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Sunderland
Non-complicated Cellulitis Pathway
For Patients aged 18 and over
(Eron’s Class II)
Revised Version following Improvement Event
April 2016
1. Project Background
Cellulitis is a common painful skin infection, usually bacterial. Patients suffering from cellulitis can be
treated with oral antibiotics, although many patients suffering from cellulitis require administration of
intravenous (IV) drugs and a hospital admission.
The infection most commonly affects the skin of the lower leg but can infect skin in any part of the body,
usually following an injury to the skin. Cellulitis can affect people of all ages, including children; rates are
thought to be roughly similar in both sexes. Known risk factors for cellulitis include:
 Having a weakened immune system
 Lymphoedema
 Intravenous drug misuse (injecting drugs such as heroin)
The development of a primary care cellulitis pathway for Sunderland avoids the need for A&E attendances
or hospital admissions for a clearly defined group of patients. As wel l as p at i en ts a tt e nd i ng A & E
ha v i n g th e ir f o ll o w u p wit h i n or b y t h e ir l o c a l pr ac t ic e ra th er t h an an em erg enc y c ar e
s et t in g.
2. Service Outline
This service will target all patients registered with a Sunderland GP who meet the referral criteria for
treatment of non complicated cellulitis accordingly to Eron’s Class II in the community. The decision to treat
the patient in the community will be made by the referring clinician either GP, GP Out of Hours, GP led WiC
or ED.
A team of appropriately skilled community based nurses from Community Health Services (Recovery at
Home Team) will administer IV medication in patient’s homes to prevent admission to hospital. The
service will be available 24 hours a day, 7 days a week.
The service aims to:
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Reduce emergency admissions
Reduce the risk of healthcare associated infections
Increase the level of care being delivered in the patient’s homes
Increase patient independence
Increase partnership with patients (through them having involvement in care planning, e.g. timing of
administration)
Deliver cost savings, by preventing admissions to secondary care
3. Service Description
The Recovery at Home Team will provide a community based service to a clearly defined group of
patients who are suffering from Eron’s Class II cellulitis, in their own homes.
If the patient meets the referral criteria for this service, they are referred to the Recovery at Home Team
by the appropriate clinician using the identified referral documentation.
Referrals to the Recovery at Home Team should be made by phone to the Recovery at Home Hub, and
backed up by the relevant referral documentation, which is to be faxed to the Recovery at Home. The
team will accept referrals for adults over the age of 18, the Recovery at Home team will carry out a
routine risk assessment and the referring GP should alert the team of any known risk factors upon referral.
The Recovery at Home Hub will take all relevant patient information during the initial telephone referral that
is required for the Recovery at Home team to visit (Appendix 2). If routine bloods, swabs or investigations
are required the Recovery at Home Team will carry out at time of cannulation, which are dependent upon
the drug treatment. The GP will flag any anomalies with the blood or swab results for necessary
action/treatment to be taken by the Recovery at Home team. During OOH periods (Friday – Sunday) the
Recovery at Home team will check patient blood results and liaise with the GP OOH service as necessary
to ensure seamless care 24 hours a day, 7 days a week.
The GP Receptionist will fax the drug treatment card to the Recovery at Home Team, then give the treatment
card to the patient to take home to share with the Recovery at Home Team when they visit. The
Receptionist will make the 48hour review appointment, document this on the patient leaflet and give this to
the patient (Appendix 4). If this falls on a weekend the appointment will be made with the Recovery at Home
GP.
Patients should be given their i nformation leaflet and drug treatment card identifying the relevant drug
prescribed for the patient; they can then share this with the Recovery at Home Team when they visit.
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If the referral is received from secondary care the Recovery at Home Team will visit to administer
treatment. The ED/UCC or Recovery at Home Team will contact the surgery to arrange the review
appointment for 48hours after commencement of treatment.
The Recovery at Home Team will contact the patient within four hours of receipt of referral to confirm
with the patient a suitable timescale for first contact and treatment to commence.
IV drugs will be prescribed by the referring clinician and administered under an agreed drug protocol.
IV Drugs will be supplied by the Recovery at Home service.
While the patient is undergoing IV therapy they will remain the clinical responsibility of the referring
clinician, but the drugs will be administered by the Recovery at Home Team. The drug protocols will
clearly specify the responsibilities towards the patient, of each stakeholder in the service. During
treatment the patient will be regularly monitored by the Recovery at Home Team. If RAH are unable to
recannulate in community setting the member of staff is to refer to Pallion UCC and only if the patient is
house bound to refer to NEAS.
