– CLINICAL GUIDELINES CELLULITIS

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.