CELLULITIS – CLINICAL GUIDELINES INITIAL ED INTERVENTIONS Vital signs Antipyretic medication if temp ≥ 100.4ºF (38 ºC) Outline perimeter of erythema with indelible ink marker Verify allergies and current medications including any recent antibiotics Estimate and document percentage of total body surface area (TBSA) POTENTIAL ED INTERVENTIONS Assess clinical findings such as the following: Lymphadenopathy or evidence of lymphangitis Vesicles or bullae Exposed bone Skin breaks or evidence of trauma Crepitance with concern for possible Acute Gangrene Differential diagnosis Infectious etiologies: Necrotizing fasciitis (obtain urgent ESS consult) Gas Gangrene (obtain urgent ESS consult) Toxic Shock Syndrome, Bursitis Acute Osteomyelitis Herpes Zoster Erythema Migrans Noninfectious etiologies: Contact Dermatitis Deep Venous Thrombosis Acute Gout Drug Reactions Insect Stings Malignancy If evidence of fluctuance or abscess  consider I&D with wound culture Labs/Studies to consider CBC, BMP, Lactate if concern for systemic disease or if diabetic/immunocompromised Blood cultures (not generally recommended in immunocompetent adults with uncomplicated cellulitis) Imaging: EMBU US or x-rays if suspicious of abscess or subcutaneous gas Medications: Analgesics (IV route recommended if considering inpatient admission) Antibiotics – Not indicated for abscesses, furuncles, carbuncles unless: severe/extensive disease rapid progression in presence of associated cellulitis signs/symptoms of systemic illness associated co-morbidities or immunosuppression extremes of age area difficult to drain completely associated septic phlebitis lack of response to I&D alone RECOMMENDED ANTIBIOTICS Empiric antibiotic coverage for skin and soft tissue infections should include MRSA except for the treatment of erysipelas or limited nonpurulent cellulitis. These treatment guidelines may not be appropriate for more complicated skin and soft tissue infections such as post-surgical infections, diabetic foot infections, infections following human or animal bite, or necrotizing fasciitis. For information on treatment of these infections: http://www.uphs.upenn.edu/antibiotics/treatment_guidelines/index.html ***Duration of treatment 10 days unless otherwise noted*** Oral Antibiotic Choices: Recommended antibiotics for erysipelas or limited non-purulent cellulitis: 1. Cephalexin - $75.83 (40 tablets) ($4 formulary) Cephalexin 500mg PO q6h Cephalexin 500mg PO q12h for CrCl 10-40 ml/min Cephalexin 500mg PO q24h for CrCl<10 ml/min 2. Cefadroxil - $98.34 (20 tablets) Cefadroxil 500mg PO q12h Cefadroxil 500mg PO q24h for CrCl < 25 ml/min 3. Dicloxacillin - $69.30 (40 tablets) ($4 formulary) Dicloxacillin 500mg PO q6h 4. Clindamycin - $140.56 (30 300-mg tablets) Clindamycin 300mg PO q8 Clindamycin 450mg PO q8 for weight > 150kg Clindamycin 600mg IV q8 Clindamycin 900mg IV q8 for weight >150kg 5. Amoxicillin (Streptococcal coverage) - $26.07 (30 tablets) ($4 formulary) Amoxicillin 500mg PO q8h Amoxicillin 500mg PO q12h for CrCl 10-30 ml/min Amoxicillin 500mg PO q24h for CrCl <10 ml/min 6. Benzathine penicillin G 1.2 million units IM x 1 (streptococcal coverage only) All penicillins and beta=lactams are Pregnancy category B Cephalexin, cefadroxil, dicloxacillin, and clindamycin have both streptococcal and staphylococcal coverage Recommended antibiotics for purulent cellulitis (concern for MRSA) 1. Doxycycline - $151.73 (20 tablets) ($4 formulary) Doxycycline 100mg PO q12h 2. Trimethoprim-sulfamethoxazole (Bactrim) +/- Cephalexin TMP-SMX alone appropriate for pustular cellulitis but