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Nurse Practitioner Clinical Practice Guidelines

for the

Management of CellulitisAll NP clinical guidelines on this site have been developed for use in a particular

Area Health Service and for specific Nurse Practitioner positions in that AHS, andtherefore reflect the specific scope of practice of the position and the operation ofthe AHS.

Therefore, prior to use by Nurse Practitioners in other positions, the guidelines wilneed to be reviewed and adapted as necessary to address local scope of practiceand Area Health Service needs. The adapted guidelines must also be approved inwriting by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive2005_556 prior to use.

This Guideline has been developed under Section 78A of the Nurses Act 1991.

It covers the care of patients aged 1+

March 2006

Area:

Sydney West Area Health ServiceClassification:

NP Guideline

Nurse Practitioner Guideline Page 1 of 13


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CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

Contents: page

Purpose 3Guideline Development Group 3

Notes for Use of Guideline 4

1. Introduction 5

2. Assessment 6, 7

3. Management 8, 9

4. Discharge 10

5. Formulary 11, 12

6. References 13

Consumer Information

Symbols used in this document

- Special Note

- Item to note

- Opinion of Guideline Development Team



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Purpose

The guideline is implemented post assessment with a robust triage system designed to identify the

critically ill patient. The guideline is intended for use by Nurse Practitioners working in Principal

Referral Hospital Emergency Departments, alongside senior medical officers. The Nurse Practitionerhas been registered by the NSW Registration Board, thus has demonstrated advanced knowledge and

clinical skills in the assessment and therapeutic management of Emergency Department Patients.

This guideline is to be used for the management of patients aged 1yr + who present with cellulitis.

Guideline Development and Reviewers Group

This guideline was collaboratively developed and reviewed by a team of Expert Clinicians andHealth Managers. The development and review team consisted of:

Byndie Warrick BA, MNNurse Practitioner, Nepean Emergency Department

Arlene Bannon BA, Grad Dip Critical Care Nursing, MNNurse Practitioner, Nepean Emergency Department

Cate Salter, BHSC (Nursing), MCN (ED)Emergency Clinical Nurse Consultant, WAHS

Specialist Approval

Dr Branley, Head of Microbiology, Infectious Diseases, SWAHS (November 2004)

Dr Rod Bishop, Director of Area Emergency Services, SWAHS (December, 2003)SWAHS Drugs & Therapeutics Committee Western cluster (April 2006)



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Notes for Guideline use

Local implementation of the Guideline

This guideline was developed for use by Nurse practitioners working at Nepean Emergency

Department. The guideline was developed and reviewed by clinical experts and health managers.

Statement of intent

This guideline is not intended to be construed or to serve as a standard of care. Standards of

Care are determined on the basis of all clinical data available for an individual case and are

subject to change as scientific knowledge and technology advance and patterns of care evolve.These parameters of practice should be considered guidelines only. Adherence to them will not

ensure a successful outcome in every case, nor should they be construed as including all propermethods of care or excluding other acceptable methods of care aimed at the same results. The

ultimate judgment regarding a particular clinical procedure or treatment plan must be made by

the nurse practitioner in light of the clinical data presented by the patient and the diagnosticand treatment options available.

In making clinical decisions the nurse practitioner should remain cognizant of their level of

expertise and take advantage of the expertise of all members of the treating team.

Review of Guideline

This Guideline was developed in December 2003. It should be viewed as an initial guide and adynamic document that should be reviewed and revised by those who use it as the basis of theirLocal Guidelines.

Signature___________________ Date____________________________ The guideline should be signed and dated by the SWAHS CEO prior to implementation.

Review Date- December 2006.

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1. Introduction

Cellulitis is a local soft-tissue inflammatory reaction secondary to bacterial invasion of the skin.

Generally characterised by erythema, swelling, pain and hardening. Cellulitis may be acute, sub-

acute or chronic. Trauma may be a predisposing cause, but hematogenous and lymphaticdissemination can be the cause of its sudden appearance in previously normal skin. The most

common bacteria causing cellulitis are staphylococci or streptococci.

The signs and symptoms of cellulitis are usually pain or tenderness, erythema that blanches on

palpation, swelling to the involved area and local warmth. A good rule of thumb is the deeper the

soft tissue infection the more normal the skin surface appears. Cellulitis caused from infection tendsto be reproducibly tender in the reddened area. Without therapy it will extend in a radial fashion

both distally and proximally with associated swelling (1). Systemic involvement with fever, and

leukocytosis is common. Bacteremia is not commonly seen without other complications. Recentstudies suggest that although bacterial invasion is what triggers the inflammation, the organisms are

largely cleared from the site within 12 hours and the infiltration of lymphoid and reticular cells andtheir products is what produces the majority of the symptoms producing a significant anti-

inflammatory response (2).

