings?
• Hymenoptera stings
• Blood-sucking flies
• True bugs (Hemiptera)
• Ticks (Ixodoidea)
• Harvest mites (Trombiculidae)
• What are the complications of insect bites and stings?

How common are insect bites?

^[1]

Insect bites tend to be seasonal and increase during the summer months when more insects are active and more skin is exposed. Studies suggest that 56-94% of people are stung by insects such as bees, wasps or ants, at least once in their lifetime. In the UK, insect stings are the second most common cause of anaphylaxis outside of medical settings.

Insect venom induces a toxic reaction at the site of the sting. Large local reactions are due to allergy. In the UK, wasp venom allergy is more common than bee venom allergy, and biting insects rarely cause systemic reactions.

A German study found that large local reactions occurred in up to 25% of the population, and as many as 3.5% develop IgE-mediated, potentially life-threatening anaphylaxis, of which about 20 people die in Germany each year.^[2]

How to identify an insect bite

The cause of a bite can often be readily diagnosed where an insect remains attached, as in ticks (small blood-sucking bugs often thought of as insects) and with bloodsuckers that are highly visible – eg, mosquitoes, midges and black flies. Others may not be so easy to diagnose because they bite at night or when the patient is asleep – eg, some mosquitoes, sandflies, bedbugs and triatomine bugs, or when it is inconspicuous and does not cause an immediately painful bite – eg, harvest mites, some fleas and biting flies. Bites typically result in single or grouped pruritic erythematous papules. Some may have a central punctum and others may be bullous.

There is often a skin reaction to an insect bite and this may lead to pruritus and urticarial papules and sometimes to secondary bacterial infection. As well as a local reaction, the bite may cause an anaphylactic reaction and may act as a vector of disease.

Human, dog, and cat fleas, as well as bedbugs, feed by biting their victims, causing acute prurigo, which is aggravated in sensitised victims (papular urticaria). Diagnosis is based on three or more bites (in most cases three) with pruritic, erythematous-oedematous papules, which are either linear or triangular, a few centimetres apart. This pattern is known as the ‘breakfast, lunch, and dinner’ sign.^[3]

General management measures include cooling the skin, use of calamine and antihistamines to reduce itching, antibiotics for secondary bacterial infection if one develops and any specific treatment for disease transmitted as a result of the bite.

What is the treatment for insect bites and stings?

^{[1, 4]}

• If a stinger is visible in the skin, remove it as quickly as possible by scraping sideways with a fingernail or a piece of card.
• Clean the area and advise that simple first aid measures such as the use of cold compresses may help reduce local pain and swelling.
• Advise the person on prevention of secondary infections with good hygiene and avoidance of itching.
• Simple pain relief with paracetamol or ibuprofen.
• Oral antihistamines or topical corticosteroids (such as hydrocortisone 1%) may help reduce itching associated with cutaneous reactions but good-quality evidence in support of this use is lacking.
• If secondary infection develops, treat cellulitis with oral antibiotics in accordance with local prescribing protocols.
• Arrange immediate admission to hospital in the following circumstances:
• Systemic hypersensitivity or toxic reaction to an insect sting or bite.
• Previous systemic allergic reaction to the same type of bite or sting.
• Severely immunocompromised and symptoms or signs of an infection.
• Stung on the mouth, throat or tongue and is at risk of airway obstruction.
• Stung around the eyes and is at risk of compromised vision.
• Cellulitis that is associated with systemic effects or is worsening despite treatment in primary care.
• Fever or persisting lesions associated with a bite or sting which occurred whilst travelling outside the UK.
• Bitten or stung by an unusual insect or one from a tropical or sub-tropical area.

Antibiotics for insect bites and stings

^[5]

• Most insect bites or stings will not need antibiotics.
• First-choice antibiotic is flucloxacillin. Alternative first-choice antibiotics for penicillin allergy or if flucloxacillin is unsuitable are clarithromycin, erythromycin, doxycycline.
• First-choice antibiotic if infection is near the eyes or nose (consider seeking specialist advice) is co‑amoxiclav.
• Alternative first-choice antibiotics if infection is near the eyes or nose for penicillin allergy or if co‑amoxiclav is unsuitable are clarithromycin with metronidazole.
• Alternative-choice antibiotics for severe infection are co‑amoxiclav, cefuroxime, clindamycin or ceftriaxone.
• Antibiotics to be added if meticillin-resistant Staphylococcus aureus infection is suspected or confirmed (combination therapy with an antibiotic listed above; other antibiotics may be appropriate based on microbiological results and specialist advice) are vancomycin, teicoplanin or linezolid (if vancomycin or teicoplanin cannot be used; specialist use only).

