Cellulitis

Prescribing Notes:

• Flucloxacillin has adequate streptococcal cover; therefore it is not necessary to prescribe penicillin in addition, for empirical treatment of non-severe cellulitis. If there has been exposure to river or sea water, discuss treatment with a microbiologist.
• All wounds have potential for bacterial infection and may become colonised but swabs should only be taken if there are clinical signs of infection.
• Prescription of antibiotics should not delay appropriate surgical management e.g. drainage or aspiration of an abscess.
• See also Wound Management section.
• Panton-Valentine Leukocidin (PVL) is a toxin produced by some Staphylococcus aureus isolated from boils/abscesses. This can very rarely cause severe necrotising pneumonia. If found topical suppression therapy should be given after wound healing. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene.

Skin and soft tissue infections in drug users:

• Initial oral treatment is advised with flucloxacillin or oral clindamycin (in penicillin allergy or intolerance). Clindamycin should be stopped and specialist infection advice sought if diarrhoea develops on treatment.
• Please take a wound swab, indicating that the infection is in a drug user.

Prescribing Notes:

• All wounds have potential for bacterial infection and may become colonised but swabs should only be taken if there are clinical signs of infection. Where anaerobic infection is a strong possibility (e.g. after perineal surgery, gangrenous appendicitis or laparotomy for peritonitis) add metronidazole.
• Prescription of antibiotics should not delay appropriate surgical management e.g. drainage or aspiration of an abscess.
• See also Wound Management section.
• Flucloxacillin has adequate streptococcal cover; therefore it is not necessary to prescribe penicillin in addition, for empirical treatment of non-severe cellulitis. If there has been exposure to river or sea water, discuss treatment with a microbiologist.
• Panton-Valentine Leukocidin (PVL) is a toxin produced by some Staphylococcus aureus isolated from boils/abscesses. This can very rarely cause severe necrotising pneumonia. If found topical suppression therapy should be given after wound healing. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene.

Prescribing Notes:

• Available under PGD for patients over 18 years of age with either an infected insect bite, cellulitis or acute paronychia with signs of cellulitis.
• Careful enquiry should be made about hypersensitivity reactions to beta-lactam antibacterials.
• Dosages are health board specific – check for which dose is recommended.
• The oral solution is strictly limited to use in patients who are intolerant of gelatine or have severe dysphagia in relation to capsules.

Example of counselling points
Take this medicine when your stomach is empty. This means an hour before food or 2 hours after food.
Take flucloxacillin regularly and completing the course.
If rash or other signs of hypersensitivity occur, stop taking the medicine and contact your doctor for advice.
Ensure patient is aware that if symptoms worsen, the patient becomes systemically unwell e.g. develops a temperature, racing heartbeat, rapid shallow breathing or confusion then they should seek medical advice that day.
If symptoms have not improved after 2-3 days treatment, then patients should be advised to seek further medical advice.
Latest recommendations are that no additional contraceptive precautions are required when combined oral contraceptives are used with antibacterials that do not induce liver enzymes, unless diarrhoea and vomiting occur.

When to advise patient to contact GP
Patient under 18 years old
Known hypersensitivity to beta-lactam antibiotic (penicillins or cephalosporins) or any excipients
Cellulitis where patient febrile and/or unwell (i.e. features suggestive of systemic infection)
Cellulitis related to a human or animal bite
Cellulitis related to surgical wound or chronic wound/ leg ulcer or burns
Peri-orbital (preseptal)/facial cellulitis present
Cellulitis on arms or torso not linked to an insect bite
Recurrent cellulitis i.e. more than once within a year
Acute paronychia with signs of cellulitis AND a collection of pus requiring drainage AND/OR in severe pain
Diabetic foot infection
Known hepatic impairment or flucloxacillin associated jaundice
Known severe renal impairment
History of MRSA infection or colonisation
History of injecting drug use (e.g. illicit drugs, anabolic steroids)
Concomitant use of interacting medication e.g. probenecid, methotrexate, oral typhoid capsule, warfarin
History of porphyria
Known immunosuppression or taking immunosuppressants
Pregnant or breastfeeding