Download Cellulitis protocol

Cellulitis
Cellulitis
–
Cellulitis is an infection of the skin with some extension into the subcutaneous tissues.13 While a lower extremity is the most common location.14
Cellulitis can involve any area of the body. Erysipelas represents a distinct form of superficial cellulitis that is associated with marked swelling of the
skin and does not involve subcutaneous tissues. The margins of involved and normal tissues are sharply demarcated, particularly at bony
prominences, in contrast to cellulitis in which the margins are generally not distinct.
Cellulitis falls into a continuum of skin infections including impetigo, folliculitis, carbuncles, and abscesses. Necrotizing cellulitis is more akin to other
necrotizing infections. With the diminished infectious organism recognition and organism attacking subsets of the immune system, entrance of an
organism into the skin begins an invasion that trespasses from the dermal layers into the subcutaneous tissues. The organism populates the area
and begins to reach out into the surrounding tissues through both tissue and hematological routes of extension.
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Cellulitis
SCOPE OF PRACTICE
PRACTITIONER
SCOPE
OUTOMES
•
Nurse Practitioner –
Aged Care
Medical Practitioner ± Nurse
Practitioner
Cellulitis.doc
The NP will refer all Hall & Prior residents outside
their scope of practice, to a medical practitioner.
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The expected outcome of use of this clinical
guideline is rapid and effective relief from
symptoms and eradication of bacteria, from
wounds skin infections and prevention of
reoccurrence, reduction in hospitalisation
rates, improved morbidity and reduce the risk
and rate of mortality.
• Upon failure of treatment, complications of
infection or recurrence of infection, referral to
an urologist is required. Referral to
occupational therapist and/or physiotherapist
should be considered if lack of mobility or
function are contributing factors.
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Cellulitis
RESIDENT’S ASSESSMENT
RESIDENT’S
HISTORY
SCOPE
OUTCOMES
Presenting symptoms
Signs and symptoms of cellulitis in the elderly:
Cellulitis is a recognizable clinical syndrome with both
systemic and local features.
Systemic findings, Increased age increases skin
frailty and increases the risk of infection. Pressure
ulcers increase the risk of mortality /morbidity.
Some become infected, cellulitis causes inflammation
tender, painful, erythematous and
oedematous
presentations.
Usually caused by Staph.aureus/streptococcus
pyogenes.
Severe myalgias and fatigue can occasionally mimic
influenza, particularly if there is a delay in onset or in
the recognition of local findings. Disorientation or
mental status changes can occur in the absence of
shock, particularly in the elderly.
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•
Gaining comprehensive and holistic data in
order to prescribe appropriate diagnostics and
interventions related to indicators identified in
assessment.
•
Constructing and ruling out related differential
diagnoses to specific pathophysiology
identified.
•
Prevent interactions and further complications
with interventions
•
If known allergy to recommended formulary,
NP & MP to instigate alternative treatment
option to ensure optimal and safe response to
treatment.
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Cellulitis
RESIDENT’S
HISTORY
INFORMATION
OUTCOMES
A number of findings are typical of cellulitis: Macular
erythema that is largely confluent generalized
swelling of the involved area, warmth to the touch of
the involved skin, tenderness in the affected
area,tender regional lymphadenopathy is common
lymphangitis may be present.
Abscess formation also may be present, significance
of accompanying tinea pedis or other dermatologic
abnormalities such as psoriasis or dyshidrosis in
resident’s with lower extremity involvement.
The absence of erythema, warmth, swelling, and local
tenderness argue strongly against the diagnosis of
cellulitis; lymphangitis is supportive of the diagnosis
of cellulitis, if present, but its absence does not
establish the diagnosis. The pattern of skin
involvement can vary, but the sharply demarcated
margins seen in erysipelas are uncommon in other
forms of cellulitis. Discrete lesions may or may not be
present; bullous cellulitis is occasionally seen, usually
due to group A streptococcus.
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Cellulitis
RESIDENT’S
HISTORY
INFORMATION
OUTCOMES
Known risk factors for the
presenting symptoms
Risk factors fall into several categories: disruption of
the cutaneous barrier (eg, leg ulcer, traumatic wound,
dermatoses) venous or lymphatic compromise (eg,
venous insufficiency, overweight. Previous history of
cellulitis. Staphylococcus aureus & beta-hemolytic
streptococci in the toe webs are significantly
associated with acute cellulitis of the lower limb.
