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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.