adult primary care

7/30/2019 Adult Primary Care

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Primary Care Cellulitis Pathway

1 Cellulitis Pathway/ LCRCHS/Version 9/ July 2011

Adult Primary CareCellulitisPathway

(Excluding Inflammatory Episodes of Lymphoedema)

Version 9 July 2011


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Index

Page Number

Introduction and Classification3-4

Pathway5

Medication recommendations 6

Primary Care Cellulitis Pathway Flowchart11

Guidance on Blood sampling12

Appendicies

A Patient information sheet13

B Audit Tool all nursing staff

15C Intermediate Care Team Cellulitis Referral Tracking Form

16

D Care Plan all nursing staff17

E Monitoring Chart all nursing staff19

F UHL Emergency Department Primary Care Nurse AuthorisationTemplate

21

G UHL Emergency Department Flowchart and decision tool 22

H Review record 24

Originating Authors: Jenny Dowling, Kate Baxter, Joanne Charles, Karen Connor, Carolyn WheatleyAndrew St John, Yvette Canty, Helen McCreedy, Sam Kirkland, Rowena Langtry, Mary Marson, KateDawson, Sayed Bukhari

This version reviewed by: Dr A St John, Dr S Bukhari, Dr M Wiese, Miss C Whittingham


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Community Cellulitis Pathway (CCP)

IntroductionDuring the period April 2005 to March 2006 UHL reported that approx 2000 patients hadbeen admitted to the acute hospital beds with a primary diagnosis of Cellulitis.

Whilst being aware that not all practises have admitted patients to acute beds with Cellulitisit is anticipated that this pathway will reduce the need for admission as well as the re-admission of patients with recurrence by using best practice in prescribing and treatment.

The classification system

Eron LJ (2000) devised this classification system of skin and soft tissue infections to aid theGP/Nurse diagnosis, treatment and admission decisions.

Severity Classification

Class 1 patients neither have features of systemic infection nor any of the comorbiditiesbelow

Class 2 patients EITHER are systemically affected (i.e. have a temperature > 37.9C

or are vomiting)OR

have one ormore comorbidities; i.e.

Peripheral vascular disease Treated diabetes or BM > 11 Chronic venous insufficiency Morbid obesity (i.e. BMI 40) Liver cirrhosis

Class 3 patients EITHER are clinically unstable, e.g. have

Acutely altered mental status Heart rate > 99/min Respiratory rate > 20/min

Systolic BP < 100mmHgOR

have unstable comorbidities; i.e. Uncontrolled diabetes Varicose ulcer Peripheral vascular disease with critical ischaemia or arterial ulcer

Class 4 patients have a systolic BP of < 90mmHg or other features of severe sepsis or life-threatening infection, such as necrotizing fasciitis (NB: Such patients may need surgery)

Clinical findings alone are usually adequate for diagnosing cellulitis, particularly innon-toxic immunocompetent patients.


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Complicated and uncomplicated cellulitis

Please note that only uncomplicated cellulitis is suitable for treatment in the community.This includes Class I & II of the above classification i.e. localised inflammation as a result ofskin and soft tissue infection without any systemic upset that involves superficial tissues.Uncomplicated cellulitis is usually caused by a single organism and carries an excellentprognosis. Most patients with uncomplicated cellulitis will respond well to standard oralantibiotics. However, those patient who cannot tolerate oral medications, or are nil bymouth, or do not respond to oral therapy may be selected for outpatient intravenousantibiotics.

Complicated cellulitis on the other hand is invasion of deep tissues and is oftenpolymicrobial in nature. It may be associated with profound systemic upset and may requiresupportive therapy and surgical intervention in addition to intravenous antibiotics e.g.

cellulitis associated with gangrene, necrotizing fasciitis, myonecrosis, abscess formation,diabetic foot ulcer, trauma, infected burns or cellulitis in an immunocompromised patient.Class III & IV of the above classification will fall into complicated cellulitis. Please note thatcomplicated cellulitis is unsuitable for treatment in the community and all cases ofcomplicated cellulitis should be managed in an acute hospital.

For all Lymphoedema patients please refer to LOROS

guidelines.


