THE OUT-OF-HOSPITAL CELLULITIS PATHWAY

THE OUT-OF-HOSPITAL CELLULITIS PATHWAY Post holder responsible for Policy: Directorate/Department responsible for Policy: Contact details: Hugh Bakere Acute Medicine Hugh Bakere, Consultant EMU, x6261 Date written: December 2010 Date revised: Approval route (names of committees): Level of Impact Assessment (Screening or Full attach to policy) N/A Antimicrobial Subcommittee Screening Date of final approval: March 29 th 2011 Date due for revision: March 2012 Date policy becomes live: March 29 th 2011 This document replaces: N/A Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Policies, Procedures, Protocols, Guidelines and Standards Policy. It should not be altered in any way without the express permission of the author or their representative. Please specify standard/criterion numbers and tick other boxes as appropriate Monitoring Information Patient Experience Assurance Framework Monitor/Finance/Performance CQC Regulations/Outcomes: Regulation 12 & 13 NHSLA Risk Management Standards for Acute Trusts The Strategic Directions 2007-2012 were agreed by the Board of Directors in October 2007 to support the Trust s vision Respond, Deliver, Enable. The Key Milestones below will ensure there is a shared understanding about what needs to be delivered. Strategic Directions Key Milestones Waiting NHSLA CNST Maternity Clinical Risk Management Standards: Other (please specify): Privacy and Dignity Efficiency and Effectiveness Delivery of Care Closer to Home Infection Control Note: This policy has been assessed for any equality, diversity or human rights implications Review date: March 2012 Page 1 of 5

Sections Page Introduction 3 Suitability criteria at the time of assessment 3 Operational Pathway (1) Initial assessment (2) Out patient treatment (3) On-going out patient treatment 4 Audit and governance 5 Associated Trust policies 5 Appendices Appendix 1 Teicoplanin dosing and monitoring regimen 6 Appendix 2 Patient letter 7 Appendix 3 MTU initial discharge checklist 8 Appendix 4 MTU daily checklist 9 Review date: March 2012 Page 2 of 5

The Out-of-Hospital Cellulitis Pathway Introduction Cellulitis is a common presentation both via ED and GP referral service and it is increasingly accepted as appropriate for outpatient parenteral antibiotic treatment. A number of patients currently treated as in patients in the RD&E could be currently treated as out patients. In a study in Scotland, skin and soft tissue infections accounted for 10% of hospitalizations with a mean stay of approximately five days 1. In this study, of the 125 patients with skin and soft tissue infections treated using an outpatient parenteral antibiotic service, 123 were cured or improved with 2 requiring admission for surgery. In this study, economic benefits were also realized despite use of more expensive agents. In another study, patients were excluded based on specific criteria 2. One hundred and twenty four patients were entered into this Australian study and in this case more patients required admission for in-hospital treatment (19 patients 15.3%), 105 patients were successfully treated. Only one patient developed adverse effects to the treatment (diarrhoea- proven to be self limiting). The issue of the safety of parenteral therapy in the outpatient is a recurring theme though studies, which have been validated, conclude that hospital at home care is very safe 3,4. A pathway is therefore proposed to standardize the assessment and management of patients with suspected cellulitis to prevent unnecessary admission of patients. Suitability criteria at the time of assessment: Diagnosis of cellulitis requiring intravenous antibiotics and a willingness and ability to undergo outpatient antibiotic administration are the main requisites. Those unstable medically or with severe cellulitis or significant co-morbidities will not be considered appropriate. Due to incidences locally of severe (PVL Staph) infection in military personnel extra caution should be taken in considering these personnel for outpatient IV antibiotic treatment. Patients with significant neutropenia or very high CRP are likely to benefit from an initial period of inpatient care/observation. Frail elderly patients with multiple co-morbidities and especially those with a previous history of Clostridium difficile are unlikely to be suitable. Patients with complex diabetic soft tissue infections may not be suitable and should be discussed with the endocrine team if necessary. Patients with a previous history of MRSA or C. difficile should initially be discussed with microbiology and a decision on the outpatient regime taken in discussion with them. Caution with facial cellulitis, cellulitis over joints, animal and human bite cellulitis, IVDU. 1 Nathwani D. The management of skin and soft tissue infections: outpatient therapy in the United Kingdom. Chemotherapy 2001;47(suppl 1):17 23. 2 M Donald, N Marlow, E Swinburn, M Wu. Emergency department management of home intravenous antibiotic therapy for cellulitis. Emerg Med J 2005;22:715 717. 3 Caplan G, Ward J, Brennan N, et al. Hospital in the home: a randomised control trial. Med J Aust 1999;170:156 60 4 Montalto M. How safe is Hospital-in-the-home care? Med J Aust, 199816, 168:262 3. Review date: March 2012 Page 3 of 5

