Primary Options for Acute Care: Management of Adult Cellulitis

Transcription

1 Primary Options for Acute Care: Management of Adult Cellulitis These guidelines provide support for IV Management of Cellulitis in the community for initial oral treatment has failed. This is to be used for guidance only and should not replace clinical judgment. Exclusion Criteria Inclusion Criteria An adult Clear diagnosis of Cellulitis Requiring IV antibiotic therapy Medically stable Satisfactory social & environmental circumstances Remember Funding does not cover ACC cases Disclaimer This guideline, which has been endorsed by the Microbiology Department, Middlemore Hospital, is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the CMDHB and ADHB funded Primary Options Services. It is not entirely inclusive or exclusive of all methods of reasonable care. It should not replace professional clinical judgment in managing each individual patient. Confirm Cellulitis Mark area of erythema with marker Laboratory Investigations FBC ESR or CRP Electrolytes, glucose, Creatinine 2x blood cultures A swab if the lesion is discharging Therapy If no history of immediate penicillin hypersensitivity and not known to be an MRSA carrier: Cephazolin 2gm daily IV plus oral Probenecid 500mg twice daily OR Flucloxacillin 2gm q6h IV If history of immediate penicillin hypersensitivity: Clindamycin 300mg qid orally If a known MRSA carrier: If there is no response to oral antibiotic to which the MRSA is susceptible (eg Cotrimoxazole or Clindamycin, depending on proven susceptibility), refer to hospital for IV Vancomycin Admission is recommended for people with: Signs of haemodynamic instability - tachycardia - relative hypotension - severe dehydration - extreme or worsening pain or swelling - circulation is compromised Unstable co-morbidities such as heart failure, diabetes A drainable collection that requires surgeon to drain Monitor for potential complications An animal or human bite Post-orbital or peri-orbital cellulitis, unless a skin lesion is obvious Local suppuration and skin necrosis Bacteraemia Thrombophlebitis, particularly of the lower limbs Recurrent cellulitis may cause local, persistent lymphoedema Clostridium difficile Switching back to oral antibiotics Review in 48 hours with the aim to initiate oral flucloxacillin 500mg 1gm qid, one hour before food of two hours after food in 48 hours. If starting oral antibiotics, give the third (48 hour) dose of Cephazolin and initiate the oral antibiotic on the same day. Bed rest and elevation of the area of Cellulitis is crucial to recovery 1 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

2 Introduction Cellulitis is a regular cause for admission to hospital, primarily for the administration of intravenous (IV) antibiotics. It is now possible for most adults with Cellulitis to be treated in the community through Primary Options. The following guideline provides information on the treatment of adult Cellulitis in the community and has been endorsed by the Middlemore Infectious Disease Team (Selwyn Lang et al). Background 1. Definition Cellulitis is diffuse, spreading, acute inflammation within solid tissues, characterised by hyperemia, WBC infiltration, and oedema without cellular necrosis or suppuration. 2. Cause The usual pathogens are Streptococcus pyogenes (group A β-haemolytic streptococcus) and Staphylococcus aureus. The incidence of Staphylococcus aureus is increasing Staphylococcus aureus usually causes superficial Cellulitis but is typically less extensive than that of streptococcal origin. It is more likely associated with open wound or cutaneous abscess, though differential diagnosis is difficult. Approximately 10% of Staphylococcus aureus may be β-lactam resistant (MRSA). Differential diagnoses such as a DVT is particularly difficult when oedema occurs in the lower limbs. Recurrent leg Cellulitis may be prevented by treating concomitant tinea pedis. 3. Symptoms & signs An acute infection of skin and soft tissue characterised by localised pain, swelling, tenderness, Erythema and warmth. Cellulitis is often, but not always, preceded by a skin problem such as trauma, cut, puncture wound, insect bite, ulceration, tinea pedis, and dermatitis. Areas of lymphoedema or other oedema seem particular susceptible. The skin is hot, red and oedematous, often with an infiltrated surface resembling an orange skin. Borders are usually indistinct, unlike in erysipelas in which the borders are sharply demarcated and raised. 4. General cares Elevating the limb is very important and is probably the main reason people who are hospitalised do better than in the community. Ensure that the person has complete bed-rest while at home. Mark the area of Erythema with indelible marker to monitor progress of the Cellulitis. 5. Potential complications Local suppuration and skin necrosis (occasional). Bacteraemia. Thrombophlebitis, particularly of the lower limbs. Recurrent Cellulitis may cause local, persistent lymphoedema. However, the prognosis is generally excellent 2 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