alone does not have good Streptococcus coverage (add Cephalexin for strep coverage) TMP-SMX DS (Bactrim) - $59.53 (40 tablets) ($4 formulary) TMP-SMX DS 2 tabs PO q12h (60-85 kg) TMP-SMX DS 2 tabs PO q8h (86-120 kg) TMP-SMX IV – check w/ pharmacy regarding current supply Adjust dose for renal dysfunction Avoid with concomitant warfarin use Pregnancy category C, avoid in final weeks of 3rd trimester Cephalexin (Keflex) - $75.83 (40 tablets) ($4 formulary) Cephalexin 500mg PO q6h Cephalexin 500 mg PO q12h for CrCl 10-40 ml/min Cephalexin 500 mg PO q24h for CrCl<10 ml/min Pregnancy category B 3. Clindamycin - $140.56 (30 300-mg tablets) Clindamycin 300mg PO q8 Clindamycin 450mg PO q8 for weight >150kg Clindamycin is cleared hepatically; no dose adjustments needed in renal impairment Pregnancy category B Clindamycin may not be as effective against community MRSA, due to resistance. 4. Linezolid (provides MRSA and Strep coverage) - $3,104.77 (20 tablets) Linezolid 600 mg PO q12h Avoid with serotonergic agents (SSRI, SNRI, TCA, etc) Has mild MAOI properties (use with caution in uncontrolled HTN, pheochromocytoma, carcinoid syndrome, untreated hyperthyroidism) Pregnancy category C Intravenous Antibiotic Choices 1. Vancomcyin Vancomycin IV (weight based and renal clearance) See HUP vancomycin dosing guidelines http://www.uphs.upenn.edu/antibiotics/antimic_dosage 2. Clindamycin Clindamycin 600mg IV q8 Clindamycin 900mg IV q8 for weight >150kg Clindamycin is cleared hepatically; no dose adjustments needed in renal impairment Pregnancy category B Clindamycin may not be as effective against community MRSA, due to resistance. 3. Cefazolin (only for non-purulent cellulitis or erysipelas) Cefazolin 1 gram IV q8 Cefazolin 1 gram IV q12 for CrCl 10-35 mL/min Cefazolin 1 gram IV q24 for CrCl < 10 mL/min 4. Linezolid (provides both MRSA and beta-hemolytic coverage) Linezolid 600 mg IV q12h Avoid with serotonergic agents (SSRI, SNRI, TCA, etc) Has mild MAOI properties (use with caution in uncontrolled HTN, pheochromocytoma, carcinoid syndrome, untreated hyperthyroidism) Pregnancy category C Documentation of TBSA of cellulitis CRC EVALUATION (prior to any bed request) ADMISSION CRITERIA Cellulitis ONE of the following findings: Located over a prosthesis or implanted device, ANC < 500, animal or human bite of the face or hand orbital or peri-orbital cellulitis, progression despite 2 days or more of outpatient anti-infective (including PO) purpura or petechiae. OR skin involvement involving 50% of limb or torso, OR > 10 % BSA. AND IV abx If not tolerating a diet, must have IVF ordered. . Abscess One of the following ANC < 500 Cultures pending < 2 days T > 99.4 PO AND BOTH IV anti-infective I & D required . Surgical / Wound Infection One of the following dehiscence requiring re exploration or debridement located over a prosthesis or implanted device T >99.4 PO AND All of the following : IV Anti-infective, wound assessment and care, diet or IVF OBSERVATION PLACEMENT CRITERIA CELLULITIS One of the following: Persistent nausea or vomiting or DM with a BS >350 AND ALL of the following: IV anti-infective, tolerating diet or IVF and cellulitis care and assessment OBSERVATION UNIT - POTENTIAL INTERVENTIONS Observation H&P, Med Rec, Orders, CRC notification, D/C Summary (start) Vital signs q4h Wound size, location and characteristics clearly documented in chart Wound demarcated with indelible ink Elevation/immobilization Imaging, if indicated Repeat labs as needed Analgesics/Antipyretics medication orders: o Acetaminophen 650mg PO/PR o Ibuprofen 600mg PO