The patient might be having lower extremity swelling in the legs or any bug bite or any kind of injury leading to skin break in the legs. The patients in these situations are more prone to cellulitis especially if they are diabetic.
ER:
Routine Labs, EKG, CXR, Lactic acid if they look septic.
X ray of the leg/foot to rule out Osteomyelitis if suspected.
IV Fluids.
Blood Cultures, Deep wound culture if possible.
First dose of IV antibiotics.
Consult Surgery if Necrotizing Fasciitis suspected.
Hospitalist:
Med-Surgery Floor if stable.
IV Antibiotics-Vancomycin and Cefepime or Zosyn if severe. Ceftriaxone or Unasyn or Clindamycin an be given. PO antibiotics like Keflex and/or Bactrim can be given too if mild.
Continue IV Fluids especially Sepsis alert was initiated in ER.
Consult Podiatrist for non healing foot ulcers.
Consult ID if severe cellulitis, MRI/Bone Scan to rule out osteomyelitis if X-ray was not showing osteomyelitis but clinical suspicion is high as patient is not improving. CT scan of the affected limb might be needed if deep abscess is suspected.
PICC line for long term antibiotics especially for Osteomyelitis.
US arterial duplex to look for Peripheral vascular disease in diabetic patients. Consult Vascular Surgery if Peripheral Arterial Disease is seen on ABI/PVR as they might need angiogram.
Ulcers or gangrene may improve after vascular procedure like Angioplasty by Vascular Surgery and if not Podiatrist might need to do surgery.
Podiatrists:
Debride nails if long and dystrophic.
Toe amputations or Trans Metatarsal Amputations (TMA)–>sends for Bone biopsy for C/S.
Order Darco shoes for ambulation after foot surgery.
If severe Peripheral Arterial Disease, patient may need above or below knee amputations by vascular surgery.
Final antibiotic duration depends upon clinical situation. A few days for simple cellulitis to 6 weeks for osteomyelitis.
Earn CME from UpToDate:
Cellulitis and skin abscess in adults: Treatment
Osteomyelitis in adults: Treatment