The team will liaise with the referring clinician, highlighting if the patient is not responding to treatment; or if
the patient has responded and needs to be transferred to oral antibiotics. The decision to move from IV to
oral antibiotics will be made by the patient’s referring clinician in liaison with the Recovery at Home Team.
Please see the detailed pathway described in Figure 1 overleaf.
Figure 1
Emergency Care Directorate
 Diagnose cellulitis Eron’s Class
II
 Consider sepsis  sepsis
pathway
 Prescribe drugs on hospital drug
chart
 IV cannula administer
first dose
 Discharge patient to care of
RAH Team
 Discharge include drugs/
drug chart
 In hours, review appointment at
GP Practice to be made by ED
Staff; OOH’s, arrange review
appointment with RAH
 Information leaflet including
time of RAH visit
GP/GP Led UCC/OOHs
 Diagnose cellulitis Eron’s Class II
 Consider sepsis  admit to ED
 Identify suitability for community
IV ABx (see exclusion criteria)
 Discuss community pathway with
patient
 Telephone RAH Team with
relevant patient information or to
discuss pathway
 Complete Drug Treatment Record
 Arrange 48 Hr review
appointment
 Give patient information leaflet
Exclusions
Exclusion criteria;
- IVDU
- Facial cellulitis
- Pregnancy / breastfeeding
- Known or
suspected MRSA
colonization
- Under 18 years of age
If bilateral symptoms
reconsider diagnosis of
cellulitis
Telephone RAH Team Co-ordinator
RAH Team co-ordinator ensures referral meets criteria for acceptance
YES
NO
Receptionist/GP fax Drug Treatment Record to
RAH Team
Arrange hospital admission using standard
admissions proforma
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RAH Team contact patient within 4 hours of receipt of referral to discuss time of visit.
RAH Nurse will obtain IV antibiotics from stock.
First Visit by RAH Team
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Discuss care to gain consent
Cannulate
Administer drugs
Provide patient information leaflet with contact details
Schedule next visit
Responsiveness to
treatment *
Referrer will review after
48 hrs or if over a
weekend RAH GP will
review. RAH Team to
discuss progress.
Ongoing review *
Deterioration *
Planned and unplanned
according to patient’s
needs
Discuss with referrer if
appropriate or admit
directly to hospital.
CONSIDER ambulatory care
between 7.30am and 10pm
weekdays and 7.30am to
8pm weekends
If no improvement after
48 hrs CONSIDER
discussion with
microbiology
If no improvement after
72 hrs MUST liaise with
microbiologist
Patients who RAH unable
to cannulate:
Housebound patient contact NEAS (ANP).
Discharge
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4. Diagnosis of Cellulitis
GP or medical practitioner will carry out clinical assessment; including risk factors and full patient
history to establish diagnosis and Erons classification II cellulitis. Eron’s classification system can be
found in Appendix 1.
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Clinical features of cellulitis are :
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Acute and progressive onset of red, painful, hot, swollen and tender skin with possible blister or
bullae formation, usually unilateral
Fever, malaise, shivering and rigors may precede or accompany the skin changes
Spreading lymphangitis in severe cases
Cause usually identifiable (such as laceration, burn, bite, leg ulceration, eczema). Differential
diagnosis are identified in table one.
Table One
Common
Varicose eczema
DVT
Acute gout
•
•
•
•
•
•
•
•
•
•
Typical Cellulitis
Rare
Gangrene
Carcinoma
Erisipeloides
Necrotising fasciitis
Acute lipopsclerosis
Vasculitis
Pyoderma gangrenosum
Bilateral Varicose Eczema
Patient assessment to include the following, erythematous edges should be marked with indelible ink pen to
allow subsequent clinical assessment of progress by the Recovery at Home Intermediate Care Team.:
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Temperature
Blood pressure
Heart Rate
Respiration Rate
Oxygen Saturation on air
Patient weight if available
Investigations to include the following, initial investigations will be carried out by the Recovery at Home
Intermediate Care Team at the patient’s first home visit:
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FBC/U&E/LFT/CRP/Glucose/INR (if applicable) and routine swab if skin is broken or blistering this is
dependent upon patient needs and GP clinical judgement
Patients suitable and unsuitable for the pathway are identified in table two.