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Primary Care Team led diagnosis for patients remaining in communityenvironment. (Own / residential /nursing home or community hospital)

Class I and II - Drug Therapy recommendations Page 6

Self-caring

Issue advice leafletConsider analgesia. BNF section10.1.1 re NSAIDsArrange SOS follow-up

Agree a maintenance plan with Multi Disciplinary Team

e.g. GPCommunity MatronDistrict NursesSelf-referral of exacerbation

Consideration should be given regarding referral to specialist services at anystage of this pathway

e.g. DermatologistDiabetologistPodiatrist

Note of caution: Face/orbit involvement/signs of septicaemia refer to acute hospital

Refer to Intermediate CareTeam/District Nurse if:

Administration of IV antibiotics. Additional healthcare input required to

support or supplement existing socialcare package

Medication compliance / review ofpatient condition / response to therapy.

Admit to Community Hospital/Nurse-led unit if:

Administration of IV antibiotics Patient cannot be supported at home Closer monitoring by nursing staff is

considered necessary

Domestic environment is clinicallyunsuitable

Symptoms/signs improveContinue antibiotics as per

recommendationsSymptoms persist

Continue with oral therapybut consider addition of IV

therapy.Deterioration or

no improvement after 48hours IV therapy

Admit to acute bed.


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Guidelines for the Treatment of Adult Patient with Cellulitis in Primary Care

Patients with cellulitis considered to be due to MRSA should be discussed with a microbiologist.

Indication 1st Line Penicillin Allergic PatientsClass 1

Localised cellulitis in otherwisefit individual who can tolerateoral antibiotics

PO Flucloxacillin 500mg qds for 7

days

PO Doxycycline 200 mg once daily

for 7 days

Class IIOR for patients in Class 1 withnoresponse to therapy ordeteriorating while on treatment

NO RESPONSE - does not meanthat the redness is not resolving this may take some time. It meansthat the clinical picture is worsening

e.g. the redness is spreadingbeyond the original boundaries and/ or the patient is becomingsystemically ill

Day 1 IV/IM Teicoplanin 400 mgevery 12 hours for 2 dosesDay 2-5 IV/IM Teicoplanin 400 mgdailyDay 6 and 7 PO Flucloxacillin 500mg qds

IN RENAL IMPAIRMENTeGFR


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AnalgesiaPatients requiring pain relief and /or treatment of fever should be prescribed an analgesic.Use paracetamol as a first choice of agent.

NSAID use is associated with an increased risk of GI bleeding this is of particularconcern in people considered to be at high risk, which includes all patients over theage of 65 years (see BNF section 10.1.1).

If an NSAID is necessary, use the lowest NSAID dosage compatible with symptom relief(ibuprofen is generally preferred) Gastric protection may also be required to minimizeadverse GI events in someone at high risk for whom NSAID continuation is necessary. Seep8.

Admission to Acute Hospital

Class III and IV

Class III patients may have a significant systemic upset such as acute confusion,tachycardia, tachypnoea and hypotension or may have unstable co-morbidities that mayinterfere with a response to therapy or have a limb threatening infection due to vascularcompromise.

Class IV patients have sepsis syndrome or severe life threatening infection such asnecrotizing fasciitis.

Admission to the acute hospital is necessary when:

Patient has history of severe reaction to penicillin.

Cellulitis affects face or orbit

Patient is IV drug user (may use community bed)

Where there is no improvement after 48 hours IV therapy

Vomiting where anti-emetics are ineffective after changing to parenteral route

Severe or rapidly worsening infection

Unstable Diabetes mellitus where sliding scale insulin is considered necessary


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Guidance for Community staff.

Clinical assessment in primary care to establish diagnosis and severity basedon local and systemic signs, history and investigations.

Clinical history, including

Previous episodes

Duration of present episode

Symptoms of fever

Itching

History of local lesions, insect bites, indwelling device, IV drug abuse, injury

History of other predisposing conditions eg diabetes, lymphoedema,immunosupression

History of allergies to penicillin, or cephalosporins

Social and domestic circumstances

Clinical examinationOutline visible margin of cellulitis with indelible marker to allow subsequent clinical assessmentof progress.

Temperature, Blood pressure.Signs of septicaemia (severe pyrexia, tachycardia, hypotension, confusion,tachypnoea, vomiting)

Local clinical presentation

Unilateral or bilateralEczematous or cellulitic or bothEvidence of deep vein thrombosisLymphangitis, tender regional lymphadenopathy

Predisposing causes

Lymphoedema, ulcer, lipodermatosclerosis, varicose veinsPeripheral pulsesToeweb scaling suggestive of candida or tineaInjury including insect bites, indwelling device

Complicating clinical conditions

e.g cardiac failure pneumonia

Underlying malignancy diabetesMRSA carriage ImmunodeficiencyLiver or renal failure

Investigations that may be indicated see CREST(2005) document for laboratory advice.Swab for causal organism (usually group A Streptococci) if skin integrity broken.Urinalysis, especially glucoseBlood culture (for suspected septicaemia) acute sectorC-reactive proteinFull blood count especially white cell count and haemoglobinBlood chemistry, especially LFT and Urea & Electrolytes

Appropriate resuscitation facilities must be available in the clinical area.Patients with a history of significant penicillin allergy should be admitted.