Hymenoptera stings

• Insects of the order Hymenoptera include bees, wasps and ants.
• Stings from these insects can cause fatal anaphylaxis.
• The insects of Hymenoptera most relevant in the UK are wasp (Vespula vulgaris) and honey bee (Apis mellifera). Hornets (Vespa crabro) are also found in Britain, more commonly in the South of England.
• Wasp venom allergy is more common in the UK. Bee venom allergy usually occurs in beekeepers, their household members or where there is occupational risk.
• The risk for systemic reactions is increased by 58% if preceded by a sting within two months, even if the first sting was well tolerated.
• Venom allergy is not more common in atopic individuals.
• Some local reactions can be large and troublesome and are characterised by oedema, erythema or pruritus.
• An area of induration with a diameter of 10 cm and which peaks between 24 and 48 hours and then subsides is referred to as a large local reaction (LLR).^[6]
• LLRs occur in up to 26% of people and systemic reactions can occur in up to 7.5% of people who are stung.
• The likelihood of anaphylaxis from a future sting following an LLR is around 5%.^[7]
• However, when there is a history of anaphylaxis from a previous Hymenoptera sting and the patient has positive skin tests to venom, at least 60% of adults and 20-32% of children will develop anaphylaxis from a future sting.

Systemic reaction to wasp or bee stings

• Venom allergy is a common cause of anaphylaxis and may be fatal.
• Food, medications and insect stings are the three most common triggers of anaphylaxis.^[8]

However, anaphylaxis due to insect stings is still under-appreciated and undertreated.^[9]

The main features of systemic reactions are:

• Rapid-onset generalised urticaria.
• Angio-oedema.
• Bronchospasm and/or laryngeal oedema.
• Hypotension with collapse and loss of consciousness.

Investigation of patients with bee or wasp sting allergy

^[10]

• All patients who experience a systemic reaction to wasp or bee stings should be referred to an allergy specialist for investigation and management.
• Minor local reactions to insect stings are normal and do not warrant allergy testing.
• Skin testing (skin prick and intradermal) is the first line of investigation.
• This is with standardised venom extracts with both bee and wasp venoms and positive (histamine) and negative controls.
• Skin testing provides greater discrimination between bee and wasp sensitisation than serum-specific IgE to whole venom.
• Skin tests are also more often positive than serum-specific IgE and correlate better with history.
• Baseline tryptase should be measured. Those with raised levels have a higher risk of severe systemic reactions.

Treatment of patients with bee or wasp sting allergy

• All patients with a history of systemic reaction should be immediately provided with a written emergency management plan, an adrenaline (epinephrine) auto-injector and education in its use.
• With children, appropriate liaison with the school is recommended.
• Venom immunotherapy (VIT) is recommended for all patients with a severe systemic reaction after a sting. It reduces the chances of a serious allergic reaction to an insect sting and improves quality of life. ^[11]
• VIT is the only specific treatment that is currently available for patients with a history of systemic reaction to a Hymenoptera insect sting.
• VIT is effective in 95% of patients allergic to wasp venom and about 80% of those allergic to bee venom.
• VIT is not often recommended for children.
• A Cochrane review found that approximately 1 in 10 people treated had an allergic reaction during their treatment.^[11]
• The usual duration of VIT is three years in the UK.
• All patients should be advised of measures to reduce their risk of future stings. These include:
• Wear light-coloured clothing.
• Avoid strong fragrances, perfumes and highly scented shampoos.
• Wear shoes while outdoors and cover the body with clothing and a hat; use gloves while gardening.
• Avoid picking fruit from the ground or trees.
• Avoid drinking out of opened drink bottles or cans to prevent being stung inside the mouth.
• Wash hands after eating or handling sticky or sweet foods outdoors (especially children).
• Keep uneaten foods covered, especially when eating outdoors.
• Always contact professionals to remove bee or wasp nests.
• Wear full protective clothing while handling bees.

Management of bee or wasp stings

• The majority of people will have a localised reaction to a sting.
• Patients should be given antihistamines. Those with large local reactions may need oral prednisolone.
• Those with infected bites or stings will need oral antibiotics, usually in addition to oral antihistamines.