3 See drug monographs below for specific dosing in renal impairment, adverse effects and IV administration. 6. Monitor for potential complications Local suppuration and skin necrosis (occasional). Bacteraemia. Thrombophlebitis, particularly of the lower limbs. Recurrent Cellulitis may cause local, persistent lymphoedema. Clostridium difficile. As Cefazolin is a broad-spectrum antibiotic, infection with clostridium difficile should be considered if diarrhoea occurs. Provide the patient and / or caregivers with the Home Cellulitis Treatment patient information leaflet so they are aware when to report to the general practitioner. Methods of monitoring that may help the patient decide whether to contact the general practitioner sooner than the 24 hours in which they would normally be checked include marking the inflamed area to monitor any spread. 7. Monitor for improvement Review the person within 24 hours (at the time of the next antibiotic dose), although if you have concerns about the domestic environment or think the person may be unduly anxious, a telephone call from the general practitioner or practice nurse sooner than this is recommended. If a person has a Streptococcus pyogenes Cellulitis the infection may be improving but the symptoms such as redness and inflammation may continue to progress because of the prior tissue damage (like sunburn, the tissue damage occurs during the day but the Erythema and pain presents later in the evening). This makes evaluation difficult but if there is any doubt, referral to the hospital is recommended. Switching back to oral antibiotics The patient should be reviewed with the aim to initiate oral antibiotics in 48 hours (i.e. after 2 doses of IV therapy, and prior to the third dose). If it is decided to start oral antibiotics, give the third (48 hours) dose of Cefazolin and start the oral antibiotic that day. Oral antibiotics are ideally Flucloxacillin 500 mg 1 gm four times daily one hour before food or two hours after. Oral antibiotics are suitable if: Temperature < 38 C for > 24 hours Clinical (redness / swelling) and laboratory (WCC, blood pressure, heart rate, respiration) signs of improvement Drug Monographs (Please refer to New Ethicals or MIMs for full product information) 1. Cefazolin Do not use in people with a previous hypersensitivity to cephalosporins or in people who have experienced an immediate or severe hypersensitivity reaction to penicillins. As seizures may occur in overdose, Cefazolin should be used cautiously in people with a history of seizures, particularly if renal impairment is present. 3 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

4 There are inadequate studies of Cefazolin in pregnancy to enable a recommendation regarding safety however there is no evidence of any risk. Creatinine clearance 35 ml/min, use Cefazolin 2 gm IV daily + Probenecid 500mg oral twice daily. Creatinine clearance ml/min, first dose of 2 gm IV daily + Probenecid 500 mg oral twice daily, with the second dose being 1gm Cefazolin + Probenecid 500 mg bd. For creatinine clearance 10 ml/min, likely admitted to hospital because of complicating renal failure. See below for equation to calculate creatinine clearance. IV administration Dilute each 1gm of Cefazolin in a minimum of 10ml sterile water for injection (total 20ml for 2 gm dose) and inject slowly over at least 5 minutes into the butterfly. Intermittent Infusion (Minibag or Burette Type Set): Prepare solution as for IM injection. Add the required dose to ml of compatible IV fluid (usually 500 or 100ml). Discard any solution that has not been used in 24 hours. Administer over minutes. Adverse effects Nausea and vomiting have been reported, though are uncommon. Similarly anorexia, diarrhoea and oral candidiasis have been reported. Pseudomembranous colitis has been reported with virtually all broad-spectrum antibiotics and so it is important to consider it in patients who develop diarrhoea while on Cefazolin. If the person has a history of antibiotic-induced candidiasis then prophylactic antifungal therapy should be considered. 2. Clindamycin People who have previously been hypersensitive to Clindamycin or Lincomycin. Safety in pregnancy has not been established however there is no evidence of any risk. Clindamycin does appear in breast milk in concentrations of µg/ml. Not necessary Oral administration 300 mg four times daily, taken with a full glass of water to avoid oesophageal irritation. Adverse effects Because Clindamycin has a moderate risk of causing pseudomembranous colitis, this should be considered if the person develops diarrhoea. A stool culture for Clostridium difficile and a stool assay for Clostridium difficile toxin is diagnostically helpful. Abdominal pain, nausea, skin rash, rarely polyarthritis. 4 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

