ABC Medical Notes.com

Cellulitis

• Likely causes Staph aureus and Group A streptococci:
• Treat BenzylPenicillin 1.2g QDS IV plus Flucloxacillin 1g qds IV until the patient shows clinical improvement when oral antibiotics can be used e.g. use Amoxicillin 500mg TDS and Flucloxacillin 500mg qds treat for a minimum of 7 days (CREST guidelines 2005)
• For Penicillin allergy use Teicoplanin 400mg IV once daily (after 3 loading doses of 400mg 12 hourly). For early discharge where IV may still be indicated use Teicoplanin 400mg IV once daily

Diabetic foot

• Likely causes: usually polymicrobial: Staph aureus, streptococci and gut flora
• Mild infections: Co-Amoxiclav 625mg tds PO or clindamycin 300mg qds PO if Penicillin allergic. Prolonged diabetes/podiatry follow-up will be needed.
• Cellulitis: As cellulitis management above.
• Severe infections: Severe/limb-threatening diabetic/Hot Foot is a medical emergency that requires coordinated input from the Diabetes Podiatrist, Diabetologist and Microbiologist in addition to surgical input.
• Co-Amoxiclav 1.2g TDS IV for Penicillin allergy contact Microbiologist. Clindamycin may be added if there is bone involvement, on the advice of a Consultant Diabetologist or Microbiologist

Leg ulcers and Pressure sores

• Are commonly colonised by faecal flora and Ps aeruginosa and does not require treatment.
• Treat with antibiotics only if demarcated cellulitis or systemic infection observed. Refer to the cellulitis guidelines above.
• Wound cleaning and skin management. Discuss with Tissue Viability Specialist Nurse.

Following clean surgery:

• Likely causes Staph aureus, (Group A streptococci now uncommon).
• Flucloxacillin 500 mg - 1g qds (oral or IV)

In contaminated sites (such as groin) consider:

• Co-Amoxiclav 625mg tds PO (or 1.2g tds IV)
• In severe infections, discuss with the Consultant Microbiologist

Surgical wound infection

• For Penicillin allergy contact Consultant Microbiologist.

Necrotising fasciitis

• Always contact Consultant Microbiologist and seek a surgical opinion
• Likely causes: Group A streptococci, could be polymicrobial.
• This is an urgent medical/surgical condition treated with surgical debridement and initially BenzylPenicillin 1.2g 4 hourly IV plus Clindamycin 600mg qds IV plus Gentamicin once daily IV
• For Penicillin allergy: clindamycin 600mg qds IV infusion plus Gentamicin once daily IV

Fournier's gangrene(severe fasciitis involving scrotum, perineum and anterior abdominal wall)

• Always contact Consultant Microbiologist and seek a surgical opinion
• Likely causes: Group A streptococci, other streptococci, coliforms and anaerobes including Clostridium sp.
• This is an urgent medical/surgical condition treated with surgical debridement and initially Piperacillin/Tazobactam 4.5g TDS IV
• For Penicillin allergy: clindamycin 600mg qds IV infusion plus Gentamicin once-daily IV

Gas gangrene

• Always contact Microbiologist and seek the surgical opinion
• Likely causes Clostridium perfringens, other Clostridium sp.
• This is an urgent medical/surgical condition treated with surgical debridement and initially BenzylPenicillin 1.2g 4 hourly IV plus Metronidazole 500mg tds IV
• For Penicillin allergy: Clindamycin 600mg qds IV infusion

Dirty / penetrating wound

• Consider tetanus prophylaxis and Co-Amoxiclav 625mg tds PO (or 1.2g tds IV for severe infection)
• For Penicillin allergy contact Consultant Microbiologist.
• Likely causes: staphylococci, streptococci, anaerobes, fastidious Gram-negatives eg Pasteurella, Eikenella.
• Co-Amoxiclav 625mg tds PO (or 1.2g tds IV for severe infection)
• For Penicillin allergy contact Consultant Microbiologist.

Animal bites

• Diabetic, asplenic, cirrhotic and immunosuppressed patients are at special risk from bites
• If animal bite acquired outside UK, urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated.
• For human bites there is a risk for inoculation of blood-borne viruses. Consult the Needle Stick Injury Guidelines. Consider tetanus prophylaxis