What is the next step in managing an 83-year-old patient with persistent swelling in the lower leg after a fall, who was initially treated with Keflex (Cephalexin) and then Clindamycin for cellulitis, with improved redness but ongoing edema?

From the Guidelines

The patient should continue to elevate the affected leg, apply compression stockings, and complete the full course of clindamycin as prescribed to manage the residual edema following cellulitis treatment. The persistent swelling in this 83-year-old patient's lower leg despite improvement in redness suggests residual edema following cellulitis treatment 1. I recommend continuing to elevate the affected leg above heart level when sitting or lying down, applying compression stockings (20-30 mmHg) during the day, and performing gentle range-of-motion exercises to improve lymphatic drainage. The patient should monitor for any return of redness, increased pain, fever, or warmth which could indicate treatment failure. Physical therapy may be beneficial to improve mobility and reduce swelling. The persistent edema is likely due to inflammatory damage to lymphatic vessels during the cellulitis infection, which can take weeks to months to fully resolve even after the infection has been adequately treated 1. If swelling persists beyond 2-3 weeks despite these measures, consider referral to a lymphedema specialist for more intensive management. Ensure adequate follow-up within 1-2 weeks to reassess the swelling and confirm continued improvement of the cellulitis. Some key points to consider in the management of this patient include:

• The importance of elevating the affected leg to promote gravity drainage of the edema and inflammatory substances 1
• The use of compression stockings to reduce swelling and improve lymphatic drainage 1
• The potential benefits of physical therapy in improving mobility and reducing swelling
• The need for close follow-up to monitor for any signs of treatment failure or complications
• The potential for referral to a lymphedema specialist if the swelling persists despite initial management.

From the FDA Drug Label

Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The usual initial dose of Furosemide tablets is 20 to 80 mg given as a single dose. Geriatric patients In general, dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range

The patient is an 83-year-old with persistent swelling, edema, after being treated for cellulitis.

• The initial dose of furosemide for edema in adults is 20 to 80 mg.
• For geriatric patients, the dose selection should be cautious, starting at the low end of the dosing range. Given the patient's age and condition, a conservative approach would be to start with a low dose, such as 20 mg, and monitor the patient's response to the medication 2.

From the Research

Patient Profile

• The patient is an 83-year-old female who presented with cellulitis and has a history of falling on her hands and knees a month ago.
• She developed swelling in her lower leg and redness, but DVT and fracture were ruled out.
• She was initially treated with Keflex and then Clindamycin, which improved the redness but not the swelling.

Possible Causes of Persistent Swelling

• According to 3, the use of diuretics, such as furosemide, may be associated with failure to relieve lower extremity swelling despite combined endovenous therapy for chronic venous insufficiency.
• 4 suggests that intravascular ultrasound (IVUS) imaging can detect venous obstruction missed by traditional venous testing, and iliac-caval venous stenting can yield satisfactory clinical relief and sometimes reverse abnormal lymphangiographic findings.
• 5 mentions that leg swelling can occur due to various etiologies, including systemic, superficial, and deep venous, and lymphatic disorders.

Association with Age and Comorbidities

• 6 found that older age, male gender, and certain comorbidities, such as cardiovascular disease, congestive heart failure, and hypertension, were independently associated with furosemide treatment.
• 7 reports that peripheral edema is common among older Americans and is strongly associated with comorbidities, pain, low activity levels, and mobility limitations.

Treatment and Outcome

• 3 suggests that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovenous therapy for chronic venous insufficiency.
• 4 found that iliac venous stenting can yield satisfactory clinical relief and sometimes reverse abnormal lymphangiographic findings.
• 6 found that treatment with furosemide in patients admitted with an infection was associated with prolonged hospital stay and increased in-hospital mortality.