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CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS.

2. Assessment and Examination

Detailed medical and surgical history including age, gender, occupation, current medications, alcohoand substance use. Include current medical problems/ co- morbidities, past cellulites, chronic venous

disease, and chronic dermatitis.

Identify the cause of the cellulitis: was it spontaneous, injury, a foreign body, surgical/medical

related. If a wound was sustained note the time and mechanism of injury.

Obtain history of inflammation time of onset, duration, preceding events, associated symptoms.

Determine prior treatment adequate rest and elevation, use of medications/lotion/type of wound

closure/dressings, maintenance of asepsis.

Note social/occupational circumstances.

If a fall occurred evaluate the cause of the fall, frequency and any loss of consciousness - If not a

simple isolated fall, or the history is unclear- refer the patient to the ED Staff specialist or Registrar

Record Tetanus/ Vaccination status

Possible allergic reaction to topical treatment or antibiotics and type of reaction

Record Temperature, Blood Pressure, Pulse and O2 saturation, and evaluate for systemic sepsis.

Inflammation to wound and/or surrounding skin (redness, swelling, radiation, tenderness)

Examine for painful thickened skin, (hardening and tenderness on pressure)

Assess for possible abscess palpate inflamed area in two planes, assessing for variance

Examine for other injuries, assess lymph nodes of associated limbs for signs of infection

Assess neurovascular status color, capillary return, sensation, warmth, range of movement.

Assess for orbital involvement.

Assess for tinea

Red Flags Bilateral cellulites, significant itch, non tender erythema, foot cellulitis only

Wounds

Assess changes size, appearance, depth (moist/dry, warmth), swelling, and accumulation of fluid

Wound type color, necrotic/ sloughy/ granulating/ epithelisation

Exudates - color, amount, consistency, odor, and blood stained


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Referral triggers include: (staff specialist review)

Diabetes

Neuropathic limbSepsisChronic ulcer

Osteomyelitis

BursitisImmunocompromised eg. Steroid use, cirrhosis

Impaired wound healing

Non-blanching rashOrbital involvement

Peri - orbital cellulitis

Cellulitis involving the hand or upper limb

History of water contactBites

Traumatic crush injury

Major (type1) allergy to beta lactamsSignificant renal impairment

Diagnostic Tests:

All Diagnostic tests are interpreted in consultation with the Emergency staff Specialist or Emergency

Registrar

Pathology tests (Take only if infection is likely)

FBC Signs of sepsis

Prolonged inflammation despite medical interventionNeutropenia

Blood dyscrasia/ blood loss/ anemia

Blood Culture - T>37.5, toxic clinical picture

BSL Children < 12 years

EUC - Relevant co- morbiditiesLFT- Relevant co- morbidities

X-RAY affected limb if fracture/ foreign body or osteomyelitis is suspected (chronic history or

diabetic)Ultrasound/CT may be needed for suspected osteomylitis/bursitis/ abscess (consult staff specialist)



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Management of Cellulitis

Refer to the flowchart p.9

Differentials

Healing woundInflammation

Allergic reactionBursitis

Osteomyelitis

Embedded foreign body

Gout

Fracture/ Charcot footVaricella

Erythema nodosumErythema multiforme

Chronic dermatitis

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CELLULITIS

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NP Guideline

History and Examination(See page 6)

YES

Sudden & localised

erythema, swelling, pain,

warmth, tenderness,erythema, soft tissue

involvement only

Cellulitis - Discharge

No systemic toxicityNo induration,

No extensive radiation of inflammation,

Consider:Oral Antibiotics (as per formulary)

Analgesia - Paracetamol

Rest/elevation

(Wound management per NP Woundguideline)

Discharge Home

Review with GP 24-48 hrs

CellulitisWCC < 5 >15

Systemic toxicityExtensive Distal/proximal radiation of

inflammation, induration

Oral antibiotics ineffective or vomitingCo-morbidities inc. renal or liver impairment

(may require antibiotic adjustment)

Immunocompromised cirrhosis, diabetes

Refer to Staff Specialist/Reg - Consider

possible Outreach referral orAdmission,

IV ABs, Rest/elevation/analgesia.

(Consider differentials p.7)NO

Referral Criteria

Systemic involvement

DiabetesNeuropathic limb

Chronic ulcerOsteomyelitis

BursitisImmunocompromised - Steroid use, cirrhos

Impaired wound healing

Embedded foreign bodyOrbital involvement

Peri orbital cellulitis

Cellulitis involving the hand and upper limHistory of water contact

Bites

Traumatic crush injurySignificant renal impairmentMajor (type1) allergy to beta lactams

Order relevantinvestigations (p.7)



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4. Discharge

See flow chart page 10.

