What are the management options for a patient with Type 1 diabetes (T1D) who develops cellulitis at the site of their continuous glucose monitor (CGM)?

From the Guidelines

If you have Type 1 diabetes and develop cellulitis at your continuous glucose monitor (CGM) site, you should remove the CGM immediately and place it at a different location away from the infected area. This approach is crucial in preventing the spread of infection and allowing the affected area to heal. According to the most recent guidelines, cleaning the infected site gently with soap and water, and applying a topical antibiotic like mupirocin if available, are recommended initial steps 1. For mild cellulitis, oral antibiotics such as cephalexin 500mg four times daily for 5 days or clindamycin 300mg four times daily (if penicillin-allergic) are typically prescribed, as a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days 1. It is essential to monitor your blood glucose levels more frequently using finger sticks while the infection heals, as infections can cause blood sugar fluctuations. Watching for signs of worsening infection, including increased redness, warmth, swelling, fever, or red streaks extending from the site, is also critical. To prevent future infections, always clean the skin thoroughly with alcohol before CGM insertion, rotate sites regularly, and avoid reusing the same area too frequently. Cellulitis occurs when bacteria (commonly Staphylococcus or Streptococcus) enter through small breaks in the skin, which can happen during device insertion. People with diabetes may be more susceptible to infections due to impaired immune function related to fluctuating blood glucose levels. The use of CGM devices is recommended from the outset of the diagnosis of diabetes that requires insulin management, as it allows for close tracking of glucose levels and removes the burden of frequent blood glucose monitoring 1. Interruption of access to CGM is associated with a worsening of outcomes; therefore, it is crucial for individuals on CGM to have consistent access to devices 1. Key considerations for managing cellulitis in the context of CGM use in Type 1 diabetes include:

• Removing the CGM from the infected site immediately
• Cleaning and applying topical antibiotics to the affected area
• Using oral antibiotics for mild cases
• Monitoring blood glucose levels closely during the infection
• Preventing future infections through proper skin care and site rotation
• Maintaining consistent access to CGM devices to avoid worsening outcomes 1.

From the Research

Cellulitis and Type 1 Diabetes

• Cellulitis is a common emergency in acute and community care settings, and can be a source of significant pain and anxiety for affected patients, especially those with underlying conditions such as diabetes mellitus 2.
• Type 1 diabetes is a chronic autoimmune disorder characterized by the destruction of pancreatic β-cells, leading to absolute insulin deficiency, and patients with this condition may be more prone to developing cellulitis due to compromised skin and subcutaneous tissues 3.

Cellulitis Diagnosis and Management

• Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma, and can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers 4, 5.
• The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 5.
• Empiric outpatient therapy with trimethoprim-sulfamethoxazole, cephalexin, or clindamycin for cellulitis has been studied, and antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy for outpatients with cellulitis in the community-associated MRSA-prevalent setting 6.

Cellulitis of CGM Site

• There is no direct evidence in the provided studies regarding cellulitis of a continuous glucose monitoring (CGM) site in patients with type 1 diabetes.
• However, the general principles of cellulitis diagnosis and management may still apply, and patients with type 1 diabetes who develop cellulitis at a CGM site should be evaluated and treated accordingly, taking into account their underlying condition and any potential complications 2, 4, 5.