Operational Pathway 1. Initial Assessment: 1.1 Patients are referred to the Acute GP or the medical team, either from A&E or from community GPs, who are diagnosed to have cellulitis. 1.2 All patients are seen in the Medical Triage Unit (10am to 10pm) and assessed by a medical doctor. A decision is then made about either inpatient or outpatient treatment. The patient s vital signs, including temperature, are recorded. Investigations can include ECG and bloods (U&E, FBC, CRP), blood cultures (if pyrexial) and wound swab if appropriate. The cellulitis site is marked and dated with black permanent marker (single patient use) to make clear area of initial demarcation. 1.3 The physician of the day (PoD) or the on-call/emu SpR will review the patient for the diagnosis to be confirmed and treatment plan implemented. 1.4 Outpatient arrangements must be discussed with the patient and the patient can decide if they are able to attend once daily for the injections to be administered. An appointment to re-attend the MTU must be made and documented. 2. Outpatient Treatment: 2.1 The clerking doctor or MTU nurse organises with the patient a time next day to reattend MTU for antibiotics, usually from 9am the next day. Details are entered in the ambulatory care patient diary in MTU for the re-attendance day. 2.2 Check allergy status: Any patient with a history of severe allergy (anaphylaxis, angioedema, urticaria) to any beta-lactam antibiotic will need second line therapy (i.e. avoid ceftriaxone). 2.3 Check MRSA status: Treat patients with a history of MRSA as positive unless cleared by infection control. 2.4 The attending doctor must prescribe the antibiotic and a saline flush on a hospital prescription chart. 1 st line 2 nd line (Severe betalactam allergy or MRSA positive) Ceftriaxone 1g IV once daily (until oral switch possible) Teicoplanin loading dose IV once daily for three days followed by maintenance dose IV once daily (if oral switch not yet possible) Administer as bolus dose Administer as bolus dose See tables in appendix for loading and maintenance dosing Switch to oral Clindamycin 450-600mg qds at earliest possibility 7 to 14 days total therapy according to clinical response Review date: March 2012 Page 4 of 5

2.5 The antibiotics can be administered through a cannula or a midline inserted under full asepsis or using a butterfly needle. Cannula should have a single lumen bionector attached and the whole assembly should be covered with a tubifast bandage or similar. Daily VIP scoring of cannulas should be undertaken and all should be changed at day three. Most patients should be able to have IV s through a cannula. 2.6 A letter giving clear instructions is given to the patient detailing the plan and the date and time for re-attending. 2.7 Transport arrangements should be made; if necessary and only where there is no alternative we may supply a taxi. 3. On-going Outpatient Treatment. 3.1 Patient returns daily to the MTU. 3.2 IV antibiotics are given by an (appropriately trained) MTU nurse. Observations are done, the nurse should ask for a medical review if concerned, or if it is likely the patient could be switched to oral antibiotics. Early switch to oral antibiotics should be considered for all patients. 3.3 At day three of treatment and at the end of treatment, there should be a formal review (albeit maybe brief if all is well) by the MTU medical doctor (MTU nurses to liaise with EMU medical staff to organize) and documented in the notes. Early switch to oral antibiotics should be considered for all patients. Most patients with uncomplicated soft tissue infections may be safely switched to oral antibiotics after 3-4 days. 3.4 Repeat blood tests may be appropriate. If there are any concerns the SpR and/or Physician of the day should be asked to review. 3.5 IV antibiotics can be changed to suitable oral alternative as soon as there is acceptable improvement in the patient s condition and inflammatory markers. Microbiology can be contacted for advice in the normal way if needed. 3.6 Once the patient is established on oral antibiotics treatment only, they can be referred to their own GP for follow up; or if necessary EMU clinic follow up can be arranged. Audit and Governance Audit of outcomes including readmissions, treatment failure and patient satisfaction will be conducted. Adverse incidents will be recorded. The patients will be the clinical responsibility of the EMU consultants. Associated Trust Policies Guidelines for Intravenous to Oral Switch of Antimicrobial Treatment Review date: March 2012 Page 5 of 5