Blood-sucking flies

• Worldwide, these are held responsible for the spread of a large number of diseases, including malaria, filariasis, yellow fever, dengue, onchocerciasis, trypanosomiasis, leishmaniasis and loiasis.
• In the UK, these are usually only a nuisance. Discomfort of a bite is followed in sensitive individuals by pruritus with scratching and possible secondary infection.
• Where possible, the problem can be minimised by wearing clothing that covers the skin, and with use of insect repellents.

True bugs (Hemiptera)

• In the UK, the only medically significant species is bedbugs (Cimex lectularius).
• There is no evidence that they transmit disease. They may cause sleeplessness and bites may be painful and swollen. Bedbugs hide during the day and feed at night. They are found by searching the bedding at night or their hiding places during the day.
• They superficially resemble lentils and can live for six months without feeding, becoming paper thin. Control is by removal or steam cleaning of infected mattresses and treatment of the room with insecticide.
• In South America, triatomine (reduviid) bugs transmit trypanosomiasis.

Ticks (Ixodoidea)

• Worldwide, tick bites are responsible for the transmission of both rickettsial and viral infections and Lyme disease.^[12]
• In America, Rocky Mountain spotted fever, Colorado tick fever and Lyme borreliosis.
• In Australia, Q fever, tick paralysis, Queensland tick typhus and worldwide tick typhus.
• Soft ticks are widely distributed and can cause endemic relapsing fever.
• Ticks attach to the skin and feed with a barbed hypostome and then detach when engorged.
• The bites are usually painless but can cause local sensitisation and secondary infection.
• In the UK, most common ticks on humans are sheep tick (Ixodes ricinus), a vector of Lyme disease, and hedgehog tick (Ixodes hexagonus).
• Where there is tick infestation, bites can be avoided by tucking trousers into boots and the body should be searched after leaving the area to allow prompt removal of ticks, which can reduce risk of disease transmission.

Treatment and management of tick bites

• There are many suggested ways for removing ticks, including, but not limited to, heat, alcohol, and Vaseline®. None of these methods is recommended and they may, in fact, agitate the tick – in the case of the paralysis tick, this can cause more toxin to be expressed into the victim.
• A method that works well and minimises further expression of tick fluids is to lay small forceps along the skin with the ends either side of the tick’s head, press down into the skin and firmly grip the head of the tick. Then steady traction can be applied perpendicular to the skin, without twisting, until the tick is finally released. The aim is not to break the tick so that mouth parts are left in the wound. If remnants do get left behind use local anaesthetic and scrape them away carefully with a scalpel blade.
• In an area of significant Lyme disease incidence, doxycycline for ten days is the antibacterial of choice for early Lyme disease. Amoxicillin, cefuroxime or azithromycin are alternatives if doxycycline is contra-indicated.
• If there is significant paralysis then tick antivenom can be administered in addition to supportive care.

Harvest mites (Trombiculidae)

In Britain during late summer, larvae of the harvest mite (Neotrombicula autumnalis), which are tiny and often not noticed, may attach under tight-fitting clothes, feed and then detach causing itchy lesions that are sometimes bullous.

What are the complications of insect bites and stings?

^[1]

• Local skin trauma.
• Allergic reactions:
• Small local reactions, causing erythema, swelling, itching and pain.
• Large local reactions, with larger areas of oedema, erythema, and pruritus.
• Systemic reactions, which range from mild to life-threatening and include urticaria and angio-oedema, bronchospasm and upper airway obstruction, arrhythmias, coronary artery spasm, hypotension and shock, nausea, vomiting, diarrhoea, and abdominal pain, and seizures.
• Systemic toxicity: multiple bee or wasp stings can precipitate hypotension, diarrhoea, vomiting, headache, and shock.
• In rare cases, serum sickness, vasculitis, neuritis, encephalitis, and nephrosis have been reported after insect stings.
• Transmission of infectious disease such as Lyme disease.
• Secondary bacterial infection such as cellulitis and impetigo.
• Exacerbation of atopic eczema.
• Psychological distress from infestations such as bedbugs and scabies.

• Insect Bite Reaction; DermIS (Dermatology Information System)

• Juckett G; Arthropod bites. Am Fam Physician. 2013 Dec 1588(12):841-7.

• Singh S, Mann BK; Insect bite reactions. Indian J Dermatol Venereol Leprol. 2013 Mar-Apr79(2):151-64. doi: 10.4103/0378-6323.107629.

