Neonatal Cellulitis Treatment

Introduction

Neonatal cellulitis alludes to a bacterial skin infection that happens in newborn infants. It typically affects the deeper parts of the skin and the tissues underneath, causing irritation, redness, warmth, and swelling within the influenced zone. Neonatal cellulitis can happen anywhere on the body but is commonly seen within the face, neck, umbilical region, and extremities. 

The contamination is usually caused by microbes such as Staphylococcus aureus or Group B Streptococcus, which may enter the skin through cuts, scratches, or other breaks within the skin barrier. Prompt recognition and treatment of neonatal cellulitis are essential to anticipate complications and safeguard the well-being of the newborn child.

Characteristics of neonatal cellulitis

Neonatal cellulitis is characterised by inflammation of the skin and subcutaneous tissues, primarily caused by bacterial invasion. Understanding the definition, characteristics, common causes, and clinical presentation of neonatal cellulitis is crucial for prompt diagnosis and effective management.¹

Unlike adults, neonates have unique physiological characteristics that predispose them to infections, including an immature immune system and reduced skin barrier function. As a result, neonatal cellulitis may present differently compared to cellulitis in older individuals.

Characteristics of neonatal cellulitis include:

• Redness (erythema): The affected skin area appears red or pink due to inflammation and increased blood flow
• Swelling (edema): The skin may become swollen and puffy, indicating fluid accumulation in the affected tissue.
• Warmth: The skin feels warm to the touch due to localised inflammation and increased blood circulation.
• Tenderness: The affected area may be tender or painful upon touch, indicating underlying tissue inflammation.

These characteristic features distinguish neonatal cellulitis from other skin conditions and help clinicians in making a differential diagnosis.

Causes and risk factors for neonatal cellulitis

Several bacterial pathogens can cause neonatal cellulitis, with Staphylococcus aureus and Streptococcus species being the most common culprits. These bacteria are typically acquired from the mother during childbirth or through environmental exposure in healthcare settings.

Common risk factors for neonatal cellulitis include:

• Premature birth: Premature infants have underdeveloped skin and immune systems, increasing their susceptibility to infections.
• Birth trauma: Skin injuries or wounds acquired during delivery, such as lacerations or abrasions, provide entry points for bacteria.
• Prolonged hospitalisation: Newborns admitted to neonatal intensive care units (NICUs) or those with underlying medical conditions are at higher risk due to prolonged exposure to healthcare-associated pathogens.
• Maternal infections: Mothers with bacterial colonisation or infections, such as methicillin-resistant Staphylococcus aureus (MRSA), can transmit pathogens to their newborns during childbirth or through direct contact.

Identifying these risk factors is essential for assessing the likelihood of neonatal cellulitis and guiding appropriate management strategies.^2,3

Diagnosis of neonatal cellulitis

Diagnosing neonatal cellulitis requires careful physical examination, appropriate laboratory tests, and consideration of differential diagnoses to rule out other conditions with similar clinical presentations.

Physical examination and assessment

1. Skin evaluation: A thorough examination of the affected skin area is essential to assess for characteristic signs of cellulitis, including redness, swelling, warmth, and tenderness. The extent of skin involvement and any associated skin lesions, such as wounds or abrasions, should be documented.
2. Vital signs monitoring: Monitoring vital signs, including temperature, heart rate, and respiratory rate, is crucial to evaluate the severity of infection and identify any systemic manifestations, such as fever or tachycardia.
3. Assessment of infant's general condition: Evaluating the infant's overall condition, including behaviour, feeding patterns, and responsiveness, can provide valuable insights into the extent of systemic involvement and guide the management approach.

