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Contents Page Number
Author : Emma Gardner, Clinical pharmacy lead – CHS. Medicines management and prescribing Owner : Gary Townsend, Head of unplanned care
Adult primary care
- 1 Developed March 2013 Review: March
- Introduction and classification
- Diagnosis
- Inclusion/exclusion criteria
- Investigations
- Management pathway
- Medication
- On-going management
- Contributors
- Bibliography
- Summary pathway
- Clinicians flowchart
- References
- A – Cellulitis patient information sheet Appendices:
- B – Cellulitis care plan
- C – Community pharmacy stockist
- D - Referral routes to community services
- E – Cellulitis monitoring chart
- F – Cellulitis body map
- G – ICT template Cellulitis authorisation sheet
- H – Cellulitis box content list
2 Developed March 2013^ Review: March 2014
Community Cellulitis Pathway (CCP)
Introduction
Cellulitis is an acute, non-contagious bacterial infection of the skin and soft tissue characterised by inflammation, pain and tenderness. Bacteria spread beyond the dermis, deep into subcutaneous tissues and may follow a skin abrasion or other similar trauma. It can be life threatening if not managed appropriately.
In 2008-9 there were 82,113 hospital admissions in England and Wales from cellulitis, lasting a mean length of 7.2 days and an estimated £133m was spent on bed stay alone; Cellulitis accounted for 1.6% of emergency hospital admissions during 2008-9i.
This pathway will enable more patients to remain in their own home and be cared for by the community team rather than being admitted to hospital. By using best practice in prescribing and treatment, patients are supported to recover quickly and recurrence should reduce.
The classification systemii
Eron LJiii^ devised this classification system of skin and soft tissue infections to aid the GP/Nurse diagnosis, treatment and admission decisions.
Class 1 Patients have no signs of systemic toxicity, have no uncontrolled co-morbidities and can usually be managed with oral antimicrobials on an outpatient basis.
Class 2 Patients are either systemically ill (i.e. have a temperature > 37.9°C or are vomiting) or are systemically well and have a co-morbidity which may complicate or delay resolution of their infection such as:
- Peripheral vascular disease
- Treated diabetes or BGM < 11
- Chronic venous insufficiency
- Morbid obesity (i.e. BMI >40)
- Liver cirrhosis
Class 3 Patients may have a significant systemic upset (i.e. acute confusion, heart rate > 99/min, respiratory rate > 20/min, systolic BP < 100mmHg) or may have unstable co-morbidities that may interfere with a response to therapy (i.e. uncontrolled diabetes; renal/liver failure) or have a limb threatening infection due to vascular compromise (i.e. varicose ulcer, peripheral vascular disease with critical ischemia or arterial ulcer)
Class 4 Patients have a systolic BP of < 90mmHg or other features of severe sepsis or life threatening infection, such as necrotizing fasciitis ( NB : Such patients may need surgery)
Note : Clinical findings alone are usually adequate for diagnosing cellulitis, particularly in non-toxic immunocompetent patients. The prescriber must assess the patient and decide upon the classification and management options before prescribing.
Oral Abx treatment at home Refer to SWECS comm services, follow guidance Refer to acute
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Complicating clinical conditions Cardiac failure Pneumonia Underlying malignancy Diabetes MRSA carriage Immunodeficiency Liver or renal failure
Differential diagnosis
Varicose eczema which is often bilateral with crusting, scaling and itch or other lower leg eczema DVT with pain and swelling without significant erythema Chronic inflammatory response in chronic venous disease and Acute liposclerosis may have pain, redness and swelling in the absence of significant systemic upset Other differential diagnosis include lower leg oedema with secondary blistering, erythema nodosum, other panniculities or vasculitis and pyoderma gangrenosum
Complications
Fasciitis Myositis Subcutaneous abscesses Septicaemia Post streptococcal nephritis Death
Inclusion criteria for IV therapy in the community
Presenting with clinical signs of cellulitis – Eron’s class/severity recorded as I or II 18 years or older Competent to make a decision, give consent and to understand and adhere to the treatment plan Can independently carry out activities of daily living or has support from carers Registered with a GP in this area or residing within South West Essex
Exclusion criteria (unless appropriately assessed and referred by secondary care)
Pregnancy History of treatment of cellulitis in the same extremity during the preceding month Cellulitis covering more than half a limb Cellulitis of the face/peri-orbital cellulitis/cellulitis of the hand Signs of rapid extension or severe pain out of proportion to the clinical symptoms – refer to secondary care, could indicate necrosis. Immunocompromised patients MRSA positive (refer to microbiology) Current Clostridium difficile infection (refer to microbiology) Hypersensitivity / contraindications to all of the treatment options (refer to microbiology) Patient is IV drug user and oral antibiotics are not sufficient
Investigations
Blood should be taken at the time of cannulation and results should be reviewed and appropriate action taken, within 48 hours
Full Blood Count (FBC). Urea and Electrolytes (U&E).