A General Practitioner should review patients discharged with cellulitis within 2 days. Instruct thepatient to return to the Emergency Department if they become systemically unwell or there issignificant extension of the cellulitis. General practitioners should be encouraged to refer patients to

the Nepean Outreach service for review by an infectious diseases physician.

Patients referred to the Nepean Outreach Service must meet the criteria set out by the service. All

treatment and medications must be charted in accordance with the guidelines set out by the service.The service must be notified and the patient must agree to receive treatment from the outreach

service. Discuss all children with the Nurse Unit Manager of the Nepean outreach service and

Infectious Disease Consultant prior to any referral


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5. FormularyDrug

Generic

Indications Route Dose Frequency Therapeutic Poisons

Class Schedule

Contrain

ParacetamolSee NSW

Health Policy

Directive

PD2006-004

Temporary relief ofpain. Reduces fever

Oral Adult &Children

> 12 yrs

500mg to1000mg

Child

15mg/kg

/dose

46 hourly asneeded. Max

60mg/ kg in

24 hrs. For no

more than 48

hrs

4-6 hourly

Max 60mg/ kg

(up to 4g) in

24 hrs. For no

more than 48

hrs

Analgesic

Antipyretic

S2 See NSWPolicy Di

PD2006-0

Precautionor hepatic

dysfunctio

Accidentaparacetam

hepatotox

Cephalexin Skin and skinstructure

infections. Caused

by Staphylococci

and/or

Streptococci.Infections due to

susceptible

organisms; see fullPI

Oral Adults:500 mg

Children:

7.5-25mg/kg

/dose

6 hourly

Daily dosage

1g-4g

6 hourly

Daily dosage

of 25mg-

50mg /kg/day

Antibiotic S4 Allergy tocephalosp

Major alle

penicillin

Precautio

Renal impGI disease

prolonged

pregnancylactation

Cephazolin Serious infections

due to susceptibleorganisms incl.

skin and softtissues.

IV

IV

IV

1g adult

Children

10-15mg/kg

/dose

OutreachCommunity

Service

WAHS 2g

Adults

8 hourly

Max 6g day

8 hourly

12 hourlyMax 6g day

Antibiotic S4 Allergy to

cephalospMajor alle

penicillin

Precautio

Renal imp

high doseprolonged

monitor W

lactation
http://c/TEMP/Precautionshttp://c/TEMP/Precautionshttp://c/TEMP/Precautionshttp://c/TEMP/Precautions


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Drug Indications Route Dose Frequency Therapeutic Poisons

Class Schedule

Contrain

Dicloxacillin

tablets orFlucloxacillin

suspension

Skin and skin

structure

infections. Caused

by Staphylococci

and/orStreptococci.

Infections due to

susceptibleorganisms; see full

PI

Oral Adults:500 mg

Children:

25mg/kg

Max

500mg

6 hourly

6 hourly

Antibiotic S4 Allergy topenicillin

Major All

cephalosp

Precautio

prolonged

pregnancy

lactation, Renal imp

Clotrimazole Tinea Corporis

Tinea crurisTinea pedis

Topical Children

>2 yearsandAdults:

Thin layer

BD

12 hourly Topical

antifungal

S2 Allergy to

clotrimaz

This formulary provides for the poisons and restricted substances that may be possessed, used, supplied or presc

section 17A of the Poisons and Therapeutic Goods Act 1966 and forms part of approved nurse practitioner guide

accordance with section 78A(2)(a) of the Nurses Act 1991.

It is the Nurse Practitioners responsibility to use this formulary in conjunction with their hospitals drug guidelin

available, including MIMS on line, Antibiotic Therapeutic Guidelines, and the Paediatric pharmacopoeia. The numentioned sources to identify correct dose, contraindications, precautions and adverse effects.

http://c/TEMP/Precautionshttp://c/TEMP/Precautions


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6. REFERENCES

1. Rosen,P. & Barkin, R. (1998). Emergency Medicine Concepts and Clinical Practice 4th

Ed. StLouis: Mosby Company.

2. Tintinalli,J. Ruiz,E. & Krome,R. (1996). Emergency Medicine A Comprehensive StudyGuide 4

thEd. New York:The McGraw-Hill Companies Inc.

3. Jones,V. & Harding,G. (2003). Wound Management A Constructive Approach. Australia:3M HealthCare.

4. Antibiotics 12th Edition, [Homepage Therapeutic Guidelines] [online] 2003 last

updated. Available: http://etg.hcn.net.au. [Accessed 10

th

September, 20035. MIMS: http://mims.hcn.net.au/

http://etg.hcn.net.au/http://mims.hcn.net.au/http://mims.hcn.net.au/http://etg.hcn.net.au/

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