Nurse Practitioner CLINICAL PROTOCOL Cellulitis

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