Version One July 2012 Page 1

Cellulitis in Adults – Guideline Flowchart

Hospital in the Home Guideline for Management at Home

Patient with suspected Cellulitis

Consider also: • Erysipelas, necrotising fasciitis, bone or joint infection, abscess • DVT, thrombophlebitis, varicose eczema, CCF

Exclude from pathway: • Cellulitis of face, orbital, periorbital, hand, perineum, diabetic foot • Cellulitis from bites (animal, human), environmental water exposure, penetrating injuries • Extensive or rapidly progressive cellulitis; presence of bullae, haemorrhage or skin necrosis;

severe, continuous pain • Systemic sepsis (tachycardia, hypotension, confusion, vomiting) • Immunocompromised host; • bilateral “cellulitis”

ED assessment: • Mark border of cellulitis • FBC, UEC, LFTs, CRP, Blood cultures if febrile, swab m/c/s of

suppurative lesions • Consider: X-ray, ultrasound of soft tissues, venous doppler, bone scan

• Investigate as appropriate • Consult relevant

discipline(s) • Manage / admit as

necessary

Options for Management Outside Hospital

Home on oral antibiotics if: • Mild to moderate cellulitis; not septic • Untreated prior to presentation or

inadequate trial of oral therapy • Able to rest and be cared for at home • GP can review in 2–3 days

Home on IV cephazolin with Hospital in the Home if: • Moderate cellulitis • May have failed oral

therapy • Not septic, medically

stable • Safe home environment

• Satisfactory IV access • Age over 16 years • Resides in catchment

area • Can transfer and

mobilise independently

Oral antibiotic options: • Dicloxacillin 500 mg 6thhrly 7–14 days; or • Phenoxymethylpenicillin 500 mg 6thhrly

7–14 days if considered streptococcal; or • Cephalexin 500mg 6thhrly if non-

immediate penicillin allergy; or • Clindamycin 450 mg 8thhrly if immediate

penicillin allergy

Option 1 Option 2 • Probenecid 500 mg 12thhrly • Cephazolin 2 g IV daily

(if probenecid contraindicated) • Cephazolin 2 g IV 12thhrly

(reduce cephazolin dose in renal impairment) ________________________________________________________ 1. Give probenecid ≥ 30 mins prior to cephazolin 2. Give 1st dose cephazolin in ED 3. Observe patient for ≥ 30 minutes after first dose 4. See over for contraindications to probenecid and cephazolin 5. Leave cannula in if safe to do so

Refer patient to Hospital in the Home Ph: 1300 443 989

Discharge arrangements after patient accepted onto Hospital in the Home • Chart cephazolin on an inpatient medication chart – give chart to patient to take home • Dispense 5 days supply of probenecid (unless contraindicated) and cephazolin to patient • Give Cellulitis and Cannula advice sheets to patient

Version One July 2012 Page 2

Cephazolin information

Cephazolin is a semi-synthetic first-generation cephalosporin with the same spectrum of antimicrobial activity as cephalothin and cephalexin. The advantage of cephazolin over the other first-generation cephalosporins is its longer half-life which allows for a longer dose interval (once or twice-daily), especially when combined with probenecid which delays its excretion. Contraindications and cautions • Allergy to cephalosporins, or major allergy to penicillin • Reduced renal function (eGFR less than 10 mL/min/1.73 m2: Cephazolin is excreted by the kidneys; it

accumulates in renal failure, when it can cause seizures) • LFTs (ALP, AST, ALT, GGT) more than twice upper limit of normal • Use with caution if history of seizures, especially if renal impairment is present

Adverse reactions • Nausea, anorexia, diarrhoea/colitis

Cephazolin dose calculator in renal impairment

Probenecid not contraindicated

Probenecid contraindicated

eGFR ≥ 30 10–29 ≥ 30 10–29 Dose (g) 2 1 2 1 Dose Interval (h) 24 24 12 24 Add Probenecid? Yes No No No

Probenecid information

Probenecid is a uricosuric and renal tubular blocking agent. It inhibits the tubular reabsorption of urate. It is used to treat hyperuricaemia (except during acute gout episodes) and to elevate and prolong plasma levels of beta-lactam antibiotics. Probenecid also interferes with the excretion of other drugs (see below). Contraindications to probenecid: • Known allergy to probenecid • Blood dyscrasias • Uric acid stones, acute gout • Salicylates in therapeutic doses antagonise probenecid. Low dose aspirin (100–150mg/day) can be continued • Probenecid is banned in sport • Reduced renal function (creatinine > 250 micromol/L or eGFR < 30 mL/min/1.73 m2) • LFTs (ALP, AST, ALT, GGT) > twice upper limit of normal

Probenecid increases the plasma concentrations of: • Methotrexate, NSAIDs (see below), rifampicin, antiviral agents (aciclovir etc.), sulphonylureas (→

hypoglycaemia), thiazides, some benzodiazepines (not temazepam), sulphonamides • Indomethacin, naproxen, ketoprofen and ketorolac should be avoided; use of other NSAIDs should not exceed

half the recommended daily dose

Adverse reactions: • Nausea, anorexia, headache, pruritus, fever, flushing

NB: If an episode of acute gout occurs during therapy it can be managed as usual without withdrawing probenecid