Management Cellulitis, 2014
Transcript of Management Cellulitis, 2014
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February 2014
CPO Guidelines for the Management of Cellulitis (Adults Only)
Exclusions: (these will not be funded by CPO)
Early cellulitis (suitable for oral antibiotics)
Abscess- need surgical debridement
Red Flags present- see below
Red Flags Consider
History of anaphylaxis to penicillin or
cephalosporin
Clindamycin 300mg, four times daily, orally (requires
Specialist Endorsement).Alternatively admit.
Blistering of skinDeep intense purple discolourationDisproportionate pain
Skin necrosis
Soft tissue collectionCellulitis involving bone, periorbital
eGFR < 10 or Dialysis Dependent
Absolute indication for admissionThis complex indicates high chance of necrotising fasciitis and
must be admitted.
Requires surgical opinion
Uncertainty over antibiotic choiceeGFR 10- 30
Relative indication for admissionJudgment call on admission
Cellulitis of hand, over a joint Careful consideration of need for orthopaedic opinion
Diabetic with ulcer May be more suited to hospital care?
More advanced cellulitis with NO RED FLAGS present:
Oral Antibiotic Treatment (dosing for normal renal function) for five to seven days
First Choice FlucloxacillinAdult: 500mg to 1000mg, four times daily
OR (if flucloxacillin not tolerated)
Cefalexin
Adult: 500mg, four times daily.
Alternatives Erythromycin
Adult: 800mg, twice daily, or 400mg, four times daily
Co-trimoxazole
Adult 160+800mg (2 tablets), twice daily
Based on BPac Antibiotic Guide July 2013
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Patient for CPO referral and meets CPO criteria.
Completed adequate trial of oral antibiotics
Suitable for practice initiated - home or practice IV Programme
Outline area of erythema
Emphasise to patientElevation of the area improves outcome
IV Treatment
Cefazolin 2g, 12 hourly for 3 days, (IV slow push 5-10mins, diluent in 20mls water);
Daily reassessment, check not extending. Area of erythema may be slow to reduce but
check for other signs of improvement, less oedema, less heat, less pain;
Arrange oral antibiotic on day 2 to start on day 3 along with final dose of IV antibiotic.
(Generally flucloxacillin, 1g 6 hourly if normal renal function, 1 hour before or 2 hours after
meals).
3 days is the standard length of antibiotic administration for cellulitis in the CPO guideline.
Extension to 6 days should only be considered in exceptional circumstances eg if the 3 day
course is due to finish in the middle of a weekend or public holiday and no AAU physician is
available and the attending doctor is absolutely clear that further IV therapy is required.
If consideration is being given to extend the normal course from 3 to 6 days please consider
ringing Dr Andrew Burns, ID Physician through hospital switchboard in the first instance, or
alternatively the on-call AAU physician to discuss (ph: 8734812)
If after 12 doses (6 days) IV cefazolin or more advanced cellulitis with red flags present:
Consider admission
Cefazolin is subsidised on prescription for treatment of cellulitis in accordance with a DHB
approved protocol and the prescription is endorsed accordingly e.g. Certified Condition. InHawkes Bay the DHB approved protocol is the CPO Guideline
IV Antibiotics
Cefazolin Sodium
Antibacterial-Cephalosporin
Dosage & Administration for eGFR> 30ml/min
Administer IV 2 gm BD for 3 days. IV slow push 5-10mins, dilute 2 gm in 20mls water.
ContraindicationsCefalosporin hypersensitivity. Up to 10% cross reaction in those with penicillin hypersensitivity.
Renal Impairment
GFR between 10 and 30ml/min 1g BD: Note: relative indication for admission
Adverse effects
- Pain at injection site, watch for extravasation
- Diarrhoea associated with all broad-spectrum antibiotics. Consider pseudo membranous colitis
- May need to stop treatment or refer to hospital depending on clinical situation
- Seek advice as needed.