What is the best management approach for a patient experiencing frequent episodes of cellulitis at the donor site following lower limb surgery for CABG?

Management of Recurrent Cellulitis at CABG Donor Site

For patients experiencing frequent episodes of cellulitis at lower limb donor sites following CABG surgery, prophylactic antibiotics such as oral penicillin or erythromycin twice daily for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks, should be administered if the patient has 3-4 episodes per year despite addressing predisposing factors. 1

Initial Assessment and Treatment of Acute Episodes

Acute Management

• For typical cases without systemic signs: Use antimicrobial agents active against streptococci (primary causative organism)

  • First-line options: Penicillin, amoxicillin, cephalexin, or clindamycin 1
  • Duration: 5 days is as effective as 10 days if clinical improvement occurs 1, 2
  • Extend treatment if infection has not improved within 5 days 1

• For cellulitis with systemic signs:

  • Consider coverage for MSSA in addition to streptococci 1
  • For severe cases: Consider vancomycin plus piperacillin-tazobactam or imipenem/meropenem 1

Supportive Measures

• Elevate the affected limb to promote gravity drainage of edema and inflammatory substances 1
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic patients to reduce inflammation and hasten resolution 1

Prevention of Recurrent Episodes

Address Predisposing Factors

1. Treat underlying conditions that increase risk:

   • Lymphedema (common after vascular harvesting)
   • Venous insufficiency
   • Edema
   • Skin barrier disruptions

2. Examine and treat interdigital toe spaces:

   • Address fissuring, scaling, or maceration
   • Treat tinea pedis if present 1

3. Maintain skin integrity:

   • Keep skin well hydrated with emollients to prevent dryness and cracking 1
   • Treat any dermatological conditions (eczema, dermatitis)

Prophylactic Antibiotic Regimens

For patients with 3-4 episodes per year despite addressing predisposing factors:

• Option 1: Oral penicillin or erythromycin twice daily for 4-52 weeks 1
• Option 2: Intramuscular benzathine penicillin every 2-4 weeks 1
• Continue prophylaxis as long as predisposing factors persist 1

Decolonization Strategies

Consider a 5-day decolonization regimen:

• Intranasal mupirocin twice daily
• Daily chlorhexidine washes
• Daily decontamination of personal items (towels, sheets, clothes) 1

Special Considerations for CABG Donor Sites

Lower extremity donor sites from CABG surgery present unique challenges:

• Disrupted lymphatic drainage increases risk of recurrent infection
• Surgical scarring may create areas of poor circulation
• Post-surgical edema may persist long-term

Monitoring and Follow-up

• Regular follow-up to assess for:
  • Lymphedema progression
  • New skin breakdown
  • Early signs of recurrent infection
• Prompt treatment of any new episodes
• Evaluate effectiveness of prophylactic regimen

Common Pitfalls to Avoid

1. Misdiagnosis of non-infectious conditions as cellulitis:

   • Venous stasis
   • Deep vein thrombosis
   • Post-surgical lymphedema
   • Consider these alternatives before diagnosing recurrent cellulitis 3

2. Overuse of broad-spectrum antibiotics:

   • MRSA is an unusual cause of typical cellulitis 1
   • Streptococci are the most common causative organisms 1
   • Reserve broad-spectrum coverage for specific indications 4

3. Failure to address underlying predisposing factors:

   • Each episode causes further lymphatic damage, increasing risk of future episodes 1
   • Treatment of predisposing factors is essential for breaking the cycle of recurrence