From the Guidelines
For a 76-year-old female with open sores on feet for 3 months treated for cellulitis, I strongly recommend a comprehensive approach including wound care, infection management, and addressing underlying causes, with a focus on preventing further morbidity and mortality. The patient should receive a broad-spectrum antibiotic such as cephalexin 500mg four times daily for 5 days, as this duration has been shown to be as effective as a 10-day course if clinical improvement has occurred by 5 days 1.
Key Considerations
- Wound care should involve daily cleaning with saline solution, application of petroleum-based ointment like Vaseline, and covering with sterile non-adherent dressings.
- Pressure offloading is essential, using appropriate footwear or devices to prevent pressure on the wounds.
- The patient should be evaluated for vascular insufficiency, diabetes, or other conditions that may impair healing, with blood glucose testing and vascular assessment with ankle-brachial index being appropriate 1.
- Nutritional support with adequate protein intake (1.2-1.5g/kg/day) and vitamin supplementation (particularly vitamin C and zinc) can promote healing.
- The prolonged duration of these wounds (3 months) suggests a need for specialist referral to a wound care center, vascular surgeon, or podiatrist for advanced assessment and treatment options such as debridement, specialized dressings, or vascular intervention if needed 1.
Addressing Underlying Causes
- Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities, as these can contribute to the development of cellulitis 1.
- Administration of prophylactic antibiotics may be considered in patients who have recurrent episodes of cellulitis despite attempts to treat or control predisposing factors 1.
From the Research
Diagnosis and Treatment of Cellulitis
- The patient's condition, open sores on feet for 3 months, was treated with cellulitis, which is a common skin infection involving the deep dermis and subcutaneous tissue 2, 3.
- Cellulitis is a clinical diagnosis based on the history of present illness and physical examination, and lacks a gold standard for diagnosis 2.
- 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 2.
- However, the optimum antibiotic treatment for cellulitis lacks consensus, and the available trial data do not demonstrate the superiority of any agent 4.
Antibiotic Selection
- Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit 3.
- For outpatients with cellulitis, antibiotics with activity against community-associated methicillin-resistant Staphylococcus aureus, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy 5.
- The use of intravenous antibiotics over oral antibiotics and treatment duration of longer than 5 days are not supported by evidence 4.
Management of Cellulitis
- Treatment for cellulitis typically involves a penicillin or cephalosporin, and most patients can be managed as outpatient 6.
- Point-of-care ultrasound can be a useful tool in unclear cases, and loop drainage is preferred over the traditional incision and drainage technique for abscesses 6.
- Adjunctive antibiotics can be considered for the treatment of abscesses 6.