b'inflammatory drugs (NSAIDs) taken at the time ofThose being treated by specialist lymphedema cellulitis may increase the risk of necrotizing fasciitis,services, especially those taking antibiotic prophylaxis, but a causative link has not been proven.) One smallare recommended to inform their service whenRCT (n=48) has demonstrated no benefit of thethey have needed to use the in case course soaddition of ibuprofen to IV antibiotics in acceleratingthat appropriate review can be planned.the resolution of cellulitis, but no patients developedPreventing or Reducing the Frequency ofnecrotizing fasciitis in this study 109 . Episodes of CellulitisWhen the patient is feeling better, a return to There is evidence that decongestive lymphoedema normal levels of activity is encouraged. therapy (DLT) reduces the frequency of attacks 111 , Management of Cellulitis in Hospital Setting and that compression reduces the risk of Choice of antibiotics in hospital is usually maderecurrence 112 . Control of the swelling is, therefore, according to local hospital guidelines. Hospitalimportant. Patients undergoing intensive DLTguidelines commonly recommend single agent IV who are known to have suffered cellulitis in thesuch as cefazolin 1 to 2 g IV every eight hours, nafcillinpast during intensive DLT may benefit from1 to 2 g IV every four hours, oxacillin 1 to 2 g IV everyantibiotic coverage in case cellulitis is provoked.four hours and flucloxacillin 2 g every six hours, asThis is an uncommon occurrence, but in thisthese choices are felt to cover both Staph. and group, it is suggested that a therapeutic courseStrep. infections. When there is evidence of clinicalof antibiotics is considered for the duration of the improvement parental antibiotics should beintensive treatment.transitioned to an oral agent 110 .Other risk factors for recurrent cellulitis, includingLocal hospital guidelines will also recommendcracked and/or macerated inter-digital skin, alternative IV antibiotics for patients allergic todermatitis, open wounds including leg ulcers, and penicillin. weeping lymphangiectasia (leaking lymph blisterson the skin surface), should be treated. Provided below is The Johns Hopkins University SchoolSkin care, including the use of emollients as part of Medicine Antibiotic Guidelines for the Hospitalizedof routine maintenance DLT, is recommended to Patient: optimize the skins natural barrier function. https://www.hopkinsguides.com/hopkins/view/Johns_Treatment of inter-digital fungus should be withHopkins_ABX_Guide/540106/all/Cellulitis the application of an antifungal topical such as terbinafine cream daily for two weeks. This mayIt is important that those with lymphedema be followed by maintenance treatment, providing have a total of at least 2 weeks of antibiotics the skin is unbroken, with alcohol wipes daily. (IV followed by oral) to treat an acute episodeof cellulitis. There is evidence that surgery carried out by experienced lymphedema surgeons in combination Antibiotics In Case (Rescue Pack) with optimized conservative treatment in carefully The risk of further recurrent cellulitis in lymphedema selected patients may reduce the frequency of is high. It is recommended that patients who have acellulitis. There is also evidence that obesity is a risk history of recurrent cellulitis carry a two-week supply factor for the development of cellulitis (Burian 2021) of antibiotics with them, particularly when away fromand recurrent episodes. Obesity is known to reduce home for any length of time, e.g., on holiday.lymph drainage. The following oral antibiotics are recommended:Weight managementin addition to thedicloxacillin 500 mg orally every six hours, flucloxacillintreatment of lymphedema and cellulitisis 500 to 1000 mg orally every six hours (not available inessential in those suffering with obesity.the United States), cephalexin 500 mg orally every six hours or cefadroxil 500 mg orally every twelve hours Prophylactic Antibioticsor 1 g orally once daily (see 1.2.2) or, for those allergicIf, as a primary care provider, you are considering to penicillin, clarithromycin 500mg 12-hourly orprophylactic antibiotics, it is recommended that the doxycycline 100 mg 12-hourly if taking statins. use and duration of prophylactic antibiotics be made together with the local specialist lymphedema service An antibiotic in case (rescue pack) should or the infectious disease specialist if there is no local be started immediately when familiar symptomslymphedema service to consult. of cellulitis develop, but a medical opinionshould be sought as soon as possible to confirmWhen considering prophylactic antibiotics in patients the diagnosis and response to treatment. with lymphedema, factor in all risk factors for cellulitis, including DLT-provoked cellulitis, history of cracked | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|29'