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Treatment of Cellulitis

Diagnose and treat predisposing causes, including tinea pedis, leg ulcer and lymphoedemaConsider antibiotic prophylaxis in patients who have more than one attack of cellulitis in ayear www.prodigy.nhs.uk and www.crestni.org.uk

Treatment should be started immediately familiar symptoms of cellulitis arise, but a medicalopinion should also be sought as soon as possible

If a recurrence occurs a change of therapy may be indicated in consultation withmicrobiologist.

A first attack of cellulitis following a human or animal bite or lick

Consider infection with Pasteurella multocida, Eikenella corrodens or Capnocytophagacanimorsus.These organisms respond best to co-amoxiclav 625mg tds for 5 days, (if penicillin allergicgive doxycycline 200mg od and metronidazole 400mg tds for 5 days for animal bites or

metronidazole 400mg tds and erythromycin 500mg qds for 5 days for human bites).These infections may be serious and require surgical exploration, particularly if presentationis delayed or the hand is involved. Any deterioration in condition refer immediately toInfectious Diseases.

Avoid compression as it may push infection proximally, but affected limb should be elevated

Treat predisposing causes and ensure proper follow-up, including managementof any subsequent lymphoedema (patient and GP to be supplied with suggestedguidelines for future management following resolution of cellulitis.

Patients requiring pain relief and /or treatment of fever should be prescribed an analgesic.Use paracetamol as a first choice of agent.

NSAID use is associated with an increased risk of GI bleeding this is of particularconcern in people considered to be at high risk that includes all patients over the ageof 65 years (see BNF section 10.1.1).If an NSAID is necessary, use the lowest NSAID dosage compatible with symptom relief(ibuprofen is generally preferred) Gastric protection may also be required to minimizeadverse GI events in someone at high risk for whom NSAID continuation is necessary. NBPast reports suggest that NSAIDs may increase the risk of streptococcal cellulitisdeveloping into life-threatening necrotizing fasciitis.

Please note:(i) that a 63-paper review concludes that prospective studies do not support suggestionsthat NSAID therapies play a causal role in increasing the risk of streptococcal necrotisingfasciitis (Aronoff & Bloch, Medicine 82: 225-235, 2003), but (ii) that the same papersuggests that NSAIDs may alleviate symptoms of streptococcal necrotising fasciitis,resulting in a delay of appropriate diagnosis and treatment.


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References:

www.crestni.org.ukwww.prodigy.nhs.uk

Bibliography

Eron , L.J 2000 Infections of skin and soft tissues: outcome of a classification scheme.Clinical Infectious Disease, 31,287.

Eron, LJ et al 2003. Managing skin and soft tissue infections: expert panelrecommendations on key decision points. Journal of Antimicrobial Chemotherapy(2003)52, Suppl. S1, i3i17

Microbiology, Infectious Disease and Pharmacy Departments, Oxford John RadcliffeHospitals. 1/10/2006. Guide to use of antibacterials.

Kettering General Hospital NHS Trust. May 2006. Antibiotics: Empiric treatment of commonconditions, antibiotic prophylaxis in surgery and other issues relating to the use of antibioticsin adults.

Seaton R A. Bell E. Gourlay Y. Simple L. 2005. Nurse led management of uncomplicatedcellulitis in the community: Evaluation of a protocol incorporating intravenous ceftriaxone.

HerchlineT et al. http://emedicine.medscape.com/article/214222-overview

Cellulitis - acute. http://www.cks.nhs.uk/cellulitis_acute#-336655

Guidelines on the Management of Cellulitis in Adults. CREST (Clinical Resource EfficiencySupport Team, Northern Ireland) June 2005(http://www.crestni.org.uk/publications/cellulitis/cellulitis-guide.pdf)

British National Formulary (BNF) No. 52 (September 2006)

References: Prodigy Treatment of Cellulitis Jan 09. British National Formulary September2008. Clinical Evidence May 2005 - What are the effects of treatments for cellulitis anderysipelas?


