What is the admitting plan for a 61-year-old male patient with severe atopic dermatitis and current cellulitis, including intravenous (IV) plan, diet, diagnostics/labs, medications, and special nursing orders?

Admitting Plan for 61-Year-Old Male with Severe Atopic Dermatitis and Cellulitis

IV Plan

Initiate IV vancomycin 15-20 mg/kg every 8-12 hours PLUS piperacillin-tazobactam 3.375-4.5 grams every 6 hours for severe cellulitis with systemic involvement. 1

• Vancomycin provides first-line MRSA coverage (A-I evidence) for complicated cellulitis requiring hospitalization 1
• Piperacillin-tazobactam adds broad-spectrum coverage for polymicrobial infection and potential necrotizing components in severely compromised patients 1
• Maintain IV access with normal saline at maintenance rate (typically 75-100 mL/hour) unless contraindicated by cardiac or renal status 1
• Plan transition to oral antibiotics (cephalexin 500 mg four times daily or clindamycin 300-450 mg every 6 hours) after minimum 4 days of IV therapy once clinical improvement demonstrated 1

Diet

Regular diet with no restrictions unless specific comorbidities dictate otherwise. 2

• Dietary elimination is not recommended for adult atopic dermatitis management as evidence does not support benefit 2
• Ensure adequate hydration to support skin barrier function and antibiotic clearance 3
• Avoid known food triggers only if patient has documented IgE-mediated food allergy with prior reactions 2

Diagnostics/Labs

Obtain the following on admission:

• Blood cultures x2 sets from separate sites before initiating antibiotics, particularly given severe systemic features and immunocompromised state from chronic atopic dermatitis 1
• Complete blood count with differential to assess for leukocytosis, bandemia, or neutropenia 1
• Comprehensive metabolic panel including renal function (for vancomycin dosing) and hepatic function 1
• C-reactive protein or erythrocyte sedimentation rate as baseline inflammatory markers 1
• Wound culture with Gram stain from cellulitis site if any purulent drainage, crusting, or weeping present 4
• Bacterial swab from atopic dermatitis lesions to assess for Staphylococcus aureus colonization/infection 4
• Vancomycin trough level before 4th dose (target 15-20 mcg/mL for complicated skin infection) 1

Do NOT routinely obtain:

• Skin biopsy unless necrotizing fasciitis suspected or diagnosis uncertain 1
• Viral cultures unless grouped vesicles or punched-out erosions suggest eczema herpeticum 4

Medications

Antibiotics (Primary Treatment)

• Vancomycin 15-20 mg/kg IV every 8-12 hours for MRSA coverage 1
• Piperacillin-tazobactam 3.375-4.5 grams IV every 6 hours for broad-spectrum coverage 1
• Duration: 5 days minimum if clinical improvement occurs; extend to 7-14 days if severe systemic toxicity or slow response 1

Atopic Dermatitis Management

• Topical corticosteroids: Apply potent-category topical corticosteroid (e.g., triamcinolone 0.1% ointment) twice daily to active eczematous lesions on trunk and extremities 4
• Topical calcineurin inhibitors: Tacrolimus 0.1% ointment twice daily to facial and flexural areas to avoid corticosteroid side effects in sensitive regions 5, 2
• Emollients: Liberal application of thick emollient ointment (petrolatum-based) at least twice daily, ideally after bathing, to all affected areas 4
• Avoid: Do not use topical corticosteroids more than twice daily as this provides no additional benefit 4

Antihistamines

• Sedating antihistamine at bedtime ONLY: Hydroxyzine 25-50 mg PO at bedtime or diphenhydramine 25-50 mg PO at bedtime for severe pruritus interfering with sleep 4
• Avoid daytime sedating antihistamines as they impair function without proven benefit 4
• Do NOT use non-sedating antihistamines as they have little to no value in atopic eczema 4

Supportive Care

• Acetaminophen 650 mg PO every 6 hours as needed for pain or fever 1
• Continue any home medications for comorbid conditions unless contraindicated 1

Special Nursing Orders

Skin Care Protocol

• Bathing: Daily bathing with soap-free cleanser (dispersible cream as soap substitute) for cleansing and hydration 4
• Dilute bleach baths: Consider 0.005% sodium hypochlorite bath (1/2 cup household bleach in full tub) twice weekly for 10 minutes to reduce bacterial colonization if recurrent infections 2
• Post-bath emollient application: Apply thick emollient within 3 minutes of bathing while skin still damp to maximize hydration 4
• Avoid irritants: Use only cotton clothing next to skin; avoid wool and synthetic fabrics 4

Extremity Management

• Elevate affected extremity above heart level continuously using pillows to promote gravitational drainage of edema and inflammatory substances 1
• Examine interdigital toe spaces daily for tinea pedis, fissuring, scaling, or maceration; treat if present to eradicate colonization 1

Infection Monitoring

• Assess cellulitis margins: Mark cellulitis borders with skin marker on admission; measure and document progression/regression every 12 hours 1
• Monitor for necrotizing infection warning signs: Severe pain out of proportion to exam, skin anesthesia, rapid progression, bullous changes, crepitus, or "wooden-hard" subcutaneous tissues require immediate physician notification 1
• Temperature every 4 hours and notify physician if fever >38.5°C or new hypotension develops 1

Nail and Scratch Prevention

• Keep fingernails trimmed short to minimize excoriation from scratching 4
• Cotton gloves at night if severe nocturnal scratching despite antihistamines 4

Patient Education

• Demonstrate proper topical medication application technique including quantity (fingertip unit method) and frequency 4
• Explain steroid potency categories and rationale for using different strengths on different body areas 4
• Reinforce that treatment should not be applied more than twice daily even if symptoms persist 4
• Provide written instructions to reinforce verbal education about chronic relapsing nature of atopic dermatitis 4

Reassessment Triggers

• Mandatory physician reassessment in 24-48 hours to verify clinical response to antibiotics 1
• Immediate notification for: spreading erythema despite 48 hours of antibiotics, new purulent drainage, altered mental status, hypotension, or signs suggesting necrotizing fasciitis 1