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Creatinine Kinase (CK) (for patients prescribed Daptomycin) Liver Function Test (LFT). C-reactive Protein (CRP). Glucose. INR if appropriate
Blood cultures should not be undertaken routinely as only 2-4% are positive and contaminants may outnumber pathogens.
There is no need to swab intact skin. Culture any skin break / ulceration / blister fluid.
Please note : Patient specific microbiology advice, following cultures or for complex patients, must be followed in preference to the generic treatment described in this guidance.
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Table 1: Antibiotic guidance for the treatment of cellulitis in the communityii,vi,vii,viii
Indication 1st Line Penicillin allergic patients
Class I No signs of systemic toxicity; no uncontrolled co-morbidities; can tolerate oral antibiotics.
Flucloxacillin 500mg-1ga^ QDS PO for xb^ days
Clarithromycinc^ 500mg BD PO for xb^ days
Class Id^ or II patients referred to community services
Ceftriaxone 2g od IVe^ for xb days
Reconstitute each 2-g vial with 40 mL of compatible infusion fluid (usually NaCl 0.9%). This can be infused directly from the vial if appropriate. The solution should be clear and light yellow to amber. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Give by intermittent IV infusion over at least 30 minutes.ix
Daptomycin 4mg/kg OD IVe^ for xb^ days
- Reconstitute each 350-mg vial with 7 mL NaCl 0.9% (use 10 mL for each 500-mg vial). Inject through the rubber stopper and aim at the wall of the vial.
- Gently rotate to fully wet the powder then leave to stand for 10 minutes.
- Gently swirl the vial (do not shake) for a few minutes until a clear solution has developed. The reconstituted solution contains 50 mg/mL.
- The solution should be clear and yellow to light brown. Inspect visually for particulate matter or discoloration and discard if present.
- Withdraw the required dose and add to a suitable volume of NaCl 0.9% (usually 50 mL).
- Give by IV infusion over 30 minutes.
Class III & IV Refer to hospital guidance Refer to hospital guidance
a. Oral doses depend upon individual patient factors and the clinical assessment of the severity of the cellulitis; in general it is prudent to use a higher dose b. Duration of treatment is dependent upon severity and the patient’s response to treatment. Antibiotics must be continued for 3 days after complete resolution of the symptoms. Patients must be fully reviewed by the prescriber after a maximum of 4 days IV therapy and 7 days of oral therapy (with daily review by staff administering IV medication) c. Clindamycin 300mg-450mg QDS PO can be considered on a case by case basis for patients under 65years with microbiology input. It is more effective than Clarithromycin but with a greater risk of C.diff d. Class I patients with no response to oral therapy or deteriorating while on treatment e. Refer to the Royal Marsden Hospital Online Manual of Clinical Nursing Procedures for best practice IV procedures including flushes, etc.
8 Developed March 2013^ Review: March 2014
Table 2: IV – oral switch guidance
1st Line Penicillin allergic patients
IV Ceftriaxone 2g od IV Daptomycin 4mg/kg OD IV
Oral Flucloxacillin 1g QDS PO days^ for x^ Clindamycin for x days **^ 450mg QDS PO
- Antibiotics must be continued for 3 days after complete resolution of symptoms ** Clindamycin is appropriate for patients under 65years with no major risks for c.diff (see information below). Discuss with microbiology if unsure of suitability.