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Table Two
Suitable
Adults with uncomplicated cellulitis (Eron’s Class II)
Any patient who, on assessment, can be safely
treated at home
Unsuitable
IV drug users
Facial/ periorbital cellulitis
Pregnancy/breastfeeding
Known or suspected colonisation/infection with
MRSA
Whether to prescribe oral or intravenous antibiotics will be a matter of clinical judgement. IV
antibiotics should be considered for patients with:
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Marked cellulitis (more than mild localised but not extensive)
Mild systemic - features (e.g. Flu-like symptoms, malaise) but not unwell
Stable co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid
obesity which may complicate or delay resolution of their infection
Cellulitis not improved on oral therapy
5. Treatment
Following diagnosis of Class II cellulitis according to Eron’s classification, patients suitable for the
pathway should be referred to the Recovery at Home Team for treatment in the community. The three
options of recommended IV treatments depending upon patient risk are outlined in Table 3.
Table 3
No particular risk of C.difficile infection
No allergies or
other contraindications
Ceftriaxone IV*
1-2g once daily
Under 80kg 1g, over 80kg 2g per day
Review the morning after the second dose
or next working day to decide whether to
orally switch or continue
Oral switch after 48/72 hours to
Flucloxacillin (Complete 7 day course)
Allergic to
cephalosporins or
anaphylactic to
penicillins
Clindamycin IV*
600mg 6 hourly
CDI within past 12 months or living
in nursing home or otherwise
deemed at high risk by the
prescriber
Flucloxacillin IV*
1-2g 6 hourly
th
th
Review with the 7 or 8 dose to
decide whether to orally switch or
continue
Oral switch after 48/72 hours to
Flucloxacillin (Complete 7 day course
)
Not suitable for the pathway
th
th
Review with the 7 or 8 dose or the next
working day to decide whether to orally
switch or continue.
Oral switch to Clindamycin 300mg qds
(Complete 5 day course)
** Doses may need to be modified in light of renal function, liver function or extremes of body weight
Drug cards can be found as Appendix 3.
Intravenous to oral switch; patients should be reviewed at 48 hours or the next working day if at a
weekend and if possible switch to oral preparations, suggested criteria are:
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Pyrexia settling
Erythema settling
Falling inflammatory markers if available
Any co-morbidities stabilized
If the patient has not improved at the time of review hospital referral should be considered
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6. Management of Healthcare Associated Infections
The list below outlines advice for GP and Recovery at Home Team to minimise the risk of C.difficile in the
community:
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Nurse and GP to liaise following patients first symptoms of diarrhoea
Test for C difficile and treat according to local guidelines if positive
Review all antibiotic treatment if applicable
Review and stop gastric acid suppressant therapy if applicable
Do not prescribe antimotility medication
7. Evaluation of Pathway
The following monitoring arrangements will be put in place to ensure the pathway is operating as planned:
Cellulitis activity data will be collected and monitored quarterly at the Project Group Meetings to inform the
key metrics below:
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Number of referrals and from Sunderland GP’s to CHS A&E
Number of admissions from Sunderland GP’s to CHS
Number of referrals to Recovery at Home Team
Number of inappropriate referrals to Recovery at Home Team ie. Class I,111 & IV
Number of patients switched to oral medication within 72 hours
Number of referrals from CHS A&E department to Recovery at Home Team
Any evidence of patients on the pathway who have developed C difficile
Number and range of antibiotics prescribed
Identify the number of practices operating the pathway
Contacts
If you have any queries or require any information relating to this project please don’t hesitate to contact:
Name
Designation
Contact Details
Natalie McClary
Sunderland CCG
Dr Tracey Lucas
Sunderland CCG
0191 5128456
[email protected]
0191 5128456
[email protected]
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Appendix 1
Eron’s Severity Classification System
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Eron LJ (2000) devised this classification system of skin and soft tissue infections to aid the GP/Nurse
diagnosis, treatment and admission decisions. Once a diagnosis of lower limb cellulitis has been made
a decision should be made as to admission/treatment options according to the following classification
system. Please see Figure 2:
Class I
Patients have no signs of systemic toxicity, have no uncontrolled co-morbidities and can usually be managed
with oral antimicrobials.
Class II
Patients are either systemically ill or systemically well but with a co-morbidity such as peripheral vascular
disease, chronic venous insufficiency or morbid obesity which
may complicate or delay resolution of their infection.
Class III
Patients may have a significant systemic upset such as acute confusion,
tachycardia, tachypnoea and hypotension or may have unstable co-morbidities that may interfere with a
response to therapy or have a limb threatening infection due to vascular compromise.
Class IV
Patients have sepsis syndrome or severe life threatening infection such as necrotizing fasciitis.
Clinical findings alone are usually adequate for diagnosing cellulitis, particularly in non-toxic
immunocompetent patients.
