Nurse Practitioner Clinical Protocol: Management of Cellulitis

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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 SCOPE OUTCOME
Nurse Practitioner
Aged Care
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 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
Medical Practitioner +Nurse
Practitioner
The NP will refer all Bethanie Group residents outside their scope of
practice to a medical practitioner.
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

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RESIDENTS ASSESSMENT
RESIDENTS HISTORY INFORMATION OUTCOMES
Presenting symptoms 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.

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

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RESIDENTS ASSESSMENT
RESIDENTS HISTORY INFORMATION OUTCOMES

Known risk factors for the
presenting symptoms

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.
Prompt diagnosis and treatment will be initiated
Previous medical history Previous vascular surgery/procedures to lower extremetities, previous
Cellulitis

Medications Current Medications
Other relevant information Allergies, previous Cellulitis history, nutrition & hydration, skin
integrity, mobility, cognition and behaviour.

Appropriate dressings and drug therapy will be initiated
PHYSICAL Ax INFORMATION OUTCOMES
Usual physical examination Record findings: temperature, pulse, blood pressure , respiratory rate
skin integrity assessment, wound assessment, pain assessment.

Correct diagnosis, provision of effective disease and
symptomatic eradication/relief.
Documentation of infection incident via The Bethanie
Groups clinical incident system



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.

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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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INVESTIGATIONS
INDICATIONS INVESTIGATIONS OUTCOMES
Routine investigations Laboratory/diagnostics used for diagnosis and identification of
organism: skin swab only if ulceration or exudate present.

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.
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

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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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FOLLOW UP AND EDUCATION
INTERVENTION INFORMATION OUTCOMES
Pharmacotherapeutics
(See pharmacotherapy section)

The treatment chosen will be dependant on the organism believed to
have caused the infection, with consideration of the residents 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
residents hospitalization versus residents 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

Eradication of infection
Prevention of exacerbation
Prevention of recurrence of infection
Management of oedema
Symptomatic relief
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.

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.


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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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FOLLOW UP AND EDUCATION
INTERVENTION INFORMATION OUTCOMES
Residents/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.

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

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October 2011
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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

1
st
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

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PHARMACOTHERAPY (Cont..)

FORMULARY
Cephalexin Amoxycillin with clavulanic acid (diabetic)

Drug (generic name): cephalixin 1
st
line

Poisons Schedule: Schedule 4

Therapeutic class: 8(b) cephalosporins

Dosage range: 250mg 1g

Route: oral

Frequency of administration: 6 hourly

Duration of order: variable

Actions: intervenes in bacteria cell wall peptidoglycan synthesis

Indications for use: staphylococcal & streptococcal infections (when mild-moderate
allergy to penicillins), susceptible gram negative bacterial UTIs, epididymo-orchitis
Contraindications for use: allergy to penicillins, cephalosporins or carbapenems

Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, rash, rare:
cholestatic hepatitis


Drug (generic name): amoxicillin with clavulanic acid

Poisons Schedule: Schedule 4

Therapeutic class: 8(a) penicillins infections & infestations

Dosage range: 500-875mg

Route: oral

Frequency of administration: 12 hourly

Duration of order: 5-10 days

Actions: intervenes in bacteria cell wall peptidoglycan synthesis

Indications for use: hospital acquired pneumonia, UTI, epidiymo-corchitis, bites &
clenched fist injuries, otitis media, acute bacterial sinusitis, acute cholecystitis,
melioidosis
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


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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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PHARMACOTHERAPY (Cont..)

FORMULARY
Flucloxacillin 1
st
line dicloxacillin

Drug (generic name): flucloxacillin

Poisons Schedule: Schedule 4

Therapeutic class: 8(a) penicillins infections & infestations

Dosage range: 250 500mg

Route: oral

Frequency of administration: 6 hourly

Duration of order: variable

Actions: bactericidal, intervenes in bacteria cell wall peptidoglycan synthesis

Indications for use: staphylococcal skin infections including: folliculitis, boils,
carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies
Contraindications for use: allergy to penicillins, cephalosporins or carbapenems.
Cholestatic hepatic associated with dicloxicillin or flucloxicillin
Adverse drug reactions: transient increase in liver enzymes bilirubin, cholestatic
hepatitis


Drug (generic name): dicloxacillin

Poisons Schedule: Schedule 4

Therapeutic class: 8(a) penicillins infections & infestations

Dosage range: 250-500mg

Route: oral

Frequency of administration: 6 hourly

Duration of order: variable

Actions: intervenes in bacteria cell wall peptidoglycan synthesis

Indications for use: staphylococcal skin infections including: folliculitis, boils,
carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies,
pneumonia, osteomyelitis, septic arthritis, septicaemia, empirical treatment for
endocarditis, surgical prophylasis
Contraindications for use: allergy to penicillins, cephalosporins or carbapenems.
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 bothPenicillinandCephalexinthe alternatetreatmentwouldbe;Clindamycin450mg8hourlyfor7days.

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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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1. Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009; chap 9.

2. Mandell GL, Bennett J E, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap
90.

3. J ones,V. & Harding,G. (2003). Wound Management A Constructive Approach. Australia: 3M HealthCare.
4. Therapeutic Guidelines - Antibiotic, Skin and soft tissue infections. 13
th
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 [The Royal College of Pathologists of Australasia] 2004; Available from:
http://www.rcpamanual.edu.au/sections/clinicalproblem.asp?s=25&i=109

8. Swartz M. Cellulitis. The New England J ournal 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 359367 _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







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Nurse Practitioner Clinical Protocol: Management of Cellulitis

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Validated by :Mr David Lyle Clinical Governance Manager the Bethanie Group( RN)
Mr Louis Anastas Clinical Pharmacist Osborne Park Pharmacy
Dr J ulius Tan General Practitioner