Medication cautions and information*
Flucloxacillin o Avoid in patients with hepatic dysfunction; allergic to penicillin, other beta-lactam antibiotics or cephalosporins. o Caution in hepatic impairment and severe renal failure (CrCl<10mL/min). o Take on an empty stomach, 30minutes before meals. o Interactions: Probenecid; combined oral contraceptives. o Side effects: GI disturbance; hypersensitivity
Clarithromycin o Caution should be in patients with QT interval prolongation or myasthenia gravis. o Renal function <30mL/min/1.73m^2 use half the dose (250mg BD) o Side effects: Nausea, vomiting, abdominal discomfort, diarrhoea, dyspepsia, tooth and tongue discoloration, smell and taste disturbances, stomatitis, glossitis, and headache o Common interactions: Statins (suspend use during antibiotic therapy); Coumarins (monitor INR); Ergotamine, Dihydroergotamine, Cisapride, Pimozide, Astemizole, and Terfenadine use is contraindicated;
Ceftriaxone o Do not give if there is known hypersensitivity to ceftriaxone, cephalosporins or previous hypersensitivity to penicillins or any other beta-lactam antibiotic, or excipients. o Development of severe, persistent diarrhoea may be suggestive of Clostridium difficile - associated diarrhoea and colitis (pseudomembranous colitis). Discontinue drug and treat. Do not use drugs that inhibit peristalsis. o Side effects: Dizziness, nausea, vomiting, abdominal pain, diarrhoea, urticaria, pruritus. o Do not use any calcium containing infusions, diluents, etc (e.g. Ringer's solution or Hartmann's solution) as life threatening precipitates can form. o Caution in patients taking amsacrine, vancomycin, fluconazole, aminoglycosides or contraceptives.
Daptomycin o Do not give if there is known hypersensitivity to Daptomycin or any of the excipients. o Side effects: Fungal infections, headache, nausea, vomiting, diarrhoea, rash, increased pulse, metallic taste.
Suggested criteria for prescribers to consider before stepping down therapy: 50% decrease in erythema; usually within 3-4 days of therapy for uncomplicated cellulitis Fall in Eron’s class severity to Eron’s class I Falling inflammatory markers (CRP should be checked where clinical improvement is not conclusive) Reduction in pain Systemic symptoms / Pyrexia settling
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Contributors :
Gary Townsend, Head of Unplanned Care Gordana Atkins, Operational Lead for Unplanned Care Nicki Walpole, Modern Matron Inpatients BCH & MCH David Smith, Operational Lead: Day Hospitals Sue Burke, Operational Lead Basildon ICT Jonathan Keay, Communications manager, creative services Sarah Roberts, Head of Neurological and Tissue Viability Specialist Services Ray Norris, CNS Tissue Viability Elizabeth Purdy, Modern Matron Minor Injury Unit and Outpatient Department at Brentwood Community Hospital Sarah Zeraschi, Senior Pharmacist - Surgery, Microbiology & Infection Control, and Nutrition Support BTUH Carol Werry, Consultant Microbiologist / Infection Control BTUH Amrit Dhanday, Antibiotic pharmacist BTUH Justin Edwards, Consultant Microbiologist BTUH
Hannah Patten, NEL CS Clinical nurse specialist – Tissue viability Beth Maryon, Practice improvement practitioner SWECS Mark Mager, District Nurse/Team Leader Jan Minter, Cardiology Nurse Consultant
Training requirements :
Mandatory training Anaphylaxis Intravenous medication mixing and administration Cannulation skills
This pathway sits under:
NHS NELFT Medicines policy Royal Marsden Hospital Online Manual of Clinical Nursing Procedures
Bibliography
Eron, L.J 2000 Infections of skin and soft tissues: outcome of a classification scheme. Clinical Infectious Disease, 31,287. Eron, LJ et al 2003. Managing skin and soft tissue infections: expert panel recommendations on key decision points. Journal of Antimicrobial Chemotherapy (2003) 52, Suppl. S1 , i3–i Microbiology, Infectious Disease and Pharmacy Departments, Oxford John Radcliffe Hospitals. 1/10/2006. Guide to use of antibacterials. Kettering General Hospital NHS Trust. May 2006. Antibiotics: Empiric treatment of common conditions, antibiotic prophylaxis in surgery and other issues relating to the use of antibiotics in adults. Seaton R A. Bell E. Gourlay Y. Simple L. 2005. Nurse led management of uncomplicated cellulitis in the community: Evaluation of a protocol incorporating intravenous ceftriaxone. HerchlineT et al. http://emedicine.medscape.com/article/214222-overview Cellulitis - acute. http://www.cks.nhs.uk/cellulitis_acute#- Guidelines on the Management of Cellulitis in Adults. CREST (Clinical Resource Efficiency
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Community cellulitis clinical pathway summary (page 1)
Diagnosisi
Class I No signs of systemic toxicity; no uncontrolled co- morbidities and the condition can be managed at home with oral antibiotics :
Issue cellulitis information leafletx Prescribe Abx as per table 1 Postpone compression therapy Consider analgesia Follow-up after 7 days or as required
Class I or II Either systemically ill (temperature > 37.9°C / vomiting) or are systemically well and have a co- morbidity e.g.