• Venom anaphylaxis – immunotherapy pharmalgen; NICE Technology appraisal guidance, February 2012

1. Insect bites and stings; NICE CKS, September 2020 (UK access only)

2. Przybilla B, Rueff F; Insect stings: clinical features and management. Dtsch Arztebl Int. 2012 Mar109(13):238-48. doi: 10.3238/arztebl.2012.0238. Epub 2012 Mar 30.

3. Peres G, Yugar LBT, Haddad Junior V; Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018 Sep-Oct93(5):759-760. doi: 10.1590/abd1806-4841.20187384.

4. Insect bites and stings: antimicrobial prescribing; NICE Guidance (September 2020)

5. Cellulitis and erysipelas: antimicrobial prescribing; NICE Guidance (September 2019)

6. Severino M, Bonadonna P, Passalacqua G; Large local reactions from stinging insects: from epidemiology to management. Curr Opin Allergy Clin Immunol. 2009 Aug9(4):334-7.

7. Koterba AP, Greenberger PA; Chapter 4: Stinging insect allergy and venom immunotherapy. Allergy Asthma Proc. 2012 May-Jun33 Suppl 1:12-4.

8. Tracy JM, Lewis EJ, Demain JG; Insect anaphylaxis: addressing clinical challenges. Curr Opin Allergy Clin Immunol. 2011 Aug11(4):332-6.

9. Demain JG, Minaei AA, Tracy JM; Anaphylaxis and insect allergy. Curr Opin Allergy Clin Immunol. 2010 Aug10(4):318-22.

10. Diagnosis and management of hymenoptera venom allergy – guidelines; British Society for Allergy and Clinical Immunology (2011)

11. Boyle RJ, Elremeli M, Hockenhull J, et al; Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012 Oct 1710:CD008838. doi: 10.1002/14651858.CD008838.pub2.

12. Radolf JD, Caimano MJ, Stevenson B, et al; Of ticks, mice and men: understanding the dual-host lifestyle of Lyme disease spirochaetes. Nat Rev Microbiol. 2012 Jan 910(2):87-99. doi: 10.1038/nrmicro2714.

Cellulitis and other bacterial skin infections

See also

Antibiotics

Invasive group A streptococcal infections: management of household contacts

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)

*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

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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Infectious cellulitis – causes, symptoms, diagnosis and treatment

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Cellulite: causes, symptoms, diagnosis and treatment.

Definition

Infectious cellulitis, or, as it is also called, streptococcal cellulitis, acute indurative cellulitis, bacterial cellulitis, is a deep inflammatory lesion of the skin and subcutaneous tissue, accompanied by induration, redness, swelling, pain.

Cosmetologists understand cellulite not as an inflammatory process, but as a lobular structure of subcutaneous fat, uneven deposition of subcutaneous fat, which manifests itself outwardly as uneven skin. It is necessary to clearly separate the dermatological nosology “cellulite” and the cosmetic problem “false cellulite”, or gynoid lipodystrophy.

Cellulite disease has nothing to do with an aesthetic defect, which is commonly referred to as “orange peel”.

Causes of cellulite

Cellulitis is usually caused by bacterial flora – group A streptococci, Staphylococcus aureus, pneumococcus. The process is associated with an open wound surface or skin abscess. In some cases (with diabetic ulcers of the lower extremities, severe tissue ischemia, after animal bites), other microorganisms, mainly aerobic gram-negative bacteria, can become the cause of cellulite. Yeast-like fungi of the genus 9 are considered rare causative agents of cellulite.0169 Candida , pathogenic fungi, parasites, viruses. There is an allergic variant of cellulitis – eosinophilic cellulitis (Wells syndrome).

Cellulite on intact skin is called “erysipelas”. Erysipelas is an acute form of cellulitis that occurs with the involvement of the lymphatic tissue in the inflammatory process, where the pathogen multiplies. Erysipelas affects the upper layers of the skin, while cellulite extends to deeper tissues. However, it is often quite difficult to draw a clear line between them, so they use the single term “cellulite”.

About half of patients with cellulite experience its recurrence. The recurrent course of the disease is often associated with pathologies of the venous and lymphatic systems. As a rule, traumatic or surgical interventions cause the first manifestations of cellulite. Cellulitis of the lower extremities usually occurs in older patients against the background of hypostatic phenomena (varicose veins, lymphostasis, etc.), as well as fungal diseases of the feet due to a violation of the barrier function of the skin.

Cellulite develops in places of skin damage as a result of microtraumas, cracks, cuts, burns, punctures, animal and insect bites, trophic ulcers, and edema of any etiology. The most susceptible to recurrent infection are patients with diabetes mellitus, obesity, liver cirrhosis, renal failure, as well as cancer patients and people who have foci of chronic infection or have reduced immunity.

