Nurse Practitioner CLINICAL PROTOCOL Cellulitis INTRODUCTION: Cellulitis presents as a spreading, diffuse area of skin erythema. There may/may not be lymphadenopathy, lymphangitis, fever and systemic toxicity. Erysipelas characteristically presents as lesions raised above the surround skin with clear lines of demarcation. Cellulitis extends more deeply than erysipelas and will often involve subcutaneous tissue. Predisposing factors for cellulitis include tinea of the feet, fissured dermatitis, lymphoedema, lymphatic malformation, previous deep vein thrombosis, vascular surgery and radiotherapy. Cellulitis may also complicate wounds (e.g. cuts, abrasions), insect bites or scabies. EPIDEMIOLOGY: Erysipelas is almost always caused by Streptococcus pyogenes. Spontaneous and rapidly spreading cellulitis is often caused by Streptococcus pyogenes, or other streptococci (grp B, C, G). Cellulitis associated with ulceration of penetrating trauma is often caused by Staphylococcus aureus. DIFFERENTIAL DIAGNOSIS • Acute contact dermatitis, septic bursitis, gout, and acute lipodermatosclerosis, which commonly occurs in obese women with venous insufficiency. Bilateral cellulitis is very uncommon. CLINICAL PRACTICE GUIDELINE Scope Isolated inflamed area of skin suggestive of cellulitis in adult patients, i.e., acute erythema, oedema, warmth, tenderness and/or fever. Medical • Underlying medical pathology / Practitioner complex patient +/• Neurovascular compromise Nurse • Multiple injuries Practitioner • Altered conscious state including effects of drugs/ETOH • Hx consistent with collapse. Initial Assessment and Interventions Presenting Isolated area of skin: acute erythema, Symptoms oedema, warmth, tenderness and/or fever. Nurse Practitioner • • Outcomes Identify patients suitable for NP clinical protocol. • Identify patients not suitable for NP CP and redirect to usual GP care +/- ED Outcomes Nurse Practitioner CLINICAL PROTOCOL Cellulitis Patient history Physical examination MIST: Mechanism, injuries sustained, signs vital, treatment given as first aid. • Time of injury, onset of infection, risk factors • Beware: Cellulitis following animal bites and clenched fist injuries. - Diabetic foot infection complicated by cellulitis - Cellulitis after significant fresh or salt water exposure. - Cellulitis in immunosuppressed patients. • Consider differential diagnosis: - Deep venous thrombosis (DVT) - Dermatosis: venous eczema, fixed drug eruption. - Gout - Ruptured Baker's cyst - Bony fracture or osteomyelitis • Allergies / Immunisation status (e.g., tetanus) • Prophylaxis (e.g., post-exposure rabies/bat lyssa virus vaccination and/or immunoglobulin) • Relevant past medical history / medication use • Last food/fluids Assess site and extent of infection. Beware: • Facial, peri orbital and upper limb cellulitis. • Soiled wounds with severe tissue damage and/or devitalised tissues. • Cellulitis on the hands, feet, and with underlying structures involved - bone, joint, or tendons. • Circumferential limb involvement. • Presence of blisters, bullae or open wounds. • Bilateral cellulitis – usually NOT cellulitis. • Be alert for necrotising fasciitis or myonecrosis: severe constant pain, rapid spread of infection and/or bullae, skin necrosis, wood-hard feeling of soft tissue, oedema beyond erythema margin, cutaneous Identify patients not suitable for NP CP → exit CPG Determine spread/distribution of problem. Identify patients not suitable for NP CP – exit CP and refer to GP. Nurse Practitioner CLINICAL PROTOCOL Cellulitis Neurovascular assessment Pain assessment • • • • • • anaesthesia, gas in soft tissue (crepitus on palpation), systemic toxicity – high fever and/or delirium, end organ dysfunction or failure. colour warmth movement sensation capillary refill peripheral pulses Asses level of pain using appropriate pain scale. Investigations U & E’s, CRP and FBE Blood cultures if T >38.5 C Swab MC&S if obvious infection (purulent exudate present). Imaging Not required if: • No Hx of injury • No bony tenderness • No suspicion of bone, joint/tendon involvement. Consider imaging if: • ? foreign body in situ • Subcutaneous collection Patient Education / Follow-up Follow up Verbal instruction to patient: appointment • Review appointment may be indicated by pathology results; NP to contact patient to schedule follow-up appointment. • Response to Rx should be reassessed in 48 hours. Pathology Patient Education Medication instructions • • • Verbal instruction and patient information handout re • When to seek further advice (wound swelling or inflammation, continued pain, drainage of pus, increasing fever). • Verbal/written instructions from NP/GP Identify patients not suitable for NP CP – exit CP and refer to GP. Determine need for and type of analgesia required. Outcomes Detect underlying pathology and identify degree of systemic infection present. Detect foreign body and determine bone, joint and/or tendon involvement. Outcomes Ensure patient understands problem, treatment and follow up. Referral to GP will be determined