Guidance for Home Intravenous Management of
Uncomplicated lower limb cellulitis
Introduction:
Cellulitis is one of the common problems in patients attending A&E and MAU. Until recently those
patients requiring IV antibiotics needed hospital admission. However in the past 10 years
increasingly these patients are being treated in the community.
A number of studies suggest that IV treatment at home is a safe alternative to in-hospital cellulitis
treatment. The benefits of OPAT include admission avoidance and reduced length of stay in
hospital, with resulting increases in inpatient capacity, significant cost savings, reduction in health
care associated infection and improved patient choice and satisfaction
Eligibility Criteria for out patient IV treatment:
The patient must fulfil all criteria to be deemed suitable for outpatient treatment of cellulitis
1. Telephone access
2. Responsible adult or responsible adult at home
3. Clinical diagnosis of Class1or 2 cellulitis
4. Rapid response nurse’s acceptability
5. Over 16 yrs age
6. Consent given
Exclusion Criteria:
If the patient has any criteria listed below they are not suitable for outpatient IV treatment
1. Hypersensitivity to Teicoplanin
2. Pregnancy, lactating
3. Hepatic and/ or renal disease
4. Neutropenia
5. Facial/ Perineal cellulitis
6. Class 3 & 4 cellulitis
1
7. Likelihood of non-compliance
8. Concurrent uncontrolled infection
9. Intravenous Drug use
10. Advanced dementia
Final decision on Inclusion or exclusion of patient from Home IV therapy rest on attending
clinician
Classification of cellulitis
Class 1:
Patients have no sign of systemic toxicity, have no uncontrolled co-morbidity and
can usually be managed with oral antimicrobials on an outpatient basis.
Class 2:
Patients are either systemically ill or systemically well but with co-morbidity such
as peripheral vascular disease, chronic venous insufficiency or morbid obesity
which may complicate or delay resolution of their infection
Class 3:
Patients may have significant systemic upset such as acute, confusion,
tachycardia, tachypnoea, and hypotension or may have unstable co-morbidities
that may interfere with a response to therapy or have a limb threatening infection
due to vascular compromise.
Class 4:
Patients have sepsis syndrome or severe life threatening infection such as
necrotising fasciitis.
2
PATHWAY
Attendance
with diagnosis of
cellulitis
Admit to CDU/AMAC,
mark cellulitic area.
Insert venflon & take
blood for FBC/CRP/
U&E/LFT/glucose
Assess for suitability
for outpatient
administration of
antibiotics see criteria
.
Give information to patient
regarding outpatient
treatment
Complete
discharge
checklist
and file it
in the
patient
notes
Administer
Antibiotics in
accordance with
the IV protocol
Ensure
cellulitic area
clearly marked
Add patient into
AMAC/CDU
outpatient
antibiotic book
Discharge the patient with
the D1 form, and information
leaflet
Fax D1 form to the GP
3
Complete
D1
Refer patient to
Rapid response and
confirm acceptance
Ensure venflon
secure, insertion
date is present and
VIP score
completed
Identify first return pointAMAC/CDU if required and
also for repeat blood
Individual Responsibilities
Initial Hospital
ResponsibilitiesDay 1
Community Nurse
Responsibility on a
Daily Basis
1. Full medical assessment and bloods taken for: FBU, U&E’s LFT’s
and swab from open wounds for Culture and Sensitivities.
2. Diagnosis made of Class 1or Class 2 Cellulitis
3. Administer Teicoplanin IV 800mg
a) Given by 30 minutes infusion
b) Patient should remain on AMAC/CDU for a minimum of 1
hour after the completion of infusion to check for any reaction
to antibiotics
4. Complete D1
5. Consultant or senior doctor to review the patient before discharge
Liaison with AMAC should take place in the following:
 If the patient’s condition deteriorates at anytime
 If the patient is still febrile after 3 days of Teicoplanin treatment
 If no improvement after 5 days of antibiotic treatment
 If patient is apyrexial for 48 hrs. and has evidence of definite
improvement of cellulitis change to oral
Daily Checking of cannula:
 The cannula site should be checked, and the Visual Infusion
Phlebitis Score (VIP) recorded on a daily basis.