Most often, cellulite is localized on the legs, face, auricles, although it can also affect other parts of the body.

Disease classification

The following clinical variants of cellulite are distinguished:

• erythematous,
• erythematous hemorrhagic,
• erythematous-vesicular,
• erythematous-vesicular-hemorrhagic,
• erythematous-bullous-hemorrhagic.

Cellulite symptoms

The disease begins acutely, usually within 1-3 days after exposure to a provoking factor. The clinical picture of cellulite is characterized by diffuse redness with blurry edges, the area of ​​inflammation is hot and painful on palpation. The lesions quickly increase in size, becoming plaque-like and edematous. Sometimes red stripes are noted – this is due to the transition of the infection to the lymphatic vessels, which become inflamed, causing hyperemia along the vessels. Slower and less acute cellulitis develops around ulcers.

A feeling of fullness, burning, pain appears in the area of ​​inflammation. Redness in a few hours turns into a bright erythema with clear uneven contours, swelling and infiltration of the skin are observed. Blisters often appear with hemorrhagic contents.

In severe cases (less than a third of patients), fever up to 38-40 ° C, chills, tachycardia, lowering blood pressure, headache, general malaise are possible.

Cellulite Diagnostics

The diagnosis of cellulite is based on a visual assessment of the clinical manifestations and laboratory confirmation. The main diagnostic measures include:

• complete blood count;

Clinical blood test: general analysis, leukoformula, ESR (with microscopy of a blood smear in the presence of pathological changes)

Synonyms: Complete blood count, UAC. Full blood count, FBC, Complete blood count (CBC) with differential white blood cell count (CBC with diff), Hemogram.
Brief description of the study CBC: general a. ..

Up to 1 business day

Available with house call

RUB 810

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General urinalysis (Urine analysis with sediment microscopy)

Method of determination

Determination of physical and chemical parameters is carried out on an automatic analyzer using the “dry chemistry” method.

Hardware microscope…

Up to 1 business day

Available with house call

410 RUB

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C-reactive protein (CRP, CRP)

C-reactive protein is an acute phase protein, a sensitive indicator of tissue damage during inflammation, necrosis, trauma.
Synonyms: Blood test for CRP; C-jet …

Up to 1 business day

Available with house call

665 RUB

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Anaerobic culture, Routine. Bacteria Identification and Susceptibility

Detection of anaerobic flora in purulent-inflammatory processes.

Anaerobic microorganisms constitute the vast majority of normal human microflora…

Up to 9 working days

Available with house call

RUB 1,945

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Gram Stain. Bacterioscopic examination of different smears.

Synonyms: Analysis of a Gram-stained smear.

Microscopic (bacterioscopic) examination of Gram-stained smear.

Brief description of the study Microscopic examination of a smear, stained

Up to 3 working days

Available with house call

RUB 685

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Culture of wound exudates and tissues for microflora and determination of sensitivity to an extended spectrum of antimicrobials

Synonyms:
Wound/tissue Culture. Aerobic Bacteria Identification and Antibiotic Susceptibility extended testing.
Brief description of the study “Sowing wound discharge and tissues for microflora and determination …

Up to 7 business days

Available with house call

2 520 RUB

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Inoculation of wound exudates and tissues for microflora, determination of sensitivity to antimicrobials and bacteriophages

Synonyms:
Wound/tissue Culture. Aerobic Bacteria Identification. Antibiotic Susceptibility and Bacteriophage Efficiency testing.
Brief description of the study “Sowing of wound discharge and tissues for microflora, determined …

Up to 7 business days

Available with house call

RUB 1,525

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Culture of wound discharge and tissues for microflora and determination of sensitivity to antimicrobial drugs

Synonyms:
Wound/tissue Culture. Aerobic Bacteria Identification and Antibiotic Susceptibility testing.
Brief description of the study “Sowing of wound discharge and tissues for microflora and determination of sensi…

Up to 7 business days

Available with house call

RUB 1,460

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Glucose (in the blood) (Glucose)

Research material

Serum or blood plasma. If it is not possible to centrifuge the sample 30 minutes after collection for serum/plasma separation…

Up to 1 business day

Available with house call

335 RUB

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Which doctors to contact

It is possible to prevent the development of cellulite at an early stage, so when the first symptoms appear, you should consult a dermatologist, a general practitioner (family doctor). It is recommended to consult a surgeon for patients with ulcerative skin defects, if necessary, surgical treatment of the ulcerative surface. Consultation

general practitioners

and

endocrinologist

is needed in the chronic course of cellulite to exclude concomitant pathology and determine the required amount of diagnostic and therapeutic measures.

