Document Ref October 2011 Page 1 of 11 Nurse Practitioner Clinical Protocol: Management of Cellulitis Cellulitis: An acute spreading bacterial infection below the surface of the skin characterized by redness (erythema), warmth, swelling, and pain. Cellulitis can also cause fever, chills, and "swollen glands" (enlarged lymph nodes). Cellulitis is a clinical diagnosis based on the spreading involvement of skin and subcutaneous tissues with erythema, swelling, and local tenderness, accompanied by fever and malaise. Cellulitis commonly appears in areas where there is a break in the skin from an abrasion, a cut, or a skin ulcer. It can also be due to local trauma, such as an animal bite. Only rarely is Cellulitis due to the bacteremic spread of infection -- bacteria arriving from a distant source via the bloodstream. Extreme complications of untreated Cellulitis can result in : • • • • • • • Blood infection (septicaemia) Bone infection (osteomyelitis) Inflammation of the lymph vessels (lymphangitis) Inflammation of the heart (endocarditis) Meningitis Shock Tissue death (gangrene) SCOPE OF PRACTICE PRACTITIONER Nurse Practitioner – Aged Care Medical Practitioner + Nurse Practitioner SCOPE The NP will treat all residents in Bethanie Care Services who present with symptoms presenting in this clinical guideline. The scope of practice of the NP will be directed by: The Nurses Act 2002 (WA) The Nurses Rules 1993 (WA) The Nurses Code of Practice 1995 (WA) The Poisons Act 1964 (WA) The NP will refer all Bethanie Group residents outside their scope of practice to a medical practitioner. OUTCOME The expected outcome of use of this clinical guideline is effective and rapid treatment, prevention of exacerbation and reoccurrence of infection. The prevention of hospital admission Upon failure of treatment, complications of infection or recurrence of infection, referral to a specialist wound care service is required. 1 Referral to occupational therapist and/or physiotherapist should be considered if lack of mobility or function are contributing factors. Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 2 of 11 RESIDENT’S ASSESSMENT RESIDENT’S HISTORY Presenting symptoms INFORMATION Signs and symptoms of Cellulitis in the elderly: Cellulitis most commonly affects the lower extremities, although symptoms can develop in any area of the body. The condition affects the skin in several ways, causing it to become: red, painful, hot, swollen, tender and or blistered Cellulitis often causes the person to feel generally unwell, causing symptoms that develop before, or in combination with, changes to your skin. These symptoms include: nausea, shivering ,fatigue, chills, general sense of feeling unwell and disorientation/confusion Systemic Presentation often includes Raised temperature, occasionally rigors and or raised white cell count Certain host factors predispose to severe infection. Individuals with comorbid conditions such as diabetes mellitus (frequently polymicrobial), immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral arterial disease, chronic kidney disease, and other systemic disease appear to be at a higher risk for both recurrent and more severe infection, owing to an altered host immune response. OUTCOMES • Collation of accurate clinical assessment data to facilitate prompt treatment and prevent re-occurrence • Appropriate systemic and topic therapies are prescribed and initiated taking into account the individual medical history and presentation. • Prevention of exacerbation and or recurrence of Cellulitis Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 3 of 11 RESIDENT’S ASSESSMENT RESIDENTS HISTORY Known risk factors for the presenting symptoms Previous medical history Medications Other relevant information PHYSICAL Ax INFORMATION Risk factors fall into several categories: disruption of the cutaneous barrier (e.g. trauma, leg ulcer etc) venous or lymphatic compromise (e.g. venous insufficiency, obesity, previous vascular surgery, pelvic radiation or malignancy, previous tibial fracture. Previous history of Cellulitis. Staphylococcus aureus and beta-hemolytic streptococci in the toe webs are significantly associated with acute Cellulitis of the lower limb. Previous vascular surgery/procedures to lower extremetities, previous Cellulitis Current Medications Allergies, previous Cellulitis history, nutrition & hydration, skin integrity, mobility, cognition and behaviour. OUTCOMES Prompt diagnosis and treatment will be initiated Appropriate dressings and drug therapy will be initiated INFORMATION Usual physical examination Record findings: temperature, pulse, blood pressure , respiratory rate skin integrity assessment, wound assessment, pain assessment. Indications for specific examinations Assess systems that may reveal fever with/without tachycardia, lymphadenopathy, vascular streaking, mental status changes, hypotension, decreased pulses & signs of deep vein thrombosis. Specific focus on lifestyle risks, previous surgery, comorbid conditions: diabetes, Peripheral vascular disease, peripheral arterial disease, heart failure, use of immunosuppressive agents and potential sources of skin disruption: ulcerations, fungal infection in the toe webs, punctures and animal bites. OUTCOMES Correct diagnosis, provision of effective disease and symptomatic eradication/relief. Documentation of infection incident via The Bethanie Group’s clinical incident system Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 4 of 11 INVESTIGATIONS INDICATIONS Routine investigations INVESTIGATIONS Laboratory/diagnostics used for diagnosis and identification of organism: skin swab only if ulceration or exudate present. Pathology To determine underlying organism, severity and sensitivity of organism. Wound/skin MCS Imaging Nil Haematology/Biochemistry If suspected pyelonephritis only FBC, U&E Other Investigations Nil OUTCOMES Results from all investigations will be used when determining future management of the residents. Accurate diagnosis will be made. Correct pharmacotherapy will be prescribed based on sensitivity of organism. Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 5 of 11 FOLLOW UP AND EDUCATION INTERVENTION INFORMATION Pharmacotherapeutics (See pharmacotherapy section) The treatment chosen will be dependant on the organism believed to have caused the infection, with consideration of the resident’s allergy history, general medical condition, and renal and hepatic status, as well as the degree and quality of infection. All may effect outcomes of the resident’s hospitalization versus resident’s treatment. In the feet, topical antifungals should be used in those with fissures, until healed. Analgesics should be used as appropriate. Consider increasing diuretic therapy if peripheral oedema is marked Non-pharmacological (including topical dressing therapy) Immobilization of the area with elevation (if in a limb) is important to decrease pain and diminish oedema. Commence initial anti-bacterial dressing such as cadexomer iodide dressing(iodosorb).If no response within 24-48hrs(i.e cellulitic area increasing:commence silver dressing such as Mepilix Ag/Atruaman Ag Blood glucose levels in known diabetics should be regularly monitored and managed. Consultation with a physician is recommended if necrotizing fasciitis or an abscess is suspected, if cellulitis occurs in the orbit of the eye, if there is a high fever or extreme pain, if the condition does not respond to treatment, or if surgical debridement is required. Hospitalization may be required if any of these instances. Ensure area of demarcation is marked on skin with skin marker to observe for exacerbation/improvement Follow up appointments Resident needs to be reviewed daily post commencing antibiotic therapy to reassess symptoms and monitor for any complications or adverse reactions to therapy. Follow up consultation is required to validate eradication of infection and determine whether further antimicrobial treatment is required. An evidence based care plan should be developed. NPs are required to follow up on all referrals to allied health/specialists and reinforce education and management strategies. OUTCOMES Eradication of infection Prevention of exacerbation Prevention of recurrence of infection Management of oedema Symptomatic relief Underlying disease will be detected at follow up. Upon failure of treatment, complications of infection or recurrence of infection, referral to a medical practitioner is required. Referral to occupational therapist and/or physiotherapist should be considered if lack of mobility is a contributing factor. Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 6 of 11 FOLLOW UP AND EDUCATION INTERVENTION INFORMATION Resident’s/staff education Resident and their caregivers need to understand the importance of completion of diagnostic and treatment plans. Completion of antibiotic regimens is important to eradicate the infecting organisms and to decrease the possibility of treatment failures, including organisms’ tolerance to antibiotics. Education regarding: possible medication side effects and anaphylaxis; signs & symptoms of super-infection of the site, DVT, systemic infection; and the importance of follow-up care is needed. Control of oedema, elevation of the affected limb, and minimization of trauma to the area should be taught. The resident or caregiver should be able to demonstrate specific wound care. Signs and symptoms that require immediate follow-up should be emphasized. OUTCOMES Optimise independence, awareness and education Optimise compliance with treatment Optimise eradication of infection and prevent recurrence of infection. Prevention of breaks to skin Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 7 of 11 PHARMACOTHERAPY The management of cellulitis can be divided into two distinct phases: Treatment directed at the acute celluitis, including the decision about hospitalization, and preventive therapy to diminish the likelihood of subsequent bouts of cellulitis, particularly in residents who have had previous episodes in the same anatomic location. Decision to hospitalize – Most residents with cellulitis present with recognizable skin findings (erythema, skin indurations, edema, lymphangitis) and low –grade fever. For the occasional resident with high fevers, rigors and other signs of systemic toxicity including mental status changes or even shock, the decision to admit the resident to the hospital is recommended 1st line treatment for cellulitis flucloxacillin/cephalexin Diabetics Cellulitis in the diabetic resident with a non-healing plantar foot ulcer usually requires broader spectrum coverage to include treatment of S. aureus, beta-hemolytic