Figure 2
Treatment in the community
Eron’s Class I Oral
Eron’s Class II
Flucloxacillin
IV antibiotics
Hospital Admissions
Eron’s Class III
Eron’s Class IV
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Appendix 2
Telephone Referral Information
Patient Demographics
Name:
Address:
Telephone Number:
D.O.B.
GP Practice Details
Name of Referrer:
GP Practice:
Telephone Number:
Reason for Referral
Erons classification
BP
Temp
Heart Rate
Respiratory Rate
Oxygen Sats on air
Past Medical History
Allergies
Routine Investigations required
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Appendix 3
Drug Therapy Record – Community Nursing Record
Patient Name:
Date of Birth
Address:
Patient Telephone Number
GP
NHS Number:
GP Address:
GP Telephone Number:
Home:
Work:
Mobile
Other cards in use:
Allergies
All drugs and changes of drug therapy to be recorded before administration by nursing staff
Regular Prescriptions
Date
Drug Name, Strength and
Preparation
Ceftriaxone injection
Dose
Route
Frequency
Additional instructions
1g
IV bolus
Once daily
Ceftriaxone injection
2g
IV
infusion
Once daily
Clindamycin injection
600mg
IV
infusion
Every 6 hrs
Flucloxacillin injection
1g
IV
Every 6 hrs
Sodium chloride 0.9%
5ml
IV
Before and
after
antibiotic
Reconstitute the vial with 10ml water
for injection according to the IV guide
and administer as bolus over 2-4
minutes
Reconstitute the vial with 40ml
sodium chloride 0.9% and infuse
over 30 minutes
Prepare the clinidamycin infusion
according to the IV guide and
administer Infusion over 20-30
minutes foreach 600mg of
clindamycin
Reconstitute the vial according to the
IV guide and administer as bolus
over 2-4 minutes
Flush the line with 5ml sodium
chloride 0.9% before and after
administration of antibiotic
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Prescriber’s Name
(PRINT) and Signature
Date
Discontinued
Appendix 4
Cellulitis and Intravenous Antibiotics: Having your Treatment at Home
You have been given this leaflet because your doctor/practitioner has seen you and diagnosed
cellulitis. The doctor/practitioner has prescribed intravenous antibiotic treatment for you to be given
at home. The doctor has referred you to the Recovery at Home Team who will contact you at your
home within 4 hours to arrange to visit. Their telephone number is 5616666
fax number
5536928
What is cellulitis?
Cellulitis is an infection of the deep layer of skin [dermis] and the layer of fat and tissues just under
the skin [the subcutaneous tissues]. It is generally caused by a break in the skin that has allowed
bacteria [germs] to get into and under the skin. Various types of bacteria can cause cellulitis.
What is the treatment for cellulitis?
A course of antibiotic tablets will often clear cellulitis but sometimes, as in this case, more is needed
and intravenous antibiotic treatment is needed. This is where the antibiotic is injected into a vein.
You will be contacted by the Recovery at Home Team who will visit you at your home. They will bring
the intravenous antibiotics with them to administer at each visit. The Recovery at Home Team will
visit twice daily to monitor condition and administer your medications.
Your doctor will review you after 48 hours of treatment. This has been arranged for you on
-------------------------------------- at ---------------------------------You should contact the Recovery at Home Team (or your doctor) sooner however if the area of
infection continues to spread or you become worse after you start your antibiotic treatment.
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The nurse from the Recovery at Home Team will provide you with a full information leaflet so that you
can monitor your symptoms and treatment but things you need to know about now are:
some patients may develop diarrhoea; this can occur up to 2-3 weeks after finishing treatment, you
should tell the Recovery at Home Team nurse or contact your doctor if you develop diarrhoea
elevating (raising) the affected body part uses gravity to help prevent excess swelling, which may also
ease pain
painkillers such as paracetamol or ibuprofen can ease pain and reduce fever and make you feel
generally more comfortable
using a moisturiser cream and soap substitute on the affected area of skin until it heals to help
prevent the skin from becoming dry and damaged
drinking plenty of fluids helps prevent dehydration and can make you feel
generally more comfortable
you may need a tetanus booster vaccination / human tetanus immunoglobulin if you have had dirty
cut or wound and your tetanus injections are not up-to-date
You should contact your nurse or doctor for advice immediately if you notice any of these symptoms.
Pain 'out of proportion' to the look of the skin changes
Feeling unwell and becoming ill 'out of proportion' to the look of the skin
Symptoms that get worse rapidly - either skin symptoms, or how you feel generally
Affected skin that goes dusky, purple or blistering
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