Cellulitis and lymphoedemaCellulitis and lymphoedema

Vaughan KeeleyVaughan KeeleyVaughan KeeleyVaughan Keeley

May 2012May 2012

What is cellulitis?What is cellulitis?

-- also called erysipelas, acute inflammatory also called erysipelas, acute inflammatory

episodes etc.episodes etc.

-- bacterial infection of skin + subcutaneous bacterial infection of skin + subcutaneous

tissues tissues

-- more common in people with lymphoedema / more common in people with lymphoedema /

recurrentrecurrent

Why are people with lymphedema Why are people with lymphedema

prone to cellulitis?prone to cellulitis?

•• Lymph nodes / lymph vessels Lymph nodes / lymph vessels

are part of the immune systemare part of the immune system

•• In lymphoedema the local In lymphoedema the local

immune system is less effectiveimmune system is less effective

What does cellulitis feel / look like?What does cellulitis feel / look like?

•• fluflu--like symptoms and feverlike symptoms and fever

•• pain, redness, rash, increased swelling, pain, redness, rash, increased swelling,

warmth, tenderness, possible blistering / skin warmth, tenderness, possible blistering / skin warmth, tenderness, possible blistering / skin warmth, tenderness, possible blistering / skin

breakdownbreakdown

•• variation from person to personvariation from person to person

•• recurrent episodesrecurrent episodes

Data from UK Cellulitis Audit:Data from UK Cellulitis Audit:

Symptoms of cellulitis (n=396) %

Redness

Hot

More swollen

91

90

81

Rash

Unwell

Fever

53

82

69

Other symptoms included: itch, pain, blisters,

‘flu-like’ symptoms, nausea and vomiting.

Is it definitely cellulitis?Is it definitely cellulitis?•• features as abovefeatures as above

•• no specific testsno specific tests

•• some tests may be helpful:some tests may be helpful:--

white blood cell countwhite blood cell countwhite blood cell countwhite blood cell count

CRP CRP

swabs for cultureswabs for culture

blood culturesblood cultures

ASOTASOT

What else can it be?What else can it be?

•• raised venous pressureraised venous pressure

•• deep vein thrombosisdeep vein thrombosis

•• eczema / dermatitiseczema / dermatitis

•• contact sensitivitycontact sensitivity

etcetc

Which bacteria cause it?Which bacteria cause it?

•• Not entirely clearNot entirely clear

•• Beta haemolytic StreptococciBeta haemolytic Streptococci

•• Staphylococcus aureusStaphylococcus aureus

•• ? others (e.g. in genital cellulitis)? others (e.g. in genital cellulitis)

How is it treated? How is it treated? •• Antibiotics Antibiotics –– oral / intravenousoral / intravenous

•• Remove compression Remove compression –– temporarilytemporarily

•• Pain relief Pain relief -- ParacetamolParacetamol•• Pain relief Pain relief -- ParacetamolParacetamol

-- avoid nonavoid non--steroidalsteroidal

antianti--inflammatories (e.g. ibuprofen)inflammatories (e.g. ibuprofen)

•• RestRest

Which antibiotics?Which antibiotics?

•• BLS / LSN Consensus guidelinesBLS / LSN Consensus guidelines

www.thebls.comwww.thebls.com

www.lymphoedema.orgwww.lymphoedema.orgwww.lymphoedema.orgwww.lymphoedema.org

•• evidence of best treatment is lackingevidence of best treatment is lacking

Need for guidelines:Need for guidelines:

�� LSNLSN

�� patient experiencepatient experience

�� cellulitis not recognised / treated by cellulitis not recognised / treated by

HCPsHCPs

�� first produced 2005first produced 2005

Why a “consensus” document ?Why a “consensus” document ?

•• Lack of high quality evidence to Lack of high quality evidence to

guide managementguide management

•• Differing views on best managementDiffering views on best management•• Differing views on best managementDiffering views on best management

•• Differing views on causative Differing views on causative

organismorganism

Cochrane review (2010)Cochrane review (2010)

�� “cannot define best treatment “cannot define best treatment

for cellulitis”for cellulitis”for cellulitis”for cellulitis”

Principles adoptedPrinciples adopted

�� Target causative organismTarget causative organism

�� Consider duration of treatmentConsider duration of treatment�� Consider duration of treatmentConsider duration of treatment

�� Consider tissue penetration of Consider tissue penetration of

antibioticsantibiotics

Staph or Strep ?Staph or Strep ?

-- Microbiologists / existing guidance Microbiologists / existing guidance

(e.g. CREST) focus on Staph (e.g. CREST) focus on Staph

(except French Dermatologist (except French Dermatologist (except French Dermatologist (except French Dermatologist

Consensus 2001)Consensus 2001)

-- Chira & Miller (2010) suggest Staph. Chira & Miller (2010) suggest Staph.

is the most common cause of is the most common cause of

cellulitiscellulitis

Microbiology of cellulitis Microbiology of cellulitis

(Cochrane review)(Cochrane review)

�� only positive in 25% cellulitis in only positive in 25% cellulitis in

hospital (blood cultures, swabs, hospital (blood cultures, swabs,

FNA)FNA)

�� skin biopsies skin biopsies �� 80% due to 80% due to ßß--

haemolytic Strep. (gp A or G)haemolytic Strep. (gp A or G)

�� Staph. probably do Staph. probably do notnot cause cause

classical erysipelas but may classical erysipelas but may

sometimes cause cellulitissometimes cause cellulitis

Additional evidence for Strep.Additional evidence for Strep.