Relevant medical, surgical and obstetric history
Prompt diagnosis and treatment will be initiated
Previous medical history
Medications
Current Medications
Other relevant information
Allergies, previous cellulitis history, nutrition &
hydration, skin integrity, mobility, cognition, behaviour
PHYSICAL Ax
SCOPE
Usual physical examination
Record findings: vital signs, skin assessment, wound
assessment, pain assessment
Assess systems that may reveal fever with/without
tachycardia, lymphadenopathy, vascular streaking,
mental status changes, hypotension, decreased
pulses & signs of DVT. Specific focus on lifestyle
risks, previous surgery, comorbid conditions:
diabetes, PVD, peripheral arterial disease, heart
failure, use of immunosuppressive agents & potential
sources of skin disruption: ulcerations, fungal
infection in the toe webs, punctures & animal bites.
Indications for specific
examinations
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OUTCOMES
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•
Correct diagnosis, provision of effective
disease and symptomatic eradication/relief
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Cellulitis
INVESTIGATIONS
INDICATIONS
INVESTIGATIONS
Routine investigations
Laboratory/diagnostics used for diagnosis and
identification of organism: skin swab only if ulceration
or exudate present.
Pathology
To determine underlying
organism, severity and
sensitivity of organism.
Wound/skin MCS
OUTCOMES
•
Results from all investigations will be used
when determining future management of the
resident’s cellulitis and appropriate treatment.
•
Accurate diagnosis will be made.
•
Correct pharmacotherapy will be prescribed
based on sensitivity of organism.
•
Appropriate dressings will be initiated
Imaging
nil
Haematology / Biochemistry
If suspected pyelonephritis
only.
FBC, U&E
Other Investigations
nil
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Cellulitis
FOLLOW UP AND EDUCATION
INTERVENTION
INFORMATION
Pharmacotherapeutics
The treatment chosen will be dependent on the
organism believed to have caused the infection, with
consideration of the residents allergy history, general
medical condition, and renal and hepatic status, as
well as the degree and quality of infection, all may
effect outcomes of resident’s hospitalization versus
resident’s treatment. In the feet, topical antifungals
should be used in those with fissures,until healed.
Analgesics should be used as appropriate.
Immobilization of the area with elevation (if in a limb)
is important to decrease pain and diminish oedema.
Blood glucose levels in known diabetics should be
regularly monitored and managed. Consultation with
a GP is recommended if necrotizing fascitis or an
abscess is suspected, if cellulitis occurs in the orbit of
the eye, if there is high fever or extreme pain, if the
condition does not respond to treatment, or if surgical
debridement is required. Hospitalization may be
required in any of these instances.
Non-pharmacological
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OUTCOMES
•
•
•
•
Eradication of infection
Prevention of recurrence of infection
Symptomatic relief
Management of oedema.
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Cellulitis
FOLLOW UP AND EDUCATION
INTERVENTION
INFORMATION
Follow up appointments
Resident needs to be reviewed daily post
commencing antibiotic therapy to reassess symptoms
& monitor for any complications or adverse reactions
to therapy.1,3 Follow up consultation is required to
validate eradication of inf. & determine whether
further antimicrobial treatment is required. An
evidence based care plan should be developed.1,3
NPs are required to follow up on all referrals to allied
health/specialists
&
reinforce
education
&
management strategies.
Resident & their caregivers need to understand the
importance of completion of diagnostic & treatment
plans. Completion of antibiotic regimens is important
to eradicate the infecting organisms & to decrease
the possibility of treatment failures, including
organisms’ tolerance to antibiotics. Education re:
possible medication side effects & anaphylaxis; signs
& symptoms of superinfection of the site, DVT,
systemic infection; & the importance of follow-up care
is needed. Control of oedema, elevation of the
affected limb, & minimization of trauma to the area
should be taught. The resident’s or caregiver should
be able to demonstrate specific wound care. Signs &
symptoms that require immediate follow-up should be
emphasized.
Letter to residents GP
Resident’s/staff education
Letters
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OUTCOMES
•
•
•
•
•
•
•
Underlying disease will be detected at follow
up.