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Primary Care Cellulitis Pathway Flowchart

Severity Classification

Class 4 patients have a systolic BPof < 90mmHg or other features ofsevere sepsis or life- threateninginfection, such as necrotizingfasciitis (NB: Such patients mayneed surgery)

Class 3 patients EITHERare clinically unstable, e.g. have

Acutely altered mental status Heart rate > 99/min Respiratory rate > 20/min Systolic BP < 100mmHgOR

have unstable comorbidities; i.e. Uncontrolled diabetes Varicose ulcer Peripheral vascular disease

with critical ischaemia orarterial ulcer

Class 2 patients EITHERare systemically affected (i.e.have a temperature > 37.9

C

or are vomiting)OR

have one or more comorbidities;i.e.

Peripheral vascular disease Treated diabetes or BM > 11 Chronic venous insufficiency Morbid obesity (i.e. BMI

40)

Liver cirrhosis

Class 1 patients neither havefeatures of systemic infection norany of the above comorbidities

Refer to appropriatespecialty for

immediate admission

Primary care clinician diagnoses cellulitis

Severity class III or IV orOPAT contraindications present?

N

Y

Discharge

During office hoursLocal pharmacyOut of hoursPO antimicrobials - use PGDIV antimicrobials - call dutypharmacist via Fosse House

Unable to be supported at home? Closer monitoring considered necessary? Domestic environment unsuitable?

N

Y

Severity Class II? Poor compliance anticipated? Unable to self-monitor response? Additional healthcare input required

to support or supplement existingsocial care package?

Y

N

Refer to district nurses /intermediate care team

Satisfactory progress?

Y

N

Need for maintenance?

Y

N

Further input as required

Consider (depending onspecific clinical situation)

Medical reviewSwitch from Class I to

Class II antimicrobialtherapyAcute hospital admission

Consider Severity classification (see LEFT box) Contraindications to Outpatient Parenteral

Antimicrobial Therapy (OPAT; see RIGHT box) Outline leading edge with indelible marker Document affected area

on body map (Appendix E)

Contraindications to OPAT

Facial or orbital involvementRapidly progressive infectionIVDU (NB: considercommunity hospital bed ratherthan acute admission)Already on OPAT since 48h,or getting worse in spite of itPersistent vomiting in spite ofparenteral antiemeticsImmunosuppression

Patient to self-monitor progress

Issue patient information leaflet (PIL;see Appendix A) after filling in the

appropriate emergency contact details

Prescribe and supply appropriateantimicrobial (guidance on page 6)

Consider analgesia

Admit to communityhospital or nurse-led unit


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Guidance on Blood Sampling to inform IV antibiotic dosing

It is the responsibility of the nurse to ensure that the blood sample forRenal Function is taken and obtain the result.

It is a suggestion that the sample is taken on Day 1 or 2. If this at aweekend staff may wait till Monday and place in URGENT bag at theGP surgery.

The aim is to obtain the result prior to the Day 5 dose.

If there is evidence of renal impairment then the nurse would need toget the authorisation sheet changed to reflect that on the 5th day thefinal IV / IM Teicoplanin dose must be omitted, or get the IVFlucloxacillin dose amended.

The change on the authorisation sheet should be made by theprescriber or in exceptional circumstances a verbal message can betaken as long as it is backed up by a fax / text from a doctor /

microbiologist.


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Patient Information Sheet Cellulitis Appendix A

You have been diagnosed with a condition called Cellulitis; this is an acute infection of theskin layers.

Instead of automatic admission to hospital you have been assessed as suitable to receiveall or most of your medication and treatment at home from the Intermediate Care/DNTeam. You may need a one off hospital assessment with discharge on the same daywhen and you will then be sent home for the rest of your treatment.

It is important that if there are any changes in your condition or you experience any of thefollowing symptoms, you inform the Intermediate Care/DN Team or your GP immediately.

The redness and swelling spreads further. You start to feel feverish or more unwell Pain increases You feel warmer and your temperature is rising You become confused Your blood glucose levels become unstable (Diabetics only)

You can help aid your treatment by: -

Finishing the course of any prescribed oral antibiotics, even though you may feelbetter and the redness is subsiding.

