What is the next step in treatment for a 71-year-old male with a history of gout and hypertension who recently had cellulitis of another toe, was treated with Keflex (cephalexin) and prednisone, and has completed both courses?

From the Guidelines

The next step in treatment for this 71-year-old male with resolved cellulitis is a follow-up evaluation to confirm complete resolution of the infection, as recommended by the Infectious Diseases Society of America in their 2014 guidelines 1. The patient should be examined for any residual signs of inflammation, tenderness, or drainage at the previously infected toe. Since the patient has completed both cephalexin and prednisone courses, no additional antibiotics are needed if the infection has resolved, as the recommended duration of antimicrobial therapy is typically 5 days, and treatment should be extended if the infection has not improved within this time period 1. However, given his history of gout and recent cellulitis, preventive measures should be implemented. These include proper foot care with daily inspection, keeping feet clean and dry, wearing appropriate footwear, and prompt attention to any new skin breaks or signs of infection. For his gout management, medications like allopurinol (starting at 100mg daily, gradually increasing to achieve uric acid levels below 6 mg/dL) should be considered if not already prescribed, as recommended by the American College of Rheumatology in their 2012 guidelines 1. The patient's hypertension medications should also be reviewed to ensure optimal control, as poor circulation can increase infection risk. Patient education about recognizing early signs of recurrent cellulitis (redness, warmth, swelling, pain) is essential, with instructions to seek prompt medical attention if these develop. This approach addresses both the immediate concern of ensuring infection resolution and the long-term management of underlying conditions that may predispose to recurrent infections. Some key considerations in the management of skin and soft tissue infections, including cellulitis, are outlined in the 2014 practice guidelines by the Infectious Diseases Society of America 1, which emphasize the importance of appropriate antimicrobial therapy, wound care, and management of predisposing factors. In the context of this patient's history of gout and hypertension, careful attention to these factors is crucial to prevent recurrent infections and manage his underlying conditions effectively.

From the Research

Next Steps in Treatment

Given the patient's history of gout and hypertension, and recent cellulitis of another toe treated with Keflex (cephalexin) and prednisone, the next steps in treatment should focus on preventing recurrence and managing underlying risk factors.

• The patient has completed the courses of Keflex and prednisone, which suggests that the acute infection has been treated.
• However, the risk of recurrence remains, especially considering the patient's history of gout and hypertension, which can increase the risk of cellulitis 2.
• Management of underlying predisposing conditions, such as gout and hypertension, is crucial to prevent recurrence 3, 2.
• The patient's history of cellulitis and completion of antibiotic treatment suggests that empiric antibiotic choices should be designed against the background of a low prevalence of multi-resistant Staphylococcus aureus 2.
• Novel antimicrobial agents registered for cellulitis can also be considered 2.
• The Cellulitis Recurrence Score (CRS) can be used to predict the risk of recurrence, and early interventions should be considered in patients with a high score 4.
• Prevention of recurrence, clinical features, and long-term disease impact are important outcome themes for patients, and future treatment trials should consider the use of longer-term outcomes to capture recurrence and long-term morbidity 5.

Considerations for Future Treatment

• The patient's treatment plan should include regular follow-up appointments to monitor for signs of recurrence and adjust the treatment plan as needed.
• The patient's gout and hypertension should be managed to reduce the risk of recurrence.
• The patient should be educated on the signs and symptoms of cellulitis and instructed to seek medical attention immediately if they experience any symptoms.
• The use of antibiotic prophylaxis can be considered to prevent recurrence, especially in patients with a high risk of recurrence 3.