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    All injuries carry a risk of infection. When the skin is breached, various microbes can invade and cause damage. Inflammation in soft tissues known as “cellulitis” may develop when bacteria enter through a crack or break in your skin. Fortunately, infections from minor wounds are relatively easy to treat today due to the availability of antibiotics. Without them, any bacteria may become life-threatening if it enters the circulation.

    If germs invade the soft tissues below the superficial level of the skin (the “epidermis”), they can rapidly infect the main layers of soft tissue below. These include the deep layer of the skin (the “dermis”), the subcutaneous fat, the muscle layers, and various blood vessels and nerves.

    image by Cerevisae 

    Cellulitis may be easy to deal with in normal times, but it will be an epidemic in the aftermath of a major disaster. This is not because it’s contagious; it isn’t unless you have an open wound yourself or exchange bodily fluids. Expect cases simply because of the sheer number of injuries incurred from performing activities of daily survival in less than sanitary conditions.

    Without antibiotics, infections can spread to lymph nodes and the bloodstream, rapidly becoming life-threatening. The end result might affect the entire body, referred to as “sepsis.” Once sepsis develops, inflammation of deep structures like the spinal cord (“meningitis”) or bone marrow (“osteomyelitis”) can further complicate the situation. In the past, sepsis was usually fatal.

    The bacteria that can cause cellulitis are on your skin right now. Normal inhabitants of the surface of your skin include Staphylococcus and Group A Streptococcus. They do no harm until the skin is broken and they enter deeper tissues where they don’t belong. In recent years, a resistant bacterium called MRSA (Methicillin-Resistant Staphylococcus Aureus) has arisen which causes cellulitis resistant to the usual antibiotics.

    As an aside, Cellulitis has nothing to do with the dimpling on the skin called “cellulite”. The suffix “-itis” simply means “inflammation”, so cellul-itis simply means “inflammation of the cells.”

    The signs and symptoms of cellulitis must be recognized as early as possible. They include:

    • Discomfort in the area of infection
    • Fever and Chills
    • Exhaustion (fatigue)
    • General ill feeling (malaise)
    • Muscle aches (myalgia)
    • Heat in the area of the infection compared to non-affected areas
    • Redness, usually spreading towards torso
    • Swelling in the area of infection (often appearing shiny and causing a sensation of tightness)
    • Drainage of pus or cloudy fluid from the area of the infection
    • Foul odor coming from the area of infection
    • Hair loss at the site of infection (less common)
    • Joint stiffness caused by swelling of the tissue over it (less common)

    Cellulitis commonly occurs in an extremity, such as a leg. In these cases, it’s helpful to keep the limb elevated. Other strategies include warm or cool compresses or soaks to the affected area, and the use of ibuprofen (Advil) or acetaminophen (Tylenol) to decrease pain, discomfort, and fever.

    Although the body can sometimes resolve cellulitis on its own, treatment usually includes the use of antibiotics. These can be topical, oral, or intravenous. Topical therapy helps more to prevent infection than cure it.

    As most cases of cellulitis are caused by bacteria, they should improve and disappear during a 7-14-day course of therapy with medications in the Penicillin, Erythromycin, or Cephalosporin (Keflex) families. Amoxicillin and ampicillin are particularly popular. MRSA cellulitis can be treated with clindamycin and the sulfa drug combination of sulfamethoxazole/trimethoprim (SMX-TMP). It’s important to complete the full course of therapy.

    Cellulitis

    Adult dosing:

    -Penicillin, amoxicillin, cephalexin, or ampicillin 250-500 mg orally four times a day for 7-14 days (Amoxicillin also comes in 875 mg).

    -Clindamycin 150-300 mg orally three times a day for 7-10 days.

    -SMX 800 mg-TMX 160 mg orally twice a day for 7-10 days.

    Those allergic to penicillins can still take clindamycin or SMX-TMP. It should be noted that not all sources will recommend the same dosage, frequency, and duration of therapy for a particular drug. In resistant infections like MRSA, combination therapy with SMX/TMP and Cephalexin 500 mg orally four times a day for 7-14 days may be necessary.

    As with all medications, the longer the therapy and the higher the dose, the more likelihood that adverse reactions may occur. A much more comprehensive discussion of antibiotics can be found in Alton’s Antibiotics and Infectious Disease: The Layman’s Guide, or online at drugs.com and rxlist.com.

    All the drugs mentioned above are available in veterinary equivalents (at least at present). In a survival situation, however, antibiotics will be precious commodities. You, as medic, should dispense them only when absolutely necessary. The misuse of antibiotics, along with their excessive use in livestock, is part of the reason that we’re seeing an epidemic of antibiotic resistance in this country.

    Joe Alton MD

    Joe Alton, MD

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