TEICOPLANIN DOSING REGIMEN Instructions: 1. Calculate the patient s creatinine clearance (CrCl) using the Cockcroft-Gault equation below: CrCl = (140 age in years) x weight (kg) x F Serum creatinine (μmol/l) F = 1.03 for women and 1.23 for men. 2. Prescribe initial loading regimen of teicoplanin, based on the patient s ideal body weight (or total body weight if lower) using Table 1. Doses to be given 24 hourly for the first 3 days. IBW = T + (2.3 x each inch over 5ft) T = 45 for women and 50 for men. Table 1. LOADING REGIMEN (DAYS 1-3) # Creatinine clearance* Ideal body weight (kg) or total body weight if lower (CrCl) 40-59 60-79 >80 <60mL/min 600mg 800mg 1000mg >60mL/min 800mg 800mg 1000mg *Where CrCl is measured using the Cockcroft-Gault equation above (using total body weight). # Doses to be given 24 hourly for the first 3 days. 3. On day four, if IV therapy still required, switch to teicoplanin maintenance dosing using Table 2. (continue dosing 24 hourly): Table 2. MAINTENANCE REGIMEN (DAY 4 ONWARDS) # Creatinine clearance* <25 25-40 41-54 55-89 90 (CrCl) Daily dose# 100mg 200mg 300mg 400mg 500mg *Where CrCl is measured using the Cockcroft-Gault equation above (using total body weight). # Doses to be given 24 hourly from day 4 onwards. If renal function changes during treatment, doses should be modified according to renal function (and teicoplanin concentration measurements if treatment prolonged). 4. If IV teicoplanin is still indicated at day seven check levels; serum teicoplanin levels should be taken 60 minutes before a dose is given (i.e. trough levels). Do NOT withhold the administration of further doses while waiting for the results, unless toxicity is suspected when Microbiology should be contacted for advice. Notes: When a teicoplanin level assay has been performed, the result should be checked and acted on within 2 days. Levels are sent to Bristol and will be reported on the Pathology system. Send a clotted blood sample (brown top tube) for serum teicoplanin levels to microbiology. Write the time of the last teicoplanin dose and the time that the blood sample was taken on the request form. Monitor baseline and ongoing LFTs, U&Es, Cr, FBC and CRP as clinically indicated. o Neutropenia or thrombocytopenia can occur after prolonged therapy. Contact microbiology or pharmacy for advice about dose adjustments in response to levels. Usual target range for cellulitis: 10-20mg/L. Refer to Medusa for further information on administration. In keeping with good clinical pharmaceutical practice reconstituted vials of teicoplanin should be used immediately and any unused portion discarded. On the few occasions when changing circumstances make this impractical reconstituted solutions should be kept at 2-8 o C and discarded within 24 hours.

Medical Triage Unit (MTU) Royal Devon and Exeter Hospital Area C, Level 1 Barrack Road Exeter EX2 5DW 01392 404614 (10-8pm) 01392 402831 / 406123 (24hrs) Dear Mr. / Mrs. Date: Outpatient treatment for cellulitis ID Number: We have arranged for you to have your soft tissue infection (cellulitis) treated on an outpatient basis. We hope you will find this more convenient then having to stay in hospital. Please report back to Medical Triage Unit at the following times Time Date Please also: Call us at any time if you are feeling unwell or having problems with your cannula and ask to speak to the nurse in charge If you feel very unwell call an ambulance or go to the Emergency Department in the usual way. Cannula care Your cannula sits in a blood vessel for up to 72 hours, following which it will be removed and changed if necessary. There is no needle present but it is important you look after it. Keep your cannula dry and covered with the dressing provided. Ensure it does not become caught in clothing or dislodged. If your cannula does come out apply pressure with a clean dressing. A new cannula will be inserted the next day. Sometimes the cannula site becomes infected. If skin around the cannula becomes red or painful call the above number for advice. If you are concerned in anyway feel free to call the nurse in charge on the above numbers. Yours sincerely Hugh Bakere Consultant EMU

The Out-of-Hospital Cellulitis Pathway Check list for MTU prior to Initial Discharge (Please circle as appropriate) Attendance with diagnosis of Cellulitis Yes No Suitable for outpatient cellulitis service (See criteria in policy) Yes No Mark cellulitic area with indelible pen. Yes No Complete discharge checklist below: (Please circle as appropriate) Patient given information letter Yes No Ensure cellulitic area clearly marked Yes No Give second dose of antibiotics if appropriate Yes No Single lumen bionector attached to cannula Yes No Cannula secure and flushed with saline Yes No Insertion date is present and VIP score completed Yes No Identifying first return point and time Yes No (09.00 next day as default) hh/mm Discharge letter Yes No Book patient into MTU ambulatory care book Yes No Book patient into MTU ambulatory care book Yes No 1. Medical and nursing notes Yes No 2. Observation chart Yes No 3. Drug chart Yes No Signature: Print Name:. Date: dd/mm/yyyy The Out-of-Hospital Cellulitis Pathway Approved by: Records Management Committee Jan 2011 Review date: December 2013 Health Records: Charts & Special Sheets Page 1 of 1

Cellulitis Daily Checklist Start date: DD/MM/YYYY Any Grey boxes ticked require ACTION : Inform medical doctor DAY 1 DAY 2 DAY 3 Assess Patient YES NO YES NO YES NO Systemic symptoms Better Effect of antibiotics GI Upset Rash Cellulitic area-ensure mark visible Better Unchanged on two visits-dr r/v Cannula - Date inserted (Use attached care plan) HH/MM HH/MM HH/MM Check Observations Normal (EWS 0)? If abnormal must be discussed with doctor Bloods repeat at 72 hours Normal? If abnormal must be discussed with doctor Antibiotics administration Check identity of patient Check for allergy Check microbiology results 3.7 Duration of treatment Has the cellulitis improved? Apyrexial for 48hours? Blood tests normal or better? DAY 1 DAY 2 DAY 3 Nurse Signature: Signature Signature Signature Print Name: Print Name Print Name Print Name Date: DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY ON FINAL DISCHARGE (signature) Cannula removed Follow up with GP/EMU clinic booked TTO s provided Discharged on: DD/MM/YYYY The Out-of-Hospital Cellulitis Pathway Health Records: Approved by Records Management Committee Jan 2011 Page 1 of 1 Charts & Special Sheets Review date: December 2013