Cellulitis & similar skin infections - ED handbook
Soft‑tissue infections range from superficial, self‑limited disease to rapidly progressive, limb‑ or life‑threatening illnesses. ED priorities are early recognition, prompt appropriate antimicrobials, sepsis care where indicated, and immediate escalation for deep or necrotising infection.
Use NICE NG141 (cellulitis & erysipelas) as the primary prescribing/referral guide; use NG184 for bites and GOV.UK / local surgical pathways for necrotising infections.
Recognition at a glance
Pathogens and special exposures
- Typical organisms: group A Streptococcus and Staphylococcus aureus predominate in uncomplicated cellulitis/erysipelas (NICE NG141).
- Bites: human and animal bites inoculate oral flora (e.g. Pasteurella spp., Eikenella corrodens) and often require different antimicrobial choices and prophylaxis-consult NICE NG184.
- Water exposures: consider Aeromonas, Vibrio or other Gram‑negatives depending on fresh/salt water and local epidemiology.
- Immunosuppressed, diabetic or lymphoedematous patients may have broader organisms and higher risk of complications-admit earlier and consider ID input.
- Microbiology sampling: routine swabbing of intact cellulitis is low yield. Obtain wound/tissue cultures when skin is broken, penetrating injury or water exposure, or when atypical organisms are suspected. Take blood cultures when sepsis is suspected and, where possible, before antibiotics (NICE NG141).
ED clinical assessment and documentation
- Immediate actions: ABC, sepsis screen, analgesia, limb elevation. Triage severity and identify red flags.