on result of laboratory tests. Refer to current GP if no response to Rx within 48 hrs. Patient understanding of the problem, treatment and measures which may reduce the risk of cellulitis Ensure patient understands problem, treatment and follow up Nurse Practitioner CLINICAL PROTOCOL Cellulitis Referrals Certificates Letter Referrals may be required for specific patient problems or as required to: • Physiotherapy • Drug and alcohol counsellor • Other problems outside of NP scope of practice • Absence from work certificates • Certificate of attendance • Copy of notes to GP / Specialist or acute care facility Interpretation of results and management decisions Patients with problems outside the NPs scope of practice are referred to appropriate health care providers Ensure appropriate documentation completed Ensure continuity of care and referral to health care team GP Æ hospital admission Outcome All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation Foreign body or underlying # diagnosed Mild to moderate localised infection Moderate to severe localised infection Severe and/or systemically unwell NP review, medication as per formulary, refer to current GP • • • • • • • • • • • • • Pt. education and health promotion Medication as per formulary Elevate and immobilise affected area Appropriate dressing as required Pt. education and health promotion Medication as per formulary Elevate and immobilise affected area Appropriate dressing as required. IF IVAB’s required-refer to current GP Medication as per formulary Elevate and immobilise affected area Appropriate dressing Refer to current GP for possible hospital admission Goals of Treatment • Relief of symptoms • Eradication of infection • Prevention of recurrence • Prevention of complications Not suitable for NP CP – refer to GP for treatment Ensure pt. understands diagnosis and treatment plan. Ensure pt. understands diagnosis and treatment plan. Identify pt. not suitable for NP CP and refer to GP Not suitable for NP CP – refer to GP for treatment Nurse Practitioner CLINICAL PROTOCOL Cellulitis Drug Formulary ANTIBIOTICS 1. Oral (localised infection) 1. Di/flucloxacillin 500mg PO 6 hourly for 7-10 days. If S. Pyogenes confirmed or suspected: 2. Phenoxymethylpenicillin 500mg PO 6 hourly for 10 days. OR 3. Procaine penicillin 1.5G IM daily for at least 3 days. If penicillin sensitive pt.: 4. Cephalexin 500mg PO 6 hourly for 710 days. OR 5. Clindamycin 450mg PO 8 hourly for 710 days. 2. IV (systemic infection or no response to oral AB’s after 48 hours) GP only 1. DI/Flucloxacillin 2G IV 6 hourly. If penicillin sensitive pt.: 2. Cephazolin 2G IV 8 hourly. Nurse Practitioner CLINICAL PROTOCOL Cellulitis FORMULARY FLUCLOXACILLIN PHENOXYMETHYLPENICILLIN Drug/generic name: Flucloxacillin Drug/generic name: Phenoxymethylpenicillin Poisons schedule: Schedule 4 Poisons schedule: Schedule 4 Dosage range: 250-500mg. Max 4G/day Dosage range: 250-500mg. Max 3G/day Route: Oral Route: Oral Frequency of administration: 6 hourly Frequency of administration: 6-8 hourly Duration of order: 7-10 days Duration of order: 10 days Actions: interfere with bacterial cell wall peptidoglycan Actions: interfere with bacterial cell wall peptidoglycan synthesis by binding to penicillin-binding proteins, eventually synthesis by binding to penicillin-binding proteins, eventually leading to cell lysis and death. leading to cell lysis and death. Indications for use: Staphylococcal skin infections, pneumonia, Indications for use: skin infections / tonsillitis / pharyngitits osteomyelitis, septicaemia. caused by S pyogenes. Contraindications: not for use in the eye or pts. on a sodium Contraindications: history of severe or immediate allergic restriction for heart failure. Care in pts. with renal impairment. reaction (including urticaria, anaphylaxis, interstitial nephritis) Contraindicated with history of cholestatic hepatitis associated to penicillin. .Be careful if there is carbapenem or with dicloxacillin or flucloxacillin. cephalosporin allergy as cross-reactivity between penicillin’s, Flucloxacillin can cause cholestatic hepatitis; risk of hepatitis cephalosporins and carbapenems can occur. increases in people >55 years, females and with courses >2 Adverse reactions: diarrhoea, nausea, pain and inflammation weeks; pre-existing hepatic impairment is not a risk factor. at injection site (less common with benzyl penicillin), super Adverse reactions: transient increases in liver enzymes and infection (including candidiasis) especially during prolonged bilirubin (common). Rarely - cholestatic hepatitis. Common treatment with broad-spectrum penicillin’s, allergy. Include rash reactions include - diarrhoea, nausea, pain and inflammation at (most frequent symptom, usually maculopapular), erythema, injection site (less common with benzyl penicillin), super urticaria, contact dermatitis, fever, anaphylactic shock, infection (including candidiasis) especially during prolonged angioedema, bronchospasm, interstitial nephritis, haemolytic treatment with broad-spectrum