Laboratory tests and diagnostic imaging

1. Blood Cultures: Obtaining blood cultures is a cornerstone of the diagnostic workup for neonatal cellulitis to identify the causative bacterial pathogen and guide antimicrobial therapy. Blood samples should be collected aseptically from the arm or through central venous access if available.⁴
2. Complete Blood Count (CBC): CBC with differential can reveal leukocytosis (elevated white blood cell count) with a left shift, indicating an inflammatory response to bacterial infection. Thrombocytosis or thrombocytopenia may also be observed.
3. C-reactive Protein (CRP) and Procalcitonin Levels: Elevated levels of CRP and procalcitonin are nonspecific markers of inflammation and can aid in assessing the severity of infection and monitoring the response to treatment.
4. Imaging Studies: In selected cases or when complications are suspected, imaging studies such as ultrasound or Magnetic Resonance Imaging (MRI) may be performed to evaluate the extent of tissue involvement, assess for abscess formation, or rule out deeper-seated infections.

Differential diagnosis and ruling out other conditions

1. Eczematous Dermatitis: Superficial dermatitis with erythema and scaling can mimic the early presentation of cellulitis. However, the absence of warmth, tenderness, and systemic symptoms helps differentiate eczematous dermatitis from cellulitis.
2. Insect Bites or Allergic Reactions: Localised skin reactions to insect bites or allergic triggers may present with redness and swelling resembling cellulitis. Careful history-taking and examination can aid in distinguishing these conditions from true cellulitis.
3. Congenital Vascular Malformations: Vascular anomalies, such as hemangiomas or lymphangiomas, can present with localised skin discolouration and swelling, mimicking cellulitis. Imaging studies may be necessary to differentiate between vascular malformations and infectious cellulitis.
4. Osteomyelitis or Septic Arthritis: In cases of suspected deeper infections, such as osteomyelitis or septic arthritis, imaging modalities such as bone scans or joint aspiration may be warranted to confirm the diagnosis and guide management.

By meticulously conducting physical examinations, appropriate laboratory tests, and considering potential differential diagnoses, healthcare providers can accurately diagnose neonatal cellulitis, initiate timely treatment, and minimise the risk of complications for affected infants.⁵

Importance of prompt and effective treatment

The timely and appropriate management of neonatal cellulitis is critical for several reasons:⁵

• Risk of Complications: Newborns have an immature immune system, making them more susceptible to bacterial infections. Without prompt treatment, neonatal cellulitis can lead to serious complications such as bacteremia (bacteria in the bloodstream), sepsis, meningitis, and even death.
• Rapid Spread: Neonatal cellulitis can spread quickly if left untreated, affecting larger areas of the skin and potentially leading to systemic infection. Early intervention helps prevent the spread of bacteria and reduces the risk of complications.
• Pain and Discomfort: Infants with cellulitis experience discomfort and pain due to skin inflammation. Prompt treatment alleviates symptoms and improves the infant's comfort and well-being.
• Prevention of Long-term Effects: Effective treatment minimises the risk of long-term consequences such as scarring and tissue damage, ensuring optimal healing and recovery for the newborn.
• Psychological Impact: Cellulitis in newborns can be distressing for parents and caregivers. Prompt diagnosis and treatment provide reassurance and alleviate anxiety associated with the infant's health condition.

Treatment approaches for neonatal cellulitis

Neonatal cellulitis requires a multidisciplinary approach for effective management, incorporating antibiotic therapy, supportive care, and in some cases, surgical intervention. Here, we outline the key components of treatment for neonatal cellulitis:

Antibiotic therapy

Empirical antibiotic therapy should be initiated promptly based on the suspected pathogens and local antimicrobial resistance patterns. Commonly used antibiotics for neonatal cellulitis include:

• First-line: Ampicillin and gentamicin combination or ampicillin and cefotaxime for coverage of Gram-positive cocci (including Staphylococcus aureus and Streptococcus species) and Gram-negative bacteria.
• Considerations for Methicillin-Resistant Staphylococcus aureus (MRSA): In regions with high MRSA prevalence or in cases with suspected MRSA infection, vancomycin or clindamycin may be preferred as empirical therapy.
• Adjustment Based on Culture and Sensitivity Results: Antibiotic therapy should be adjusted based on culture and sensitivity results to target the identified pathogens and ensure optimal treatment efficacy.

The duration of antibiotic therapy for neonatal cellulitis is typically 7 to 14 days, depending on the severity of infection, clinical response to treatment, and presence of complications. Shorter durations may be considered for uncomplicated cases with early clinical improvement.