q6h prn o Ketorolac 30mg IV/IM Antibiotics continued as per ED initiation (see above) DISPOSITION FROM OBSERVATION UNIT Admission - CRC Evaluation See above admission criteria Home Improvement or no progression of cellulitis >12-18hrs since ED arrival Improved and good clinical condition (ie. No fever, good VS) for 8 hrs Able to perform cellulitis care at home and take oral medications CRC/SW/RN – Bedside teaching Ensure patient able to fill Rx Ensure adequate follow-up with PMD and/or dermatologist when indicated/ Refer to District Health centers if uninsured Ensure patient able to clearly complete wound care at home as needed Treatment of Cellulitis ± Abscess (CID 2011;52:1-38) Average wholesale price (1 day therapy) $4 List* (Target, Walmart) Free List* (ShopRite, Wegmans) TMP-SMX DS 2 tabs q12hrs (60-85 kg) or 2 tabs q8hrs (86-120 kg)** 10 mg/kg/day of TMP, use adjusted body weight for patients > 120 kg Adjust dose for renal dysfunction Avoid with concomitant warfarin use Pregnancy category C/D $2.80 Yes Yes Clindamycin 300 mg q8hrs (consider 450 mg q8hrs for morbidly obese)** C. difficile-associated disease may occur more frequently, compared with other oral agents $8.00 No No Doxycycline 100 mg q12hrs** Minocycline 100 mg q12hrs** Minocycline more GI intolerance issues than doxycycline Doxycycline and minocycline are pregnancy category D $0.87 $1.53 Yes No Yes No $198.92 No No Amoxicillin 500 mg q8hrs 500 mg q12hrs for CrCl 10-30 ml/min; 500 mg q24hrs for CrCl < 10 ml/min $1.50 Yes Yes Cefadroxil 500 mg q12hrs 500 mg q24hrs for CrCl < 25 ml/min $2.40 No No Cephalexin 500 mg q6hrs 500 mg q24hrs for CrCl < 10 ml/min $2.27 Yes Yes Dicloxacillin 500 mg q6hrs $3.33 No No Clinical Scenario Treatment of choice No antibacterial coverage recommended: Incision & Drainage (I&D) is the treatment of choice. Consider adding CA-MRSA coverage per criteria listed below. Conditions in which antimicrobial therapy is recommended after I&D of an abscess due to CA-MRSA: Severe or extensive disease (eg, involving multiples sites of infection) or rapid progression in presence of associated cellutlitis Signs and symptoms of systemic illness Associated comorbidites or immunosuppression (DM, HIV, AIDS, neoplasm) Extremes of age Abscess in area difficult to drain completely (eg, face, hand, and genitalia) Associated septic phlebitis Lack of response to I&D alone Abscess, furuncles, carbuncles CA-MRSA coverage recommended: Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of an drainable abscess) S. aureus susceptibility rate (outpatient, non-urinary isolates) HUP as of 12/2012 Agent Percent susceptible Cefazolin Clindamycin Linezolid Nafcillin TMP-SMX 59 69 100 59 97 β-hemolytic streptococcal coverage recommended: Non-purulent cellulitis (defined as cellulitis with no purulent drainage or exudates and no associated abscess) Linezolid 600 mg q12hrs Provides both CA-MRSA and beta-hemolytic coverage Has mild MAOI properties, monitor for enhanced pressor effect – use with caution in uncontrolled HTN, pheochromocytoma, carcinoid syndrome, untreated hyperthyroidism Avoid use with serotonergic agents such as TCAs, SSRI, SNRI, etc due to serotonin syndrome, meds to avoid http://www.fda.gov/Drugs/DrugSafety/ucm276251.htm Associated with myelosuppression, monitor CBC weekly Pregnancy category C *CVS, RiteAid, Pathmark, Acme, Giant, Kmart, Costco, Walgreens – annual/enrollment fee required, ask about restrictions, prices may vary by location, review the discount lists frequently. **TMP-SMX,doxycyline, minocycline have poor β-hemolytic streptococcal coverage.