Page 119 - 2025 Ranger Medic Handbook

Cellulitis / Cutaneous Abscess
DEFINITION: Acute superficial bacterial skin infection due to trauma, scratching or other lesions. Generally begins about
24 hours following a break in the skin, but more serious types of cellulitis may be seen as early as 6–8 hours following
animal or human bites.
S/Sx: Local warmth; painful, erythematous, swollen, tender area; induration, regional lymphadenopathy, Fever may
or may not be present; Typically, erythema spreads without treatment; Rapidly spreading and very painful infections
suggest the possibility of necrotizing fasciitis, a life-threatening infection of the deeper tissues that should be treated
per Sepsis/Septic Shock Protocol and URGENT evacuation to a surgical facility; Fluctuant, tender, well-defined mass
indicates abscess formation.
MANAGEMENT:
1. Clean and dress wound and surrounding area.
2. Use a pen to mark the demarcation border of the infection and reevaluate in 24 hours. SECTION 3
3. Antibiotics: Mild: doxycycline 100mg PO bid + amoxicilin 250mg bid OR trimethoprim-sulfamethoxazole (DS) 1–2
tabs bid × 5 days. Moderate: cephalexin 500mg PO qid × 7 days OR clindamycin 450mg PO tid × 7 days for first-
line failure/concern for MRSA. For human/animal bite, use amoxicillin/clavulanic acid 875mg PO bid for 7–10 days.
4. If no other antibiotics available, then moxifloxacin 400mg PO qd for 10 days.
5. Limit activity until infection resolves.
6. Add ertapenem 1g IV/IM qd if worsening at 48 hours or no improvement after 48 hours of treatment and seek evac/
higher care and look for abscess.
7. Treat per Pain Management Protocol. Cellulitis will not resolve if there is an abscess present.
8. IF ABSCESS IS PRESENT: Incise and drain (I&D) if the environment permits:
a. Establish sterile incision site with Chlorhexidine or comparable antiseptic.
b. Local anesthesia using Lidocaine.
c. Incise the length of the abscess cavity, but no further.
d. Incision should be parallel to skin tension lines if possible.
e. irrigate with adequate crystalloid solution or potable water.
f. Pack the wound loosely with iodoform or dampened gauze, if available. On subsequent dressings, you can wick
the wound. Bandage site and perform wound checks daily. DO NOT SUTURE THE SITE.
g. Abscess < 5cm in size do not require packing and studies show packing increases post procedural pain, pain at
48 hours, and more commonly require narcotics for pain control.
9. Duration of treatment should only be 5 days, reassessed and extended if the cellulitis is slow to resolve (J of Infection
Vol 81, issue 4 Oct 2020).
10. a. TMP/SMX (trimethoprim/sulfamethoxazole) dose is 1–2 DS tabs twice daily, effective against MRSA.
b. Doxycycline does not have very good strep coverage, recommendation is to use doxy + amoxicillin.
c. Cephalexin is effective against group A Strep and MSSA but not against MRSA coverage.
DISPOSITION: Reevaluate daily and watch for progression of erythema while on antibiotics. Cellulitis in critical areas
(head, neck, hand, joint involvement, perineal) requires Priority evacuation. Use of IV antibiotics requires Priority evacu-
ation or medical officer consultation. Instruct patient to keep area covered and avoid close contact to prevent spreading
infection to others or swimming to worsen infection.
SPECIAL CONSIDERATIONS: If abscess formation occurs, only attempt I&D in the tactical setting IF:
a. Patient is compromising mission due to inability to perform.
b. Delay I&D until mission completion is not possible.
c. The abscess is clearly well demarcated and superficial.
d. Local anesthesia and antiseptic are available.

2025 RANGER MEDIC HANDBOOK 105