Supportive care

Supportive care is an integral part of the treatment regimen in neonatal cellulitis. It includes wound care, pain management and monitoring the infant throughout their treatment.

• Proper wound care is essential for promoting healing and preventing secondary infections. This includes gentle cleansing of the affected skin with saline or antiseptic solutions, followed by the application of topical antimicrobial agents or barrier creams as recommended by healthcare providers.
• Infants with cellulitis may experience discomfort or pain, necessitating appropriate pain management strategies. Non-pharmacological interventions such as positioning and comfort measures, as well as pharmacological options like acetaminophen or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), may be used.
• Regular monitoring of the infant's clinical status, including vital signs, response to treatment, and resolution of symptoms, is crucial for assessing treatment efficacy and identifying any complications or adverse effects associated with antibiotic therapy.

Surgical intervention

Surgical intervention may be indicated in cases of neonatal cellulitis with associated abscess formation, extensive tissue necrosis, or inadequate response to medical therapy. Draining pus or removing dead tissue with surgery may be needed to help the wound heal and stop the infection from spreading.

Surgical procedures should be performed under sterile conditions by experienced healthcare providers to minimise the risk of complications. Preoperative and postoperative antibiotic therapy may be warranted to optimise outcomes and reduce the risk of recurrence.

Thus, by implementing a comprehensive treatment approach that includes appropriate antibiotic therapy, supportive care measures, and, when necessary, surgical intervention, healthcare providers can effectively manage neonatal cellulitis and promote the rapid resolution of infection while minimising the risk of complications for affected infants.⁶

Strategies for prevention and minimising risks of recurrence

1. Antenatal Screening: Screening pregnant women for bacterial colonisation, particularly with Methicillin-Resistant Staphylococcus aureus (MRSA), can help identify high-risk neonates and implement preventive measures to reduce the risk of transmission during childbirth.
2. Strict Hygiene Practices: Healthcare facilities should adhere to strict infection control measures, including hand hygiene, environmental cleaning, and adherence to aseptic techniques during delivery and neonatal care, to minimise the risk of healthcare-associated infections.
3. Early Recognition and Treatment: Prompt recognition of signs and symptoms of cellulitis and initiation of appropriate antibiotic therapy are essential for preventing complications and minimising the risk of systemic spread of infection.
4. Wound Care and Follow-Up: Proper wound care and regular follow-up evaluations are important for monitoring the healing process, detecting any signs of recurrence or secondary infections, and addressing any concerns or complications promptly.
5. Immunisation: Ensuring timely vaccination of newborns according to recommended immunisation schedules can help prevent certain infectious diseases and reduce the risk of cellulitis caused by vaccine-preventable pathogens.
6. Patient Education: Providing education to parents or caregivers about signs of infection, its recurrence, wound care instructions, and when to seek medical attention is essential for ensuring continuity of care and early intervention if needed.

By implementing comprehensive preventive strategies and optimising management approaches for neonatal cellulitis, healthcare providers can minimise the risk of complications, improve long-term outcomes, and enhance the overall prognosis for affected infants.

Summary

Early diagnosis and prompt initiation of treatment are critical for preventing complications and optimising outcomes in neonatal cellulitis. Neonatal cellulitis is diagnosed based on clinical examination, laboratory tests (including blood cultures and CBC), and imaging studies when indicated. Differential diagnosis is essential to rule out other conditions with similar presentations.

Prompt initiation of antibiotic therapy, wound care, pain management, and supportive measures are crucial for effective management of neonatal cellulitis. Surgical intervention may be necessary in cases of abscess formation or inadequate response to medical therapy.

Untreated or inadequately treated neonatal cellulitis can lead to serious complications such as bacteremia, sepsis, abscess formation, and long-term sequelae. Close monitoring and multidisciplinary management are essential to mitigate these risks.

The prognosis of neonatal cellulitis depends on the timeliness and adequacy of treatment, as well as the presence of underlying medical conditions. Early diagnosis and appropriate management are paramount for favourable outcomes.