When should I consider referring a patient with cellulitis to secondary care?

Consider referring a patient with cellulitis to secondary care if they have:

• Signs or symptoms suggesting a more serious condition such as necrotizing fasciitis, orbital cellulitis, osteomyelitis, sepsis, or septic arthritis.
• Signs of systemic illness including confusion, tachycardia, tachypnoea, or hypotension.
• Comorbidities that may complicate or delay recovery, or that are unstable.
• Limb-threatening infection due to vascular compromise.
• Severe immunocompromise.
• Severe illness, frailty, elderly or very young age.
• Facial cellulitis (unless very mild), especially infection near the eyes or nose (including periorbital cellulitis).
• Spreading infection not responding to oral antibiotics.
• Lymphangitis.
• Inability to take oral antibiotics.
• Recurrent episodes of cellulitis (two or more episodes in the previous 12 months) to consider prophylactic antibiotic advice.
• Severe pain out of proportion to the infection or redness/swelling extending beyond initial presentation.
• Suspected uncommon pathogens (e.g., after penetrating injury or water exposure).

Urgency of referral depends on clinical judgement, with immediate referral for life- or sight-threatening conditions such as necrotizing fasciitis or orbital cellulitis. Intravenous antibiotics may be administered in hospital or, where services exist, in the community for selected patients.

These recommendations align with NICE guidelines on cellulitis and erysipelas antimicrobial prescribing and other expert consensus.

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