b"and/or macerated inter-digital skin, dermatitis, openHowever, if there are ongoing significant risk factors wounds including leg ulcers, and weepingcontinuing prophylaxis for a further year should be lymphaniectasia (leaking lymph blisters on the considered. If there have been no further episodes of skin surface) and history of obesity.cellulitis during this period, antibiotic prophylaxis In addition, antibiotic prophylaxis should beshould be stopped.considered in patients who have had two or moreProphylaxis may need to be life-long if relapse occurs attacks of cellulitis per year.after prophylactic antibiotics have been discontinued The following should be considered in this decision: and there are persistent risk factors. However, ongoing regular review (at least annually, ideally by local 1.Were the episodes all bacterial cellulitis?specialist lymphedema services) is still recommended 2. Could they have been due to conditions such asfor those on long-term prophylaxis. Discontinuationacute venous hypertension/ lipodermatosclerosis,again should be considered if risk factors have which are not bacterial and should be managed withimproved at any stage. compression etc. See the British LymphologyIt may not be possible to fully prevent further episodes Society Red Legs Pathway: https://www.thebls.of cellulitis even with prophylactic antibiotics. However, com/public/uploads/documents/document-there may be a reduction in the frequency of cellulitis 40881639738634.pdf and/or the severity of episodes. 3.Were the episodes bacterial cellulitis which wasIf the response to first-line prophylactic antibiotics is incompletely treated, e.g., by multiple short inadequate, then alternative strategies, including trials (57 days) courses of antibiotics? In this situation, of other prophylactic antibiotics, e.g., cefalexin 125 mg the symptoms of cellulitis may resolve in a few daily or clindamycin 150 mg daily, may need to be days but recur after 23 weeks. This may reflect considered. In these circumstances, review by local an incompletely treated single episode of cellulitisspecialist lymphoedema services and advice from which should be treated with a longer course microbiologists is recommended.of antibiotics (at least 2 weeks) and counted asone episode. There is a need to balance the use of certain 4.Was there a clear, easily reversible cause e.g.,antibiotics (e.g. clindamycin, cefalexin) as prophylaxis athlete's foot/other skin problem? If so, treating against the risks of predisposing to Clostridium difficile this may reduce the risk of further cellulitis andinfections and promoting antibiotic resistance. If at any remove the need for antibiotic prophylaxis. stage with prophylactic antibiotics Clostridium difficile occurs, then those antibiotics should be stopped Choice of Prophylactic Antibiotics to immediately.Prevent CellulitisIf antibiotic prophylaxis is indicated, Pencillin V KIt is usual practice to discontinue antibiotic(phenoxymethylpenicillin) 250mg two times daily prophylaxis while antibiotics are taken toof if BMI33, use 500 mg two times daily should betreat acute cellulitis.the first choice 114 .For those allergic to penicillin, clarithromycin 250mgAntibiotic Prophylaxis to Prevent Cellulitis daily is recommended. in Patients with Lymphedema UndergoingFor those with penicllin allergy and taking statins,Surgical Procedures doxycycline 100mg daily is recommended. Patients undergoing surgical procedures such asknee replacement or carpal tunnel surgery in the It is recommended that patients requiring antibioticlymphoedematous region should receive a therapeutic prophylaxis for anogenital cellulitis should receivecourse of antibiotics commenced before surgeryPenicillin V (phenoxymethylpenicillin) or an alternative(oral or IV as appropriate) as described previouslyas above if penicillin-allergic, but if this is not effective,or as indicated by the procedure. This would also trimethoprim 100 mg daily taken at night, should beinclude surgery to treat lymphedema, such as used instead. lymphaticovenular anastomosis or lymphoedema Following one year of successful prophylaxis,liposuction. The antibiotics should begin justdiscontinuation should be considered, particularly ifbefore surgery and are usually continued forthe risk factors described above, including DLT- five to seven days after surgery.provoked cellulitis, history of cracked and/orThe risk of cellulitis after minor skin surgery, e.g.,macerated inter-digital skin, dermatitis, open woundsmole removal, is believed to be small. For minorincluding leg ulcers, and weeping lymphaniectasiaskin procedures in people who have previously had (leaking lymph blisters on the skin surface) and historycellulitis a single prophylactic dose of antibioticsof obesity have been successfully addressed. may be considered by the operating surgeon.| Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|30"