Treatment of cellulite

The basis of the treatment of infectious cellulite is antibacterial therapy, taking into account the sensitivity of the pathogen to certain drugs. Broad-spectrum antibiotics are used, which is associated with difficulties in laboratory verification of the pathogen. Antimicrobial treatment of cellulite involves the use of antibacterial agents active against streptococci and staphylococci for 5 to 10 days in the case of uncomplicated cellulitis. In severe forms of cellulitis, antibacterial therapy is carried out with the use of drugs that are effective against both strepto- and staphylococci, and gram-negative aerobic microorganisms, until negative culture results are obtained. If the inflammation is autoimmune, then antibiotics are not required. Corticosteroids are often prescribed to relieve inflammation.

Localized erysipelas and cellulite care includes bed rest and elevation of affected areas to reduce local swelling. Cool, sterile saline dressings relieve pain and are especially indicated in the presence of bullous lesions. Application of moist heat may help localize an abscess associated with cellulitis.

Note that local therapy is indicated only for bullous, hemorrhagic manifestations of the disease.

In most cases of typical cellulite, there is no need to prescribe local agents – systemic antibacterial drugs are sufficient.
In complex and severe cases, surgery may be required to remove gangrene, tissue necrosis.

Among physiotherapeutic methods, the use of ultraviolet irradiation, laser therapy and photodynamic therapy is recommended. Hyperbaric oxygen therapy is used in patients with progressive cellulitis, when surgical excision of pathological tissues may be crippling.

Complications

Cellulite treatment should be started as soon as the doctor prescribes it, and all recommendations must be fully followed. The patient should not stop treatment as soon as he feels better, otherwise the disease may spread, causing serious complications.

Complications of cellulitis can be abscesses, osteomyelitis, septic arthritis, thrombophlebitis, bacteremia, necrotizing fasciitis, as well as lymphangitis and glomerulonephritis.

Recurrent infection of the lower extremities may be complicated by the development of dermal fibrosis and thickening of the epidermis. In older people, cellulitis of the lower third of the lower leg may be complicated by thrombophlebitis. In addition, inflammation of the subcutaneous tissue can trigger the development of meningitis.
In severe cases, cellulitis turns into gangrene. In turn, gangrene is often complicated by necrosis, in which the affected skin and subcutaneous fat die off. And this can lead to sepsis and death.

Prevention of cellulite

In order to prevent the recurrence of cellulite, it is effective to use bicillin administered intramuscularly. The duration of bicillin prophylaxis is 3 years, one preventive course per year.

The success of preventive treatment of cellulite also depends on the effectiveness of therapy for diseases that predispose to the occurrence and recurrence of cellulite – diabetes mellitus, foot mycosis, microcirculation disorders, carbohydrate metabolism.

To prevent cellulite, you need to observe personal hygiene, monitor the condition of the skin – it should always be clean, do not allow it to peel or crack.

You should not get carried away with local antibacterial agents, as this can lead to a violation of the natural microflora of the skin and a weakening of its barrier function.

For the prevention of cellulite and erysipelas, it is necessary to follow the general recommendations:

• be careful when handling raw fish, poultry or meat;
• when working with the ground, it is recommended to wear rubber gloves;
• treat fungal infections in a timely manner; skin wounds must be thoroughly washed so that the infection does not enter the underlying tissues;
• at the first symptoms of inflammation, you should consult a doctor.

Sources:

1. Plieva L.R. Cellulitis versus cellulite. Russian journal of skin and venereal diseases. 2015; 18(6). pp. 42-49.
2. Federal clinical guidelines for the management of patients with pyoderma. Russian Society of Dermatovenerologists and Cosmetologists. Moscow, 2015.
3. Plavunov N.F., Kadyshev V.A., Chernobrovkina T.Ya., Proskurina L.N. Features of the clinic and differential diagnosis of erysipelas. Review. Archive of internal medicine. 2017; 7(5). pp. 327-339. DOI: 10.20514/2226-6704-2017-7-5-327-339

IMPORTANT!

The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.
For a correct assessment of the results of your analyzes in dynamics, it is preferable to do studies in the same laboratory, since different laboratories may use different research methods and units of measurement to perform the same analyzes.

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