Cellulitis in Adults Guideline Flowchart

Patient with suspected Cellulitis

Exclude from pathway:

Hospital in the Home Guideline for Management at Home

Consider also:
Erysipelas, necrotising fasciitis, bone or joint infection, abscess DVT, thrombophlebitis, varicose eczema, CCF

Cellulitis of face, orbital, periorbital, hand, perineum, diabetic foot Cellulitis from bites (animal, human), environmental water exposure, penetrating injuries Extensive or rapidly progressive cellulitis; presence of bullae, haemorrhage or skin necrosis; severe, continuous pain Systemic sepsis (tachycardia, hypotension, confusion, vomiting) Immunocompromised host; bilateral cellulitis

ED assessment:
Mark border of cellulitis FBC, UEC, LFTs, CRP, Blood cultures if febrile, swab m/c/s of suppurative lesions Consider: X-ray, ultrasound of soft tissues, venous doppler, bone scan

Investigate as appropriate Consult relevant discipline(s) Manage / admit as necessary

Options for Management Outside Hospital

Home on IV cephazolin with Hospital in the Home if: Moderate cellulitis Satisfactory IV access May have failed oral Age over 16 years therapy Resides in catchment area Not septic, medically stable Can transfer and Safe home environment mobilise independently Home on oral antibiotics if: Mild to moderate cellulitis; not septic Untreated prior to presentation or inadequate trial of oral therapy Able to rest and be cared for at home GP can review in 23 days

Option 1 Option 2 th (if probenecid contraindicated) Probenecid 500 mg 12 hrly th Cephazolin 2 g IV 12 hrly Cephazolin 2 g IV daily (reduce cephazolin dose in renal impairment) ________________________________________________________ 1. Give probenecid 30 mins prior to cephazolin st 2. Give 1 dose cephazolin in ED 3. Observe patient for 30 minutes after first dose 4. See over for contraindications to probenecid and cephazolin 5. Leave cannula in if safe to do so

Oral antibiotic options: th Dicloxacillin 500 mg 6 hrly 714 days; or th Phenoxymethylpenicillin 500 mg 6 hrly 714 days if considered streptococcal; or th Cephalexin 500mg 6 hrly if nonimmediate penicillin allergy; or th Clindamycin 450 mg 8 hrly if immediate penicillin allergy

Refer patient to Hospital in the Home

Ph: 1300 443 989

Discharge arrangements after patient accepted onto Hospital in the Home

Chart cephazolin on an inpatient medication chart give chart to patient to take home Dispense 5 days supply of probenecid (unless contraindicated) and cephazolin to patient Give Cellulitis and Cannula advice sheets to patient

Version One

July 2012

Page 1

Cephazolin information
Cephazolin is a semi-synthetic first-generation cephalosporin with the same spectrum of antimicrobial activity as cephalothin and cephalexin. The advantage of cephazolin over the other first-generation cephalosporins is its longer half-life which allows for a longer dose interval (once or twice-daily), especially when combined with probenecid which delays its excretion. Contraindications and cautions Allergy to cephalosporins, or major allergy to penicillin 2 Reduced renal function (eGFR less than 10 mL/min/1.73 m : Cephazolin is excreted by the kidneys; it accumulates in renal failure, when it can cause seizures) LFTs (ALP, AST, ALT, GGT) more than twice upper limit of normal Use with caution if history of seizures, especially if renal impairment is present Adverse reactions Nausea, anorexia, diarrhoea/colitis

Cephazolin dose calculator in renal impairment Probenecid Probenecid not contraindicated contraindicated
eGFR Dose (g) Dose Interval (h) Add Probenecid? 30 2 24 Yes 1029 1 24 No 30 2 12 No 1029 1 24 No

Probenecid information
Probenecid is a uricosuric and renal tubular blocking agent. It inhibits the tubular reabsorption of urate. It is used to treat hyperuricaemia (except during acute gout episodes) and to elevate and prolong plasma levels of beta-lactam antibiotics. Probenecid also interferes with the excretion of other drugs (see below). Contraindications to probenecid: Known allergy to probenecid Blood dyscrasias Uric acid stones, acute gout Salicylates in therapeutic doses antagonise probenecid. Low dose aspirin (100150mg/day) can be continued Probenecid is banned in sport 2 Reduced renal function (creatinine > 250 micromol/L or eGFR < 30 mL/min/1.73 m ) LFTs (ALP, AST, ALT, GGT) > twice upper limit of normal Probenecid increases the plasma concentrations of: Methotrexate, NSAIDs (see below), rifampicin, antiviral agents (aciclovir etc.), sulphonylureas ( hypoglycaemia), thiazides, some benzodiazepines (not temazepam), sulphonamides Indomethacin, naproxen, ketoprofen and ketorolac should be avoided; use of other NSAIDs should not exceed half the recommended daily dose Adverse reactions: Nausea, anorexia, headache, pruritus, fever, flushing NB: If an episode of acute gout occurs during therapy it can be managed as usual without withdrawing probenecid

Version One

July 2012

Page 2