Symptoms of cellulitis (n=396) %

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1 Cellulitis and lymphoedema Vaughan Keeley May 2012

2 What is cellulitis? - also called erysipelas, acute inflammatory episodes etc. - bacterial infection of skin + subcutaneous tissues - more common in people with lymphoedema / recurrent

3 Why are people with lymphedema prone to cellulitis? Lymph nodes / lymph vessels are part of the immune system In lymphoedema the local immune system is less effective

4 What does cellulitis feel / look like? flu-like like symptoms and fever pain, redness, rash, increased swelling, warmth, tenderness, possible blistering / skin breakdown variation from person to person recurrent episodes

5 Data from UK Cellulitis Audit: Symptoms of cellulitis (n=396) % Redness Hot More swollen Rash Unwell Fever Other symptoms included: itch, pain, blisters, flu-like symptoms, nausea and vomiting.

6 Is it definitely cellulitis? features as above no specific tests some tests may be helpful:- white blood cell count CRP swabs for culture blood cultures ASOT

7 What else can it be? raised venous pressure deep vein thrombosis eczema / dermatitis contact sensitivity etc

8 Which bacteria cause it? Not entirely clear Beta haemolytic Streptococci Staphylococcus aureus? others (e.g. in genital cellulitis)

9 How is it treated? Antibiotics oral / intravenous Remove compression temporarily Pain relief - Paracetamol - avoid non-steroidal anti-inflammatories inflammatories (e.g. ibuprofen) Rest

10 Which antibiotics? BLS / LSN Consensus guidelines evidence of best treatment is lacking

11 Need for guidelines: LSN patient experience cellulitis not recognised / treated by HCPs first produced 2005

12 Why a consensus document? Lack of high quality evidence to guide management Differing views on best management Differing views on causative organism

13 Cochrane review (2010) cannot define best treatment for cellulitis

14 Principles adopted Target causative organism Consider duration of treatment Consider tissue penetration of antibiotics

15 Staph or Strep? - Microbiologists / existing guidance (e.g. CREST) focus on Staph (except French Dermatologist Consensus 2001) - Chira & Miller (2010) suggest Staph. is the most common cause of cellulitis

16 Microbiology of cellulitis (Cochrane review) only positive in 25% cellulitis in hospital (blood cultures, swabs, FNA) skin biopsies 80% due to ß- haemolytic Strep. (gp A or G) Staph. probably do not cause classical erysipelas but may sometimes cause cellulitis

17 Additional evidence for Strep. anecdotal apparent effectiveness of Penicillin V prophylaxis blood cultures

18 Lymphoedema or no lymphoedema: is the cause different? studies / guidelines don t distinguish underlying lymphatic abnormality in those presenting with first episode of cellulitis (without pre-existing existing overt oedema) local immune deficiency in lymphoedema

19 Flucloxacillin v. Amoxicillin - anti-streptococcal both anti- Staphylococcal Flucloxacillin - MIC for Fluclox. > Amoxicillin for Strep. - tissue penetration blister fluid Fluclox. < Amox. (protein binding) - side effect profile similar according to emc

20 Drug resistance: Gp A Strep. Resistance reported for Clindamycin, Erythromycin + Tetracycline but not Penicillins to date

21 Conclusion / Consensus Amoxicillin is preferred Flucloxacillin acceptable Audit results no apparent difference

22 C.difficile concerns about use of a number of antibiotics Clindamycin Cefalexin etc. especially as prophylaxis

23 Antibiotics at home: (oral): Amoxicillin 500 mg three times a day for at least 2 weeks Flucloxacillin is an alternative

24 Antibiotics in hospital: (intravenous): if v. unwell, low blood pressure etc or getting worse on oral antibiotics Flucloxacillin 1 g every 6 hrs until temperature normal etc. then oral

25 What may cause an episode of cellulitis? Broken skin - cuts - insect bites - Athlete s foot / fungal infection - eczema / dermatitis - ulcers - ingrowing toenail Others -? sore throat -? stress

26 Recurrent cellulitis UK survey patients with cellulitis lymphoedema and - 76% had previous episodes of cellulitis - average 1.8 episodes in previous year

27 Why is this a problem? acute cellulitis unpleasant, may need hospital admission; loss of time at work etc. cellulitis damages lymph vessels making lymphoedema worse

28 Reducing the chance of getting cellulitis: Skin care Control of swelling

29 Precautions - insect repellent - antiseptic creams for cuts - treat dermatitis, ingrowing toenail, Athlete s foot etc - avoid cuts e.g. gloves when gardening, avoid bare feet in garden

30 Prophylactic antibiotics? - if 2 or more episodes of cellulitis in 1 yr. - address risk factors - control swelling - Phenoxymethylpenicillin (1 year to begin with)

31 Websites: Consensus document + rationale for Amoxicillin v. Flucloxacillin: