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Nurse Practitioner Clinical Practice Guidelines

for the

Management of Cellulitis
All 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, and
therefore reflect the specific scope of practice of the position and the operation of
the AHS.

Therefore, prior to use by Nurse Practitioners in other positions, the guidelines will
need to be reviewed and adapted as necessary to address local scope of practice
and Area Health Service needs. The adapted guidelines must also be approved in
writing by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive
2005_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: Classification:
Sydney West Area Health Service NP Guideline

Nurse Practitioner Guideline Page 1 of 13


Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

Contents: page

Purpose 3
Guideline 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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Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

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 Practitioner
has 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 patient’s aged 1yr + who present with cellulitis.

Guideline Development and Reviewers Group

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

Byndie Warrick BA, MN


Nurse Practitioner, Nepean Emergency Department

Arlene Bannon BA, Grad Dip Critical Care Nursing, MN


Nurse 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)

Nurse Practitioner Guideline Page 3 of 13


Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

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 proper
methods 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 diagnostic
and 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 a
dynamic document that should be reviewed and revised by those who use it as the basis of their
Local Guidelines.

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

Review Date- December 2006.

Area: Classification:
Sydney West Area Health Service NP Guideline
Nurse Practitioner Guideline Page 4 of 13
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

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 lymphatic
dissemination 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 tends
to 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. Recent
studies 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 and
their products is what produces the majority of the symptoms producing a significant anti-
inflammatory response (2).

Area: Classification:
Sydney West Area Health Service NP Guideline

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Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS.

2. Assessment and Examination

Detailed medical and surgical history including age, gender, occupation, current medications, alcohol
and 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

Nurse Practitioner Guideline Page 6 of 13


Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

Referral triggers include: (staff specialist review)


Diabetes
Neuropathic limb
Sepsis
Chronic ulcer
Osteomyelitis
Bursitis
Immunocompromised – eg. Steroid use, cirrhosis
Impaired wound healing
Non-blanching rash
Orbital involvement
Peri - orbital cellulitis
Cellulitis involving the hand or upper limb
History of water contact
Bites
Traumatic crush injury
Major (type1) allergy to beta lactams
Significant 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 intervention
Neutropenia
Blood dyscrasia/ blood loss/ anemia

Blood Culture - T>37.5, toxic clinical picture

BSL – Children < 12 years

EUC - Relevant co- morbidities


LFT- 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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Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

Management of Cellulitis

Refer to the flowchart p.9

Differentials
Healing wound
Inflammation
Allergic reaction
Bursitis
Osteomyelitis
Embedded foreign body
Gout
Fracture/ Charcot foot
Varicella
Erythema nodosum
Erythema multiforme
Chronic dermatitis

Area: Classification:
Sydney West Area Health Service NP Guideline

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Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

CELLULITIS Referral Criteria


History and Examination Systemic involvement
(See page 6) Diabetes
Neuropathic limb
Chronic ulcer
Osteomyelitis
Bursitis
Immunocompromised - Steroid use, cirrhosis
Impaired wound healing
Embedded foreign body
Orbital involvement
Peri orbital cellulitis
Cellulitis involving the hand and upper limb
History of water contact
Bites
Traumatic crush injury
Significant renal impairment
Sudden & localised – Major (type1) allergy to beta lactams
erythema, swelling, pain,
warmth, tenderness,
erythema, soft tissue NO
involvement only (Consider differentials p.7)

YES

Order relevant
investigations (p.7)

Cellulitis - Discharge Cellulitis


No systemic toxicity WCC < 5 >15
No induration, Systemic toxicity
No extensive radiation of inflammation, Extensive Distal/proximal radiation of
Consider: inflammation, induration
Oral Antibiotics (as per formulary) Oral antibiotics ineffective or vomiting
Analgesia - Paracetamol Co-morbidities – inc. renal or liver impairment
Rest/elevation (may require antibiotic adjustment)
(Wound management per NP Wound Immunocompromised – cirrhosis, diabetes
guideline) Refer to Staff Specialist/Reg - Consider
Discharge Home possible Outreach referral or Admission,
Review with GP 24-48 hrs IV AB’s, Rest/elevation/analgesia.

Area: Classification:
Sydney West Area Health Service NP Guideline

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Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

4. Discharge

See flow chart page 10.

A General Practitioner should review patients discharged with cellulitis within 2 days. Instruct the
patient to return to the Emergency Department if they become systemically unwell or there is
significant 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

Nurse Practitioner Guideline Page 10 of 13


Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

5. Formulary
Drug Indications Route Dose Frequency Therapeutic Poisons Contraindications Adverse
Generic Class Schedule Effects
Paracetamol Temporary relief of Oral Adult & 4–6 hourly as Analgesic S2 See NSW Health Dyspepsia, nausea,
See NSW pain. Reduces fever Children needed. Max Antipyretic Policy Directive allergic and
Health Policy > 12 yrs 60mg/ kg in PD2006-004 haematological
Directive 500mg to 24 hrs. For no Precautions – renal reactions
PD2006-004 1000mg more than 48 or hepatic
hrs dysfunction.
Accidental
Child 4-6 hourly paracetamol
15mg/kg Max 60mg/ kg hepatotoxicity
/dose (up to 4g) in
24 hrs. For no
more than 48
hrs
Cephalexin Skin and skin Oral Adults: 6 hourly Antibiotic S4 Allergy to Superinfection
structure 500 mg Daily dosage cephalosporins, pseudomembranous
infections. Caused 1g-4g Major allergy to colitis; GI upset;
by Staphylococci penicillin sensitivity
and/or Children: 6 hourly Precautions: phenomena
Streptococci. 7.5-25mg/kg Renal impairment;
Infections due to /dose Daily dosage GI disease;
susceptible of 25mg- prolonged use;
organisms; see full 50mg /kg/day pregnancy,
PI lactation

Cephazolin Serious infections IV 1g adult 8 hourly Antibiotic S4 Allergy to Superinfection


due to susceptible Max 6g day cephalosporins, Pseudomembranous
organisms incl. IV Children Major allergy colitis;
skin and soft 10-15mg/kg 8 hourly penicillin thrombophlebitis;
tissues. /dose Precautions: sensitivity
Renal impairment; phenomena;
Outreach 12 hourly high doses, haematological
Community Max 6g day prolonged use; abnormalities
IV Service monitor WBC;
WAHS 2g lactation
Adults
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Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

Drug Indications Route Dose Frequency Therapeutic Poisons Contraindications Adverse Effects
Class Schedule
Dicloxacillin Skin and skin Oral Adults: 6 hourly Antibiotic S4 Allergy to Gastrointestinal
tablets or structure 500 mg penicillin disturbances, allergy,
infections. Caused Major Allergy to Cholestatic hepatitis,
Flucloxacillin by Staphylococci Children: 6 hourly cephalosporins, renal impairment,
suspension and/or 25mg/kg Precautions: increased risk of
Streptococci. Max prolonged use; seizures and coma.
Infections due to 500mg pregnancy,
susceptible lactation, elderly,
organisms; see full Renal impairment
PI

Clotrimazole Tinea Corporis Topical Children 12 hourly Topical S2 Allergy to Pruritus, skin
Tinea cruris >2 years antifungal clotrimazole irritation
Tinea pedis and
Adults:
Thin layer
BD

This formulary provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by nurse practitioners under
section 17A of the Poisons and Therapeutic Goods Act 1966 and forms part of approved nurse practitioner guidelines, in
accordance with section 78A(2)(a) of the Nurses Act 1991.

It is the Nurse Practitioner’s responsibility to use this formulary in conjunction with their hospitals drug guidelines and the most recent MIMS
available, including MIMS on line, Antibiotic Therapeutic Guidelines, and the Paediatric pharmacopoeia. The nurse practitioner should use the above-
mentioned sources to identify correct dose, contraindications, precautions and adverse effects.

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Area: Classification:
Sydney West Area Health Service NP Guideline
Subject:
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CELLULITIS

6. REFERENCES

1. Rosen,P. & Barkin, R. (1998). Emergency Medicine Concepts and Clinical Practice 4th Ed. St
Louis: Mosby Company.
2. Tintinalli,J. Ruiz,E. & Krome,R. (1996). Emergency Medicine A Comprehensive Study
Guide 4th Ed. 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 10th September, 2003
5. MIMS: http://mims.hcn.net.au/

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