�� “anecdotal”“anecdotal”

�� apparent effectiveness of Penicillin V apparent effectiveness of Penicillin V �� apparent effectiveness of Penicillin V apparent effectiveness of Penicillin V

prophylaxisprophylaxis

�� blood culturesblood cultures

Lymphoedema or no lymphoedema:Lymphoedema or no lymphoedema:

is the cause different ?is the cause different ?

•• studies / guidelines don’t distinguishstudies / guidelines don’t distinguish

•• underlying lymphatic abnormality in those underlying lymphatic abnormality in those

presenting with first episode of cellulitis presenting with first episode of cellulitis presenting with first episode of cellulitis presenting with first episode of cellulitis

(without pre(without pre--existing overt oedema)existing overt oedema)

•• local immune deficiency in lymphoedemalocal immune deficiency in lymphoedema

Flucloxacillin v. AmoxicillinFlucloxacillin v. Amoxicillin

-- antianti--Streptococcal Streptococcal –– both antiboth anti--

Staphylococcal Staphylococcal –– FlucloxacillinFlucloxacillin

-- MIC for Fluclox. > Amoxicillin for MIC for Fluclox. > Amoxicillin for

Strep.Strep.Strep.Strep.

-- tissue penetration tissue penetration –– blister fluid blister fluid

Fluclox. < Amox. (protein binding)Fluclox. < Amox. (protein binding)

-- side effect profile side effect profile –– similar similar

according to eMCaccording to eMC

Drug resistance:Drug resistance:

�� Gp A Strep. Resistance reported for Gp A Strep. Resistance reported for

Clindamycin, Erythromycin + Clindamycin, Erythromycin + Clindamycin, Erythromycin + Clindamycin, Erythromycin +

Tetracycline but not Penicillins to Tetracycline but not Penicillins to

datedate

Conclusion / Consensus Conclusion / Consensus

�� Amoxicillin is preferredAmoxicillin is preferred

�� Flucloxacillin acceptableFlucloxacillin acceptable

�� Audit results Audit results –– no apparent no apparent

differencedifference

C.difficileC.difficile

�� concerns about use of a number of concerns about use of a number of

antibioticsantibiotics

ClindamycinClindamycin

CefalexinCefalexin

etc.etc.

especially as prophylaxisespecially as prophylaxis

Antibiotics at home: (oral):Antibiotics at home: (oral):

•• Amoxicillin 500 mg three times a day Amoxicillin 500 mg three times a day

for at least 2 weeks for at least 2 weeks

•• Flucloxacillin is an alternativeFlucloxacillin is an alternative

Antibiotics in hospital: (intravenous):Antibiotics in hospital: (intravenous):

•• if v. unwell, low blood pressure etc if v. unwell, low blood pressure etc

or getting worse on oral antibioticsor getting worse on oral antibiotics

•• Flucloxacillin 1 g every 6 hrs until Flucloxacillin 1 g every 6 hrs until

temperature normal etc. then oraltemperature normal etc. then oral

What may cause an episode of cellulitis?What may cause an episode of cellulitis?

•• Broken skinBroken skin -- cutscuts

-- insect bitesinsect bites

-- Athlete’s foot / fungal infectionAthlete’s foot / fungal infection

-- eczema / dermatitiseczema / dermatitis-- eczema / dermatitiseczema / dermatitis

-- ulcersulcers

-- ingrowing toenailingrowing toenail

•• OthersOthers -- ? sore throat? sore throat

-- ? stress? stress

Recurrent cellulitisRecurrent cellulitis

UK surveyUK survey -- 396 patients with 396 patients with

lymphoedema and lymphoedema and

cellulitiscellulitis

-- 76% had previous 76% had previous -- 76% had previous 76% had previous

episodes of cellulitisepisodes of cellulitis

-- average 1.8 episodes in average 1.8 episodes in

previous yearprevious year

Why is this a problem?Why is this a problem?

•• acute cellulitis acute cellulitis –– unpleasant, may unpleasant, may

need hospital admission; loss of time need hospital admission; loss of time

at work etc.at work etc.at work etc.at work etc.

•• cellulitis damages lymph vessels cellulitis damages lymph vessels

making lymphoedema worsemaking lymphoedema worse

Reducing the chance of getting Reducing the chance of getting

cellulitis: cellulitis:

•• Skin careSkin care

•• Control of swellingControl of swelling

PrecautionsPrecautions

-- insect repellentinsect repellent

-- antiseptic creams antiseptic creams for cutsfor cuts

-- treat dermatitis, treat dermatitis, ingrowing toenail, ingrowing toenail, ingrowing toenail, ingrowing toenail,

Athlete’s foot etcAthlete’s foot etc

-- avoid cuts e.g. avoid cuts e.g. gloves when gloves when

gardening, avoid gardening, avoid bare feet in gardenbare feet in garden

Prophylactic antibiotics?Prophylactic antibiotics?

-- if 2 or more episodes of if 2 or more episodes of

cellulitis in 1 yr. cellulitis in 1 yr.

-- address risk factorsaddress risk factors-- address risk factorsaddress risk factors

-- control swelling control swelling

-- Phenoxymethylpenicillin Phenoxymethylpenicillin

(1 year to begin with)(1 year to begin with)

Websites:Websites:

Consensus document + rationale for Consensus document + rationale for

Amoxicillin v. Flucloxacillin:Amoxicillin v. Flucloxacillin:

www.thebls.comwww.thebls.comwww.thebls.comwww.thebls.com

www.lymphoedema.orgwww.lymphoedema.org