5 3. Flucloxacillin Insert from NZHPA handbook on injectable drugs Do not use in people with a previous hypersensitivity to cephalosporins or penicillins. Each Gram of Flucloxacillin contains 2.2mmol of Sodium Use with caution in people with evidence of hepatic dysfunction Adjust dose in severe renal impairment. If creatinine clearance is < 15ml/min, likely admission to hospital because of complicating renal impairment. See below for equation to calculate creatinine clearance. IV Administration (into vein or side arm) Add 5 mls of Water to 250mgs or 500mg or 1G vial. Shake gently until all powder is dissolved. Withdraw contents and dilute contents with Water for Injection in the syringe to 10ml for the 250mg and 500mg vials, or to 10-20ml for the 1g vial. Inject slowly over 3-5 minutes. Intermittent Infusion: (Minibag or Burette type set) Prepare as for direct IV injection. Add required dose to 100 ml of compatible IV fluid. Infuse over 30 minutes. Continuous Infusion: Not recommended by this Method Stability: (After reconstitution or dilution) It is recommended that solutions for IM or direct IV injection be prepared immediately before use, and that dilutions in IV fluids be used within 1 hour of preparation. Compatibility Data Compatible with the following IV fluids 0.9% Sodium Chloride Dextran solutions 5% Glucose Glucose and Sodium Chloride Lactated Ringers (Hartmann s) Ringers Injection Do NOT add to blood products, amino-acid solutions or IV fat emulsions. Do NOT mix with any other medications. Adverse Effects Hypersensitivity reactions: rash, urticaria, purpura, fever, eosinophilia and sometimes anaphylaxis. GI disturbances, including (rarely) clostridium difficile. Cholestatic jaundice is the predominant sign of hepatotoxicity, usually with treatment longer than 2 weeks and in older people. This reaction may be delayed up to 2 months. Other Information 1. Use with caution in patients who are sensitive to Cephalosporins. 2. Hypersensitivity to penicillins is an absolute contraindication. 5 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

6 3. Each Gram contains approximately 2mmol (46.6mg) Na+ 4. PH of 5-7 when reconstituted as a 10% solution in water. 4. Probenecid People with blood dyscrasias or uric acid kidney stones Do not use in people with an acute episode of gout Use with caution in people with a history of peptic ulcer disease Probenecid does cross the placenta Probenecid decreases the excretion of Methotrexate Probenecid may increase the serum concentrations of NSAIDs, Lorazepam, Acyclovir Nil Oral administration 500 mg twice daily Adverse effects Headache, nausea, anorexia, pruritus, fever, flushing Calculation of creatinine clearance Creatinine clearance (ml/min) = (140-age) x Lean Body Weight (kg) x 60 x 0.85 (for women) 50,000 x s.creatinine (mmol/l) 6 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis

7 Cellulitis IV Antibiotic Treatment (where POAC Guidelines are being followed) Schedule One: Use this schedule for Cephazolin where practice has purchased the antibiotics. Schedule Two: Use this schedule when using Flucloxacillin (strictly 6 hourly) or when POAC pays for antibiotics directly to pharmacy. Per Day Per Day Day 1 $ $ Day 2 and Day 3 $93.00 $73.00 Admin Fee $15.50 TOTAL $ $ Where deemed clinically necessary, POAC will fund an additional day (to a maximum of the Day 2/3 fees) without prior approval needing to be sought. However, we expect the amount charged to reflect the work undertaken, as some patients may require further IV therapy whilst for others, a brief clinical review may be sufficient. Any additional days of IV antibiotic treatment must be approved by the POAC office on a dose by dose basis. Approval for extension above the fifth dose will be given only where the GP has discussed with an Infectious Disease Consultant. 7 Primary Options for Acute Care: Guideline for Management of Adult Cellulitis