Cellulitis Unresponsive to Antibiotic Therapy

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Cellulitis is a bacterial infection involving the skin and underlying soft tissue. It is often associated with an open wound, but this may not always be the case. Antibiotic therapy is usually the first choice for treatment. Staph aureus and group A Strep are the common bacterial etiology.

What can be done if there is no appropriate response to antibiotics therapy?

A Closer Look at the Patient Presentation

A 58-year-old female with diabetes and a healed left below-knee amputation developed cellulitis of the amputation stump. The etiology of the infection was unclear but minor trauma was the presumed cause. She was started empirically on doxycycline by her family physician 4 days prior to her evaluation at our wound care center. When seen there were no open wounds. The patient had a temperature of 100ºF, the stump was warm, edematous, erythematous and tender to palpation.

The patient was treated as an outpatient at our wound care center. Local anesthesia 2% lidocaine without epinephrine was used to infiltrate and raise a wheal at the lateral and medial areas of her amputation site. Next using a #15 scalpel blade, two elliptical, vertical incisions were made removing a 2.0 cm x 1.0 cm area of full-thickness skin. Hemostasis is maintained by digital pressure and a silver nitrate stick. The two sites were then connected by subcutaneous dissection using a curved hemostat, which was left in place. Serous fluid was noted and cultured.

A ¼-inch Penrose drain was then grasped by the hemostat and pulled through exiting on the opposite incision. To prevent dislodgment of the drain it was sutured together. Safety pins can also be used. The patient's doxycycline was continued. Absorptive foam dressings were utilized to dress the site. The periwound was protected with Skin-Prep and a stump shrinker was applied.

The drain was removed 4 days later with complete resolution of the cellulitis. The culture positive for Staph aureus susceptible to doxycycline which was continued for a total of seven days. With this treatment, the cellulitis resolved within a week and the incision site, which remained open, was dressed with Hydrofera Blue (Hydrofera) rope and covered with a foam dressing. The rope was removed and reapplied every 2 days. Complete closure was appreciated after 2 weeks.

In Conclusion

This treatment demonstrates the standard, but rarely employed, surgical procedure of incision and drainage for cellulitis. As the patient's infection did not respond to oral antibiotics, drainage was added to the treatment. The Penrose drains function to keep the elliptical incisions from closing allowing for continuous wound drainage. 

Occasionally, it may be necessary to mobilize the drain by pulling it back and forth or "cracking the drain at the insertion site." This avoids fibrin deposits at the incision sites, which can impede drainage. The drain should be removed after 4 days as it will colonize rapidly with bacteria. Once removed, the drain sites will be closed with moist wound care and minor debridement as necessary.

James V. Stillerman, MD, CWSP, FACCWS, is the Medical Director of Samaritan Medical Center for Advanced Wound Care in Watertown, NY. He is board certified in advanced wound care by the American Board of Wound Management and has 35 years of experience including vascular surgery. Dr. Stillerman is a board member for Hospice in Jefferson County, New York. Most recently, he received the SAWC Grand Rounds award for his poster presentation the treatment of enterocutaneuos fistulas. Dr. Stillerman has initiated a wound care lecture series for teaching the medial students and medical residents. He also provides lectures to many of the regional wound care centers. He is currently is developing a wound care treatment template to assist the emergency department, local nursing homes and hospital with wound care and prevention. He also consults via telemedicine as an adjunctive evaluation tool.

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