Should antibiotics be restarted in a patient with lymphedema and recurrent cellulitis, recently discharged on Augmentin (amoxicillin/clavulanate) with a normal white blood cell count?

Management of Cellulitis in a Patient with Lymphedema

Antibiotics should be restarted immediately in this patient with lymphedema and recurrent cellulitis, despite a normal white blood cell count, as patients with lymphedema are at high risk for severe infections and complications.

Assessment of Current Situation

When evaluating a patient with lymphedema and cellulitis who was recently discharged on Augmentin (amoxicillin/clavulanate) but has been referred back to the hospital:

• A normal WBC count does not rule out active infection in lymphedema patients
• Lymphedema creates a favorable environment for bacterial growth and impairs immune response
• Patients with lymphedema are at high risk for recurrent cellulitis and progression to severe infection 1

Diagnostic Tests to Order

1. Blood cultures - even though WBC is normal, blood cultures should be obtained before restarting antibiotics
2. Wound cultures (if any open areas are present)
3. C-reactive protein and ESR - inflammatory markers that may be elevated even with normal WBC
4. Ultrasound of affected area - to evaluate for abscess formation or deeper infection
5. Comprehensive metabolic panel - to assess organ function and guide antibiotic therapy

Antibiotic Management

Immediate Action

• Restart antibiotics immediately without waiting for culture results
• Continue with Augmentin (amoxicillin/clavulanate) if the patient was tolerating it well and showing initial improvement before discharge 2
• Consider IV antibiotics if there are signs of systemic illness or significant progression

Antibiotic Selection

• For mild to moderate cellulitis in lymphedema:

  • Amoxicillin-clavulanate 875/125 mg twice daily orally for 7-14 days 3, 4
  • Alternative if penicillin allergic: Clindamycin 300-450 mg orally three times daily 3

• For moderate to severe cellulitis:

  • Consider broader coverage with vancomycin plus piperacillin-tazobactam or ceftriaxone plus metronidazole 3

Duration of Therapy

• Extend treatment duration beyond the typical 7-10 days used for uncomplicated cellulitis
• For lymphedema-associated cellulitis, a 14-21 day course is often necessary to prevent recurrence 3

Special Considerations for Lymphedema Patients

1. Elevated risk of recurrence

   • Patients with lymphedema have higher rates of cellulitis recurrence 5
   • Bacterial colonization is common in lymphedematous tissue 6

2. Potential for rapid progression

   • Cellulitis in lymphedematous extremities can progress rapidly to septic shock 1
   • Normal WBC does not rule out serious infection in these patients

3. Antibiotic resistance concerns

   • Patients with history of cellulitis in lymphedema have higher rates of antibiotic-resistant bacteria (31% vs 11%) 6
   • Consider this when selecting empiric antibiotics

Prevention of Recurrent Episodes

After treating the current episode:

1. Consider prophylactic antibiotics

   • For patients with frequent recurrences (≥2 episodes per year)
   • Options include monthly intramuscular benzathine penicillin injections of 1.2 MU or oral therapy with twice-daily doses of either 250 mg of erythromycin or 1 g of penicillin V 3

2. Lymphedema management

   • Compression therapy
   • Elevation of affected limb
   • Meticulous skin care
   • Treatment of any underlying conditions (e.g., tinea pedis)

Follow-up Plan

• Reassess in 48-72 hours to evaluate response to antibiotics
• Consider outpatient parenteral antibiotic therapy if IV antibiotics needed but patient otherwise stable
• Schedule follow-up with lymphedema specialist after resolution of acute infection

Common Pitfalls to Avoid

1. Relying solely on WBC count to rule out infection in lymphedema patients
2. Inadequate duration of antibiotic therapy
3. Failure to address underlying lymphedema management
4. Not considering prophylactic antibiotics for patients with recurrent episodes

Remember that patients with lymphedema require more aggressive and prolonged treatment for cellulitis due to their compromised lymphatic drainage and immune function.