Other Measures where necessary:
 Leg elevation
 Look for ports or entry of infection; toe clefts, heels, sites of trauma
 Dressings and bandages as required
Community Nurse
Responsibilities – 2nd,
3rd and 4th day
1. Administer IV Teicoplanin
2. Provide appropriate care according to assessment and care plan
3. The cannula must be checked daily, and should be renewed if there
is any evidence of infection/extravasation
Community Nurse
Responsibilities – 5th
Day
1. Administer IV Teicoplanin
2. Provide appropriate care according to assessment and care plan.
Cellulitis Improving
 Change to oral therapy
 based on culture and
sensitivities, or
 empirical Flucloxacillin 1g
QDS for 7 days or longer if
necessary
1
No Improvement
 Refer to AMAC
 Change antibiotics –
discuss with microbiology.
SUITABILITY FOR OUTPATIENT ADMINISTRATION OF IV
ANTIBIOTICS
Diagnosis of cellulitis requiring IV antibiotics?
Yes
Does the patient have ≥2 signs of systemic
sepsis?
•
Temperature >38 or <36oC
•
Pulse >90/min
•
Systolic BP <100
•
RR >20
No
Does the patient have >1 of the following?
• WBC >14 or <4
• Severe lymphangitis, blistering
or large affected area
• Immunosuppression
• Pregnant
• Poorly controlled diabetes
• Peripheral vascular disease
Yes
Hospital admission required
See also other exclusion criteria
Final decision rests on the clinician
No
Patient suitable for outpatient IV administration protocol
2
Yes
Hospital admission required
ANTIBIOTIC CHOICES FOR THE OUTPATIENT TREATMENT OF
CELLULITIS
Day 1
Teicoplanin 800mg
(as infusion over
30mins)
Or if
Teicoplanin
allergy*
Ceftriaxone 2G
(Over 30min infusion)
*Ceftriaxone is only to be used if the patient is known to either be allergic or
they have had previous significant reaction to Teicoplanin. If there is any
concern as to the suitability of a patient, please discuss with a doctor.
Day 2 onwards
Teicoplanin 400mg OD
(2nddose as Infusion for 30 min
then bolus 3-5 min)
Ceftriaxone 1G
(bolus over 3-5mins)
OR
If a patient is on Ceftriaxone and is failing to improve consider increasing
dose to 2G (by 30min infusion)
Oral conversion:
Once patient is apyrexial for 48 hours and has evidence of definite
improvement in the appearance of their cellulitis:
Flucloxacillin 1 qds
(for minimum 7 days)
OR if
penicillin
allergic
Clarithromycin 500mg
bd
(for minimum 7 days)
-7
Dose of teicoplanin in renal impairment
3
CrCl>20
Dose as above for all patients
CrCl 10-20
Teicoplanin 800mg o.d (DAY 1) Then 200mg every 24hr
CrCl<10
Patient not suitable for outpatient IV antibiotic therapy
Date:
Patient Sticker
CHECK LIST FOR A&E/AMAC PRIOR TO INITIAL
DISCHARGE
(Please circle as appropriate)
Attendance with diagnosis of Cellulitis(Class 1or 2)
Yes
No
Suitable for outpatient cellulitis service
Yes
No
Accepted by Rapid response team
Yes
No
Consent documented in notes
Yes
No
Mark cellulitic area with indelible pen
Yes
No
Photograph of area (if possible)
Yes
No
IV cannula inserted
Yes
No
Bloods Taken (FBC, U&E , ESR or CRP)
Yes
No
Patient given information leaflet
Yes
No
IV cannula secure, flushed with saline and dressed with sterile,
semipermeable transparent dressing e.g iv 3000
Yes
No
Insertion date is present and VIP score in completed
Yes
No
Identifying first return point time AMAC if required
Yes
No
Requirement for bloods identified
Yes
No
D1 complete
Yes
No
Book patient into AMAC /CDU outpatient antibiotic book
Yes
No
TTOs completed Including the following
 Teicoplanin 400mgx 6vials
Yes
No
Complete discharge checklist below
(Please circle as appropriate)
D1 faxed to the GP
All boxes must be ticked and clear for patient to be entered into the pathway.