If your cellulitis is on your leg you must sit and elevate it above hip level. If it affects

your arm lift lower arm above level of elbow. If this is uncomfortable lie on a sofa or bed as much as possible to help the

drainage and circulation in the limb. Although rest and elevation are essential, you must also mobilise your ankle joint

and walk to the toilet. It is important that you take pain relief so that you are able to exercise your ankle

and mobilise to the toilet. Important to drink plenty of clear fluids eg. water, squash and tea.

Passive ankleexercises


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Aftercare

Once the acute stage has passed and the inflammation is subsiding, it is important to care

for the skin on your legs to prevent further problems: -

Wash feet/legs daily in warm water using non-soap/non perfumed moisturiser e.g.Aqueous cream or Hyromol.

Do not allow scabs or dry skin scales to form, these can allow bacteria to build upunderneath un-noticed and are a potential source of further infection.

As the cellulitis gets better the surface layer of skin will loosen and slough off, it isimportant to maintain skin hygiene and moisturise the skin regularly e.g. morningand evening to increase elasticity and suppleness and prevent cracking anothersource of infection.

Avoid direct exposure of your legs to sunlight or trauma.

If you have been advised to wear compression hosiery, renew these every 3months as they can lose their effectiveness over time. You will need to measurethe largest part of your ankle and calf or your pharmacist can measure these for youso that the correct size hosiery is ordered.

The moisturisers/emollients can reduce the lifetime of the elastic in your hosiery,therefore allow time for it to soak in or apply in the evening after removal of hosiery(a stockinette can be applied to protect your bed linen e.g. Clinifast

GP NAME:PHONE NO:....

INTERMEDIATE CARE TEAM:

NAMED NURSE:PHONE NO:

DISTRICT NURSE

NAME: PHONE NO:

WEEKEND/BANK HOLIDAY CONTACT NO:


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Audit Tool Appendix B

Please complete all areas of the form for each patient presenting with or developing cellulitis

Locality GPs Name PatientDate of Birth

Date

N&S Charnwood / Melton/RutlandHarb & S.Leics / Hinckley & Bosworth

North West Leicestershire/Leicester City

1. Who was the patient referred by?

DN Active on Caseload EMAS

Community Matron GP OtherProfessional

Out of Hours GP

2. Who received the referral? DN Out of Hours GP Community

Hospital Rapid Response/Intermediate Care

3. Had the patient been previously admitted to acute hospital with cellulitis Yes No

Was this the same site/limb? Yes No

Timescale ..

4. Time of day referral received? AM PM Out of Hours

5. Treatment Oral Antibiotics IV & Oral Antibiotics

6. Adverse drug reaction? Yes NoDetails ..

7. What was the outcome of treatment?

Discharge Admission UHL Remain on caseload formaintenance

Please return the completed form to locality lead as soon as possible following

treatment. Weekly return on Mondays by 11am Fax 01509 568883

Appendix 1


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Referral Tracking Form Appendix C

Patient Name: G.P.

Date of Birth

Address:

Surgery Address:

Phone No.: Phone No.:

Access/Key safe details: Fax No.:

Emergency Contact:: Emergency Contact Address:

Referrer:

Medical History:

Phone No.:

Allergies: Referral Date:

Please tick appropriate box:

Hospital Avoidance?

Early Discharge?

1st Episode of Cellulitis?

Recurring bout of Cellulitis? How many times?

Past treatment

Swabbed Date taken

Urinalysis? Date taken

FBC? Date taken

U & Es? Date taken

Area marked on diagnosis

Oral antibiotic therapy prescribed details .

IV Antibiotic therapy prescribed details .

Prescription supplied

Equipment supplied (see equipment list)

Venflon in situ

Audit sheet initiated

Accepted If no why not

Signature: Status

Date .


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Care Plan Appendix DVersion4amended 06/09

Name: Care Plan No.

Address: NHS No.

Date of Birth:

Date Identified Need Signature

has been diagnosed with Cellulitis affecting

...

Date Plan of Care/Patient Goal(Including stages)

As negotiated and with verbal consent of The patient/nursing goals will be to resolve theCellulitis infection with the aid of oral / IV / IMantibiotics.

1. Ensure that all procedures are clearly explained to and consent obtained

2. Monitor and record vital signs 8 Hrly in the initial

stages of treatment. A clinical decision may bemade to reduce monitoring if patient is clinicallystable and is able and aware of how to contactteam if necessary.