penicillin’s, allergy. anaemia, eosinophilia, serum sickness-like syndrome, Immunologic reactions include - rash (most frequent symptom, exfoliative dermatitis, Stevens-Johnson syndrome and toxic usually maculopapular), erythema, urticaria, contact dermatitis, epidermal necrolysis. fever, anaphylactic shock, angioedema, bronchospasm, interstitial nephritis, haemolytic anaemia, eosinophilia, serum Nurse Practitioner CLINICAL PROTOCOL Cellulitis sickness-like syndrome, exfoliative dermatitis, StevensJohnson syndrome and toxic epidermal necrolysis. PROCAINE PENICILLIN CEPHALEXIN Drug (generic name): Procaine penicillin Drug(generic name): Cephalexin Poisons schedule: Schedule 4 Poisons schedule: Schedule 4 Dosage range: 1-1.5g Dosage range: 250-500mg / 500mg-1G Route: IM Route: Oral Frequency of administration: Daily Frequency of administration: 6 hourly / 12 hourly Duration of order: 3 days Duration of order: 7 – 10 days Actions: interfere with bacterial cell wall peptidoglycan Actions: Bactericidal. Interferes with bacterial cell wall synthesis by binding to penicillin-binding proteins, eventually peptidoglycan synthesis by binding to penicillin binding leading to cell lysis and death. proteins, leading to cell lysis and death. Indications for use: Respiratory tract infections (e.g. Indications for use: Staph and strep infections in people with pneumococcal) in remote areas where compliance with oral allergy to penicillin’s. treatment is unlikely, Syphilis, Cellulitis, erysipelas. Adverse reactions: diarrhea, nausea, vomiting, rash, rarely – Adverse reactions: diarrhoea, nausea, pain and inflammation neurotoxicity, blood dyscrasias. at injection site (less common with benzyl penicillin), super CARE: If pt. has a penicillin or carbapenem allergy – cross infection (including candidiasis) especially during prolonged reactivity may occur. treatment with broad-spectrum penicillin’s, allergy. CLINDAMYCIN PARACETAMOL Drug (generic name): Clindamycin Drug (generic name): paracetamol Poisons schedule: Schedule 4 Poisons schedule: unscheduled Dosage range: 150 – 450mg Therapeutic class: 4(b) simple analgesics and antipyretics, Route: oral non-opioid analgesic. Frequency of administration: 8 hourly Dosage range: 500mg-1g Duration of order: 7-10 days Route: oral/rectal Actions: Bactericidal. Inhibits bacterial cell wall synthesis by Frequency of administration: 4- 6 hourly preventing the formation of peptidoglycan polymers. Duration of order: as required max 4g daily Indications for use: used for skin and soft tissue infection, Actions: inhibition of prostaglandin synthesis Nurse Practitioner CLINICAL PROTOCOL Cellulitis pneumonia, dental infection in pts. with severe penicillin and Indications for use: mild-moderate pain, migraine, headache, cephalosporin allergy. fever, muscular pain Adverse reactions: rarely: taste disturbance, Contraindications for use: nil –caution for resident with liver disease. Adverse drug reactions: (rare) rash, drug fever, mucosal lesions, neutro/pancyto/thrombocytopenia Unexpected representation NP Clinical Practice Evaluative strategies Review Patient Notes. Full audit of clinical events. NP Clinical Practice/Medical Report Audit Key Terms CP – Clinical Protocol NP – Nurse Practitioner GP – General Practitioner S4 – Schedule of the drug administration act References 1. Swartz M. Cellulitis. The New England Journal of Medicine. 2004; 350:904-12. 2. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections. [Infectious Diseases Society of America] 2005; Available from: http://www.idsociety.org 3. Cannula: Insertion of peripheral intravenous cannula (PIVC), Nursing Practice Standard, Nursing Practice Committee, 29th June 2006, Servio Online, SMAHS Online (Intranet). 4. The Royal College of Pathologists Australasia, RCPA Manual [The Royal College of Pathologists of Australasia] 2004; Available from: http://www.rcpamanual.edu.au/sections/clinicalproblem.asp?s=25&i=109 5. Treatment of infections in "Hospital in the Home" programs, Hospital in the Home IV antibiotic service: RPH Microbiology and Infectious Diseases, Departments & Services, Servio Online, SMAHS Online (Intranet). 6. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov. Accessed 2011 Nov 25 at http://etg.tg.com.au/ref/ref 7. Australian Medicines handbook (internet). 2011, Nov. Accessed 2011 Nov 25 at http://www.amh.net.au 8. Inflammation Suggestive of Cellulitis. Royal Perth Hospital emergency services NP clinical practice protocol. May 2008 Nurse Practitioner CLINICAL PROTOCOL Cellulitis Authorship, Endorsement and acknowledgement This CP was originally written by: Reviewed and authorised by: Carol Jones Nurse Practitioner Dr. Frank Reedman Jones Murray Medical Centre Mandurah MBBCh, DCH, DRCOG, FRACGP, FACRRM Murray Medical Centre: Primary Care Physician We acknowledge the authorship and input of : Dr. Eileen Bristol MBChB,MRCGP,DRCOG,FRACGP Murray Medical Centre: Primary Care Physician Carol Jones RN, RM, PGradDipNursePractitioner, NP Nurse Practitioner Date Written: November 2011 Review Date: November 2013