Cellulitis Assoc Prof Mark Thomas Conference for General Practice Auckland Saturday 28 July 2018
Summary Cellulitis Usual treatment flucloxacillin for 5 days Frequent recurrences consider penicillin 250mg BD Boils Drainage +/- flucloxacillin for 3-5 days
Cellulitis Erysipelas
Cellulitis on background of chronic ulcer, an unusual injury, etc. meded.ucsd.edu
Gram negative bacilli Staph aureus Strep pyogenes Group C or G streptococci
Staph aureus Strep pyogenes Group C or G streptococci
Chronic ulceration? Yes No A broad spectrum agent Amox/clav Cefalexin Cotrimoxazole
Chronic ulceration? Yes No A broad spectrum agent Amox/clav Swab the ulcer! Cefalexin Cotrimoxazole but only if cellulitis!
Chronic ulceration? Yes No Flucloxacillin
Chronic ulceration? Yes No Flucloxacillin or a macrolide
Other Gram Negative Bacilli (n=9,553) Streptococci (n=2,310) Staphylococci (n=38,187) Bacteria isolated by Labtests Auckland during 2014 (from urine, sputum, pus swabs, throat swabs, etc.) Escherichia coli (n=36,844) H. influenzae (n=1,390) Enterococci (n=3,615)
Flucloxacillin Very good for streptococci and staphylococci. Other GNBs (0%) Streptococci (90%) Staphylococci (88%) Narrow spectrum E. coli (0%) H. influenzae (80%) Enterococci (100%)
Amoxycillin + Clavulanate Other GNBs (60%) Streptococci (90%) Staphylococci (88%) Augmentin Equivalent activity vs strep and staph E. coli (84%) H. influenzae (100%) Enterococci (100%)
Amoxycillin + Clavulanate Other GNBs (60%) Streptococci (90%) Staphylococci (88%) Augmentin But also active against many GNBs E. coli (84%) H. influenzae (100%) Enterococci (100%)
Augmentin NOT more effective than flucloxacillin for streptococci or staphylococci. unnecessarily broad spectrum for most patients with cellulitis
Response to therapy Persistence of redness, swelling and tenderness is common. Resolution of fever, return of appetite and wellbeing are better markers of recovery. Five days therapy is adequate in the majority.
Referral to hospital? 1. Is the patient systemically unwell? 2. Is the patient at increased risk of treatment failure? 3. Are there social reasons for admission?
Systemically unwell? Temperature <36 o C SBP<100mmHg Heart rate >100 Respiratory rate >20 Confusion/decreased alertness Appearance of being very unwell
Increased risk of treatment failure? Prior cellulitis 1.75 (1.13 2.68)* Chronic venous ulceration 2.14 (1.29 3.51)* NOT: Age>65, CHF, diabetes, obesity, immune suppression Cutfield T, Ritchie S, et al. JAC in press.
ACH guidelines 1. Not systemically unwell, no prior cellulitis or chronic ulceration. manage at home oral flucloxacillin for 5 days
ACH guidelines 2. Not systemically unwell, but prior cellulitis or chronic ulceration. manage at home IV cefazolin (POAC) for 1-3 days then oral cefalexin
ACH guidelines 3. Systemically unwell admit to hospital IV flucloxacillin for 1-3 days then oral flucloxacillin
ACH guidelines 4. Severely systemically unwell admit to hospital surgical review, ICU review antibiotic cocktail
Penicillin to prevent recurrent leg cellulitis NEJM 2013; 368:1695-1703. 28 hospitals in UK and Ireland Adults with 2 episodes of cellulitis in previous 3 years, most recent episode in last 6 months Penicillin 250mg BD or placebo for 12 months Follow-up (off Rx) for another 2 years
30/136 (22%) RR= 0.55 (0.35-0.86) p=0.01 51/138 (37%) Factors predictive of prophylaxis failure: 3 previous episodes of cellulitis, BMI>33, leg oedema
Off target! Treatment of boils
Cotrimoxazole versus placebo for uncomplicated skin abscess NEJM 2016; 374:823-1832. 5 hospital EDs in US Outpatients 12 years treated with drainage Cotrimoxazole 1920mg BD or placebo for 7 days Follow-up at 7-14 days
1247 patients Abscess 2-3.5 cm diam (IQR) Erythema 4-10 cm diam (IQR) methicillin susceptible S. aureus 16% MRSA 45% Streptococcus 5% Coag neg staph 11% Other 14%
Cotrimoxazole Placebo p (n=630) (n=617) Cure of abscess 80.5% 73.6% 0.005 Hospitalisation 3.6% 6.4% NS New infection 10.9% 19.1% (different site) Days missed 2.0+/-3.1 2.6+/-3.8 normal activities
Summary Cellulitis Usual treatment flucloxacillin for 5 days Frequent recurrences consider penicillin 250mg BD Boils Drainage +/- flucloxacillin for 3-5 days
Whyler N et al. Ethnic disparities in antibacterial dispensing in NZ, 2015. NZ Med J in press.
Whyler N et al. Ethnic disparities in antibacterial dispensing in NZ, 2015. NZ Med J in press.
Recurrent Furunculosis Nasal colonisation is the usual source of recurrences Flucloxacillin (and other beta-lactams) achieve low levels in nasal mucous Rifampicin achieves high levels in nasal mucous, but resistance to rifampicin can emerge very quickly. Therefore protect rifampicin with flucloxacillin or another agent eg clindamycin.
Recurrent Furunculosis Swab boil or anterior nares to isolate S. aureus and test susceptibilities S. aureus sensitive to methicillin sensitive to rifampicin Fluclox 500mg QID + Rifampicin 300mg BD Both regimens: both medicines given together for one week each month for 3-6 months
Recurrent Furunculosis Swab boil or anterior nares to isolate S. aureus and test susceptibilities S. aureus resistant to methicillin sensitive to rifampicin Clindamycin 300mg TDS + Rifampicin 300mg BD Both regimens: both medicines given together for one week each month for 3-6 months
Other actions 1. If S. aureus sensitive to fusidic acid use Foban ointment, or if resistant to fusidic acid but sensitive to mupirocin, then Bactroban ointment TDS for 5 days (to mop up remnant colonisation) 2. Chlorhexidine 4% liquid soap may be helpful 3. Attention to skin conditions 4. Treat boils as usual. Incision +/- 5days antibiotics.
Comorbidities: 1462 adults with cellulitis at ADHB Co-morbidities associated with failure of oral antibiotic treatment and with increased length of stay 30% 23% 24% Co-morbidities associated with increased length of stay 21% 18% 15% 13% 12% 8% 4% 4% 3% 0% Prior Cellulitis Diabetes Morbid Obesity Chronic Venous PAD Previous DVT Heart Failure Cutfield T, Ritchie S, et al. JAC in press. Immune suppression