3. Check between the toes for fungal infection andtreat as required. Record findings and actions.

4. Record site and point of entry on reverse ofcellulitis chart.

5. Ensure all fields are completed at EACH visit.

6. Ensure that antibiotics are administered asprescribed


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7. If cannula in situ, check patency and observe forsigns of extravasation / inflammation. Recordstatus. Resite cannula as required. Consider IM ifvenous access poor.

8. Ensure that IV / IM medication is administered asprescribed following trust policy. IV monographs

are available through the LMSG website.

9. Undertake blood samples to test Renal function.Obtain result as per guidance. Discuss withreferrer / prescriber if difficulty is anticipated inobtaining sample or results. Record conversationand decisions.

10. Document the date and time the sample is takenand results obtained.

11. Refer to prescriber / Dr / Microbiologist for doseomission. Obtain authorisation with fax or textevidence.

12. Document if ..is experiencing pain / discomfort from the infectedarea. Advise simple analgesia e.g. Paracetamol ifnot contra-indicated or refer to GP / NursePrescriber for prescription of oral analgesia. Painchart to be in notes. Monitor pain control andrecord effect on pain chart.

13. Encourage elevation of affected limb (do not apply

compression as it may push infection proximally).

14. Send swab for M, C & S if clear route for infection.E.g. insect bite or exudates present.

15. Record date sent.

16. Record result.

17. Assess if . is weightbearing;

18. Refer to Physio / OT for assessment for aids /equipment / mobility if required...

19. If cellulitis is not improving or deterioration is seenrefer for medical review.

20. Ensure patient has Information leaflet and is awareof how to contact team.

21. Complete audit form and return to local lead whencare episode is complete


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Cellulitis ChartName:- . Date of Birth:

Oral or IV medication:- .

Date

Visit No

Temperature

Blood Pressure

Pulse

Respiratory Rate

BM

Vomiting?

Swab of area taken?

Pain (ie, on movement, at rest)

Hot to touch?

Colour of cellulitis

Spread outside of marked area

or reduced in size

Weight bearing?

Signature


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Primary Care Nurse Authorisation Appendix F

Emergency Department (ED)Leicester Royal Infirmary

Infirmary SquareDateLeicester, LE1 5WW

ED Majors desk 0116 258 6385EDU desk 0116 258 6214ED office fax 0116 204 7935

Re:

Dear District Nurse,

This letter authorizes you to administer the following medication(s) to the above named patient:

Drug name Dose Route Frequency Duration

This is not a prescription a copy of the prescription is attached

Yours sincerely,

Signature Role / job title Print Name


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Appendix G

This patient was managed by

Print name Signature Position Date Time completed

This patient was managed by

Print name Signature Position Date Time completed

Version19

.Jun11

DesignedbyMFWieseas

partoftheLeicestershire

AdultPrimaryCareCellulitisPathway.v9.Jul11

(use sticker if available)


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mark the appropriate regimen by ticking the box


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Review Record

Date Issue

No.

Reviewed By Description of change (if any)

December

2008

2 Andrew St John (Chairman) Assistant MedicalDirector UHLSayed Bukhari Consultant Microbiologist UHL(Antimicrobial Lead Clinician)Kate Parsons Principal Pharmacist UHL(Antimicrobial Prescribing)Lesley Tooley Education Lead N. West LeicesterMark Millar Education Lead South Leicestershireand Melton MowbrayAnne Richardson Single Point of Access Lead(LCRPCT)Lynn Spencer TV Lead N. West LeicesterLynn Angrove Nurse ManagerSonia Barnes Locality Pharmacist (LCPCT)Helen Knight Medicines Governance Pharmacist(LCPCTCo-ordinator Intermediate Care (LCPCT)Sue Maguire Divisional Medicine ManagementLead (LCRPCT)Kerry OReardon Intermediate Care Manager(LCPCTSystem One Change Manager (LCRPCT)

March

2010

3 Dr A St John, Dr S Bukhari, Mrs K Dawson Addition of advice: if cellulitis consideredto be due to MRSA..Addition to notes on administrationadvise if switching from Flucloxacillin toTeicoplaninAdditional wording Rapidly deterioratingcellulitis with purple discoloration and/orsevere pain may indicate necrotisingfasciitisRevision of penicillin allergic animal andhuman bite antibiotic recommendations

July 2011 4 Dr A St John, Dr S Bukhari, Dr M Wiese,Miss C Whittingham

Updated guidance in renal impairmentClassification of cellulitis clarifiedFlow chart up datedLRI ED flowchart added to appendixUHL Primary Care Nurse Authorisationadded as appendix

adult primary care

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