Peripheral vascular disease Treated diabetes or BM < 11 Chronic venous insufficiency Morbid obesity (i.e. BMI >40) Liver cirrhosis
If the patient can be managed safely at home with I.V. antibiotics: Refer to community services (appendix D) Issue cellulitis information leafletxi Postpone compression therapy Prescribe IV Abx as per table 1 Consider analgesia Follow-up after 4 days or as required Refer to specialist servicesii
Class III or IV Significant systemic upset (acute confusion / Heart rate > 99/min / Respiratory rate > 20/min / Systolic BP < 100mmHg) or has unstable co-morbidities (uncontrolled diabetes; renal/liver failure) or has a limb threatening infection due to vascular compromise (varicose ulcer, peripheral vascular disease with critical ischaemia or arterial ulcer).
Class IV Systolic BP of < 90mmHg or other features of severe sepsis or life threatening infection, such as necrotizing fasciitis
Immediate referral to secondary
care
Medication
Flucloxacillin 500mg- 1g qds po
Penicillin allergy: Clarithromycin 500mg BD PO
Medication
Ceftriaxone 2g od IV
Penicillin allergy: Daptomycin 4mg/kg IV OD
Refer to secondary care guidance
Community care referral criteriaiii^ (class I or II patients)
Day Hospital/Integrated community team (ICT) Administration of IV antibiotics. Additional healthcare input required to support or supplement existing social care package Medication compliance / review of patient condition / response to therapy.
Community Hospital/Nurse led unit Administration of IV antibiotics Patient cannot be supported at home Closer monitoring by nursing staff is considered necessary Domestic environment is clinically unsuitable
i (^) Caution: Face/orbit involvement/signs of septicaemia refer to acute hospital. ii (^) Referral to specialist services should be considered at all stages in the patient’s journey e.g. Diabetes service if BGM is raised, Tissue viability nurses if a wound is present, etc. iii iv Agree a maintenance plan with Multi-Disciplinary Team e.g. GP; Community Matron; District Nurses (ICT); Self-referral No improvement does not mean that the redness is not resolving, this may take some time. It means that the clinical picture is worsening e.g. the redness is spreading beyond the original boundaries and / or the patient is becoming systemically ill
- Class I patients with no response to oral therapy or deteriorating while on treatment ** Dosages depend upon the clinical situation and individual patient factors. See BNF for further information. Note : Clinical findings alone are usually adequate for diagnosing cellulitis, particularly in non-toxic immunocompetent patients
Review patient 48 hours after starting therapy
Symptoms/signs improve: Continue antibiotics as per recommendations
Deterioration or no improvementiv^ after 48 hours of IV therapy: Speak to microbiology and refer to secondary care as appropriate
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Appendix A: Cellulitis PIL
Patient information sheet – Cellulitis
You have been diagnosed with a condition called Cellulitis; this is a bacterial
infection of the skin which can occur very quickly. You may need to be treated with
strong antibiotics, sometimes they need to be given straight into your blood.
Our community nursing team will support you to remain at home rather than be
admitted to hospital whilst you have the antibiotics.
It is important that if there are any changes in your condition or you experience any
of the following symptoms, you inform the nurses or your GP immediately.
The redness and swelling spreads further
You start to feel feverish or more unwell
Pain increases
You feel warmer and your temperature is rising
You become confused
Your blood glucose levels become unstable (Diabetics only)
You can support your treatment by: -
Stop wearing any compression tights/stockings whilst you have cellulitis.
Finishing the course of any oral antibiotics, and taking them for at least 3 days
after you feel better and the redness has gone.
If your cellulitis is on your leg you must sit and elevate it above hip level. If it
affects your arm, lift your lower arm above the level of your elbow.
If this is uncomfortable lie on a sofa or bed as much as possible to help the
drainage and circulation in the limb.
Although rest and elevation are essential, you must also mobilise your joint
and walk to the toilet.
It is important that you take pain relief if you need it so that you are able to
exercise your joint and mobilise.
It is important to drink plenty of clear fluids eg. water, squash and tea.
Passive ankle exercises
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Aftercare
Once the first stage has passed and the swelling is going down, it is important to
care for the affected skin to prevent further problems: -
Wash the area daily in warm water using non-soap/non perfumed moisturiser
e.g. Hydromol.
Do not allow scabs or dry skin scales to form, these can allow bacteria to build
up un-noticed and are a potential source of further infection.
As the cellulitis gets better the surface layer of skin will loosen and ‘slough
off’, it is important to maintain skin hygiene and moisturise the skin regularly
e.g. morning and evening to increase elasticity and suppleness and prevent
cracking – another source of infection.
Avoid direct exposure of your legs to sunlight or trauma.
If you normally wear compression hosiery (tight or stockings) you will need to
ask your GP for a new assessment once the infection has gone.
Compression hosiery should be replaced every three months as they can lose
their effectiveness over time. You should be re-measured for the stockings by
a trained professional each time they are replaced.
The moisturisers/emollients can reduce the lifetime of the elastic in your
hosiery, therefore allow time for it to soak in or apply in the evening after
removal of hosiery.
GP name :………………………………… Phone no:…………………..……..
Day hospital:
Named nurse:………………………… Phone no:…………………………
Community nurse
Name: …………………………………… Phone no:…………………………
Weekend/bank holiday contact no: …………………………………
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7. If cannula in situ, check patency and observe for signs of extravasation / inflammation. Record status. Resite cannula as required.
- Ensure that IV medication is administered as prescribed following trust policy.
- Undertake blood samples and obtain result as per guidance. (FBC, U&E’s, CK - for patients prescribed Daptomycin, LFTs, CRP, BGM, INR if appropriate). Discuss with referrer / prescriber if difficulty is anticipated in obtaining sample or results. Record conversation and decisions.
- Document the date and time the sample is taken and results obtained.
- Document if the patient is experiencing pain / discomfort from the infected area. Advise simple analgesia e.g. Paracetamol if not contra-indicated or refer to GP / Nurse Prescriber for prescription of oral analgesia. Pain chart to be in notes. Monitor pain control and record effect on pain chart.
- Encourage elevation of affected limb ( do not apply compression as it may push infection proximally).
- Send swab for M, C & S if clear route for infection e.g. insect bite or exudates present.
- Record date sent.
- Record result.
- Assess if the patient is weight bearing;
- Refer to physiotherapy / OT for assessment for aids / equipment / mobility if required.
- If cellulitis is not improving or deterioration is seen refer for medical review.
- Ensure patient has Information leaflet and is aware of how to contact the team.
- Complete audit form and return to local lead when care episode is complete
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Appendix C : Community pharmacy Ceftriaxone stockists
Community pharmacy stockists
(2 x 1g Ceftriaxone and 2 x 2g Ceftriaxone kept in stock at all times)
Pharmacy Address Telephone Pharmacist Opening hours
PharmChoice 9 Ingrave Road, Brentwood,
CM15 8AP
01277 215809 Ada Mon – Sat: 7am - 10pm
Sun: 9am-9pm
Vision pharmacy 11 Crammavill Street, Grays,
RM16 2AP
01375 376007 Wassim Mon – Sat: 7am - 10pm
Sun: 9am-7pm
Sainsburys pharmacy Cricketer’s Way, Basildon,
SS13 1SA
01268 280584 Nicki Mon: 8am – 11pm
Tues – Fri: 7am – 11pm
Sat: 7am – 10pm
Sun: 10am – 4pm
Appendix D: Referral routes to community services
Service Contact telephone Fax number Operating hours Operating days
Single point
of access
(SPA)
01268 242140 01268 242148 7am – 7pm Every day
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Appendix F: Cellulitis body map
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Appendix G: ICT authorisation to administer medication
Patient name: GP:
DOB:
Patients weight: NHS Number:
Allergy status:
This document must be completed electronically except signatures which must be handwritten.
No (^) Date started Medication Dosage Frequency /Route
GP/Prescriber Signature
1 Ceftriaxone powder for infusion
2g
Once daily for x days IV infusion
2 Sodium chloride 0.9% infusion fluid
40mL for reconstituting ceftriaxone powder
Once daily for x days IV infusion
Sodium chloride 0.9% flush
Before and after infusion as required
As required
Extra information:
Give by IV infusion over at least 30 minutes
Expiry: (Maximum of 4 days treatment to be given before GP review)
Note: Cross through this document upon replacement and file in the patient’s notes.
Appendix H : Community cellulitis IV kit contents list
