BNURS20 Nursing
Question
Answer
Cellulitis
Pathophysiology of cellulitis
Cellulitis is a potentially dangerous infectious disease which affects the skin, particularly the dermal layer and the soft subcutaneous fat tissues. It commonly affects the lower portions of the legs in adults while face and neck are mostly infected in children (Raff & Kroshinsky, 2016). The disease is manifested through breaching of skin, wounds or injuries, abrasion of skin layers. Affected site of skin is tender to touch and appears red with swollen appearance. The infection occurs due to bacterial penetration through the breaches or abrasions of skin. Streptococcus pyogenes and Staphylococcus aureus are the common causal bacterial agents bringing about the skin infection (Bruun et al., 2016). The bacteria penetrates through the injured skin, inflammation and erythema or redness of the infected site occurs in response. The manifestation of cellulitis is associated with impairment of physical skin barriers, immune system barriers and circulatory system barriers. Recurrent episodes of cellulitis causes damage to the lymphatic drainage system, which thereby leads to the chronic inflammation of the infected legs. Severity of cellulitis causes the infection to spread to deeper layers of the dermal tissue leading to necrotizing fasciitis. The impairment of immune system is accompanied with a delayed type-IV hypersensitivity mechanism (Kamiya et al., 2015). This is manifested through cell-mediated reactions involving lymphocyte or macrophage as key players. The bacterial exotoxins, also known as super-antigens cause connective tissue damage through cellular dysregulation, which ultimately result in cellular lysis. These dead cells become the constituents of pus or abscesses in purulent cellulitis. The bacterial products or exotoxins are released post bacterial penetration, which are endocytosed, degraded and presented to the antigen-presenting cells or APCs. APCs present these degraded bacterial products to the T-cells; this results in inflammatory response by cytokines and complement pathway (Brodell, Brodell & Brodell, 2014) A form of cellulitis called purulent cellulitis is characterised by the formation of pus at the infected site. Abscesses are also formed containing pus; lymphatic vessels are infected and undergo damage in cellulitis. Infected lymphatic vessels cause a block in the flow of lymphatic fluid. This causes accumulation of lymphatic fluid which results in swelling and poor circulation within the infected tissue.
Pharmacological treatment of cellulitis
Cellulitis is a treatable and curable infection. The common form of treatment involves antibiotic therapy post diagnosis. Oral antibiotics are the first line of treatment for cellulitis. Both Streptococcus and Staphylococcus are gram-positive bacteria possessing thick cell wall, therefore treatment involves targeting these gram-positive bacteria. Medications targeting these bacteria commonly involve the drugs belonging to penicillin family (Thomas et al., 2013). Penicillin, amoxicillin (250-300 milligrams thrice daily) and ampicillin are the commonly prescribed drugs to patients suffering from cellulitis. Medications targeting both gram-positive and gram-negative bacteria are often prescribed. Antibiotics like clindamycin, doxycycline, amoxicillin, dicloxacillin (25-50 milligrams per kg of body weight per day) and cephalexin (500 milligrams at a dosage of four times daily) are commonly prescribed by doctors. Antibiotic treatment takes around a week to ten days for the patient to get rid of cellulitis. However, in immunocompromised individuals, antibiotic treatment may take a longer time period to completely heal the patient. The emergent cases of cellulitis due to MRSA or methicillin-resistant Staphylococcus aureus have become a serious concern. MRSA dependent cellulitis leads to pus formation at the infected site. The treatment is therefore targeted against MRSA induced infection; trimethoprim sulfamethoxazole is given in combination with clindamycin or doxycycline. The former is added to address the MRSA infection (Pallin et al., 2013). Patients who are severely suffering with cellulitis are admitted to hospitals and administered with vancomycin as the primary drug treatment to reduce the inflammation at the site of infection. Piperacillin-tazobactam or imipenemmeropenem (3.375 grams) is also added in combination with vancomycin (15 milligrams) in order to enhance its efficacy in treating severity of cellulitis. This combination of drug is best for polymicrobial infection causing cellulitis. Pus formation at the infected site or purulent form of cellulitis is the most severe form affecting patients, which cannot be treated through antibiotic therapies and require treatments beyond antibiotics. These patients have additional symptoms of high fever and low blood pressure. They do not respond to oral antibiotics in purulent cellulitis. Linezolid (600 milligrams for every 12 hours), daptomycin (6-8 milligrams per kg of body weight per day), telavancin (10 milligrams with an hourly infusion period), ceftaroline (600 milligrams every 8-12 hours) are also prescribed to treat purulent cellulitis (Singer & Talan, 2014). To address the purulent cellulitis, intravenous antibiotic administration seems to be a better treatment. Antibiotics like penicillin, ceftriaxone (1-2 grams every 24 hours), cefazolin (1-2 grams every 8 hours), nafcillin (1-2 grams every 4-6 hours) and clindamycin (600-900 milligrams every 8 hours) are administered intravenously to treat purulent cellulitis (Singer & Talan, 2014). Cellulitis can cause recurrent episodes which can be cured with a long term administration of prophylactic antibiotics; this may even be continued for almost a year (Oh et al., 2014). Oral antibiotics like erythromycin is often prescribed for a period of 4 to 52 weeks to address the recurrent episodes of cellulitis. Intramuscular administration of banzathine penicillin antibiotic also yields a promising outcome when prescribed for a period of every two to four weeks.
