Do these interventions for cellulitis in children
Do these interventions for cellulitis in children
MRSA is a consideration
At Childrens Hospital in Los Angeles, ED nurses typically give cephalexin for children with straightforward cellulitis without an abscess, says Inge Morton, RN, CPN, education manager for the ED. "However, nowadays with MRSA [methicillin-resistant Staphylococcus aureus] being prevalent in the community, clindamycin or trimethoprim/sulfamethoxazole are the choice especially with repeated cellulitis or if there is an abscess involved," she says.
There is a great deal of concern now for MRSA as a causative agent for cellulitis, says Fran Porcher, EdD, RN, CPNP, an ED pediatric nurse practitioner at Medical University of South Carolina in Charleston. "Not all antibiotics are effective against MRSA, but on an outpatient basis, oral trimethoprim/sulfamethoxazole generally is," she says.
Cephalexin was the most common oral antibiotic given to 269 children with noncomplicated, nonfacial cellulitis from 2001 to 2003, according to a new study.1 The most common intravenous (IV) antibiotic given was cefazolin, with 39 children given cefazolin alone and 85 children given cefazolin and probenecid. The cefazolin-only group had 12 (31%) treatment failures, whereas the cefazolin and probenecid group had seven (8.1%) treatment failures. More time in the ED (521 minutes on average) and more visits (3.4 on average) were seen in the IV group as compared with the oral group, which spent an average of 164 minutes, with 1.4 visits.
Since twice-daily cefazolin and probenecid were associated with fewer treatment failures and admissions than cefazolin alone, this alternative may be good for children with nonfacial cellulitis requiring IV antibiotics, say the researchers. To improve care of children with cellulitis:
• Manage the child's pain.
Cellulitic tissue is very sensitive, so pain control is important, says Morton. "Never insert an IV into a cellulitic area or administer intramuscular or subcutaneous injections."
• If the cellulitis is over a joint, consider splinting the joint.
"Mark the perimeter of the erythema to monitor progression," she says.
• Ask the right questions at triage.
The age of the child, the location of the cellulitis, and the overall health status of the child could all raise the acuity level of the situation, says Porcher. Ask these questions, she advises:
How old is the child? A young infant with cellulitis might be much more serious than a teenager with cellulitis, says Porcher.
Is there presence of fever?
A fever, especially greater than 100.4° F, would suggest a more systemic illness and should be treated aggressively, says Porcher.
How and when did the cellulitis develop?
Determine how rapidly the cellulitis appeared, whether over hours or days, says Morton. "The more rapid the progression, the more aggressively it should be treated, especially if the child also has a fever over 39°C, which would point to a more systemic course of the disease," says Morton. In this case, IV clindamycin still would be given, unless the child has multiresistant organisms causing the cellulitis, in which case vancomycin would be given, says Morton.
What is the location?
A cellulitis occurring in a more vascular area of the body, such as the perineal area, or close to the blood-brain barrier, such as the periorbital area, potentially would be more serious than one occurring on the forearm or leg, says Porcher.
What past or current treatment has there been?
If the child has been receiving antimicrobial treatment for the cellulitis without improvement or resolution, the treatment plan should be reconsidered, given the possibility of resistant microorganisms, says Porcher.
Does the child have any allergies?
What is the past medical history?
What medications is the child currently taking?
What is the child's immunization status?
Immunization status reflects the child's overall health status and protection against illnesses such as pertussis and tetanus, says Porcher.
Are there any associated symptoms?
In addition to fever, other symptoms suggesting a more systemic illness include decreased appetite, decreased urination, changes in behavior or activity levels, excessive crying or fussiness, or refusal to use that part of the body involved, such as an extremity, says Porcher.
"If a patient is systemically septic, then monitoring of blood pressure and cardiovascular status is important to recognize signs of septic shock, such as drop in blood pressure, tachycardia, and poor perfusion," says Morton.
- Khangura S, Wallace J, Kissoon N, et al. Management of cellulitis in a pediatric emergency department. Ped Emerg Care 2007; 23:805-811.
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