Putting a damper on cellulitis

Nursing, Dec 2000 by Phillips, Lisa L

Like wildfire, this skin infection can rage out of control. Find out how to identify patients at high risk and respond appropriately.

INTACT SKIN IS AN EFFECTIVE barrier to bacteria. But when this protective barrier is breached, cellulitisnoncontagious inflammation of the skin-can result. Although often mild, cellulitis sometimes flares into a life-threatening systemic infection. In this article, I'll discuss how to care for a patient with cellulitis and what complications to watch for. First, though, let's take a closer look at the disease process.

Bad break

Any break in the skin-whether from an insect bite, intravenous (I.V.) catheter, or skin breakdown-can open the door to cellulitis by allowing bacteria into the body.

Cellulitis is most common on the face and lower legs, although other areas of the body can be involved.

The typical cause is group A Streptococcus or Staphylococcus aureus, although in infants, group B Streptococcus is the usual suspect. Other potential culprits include Aeromonas hydrophila, Escherichia coli, or fungi.

Anyone can get cellulitis, but some patients are at greater risk; for example, those with diabetes, peripheral vascular disease, immunosuppressive conditions, burns, and cardiovascular or pulmonary insufficiency. Intravenous drug use, whether medical or illicit, also heightens the risk.

When you assess a patient with cellulitis, you'll set a skin lesion or rash that probably has distinct borders. The rash, which may appear suddenly, can spread rapidly in the first 24 hours. Warm, painful, and tender, the skin may have a glossy, stretched appearance. You may also see erythema along a vein traveling from the site toward the heart. The patient may complain of muscle aches and malaise and may have a fever and regional lymphadenopathy.

Confirming the diagnosis

The patient's history, contributing factors, and symptoms help confirm cellulitis. When the affected area is small and the patient has no risk factors for serious illness, no further workup is indicated. But in high-risk patients and those with systemic signs, prepare to conduct a more extensive investigation: Draw blood for a complete blood cell count and blood culture (to rule out systemic infection) and blood urea nitrogen and creatinine (to check that kidney function is adequate to handle antibiotic excretion).

Now to intervene

Mild cases of cellulitis can be treated on an outpatient basis with a 7- to 10-day course of oral antibiotics. Tell the patient to elevate the affected area above heart level and to apply warm, moist packs to the site every 2 to 4 hours. If symptoms persist or worsen, tell him to call his health care provider.

A patient with serious cellulitis--extremely reddened, warm, and inflamed skin; pain over the affected area; and fever-should be hospitalized and treated with LV antibiotics. Because systemic infection can develop swiftly, monitor the patient closely and administer fluids. Remember that in immunocompromised patients and those on corticosteroid therapy, the onset of sepsis can be extremely subtle. Be prepared to administer vasopressors to increase blood pressure if sepsis develops.

Because cellulitis reduces blood flow and glucose transport to the affected area, healing may be slow, so 4- to 6-week courses of therapy are common in severe cases of cellulitis. After completing the course of IN. therapy, the patient may undergo a 7- to 10-day course of oral antibiotics to continue eradicating the infection and to prevent a recurrence. High-risk patients should take oral antibiotics for 4 to 6 weeks.

During this time, the patient should continue to rest and to elevate the affected area. Tell him to see his health care provider for a follow-up exam after completing the course of oral antibiotics.

For high-risk patients, managing the disease that contributed to cellulitis is the best way to prevent a recurrence. For example, patients with diabetes should be given follow-up instruction on controlling blood glucose levels, and those with circulatory deficits should review skin and foot inspection and care. If necessary, refer the patient to home health care services for ongoing education.

Dealing with complications

High-risk patients and those who don't adhere to treatment are especially prone to complications of cellulitis. Although extreme examples, such as sepsis, meningitis, local necrosis, and gangrene, are uncommon, they can develop rapidly and be irreversible and devastating. Teach patients and their families to watch for ominous signs and symptoms, such as fever, painful or stiff neck, and discoloration of the affected area of skin, and report them to the health care provider immediately.

Patients with severe facial cellulitis (erysipelas) are at risk for developing bacterial meningitis if the infection travels to the sinuses. Teach the patient the signs and symptoms of meningitis and tell him to go to the emergency department if acute symptoms occur when his primary health care provider's office is closed.
Tissue necrosis is a risk for patients with peripheral vascular disease or diabetes. Small areas of necrosis may require surgical debridement; large areas of necrosis may lead to amputation.

Rarely, anaerobic bacteria invade the necrotic tissue and cause gas gangrene. Extensive tissue and nerve damage in an arm or leg makes amputation likely. Keeping infection in check Because of its potentially devastating consequences, give cellulitis the respect it deserves. By understanding how to douse the inflammation, you can prevent it from flaring out of control.

SELECTED REFERENCES

Holzapfel, L., et al.: "Microbiological Evaluation of Infected Wounds of the Extremities in 214 Adults," Journal of Accident and Emergency Medicine. 16(l):32-34, January 1999.

Rodriguez, J., et al.: "Incisional Cellulitis after Total Hip Replacement," Journal of Bone and Joint Surgery (British volume). 80(5):876-878, September 1998.

Schwartz, R., et al.: "Current and Future Management of Serious Skin and Skin-Structure Infections," American Journal of Medicine. 100(6A):90S-955, June 1996.

BY LISA L. PHILLIPS, RN Clinical Supervisor Crescent Healthcare, Inc. * Modesto, Calif.

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