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