streptococci, aerobic gram-negative bacilli, and anaerobes pending results of cultures and susceptibility testing: antibiotic therapy is a treatment option in these residents but should be used first for Cellulitis in the absence of an ulcer. Diagnostic testing for accompanying osteomyelitis or abscess formation should be included in the evaluation of diabetic residents with Cellulitis of the foot. Treatment Augmentin duo 1 tb bd Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 8 of 11 PHARMACOTHERAPY (Cont..) FORMULARY Cephalexin Amoxycillin with clavulanic acid (diabetic) Drug (generic name): cephalixin 1st line Drug (generic name): amoxicillin with clavulanic acid Poisons Schedule: Schedule 4 Poisons Schedule: Schedule 4 Therapeutic class: 8(b) cephalosporins Therapeutic class: 8(a) penicillins – infections & infestations Dosage range: 250mg – 1g Dosage range: 500-875mg Route: oral Route: oral Frequency of administration: 6 hourly Frequency of administration: 12 hourly Duration of order: variable Duration of order: 5-10 days Actions: intervenes in bacteria cell wall peptidoglycan synthesis Actions: intervenes in bacteria cell wall peptidoglycan synthesis Indications for use: staphylococcal & streptococcal infections (when mild-moderate Indications for use: hospital acquired pneumonia, UTI, epidiymo-corchitis, bites & allergy to penicillin’s), susceptible gram negative bacterial UTI’s, epididymo-orchitis clenched fist injuries, otitis media, acute bacterial sinusitis, acute cholecystitis, Contraindications for use: allergy to penicillins, cephalosporins or carbapenems melioidosis Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, rash, rare: cholestatic hepatitis Contraindications for use: allergy to penicillins, cephalosporins or carbapenems. Cholestatic jaundice or hepatic dysfunction associated with amoxicillin with Clavulanic acid, or ticarcillin with Clavulanic acid. Adverse drug reactions: transient increases in liver enzymes & bilrubin, cholestatic hepatitis, rare: acute generalized exanthematous pustulosis Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Document Ref October 2011 Page 9 of 11 PHARMACOTHERAPY (Cont..) FORMULARY Flucloxacillin 1st line dicloxacillin Drug (generic name): flucloxacillin Drug (generic name): dicloxacillin Poisons Schedule: Schedule 4 Poisons Schedule: Schedule 4 Therapeutic class: 8(a) penicillins – infections & infestations Therapeutic class: 8(a) penicillins – infections & infestations Dosage range: 250 – 500mg Dosage range: 250-500mg Route: oral Route: oral Frequency of administration: 6 hourly Frequency of administration: 6 hourly Duration of order: variable Duration of order: variable Actions: bactericidal, intervenes in bacteria cell wall peptidoglycan synthesis Actions: intervenes in bacteria cell wall peptidoglycan synthesis Indications for use: staphylococcal skin infections including: folliculitis, boils, Indications for use: staphylococcal skin infections including: folliculitis, boils, carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies, Contraindications for use: allergy to penicillins, cephalosporins or carbapenems. pneumonia, osteomyelitis, septic arthritis, septicaemia, empirical treatment for Cholestatic hepatic associated with dicloxicillin or flucloxicillin endocarditis, surgical prophylasis Adverse drug reactions: transient increase in liver enzymes bilirubin, cholestatic Contraindications for use: allergy to penicillins, cephalosporins or carbapenems. hepatitis Cholestatic hepatic associated with dicloxicillin or flucloxicillin Adverse drug reactions: transient increase in liver enzymes bilirubin In the rare occurrence that the resident is allergic to both Penicillin and Cephalexin the alternate treatment would be ; Clindamycin 450mg 8‐hourly for 7 days. Document Ref October 2011 Page 10 of 11 Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis 1. Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009; chap 9. 2. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 90. 3. Jones,V. & Harding,G. (2003). Wound Management A Constructive Approach. Australia: 3M HealthCare. th 4. Therapeutic Guidelines - Antibiotic, Skin and soft tissue infections. 13 Edition, 2006, pages 269-98. 5. eMIMS. [eMIMS on Clinical Information Access Online website] 2008; Available from: http://www.use.hcn.com.au/html/wah/godirect.html 6. 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). 7. The Royal College of Pathologists Australasia, RCPA Manual http://www.rcpamanual.edu.au/sections/clinicalproblem.asp?s=25&i=109 [The Royal College of Pathologists of Australasia] 2004; Available from: 8. Swartz M. Cellulitis. The New England Journal of Medicine. 2004;350:904-12. 9. 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 10. A randomized-controlled trial comparing cadexomer iodine and nanocrystalline silver on the healing of leg ulcers. April 26, 2010 Wound Rep Reg (2010) 18 359–367 _c 2010 by the Wound Healing Society. N Newall, c Karville etal http://www.silverchain.org.au/assets/files/RA0064-Angior-Main-RCT-results-paper-WRR.pdf Cellulitis Nurse Practitioner Clinical Protocol: Management of Cellulitis Validated by :Mr David Lyle Clinical Governance Manager the Bethanie Group( RN) Mr Louis Anastas Clinical Pharmacist Osborne Park Pharmacy Dr Julius Tan General Practitioner Document Ref October 2011 Page 11 of 11