Upon failure of treatment, complications of
infection or recurrence of infection, referral to a
medical practitioner is required.1 Referral to
occupational therapist and/or physiotherapist
should be considered if lack of mobility is a
contributing factor.
Optimise independence, awareness and
education
Optimise compliance with treatment
Optimise eradication of infection and prevent
recurrence of infection
Review of resident notes
Letters/progress reports are provided at the
discretion of the NP
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Cellulitis –
PHARMACOTHERAPY
The management of cellulitis can be divided into two distinct phases: Treatment directed at the acute cellulitis, including the decision about
hospitalization Preventive therapy to diminish the likelihood of subsequent bouts of cellulitis, particularly in resident’s who have had previous
episodes in the same anatomic location.
Decision to hospitalize -
Most resident’s with cellulitis present with recognizable skin findings (erythema, skin induration, edema,
lymphangitis) and low-grade fever. For the occasional resident’s with high fevers, rigors and other signs of systemic
toxicity including mental status changes or even shock, the decision to admit the resident’s to the hospital is
obvious.
1st line treatment for cellulitis flucloxacillin/cephalexin
Diabetics –
Cellulitis in the diabetic resident with a nonhealing plantar foot ulcer usually requires broader spectrum coverage to
include treatment of S. aureus, beta-hemolytic streptococci, aerobic gram-negative bacilli, and anaerobes pending
results of cultures and susceptibility testing : antibiotic therapy is a treatment option in these resident’s but should
not be used first for cellulitis in the absence of an ulcer. One study of 90 diabetic resident’s with limb-threatening
foot infections concluded that an antibiotic such as ampicillin-sulbactam was less costly and just as effective.19
Diagnostic testing for accompanying osteomyelitis or abscess formation should be included in the evaluation of
diabetic resident’s with cellulitis of the foot. Treatment Augmentin duo 1 tab bd
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Cellulitis PHARMACOTHERAPY
FORMULARY
cephalexin
Drug (generic name): cephalexin 1st line
Poisons schedule: schedule 4
Therapeutic class: 8(b) cephalosporins
Dosage range: 250mg – 500mg
Route: oral
Frequency of administration: 6 hourly
Duration of order: variable
Actions: intervenes in bacteria cell wall peptidoglycan synthesis
Indications for use: staphylococcal & streptococcal infections
(when mild-moderate allergy to penicillins), susceptible gram
negative bacterial UTIs, epididymo-orchitis
Contraindications for use: allergy to penicillins, cephalosporins
or carbapenems
Adverse drug reactions: nausea, diarrhoea, electrolyte
imbalance, rash, rare: cholestatic hepatitis
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Cellulitis PHARMACOTHERAPY
flucloxacillin 1st line
amoxycillin with clavulanic acid (diabetic)
Drug (generic name): amoxycillin with clavulanic acid
Poisons schedule: schedule 4
Drug (generic name): flucloxacillin
Therapeutic class: 8(a) penicillins – infections & infestations
Poisons schedule: schedule 4
Dosage range: 875mg/125mg
Therapeutic class: 8(a) penicillins – infections & infestations
Route: oral
Dosage range: 250-500mg
Frequency of administration: 12 hourly
Route: oral
Duration of order: 5-10days
Frequency of administration: 6 hourly
Actions: bactericidal, intervenes in bacteria cell wall
Duration of order: variable
peptidoglycan synthesis
Actions: bactericidal, intervenes in bacteria cell wall
Indications for use: hospital acquired pneumonia, UTI,
peptidoglycan synthesis
epididymo-orchitis, bites & clenched fist injuries, otitis media,
Indications for use: staphylococcal skin infections incl:folliculitis,
acute bacterial sinusitis, acute cholecystitis, melioidosis
boils, carbuncles, bullous impetigo, mastitis, crush injuries, stab
Contraindications for use: allergy to penicillins, cephalosporins
wounds, infected scabies
or carbapenems. Cholestatic jaundice or hepatic dysfunction
Contraindications for use: allergy to penicillins, cephalosporins
associated with amoxycillin with Clavulanic acid, or ticarcillin with
or carbapenems. Cholestatic hepatic associated with dicloxicillin
Clavulanic acid
or flucloxicillin
Adverse drug reactions: transient increases in liver enzymes &
Adverse drug reactions: transient increase in liver enzymes &
bilirubin, cholestatic hepatitis
bilirubin, cholestatic hepatitis, rare: acute generalised
exanthematous pustulosis
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Cellulitis PHARMACOTHERAPY
dicloxacillin
Drug (generic name): dicloxacillin
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins – infections & infestations
Dosage range: 250-500mg
Route: oral
Frequency of administration: 6 hourly
Duration of order: variable
Actions: bactericidal, intervenes in bacteria cell wall
peptidoglycan synthesis
Indications for use: staphylococcal skin infections incl: folliculitis,
boils, carbuncles, bullous impetigo, mastitis, crush injuries, stab
wounds, infected scabies, pneumonia, osteomyelitis, septic
arthritis, septicaemia, empirical treatment for endocarditis, surgical
prophylaxis
Contraindications for use: allergy to penicillins, cephalosporins
or carbapenems. Cholestatic hepatitis with dicloxacillin or
flucloxacillin
Adverse drug reactions: transient increase in liver enzymes &
bilirubin
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REFERENCES
1. Clinical Practice Guidelines for Nurses in Primary Care [monograph online]. 2000 [cited 2006 Apr 12]. Available from: http://www.hc-sc.gc.ca/msb/fnihp.