Completed By:
Please print the name of the person completing this check list
4
Date:
Patient sticker
Barnsley Hospital NHS Foundation Trust
Discharge Instructions
Discharge instructions for patients with Cellulitis
You have been treated on the CDU for the cellulitis
The medical team have assessed you and have decided that you are well enough to be treated as an
outpatient. You should return or contact the AMAC if:




You feel generally unwell / dizzy
The redness gets worse
You have an episode of uncontrolled shaking
You have any problems with your cannula / drip
o
o
o
o
o
There is no needle present but it is important you look after it.
Keep your cannula dry and covered with the dressing provided.
Ensure it does not become caught in clothing or dislodged.
If your cannula does come out apply pressure with a clean dressing. A new cannula will
be inserted the next day.
Sometimes the cannula site becomes infected. If skin around the cannula becomes red or
painful call the number below for advice.
If you are concerned in anyway feel free to call on the numbers below
Yours Sincerely
If you have any problems / concerns please call
Barnsley AMAC unit
Or Rapid response team
5
01226 431345
07747794698
Date:
Patient sticker
CELLULITIS PATHWAY: RECORD OF TEICOPLANIN ADMINISTRATION BY RAPID RESPONSE
To be administered using aseptic technique and as per trust clinical procedure.
PATIENT NAME
PATIENT NHS NO:
DATE &
TIME
VIP SCORE
1ST DOSE
TO BE
6
PERIPHERAL CANNULA
INSERTED
REMOVED
LINE CLEANED
(CHLORHEXIDINE
GLUCONATE IN 70%
ALCOHOL)
GIVEN AS
INFUSION
PRE & POST DOSE
FLUSH
(5ml 0.9% saline)
ANTIBIOTIC
GIVEN
DOSE
BATCH/EXPIRY
SIGNATURE OF NURSE
Date:
Patient sticker
CELLULITIS: DAILY RECORD BY RAPID RESPONSE
PATIENT NAME
DAY
AT
HOME
DATE &
TIME
PATIENT NHS NO:
EFFECT OF ANTIBIOTICS
SYSTEMIC SYMPTOMS


IMPROVING
IF DETERIORATING; SEEK
MEDICAL ADVICE FROM
AMAC.



NIL NOTED
IF GI UPSET/ RASH SEEK
MEDICAL ADVICE FROM
AMAC.
SEVERE REACTION; 999
ADMINISTER ADRENALIN
AS PER ANAPHYLAXIS
POLICY.
MARKED CELLULITIC AREA


IMPROVING
IF UNCHANGED ON 2
VISITS /REMAINS
CELLULITIS CLASS2 OR
DETERIORATES SEEK
MEDICAL REVIEW.
TEMPERATURE
OUT
PATIENT
REVIEW
SIGNATURE OF NURSE
YES/NO
1
2
CHECK SWAB RESULTS IF
3
TAKEN IN HOSPITAL
REPEAT BLOODS
4
5
6
7
ONCE PATIENT IS APYREXIAL FOR 48 HOURS AND HAS DEFINITE IMPROVEMENT IN THE APPEARANCE OF CELLULITIS ,THEN COMMENCE ORAL ANTIBIOTICS.
IF NO IMPROVEMENT BY DAY 5 SEEK MEDICAL ADVICE FROM AMAC REGARDING FURTHER TREATMENT.
7
Author: Dr J Rao, Consultant Microbiologist/DIPC
Issue Date: November 2014
Review Date: November 2016