Care plan for cellulitis
Treatment of cellulitis requires a proper care plan to reduce the infection and patient discomfort. It is advised for the patient to leave the infection undisturbed. The region of swelling and localized pain should be elevated in order to reduce the swelling and relieving discomfort (Carter, Kilburn & Featherstone, 2017). The patient should take pain relievers like acetaminophen or ibuprofen to ameliorate the localized pain, simultaneously keeping the fever down. In case of severity the oral antibiotics need to be taken for a period of two weeks. Cellulitis can be prevented through practising good personal hygiene and maintaining cleanliness (Yarbrough et al., 2015). In case of any mild injury, the site should be cleaned with luke warm water and should be kept covered from external exposure to prevent bacterial penetration.
References
Brodell, L. A., Brodell, J. D., & Brodell, R. T. (2014). Recurrent lymphangitic cellulitis syndrome: A quintessential example of an immunocompromised district. Clinics in dermatology, 32(5), 621-627.
Bruun, T., Oppegaard, O., Kittang, B. R., Mylvaganam, H., Langeland, N., & Skrede, S. (2016, January). Etiology of cellulitis and clinical prediction of streptococcal disease: a prospective study. In Open forum infectious diseases (Vol. 3, No. 1). Oxford University Press.
Carter, K., Kilburn, S., & Featherstone, P. (2017). Cellulitis and treatment: a qualitative study of experiences. British Journal of Nursing, 16(Sup1), S22-S28.
Kamiya, K., Kamiya, E., Kamiya, Y., Niwa, M., Saito, A., Natsume, T., … & Tokura, Y. (2015). Drug eruption to clavulanic acid with sparing of cellulitis-affecting site. Allergology International, 64(3), 280-281.
Oh, C. C., Ko, H. C. H., Lee, H. Y., Safdar, N., Maki, D. G., & Chlebicki, M. P. (2014). Antibiotic prophylaxis for preventing recurrent cellulitis: a systematic review and meta-analysis. Journal of Infection, 69(1), 26-34.
Pallin, D. J., Binder, W. D., Allen, M. B., Lederman, M., Parmar, S., Filbin, M. R. & Camargo Jr, C. A. (2013). Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases, 56(12), 1754-1762.
Raff, A. B., & Kroshinsky, D. (2016). Cellulitis: a review. Jama, 316(3), 325-337.
Singer, A. J., & Talan, D. A. (2014). Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. New England Journal of Medicine, 370(11), 1039-1047.
Thomas, K. S., Crook, A. M., Nunn, A. J., Foster, K. A., Mason, J. M., Chalmers, J. R., & Reynolds, N. J. (2013). Penicillin to prevent recurrent leg cellulitis. New England Journal of Medicine, 368(18), 1695-1703.
Yarbrough, P. M., Kukhareva, P. V., Spivak, E. S., Hopkins, C., & Kawamoto, K. (2015). Evidence?based care pathway for cellulitis improves process, clinical, and cost outcomes. Journal of hospital medicine, 10(12), 780-786.
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