Clinical protocol for cellulitis

CLINICAL PROTOCOL FOR CELLULITIS
Inclusion Criteria
Exclusion Criteria
Cellulitis of the face, neck or perineum (unless agreed by an Infectious Diseases Physician). dosing and not under the care of a Paediatrician. Rapidly progressive soft tissue infection, skin necrosis or impending septic shock (fever >38.5°C, been assessed as stable, has a clear diagnosis and prognosis and  Suspected or confirmed immediate penicillin or and/or urticaria) or cephalosporin hypersensitivity. Co-existing medical conditions requiring hospital admission. Cellulitis following specific marine exposure. Clinical suspicion or laboratory confirmation of multi-resistant organisms (ie previous infection or colonisation with Methicillin Resistant Staphlycoccus Aureus [MRSA]). Necrotic changes to skin or other signs of acute vascular insufficiency.
PATHOLOGY WORK UP
Verify if any recent pathology has been ordered prior to requesting the below:


Urea and electrolytes, full blood picture, liver function, and blood glucose level. Wound swab if open wound or purulent discharge. If microbiology investigations indicate cause other than Streptococcus Pyogenes or Methicillin Sensitive Staphylococcus Aureus, consult an Infectious Diseases Physician.
INTRAVENOUS THERAPY AT HOME
Cephazolin 2 grams IV once daily plus Probenecid 500mg orally twelve hourly.
For animal or human bites refer to section below on Management of Soft Tissue Infections
Associated with Animal or Human bites. (Consult Infectious Disease Physician.)

SUITABILITY FOR ORAL PROBENECID
Drug interactions, use of methotrexate concurrently is contraindicated. Caution with
sulphonylureas (monitor blood glucose levels) and caution with benzodiazepines as they
increase plasma levels.

Absence of blood dyscrasia, renal urate stones and acute gout. Renal function, creatinine clearance >30mL/min. For clients unsuitable for oral Probenecid (as outlined above) Cephazolin 2 grams IV twelve hourly. Management of Soft Tissue Infections Recommended Medication Regime
Associated with Animal or Human Bites

Assessment of extent of infection and Intravenous Ceftriaxone 1 gram daily
the possibility of involvement of +
underlying tendon, joint or bone.
Change to oral therapy when client stable as If infecting organism clearly identified use oral antibiotic based on culture and sensitivity. If infecting agent unknown use amoxicillin + assessment and prevention of blood borne viral diseases (eg HIV, Hep B  If immediate penicillin hypersensitivity use oral metronidazole 400mg twelve hourly + EITHER Trimethoprim + sulfamethoxazole 160mg/800mg
orally twelve hourly
OR
Ciprofloxacin 500mg orally twelve hourly

TREATMENT REGIME

Access pathology results from referral source and if necessary organise blood cultures, wound swab and full blood picture. Collaborate with medical governance doctor regarding abnormal pathology results. Initiate intravenous access and commence intravenous therapy as prescribed. Nursing assessment as per Cellulitis Assessment Tool. If no clinical signs of improvement within three days liaise with medical governance doctor regarding referral to an Infectious Diseases Physician. If atypical features consider deep vein thrombosis, venous eczema, underlying bone/joint infection, bursitis or gout. Advise client to rest with limb elevated. Advise client on the use of oral Probenecid if prescribed. Advise client on the use of oral analgesia/antipyretic medication as directed. Monitor and advise client on psychological wellbeing and refer to other agencies if evidence of de-compensating mental health.
Consider discharge on evidence of:

Substantial clinical improvement: resolution of fever, soft tissue erythema and pain. If improvement in local signs of cellulitis and able to tolerate oral antibiotic therapy – commence Flucloxacillin 500mg 6-hourly orally or Clindamycin 450mg 8-hourly orally (if penicillin hypersensitivity). Continue oral antibiotics for 7-10 days depending on clinical response. Clinical deterioration as indicated by any of the following: persistent fever (>37.80C) after 72 hours of IV antibiotic therapy, tachycardia, hypotension, extension of skin erythema or development of skin necrosis, increasing pain uncontrolled by prescribed analgesia. In these situations consider referral to hospital or urgent review by an Infectious Diseases Physician.

MEDICAL GOVERNANCE

Client has access to medical governance support for twenty four (24) hours per day, seven (7), days per week. Care delivery is planned and provided in consultation with the client, medical officer/specialist holding medical governance and nursing staff. Medical specialists may retain medical governance with treatment interventions delivered by Silver Chain. When governance is retained by a Silver Chain medical officer the client will have a medical review within twenty four (24) hours of admission and scheduled follow up as determined by the medical officer for that individual client. In the instance when a client’s condition deteriorates the Silver Chain medical officer or nursing staff will confer with an emergency department medical officer. All Silver Chain medical officers are formally credentialed. Silver Chain’s medical officer holding governance will determine when the client is discharged and a summary is sent to the referrer or the client’s General Practitioner (GP).
FOLLOW UP
Refer back to client’s GP.
REFERENCES
eTG complete 2012. Therapeutic Guidelines Ltd [online] March 2012. Available from

ACKNOWLEDGEMENTS
Dr Duncan McLellan – Infectious Diseases Physician

Source: http://www.silverchain.org.au/assets/WA/Health/Home-Hospital-Protocols/CC-CP-003.pdf