2. Tal S, Guller V, Levi S, Bardenstein R, Berger D, Gurevich I, Gurevich A. Profile and prognosis of febrile elderly resident’s with bacteremic urinary tract infection. Journal of Infection [serial online]. 2005 [cited 2006
Oct 20]; 50:296-305. Available from: ScienceDirect.
3. The Royal Australian College of General Practitioners. Medical Care of Older Persons in Residential Aged Care Facilities. 4th ed. South Melbourne: The Royal Australian College of General Practitioners; 2005.
4. Wagenlehner FM, Naber KG. Treatment of bacterial urinary tract infections: presence and future. European Urology [serial online]. 2006 [cited 2006 Oct 20]; 49:235-244. Available from: ScienceDirect.
5. Dartnell JG, editor. Therapeutic guidelines: antibiotic. 12th ed. Victoria: Therapeutic Guidelines Limited; 2003.
6. Rossi S, editor. Australian medicines handbook. Adelaide SA: Australian Medicines Handbook Pty Ltd; 2011.
7. eMIMS MIMS. MIMS medicine information [standard online]. c2005 [cited 2006 Oct 20]. Available from: eMIMS MIMS Online.
8. Hughes J. Urinary tract infections. Proceedings from The Infectious Diseases Module Lectures; 2006 Oct 9-16; Bentley, Perth: Curtin University of Technology; n.d.
9. McMurdo M, Bissett L, Price R, Phillips G, Crombie I. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? A double-blind, placebo-controlled trial. Age and
Ageing. 2005; 34: 256-261.
10. etg complete( internet ). Melbourne : Therapeutic Guidelines Limited; 2011 Nov Accessed 2001at http://etg.com.au/ref/ref
11. Grayson ML, McDonald M, Gibson K, Athan E, Munckhof WJ, Paull P, et al. Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the
treatment of moderate-to-severe cellulitis in adults. Clinical Infectious Diseases. 2002; 34(11): 1440-1448.
12. Ginsberg MB. Cellulitis: analysis of 101 cases and review of the literature. Southern Medical Journal. 1981; 74(5): 530-533.
13. Fleisher G, Ludwig S. Cellulitis: a prospective study. Annals of Emergency Medicine. 1980; 9(5): 246-249.
14. Kennedy M L, Fletcher KR, Plank LM. Management guidelines for nurse practitioners working with older adults. 2nd ed. Philadelphia: F. A. Davis; 2004.
15. Reuben DB, Herr KA, Pacala JT. Geriatrics at your fingertips. 6th ed. Malden, MA: Blackwell; 2004.
16. McKinnon PS, Paladino JA, Grayson ML, Gibbons GW, Karchmer AW. Cost-effectiveness of ampicillin/su;bactam versus imipenum/cilastatin in the treatment of limb-threatening foot infections in diabetic
resident’s. Clinical Infection Diseases. 1997; 24(1): 57-63.
17. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical Therapeutics. 1995; 17(5): 800-810.
18. Wan W L, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American Journal of Ophthalmology. 1986; 102(5): 575-583.
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