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1 Policy No: MM09 Version: 1.0 Name of Policy: Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care Effective From: 27/06/2017 Date Ratified 14/06/2017 Ratified Medicines Governance Group Review Date 01/06/2019 Sponsor Medical Director Expiry Date 13/06/2020 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1

2 Version Control Version Release Author/reviewer Ratified by/authorised by /06/2017 Dr J Moore Dr R Petch S Robinson M Young Medicines Governance Group Date 14/06/2017 Changes (Please identify page no.) Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 2

3 Contents Section Page 1 Introduction Policy scope Aim of policy Duties (Roles and Responsibilities) Definitions Main body of the policy: Service outline Service description Diagnosis of cellulitis Cellulitis treatment pathway hour clinical review Management of patients suitable for oral antibiotics Monitoring for and management of healthcare acquired infections Evaluation of this pathway Training Equality and diversity Monitoring compliance with the policy Consultation and review Implementation of policy (including raising awareness) Associated documentation (Policies and Appendices) Appendices Appendix 1 Eron s Classification of Severity of Cellulitis Appendix 2 Referral forms Appendix 3 Antibiotic monitoring recommendations Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 3

4 Gateshead Cellulitis Pathway 2017 Primary, Community and Acute Care This pathway has been developed in partnership by Gateshead Health NHS Foundation Trust, Newcastle Gateshead Clinical Commissioning Group and the North East Commissioning Support Unit with input from stakeholder clinicians. Queries relating to the pathway should be directed towards the following contacts: Organisation Gateshead Health NHS Foundation Trust Designation Ambulatory Care: Dr Ruth Petch Microbiology: Dr Jonathan Moore Pharmacy: Neil Gammack Newcastle Gateshead Clinical Commissioning Group North East Commissioning Support Unit Lesley Bainbridge Medicines Management: Anne-Marie Bailey 1 Introduction Cellulitis is a common painful bacterial infection of the skin and subcutaneous tissues. The majority of patients suffering from cellulitis can be treated with oral antibiotics, although some patients may require administration of intravenous (IV) antibiotics. The infection most commonly affects the skin of the lower leg, but can infect skin in any part of the body. Disruption to the skin barrier or a site of injury may be apparent providing an obvious portal of entry for bacteria. Most cases of cellulitis are caused by Staphylococcus aureus and/or Streptococcus pyogenes. Other rarer bacterial causes of cellulitis include group B, C and G Streptococcus, Gram negative bacilli from the Enterobacteriaceae family (coliforms), Pseudomonas aeruginosa and anaerobes. Cellulitis can affect people of all ages. Rates are similar in males and females. The main predisposing factors are diabetes mellitus, obesity, lymphoedema, immunodeficiency, chronic liver and renal disease, leg ulcers in the context of peripheral vascular disease and Intravenous drug misuse. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 4

5 In England, the number of patients admitted to hospital with cellulitis has increased threefold over the past 15 years. Since 2010 Gateshead patients have been able to have their IV treatment at home via a shared care pathway meaning some are diagnosed and prescribed treatment by their GP, while others are diagnosed and begin their treatment in hospital. In both cases, patients are either stepped down to have their care continued at home by the Gateshead Intermediate Care Team (GIC team) or stepped up to the team by their GP. The responsibility of the patient lies with the diagnosing clinician and patients are reviewed by them within 48/72 hours or earlier if deemed necessary by the community nursing team. Inclusion and exclusion criteria exist and a clearly defined group of patients only are referred for community IV antibiotic administration. This pathway is constantly being reviewed and updated. This latest version of the guidelines, updated in May 2017 ensures that this policy follows the new trust policy standard and reflects changes made to the antibiotics in the pathway and updated monitoring guidance. 2. Policy scope This policy applies to all healthcare professionals working across acute services within Gateshead Health NHS Foundation Trust and community services (including General Practitioners) who are involved with the management of cellulitis that may require intravenous therapy. This includes medical, nursing and pharmacy staff. 3. Aim of policy The aim of this policy is to provide a framework to guide the management of patients with cellulitis that is deemed at initial assessment to require intravenous therapy in a patient who does not require admission to hospital. 4. Duties (Roles and responsibilities) 4.1 Named clinicians (i.e. consultant physicians / surgeons and general practitioners) and the acute medical and ambulatory care medical team: Are responsible for:- - Ensuring that the patient concerned is suitable for OPAT treatment and meets the criteria set out in these guidelines. - Prescribing antimicrobial agents prudently in accordance with these guidelines and documenting antibiotic choice, route and duration. Documenting the reasons for deviating from these guidelines when prescribing antibiotics not in concordance with these guidelines. - Ensuring that antibiotic prescriptions are reviewed every hours and that this review is documented in the patient s medical records. - Ensuring that the patient receives appropriate monitoring and follow up. - Any outstanding investigations and all aspects of source control (or referral for this). - Communicating information in a timely fashion. This includes communicating with the patient as well as with the ambulatory care team, microbiology team and general practitioner / hospital teams. - NOTE: Overall responsibility for the patient REMAINS with the referring clinician. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 5

6 4.2 Nurse prescribers: Are responsible for:- - Prescribing antimicrobial agents prudently in accordance with these guidelines and documenting antibiotic choice, route and duration. Documenting the reasons for deviating from these guidelines when prescribing antibiotics not in concordance with these guidelines. - Reviewing antibiotic prescriptions every hours and documenting the outcome of these reviews. - Ensuring that the patient receives appropriate onward monitoring and follow up. 4.3 Consultant microbiologists: Are responsible for:- - Ensuring that the guidelines are regularly reviewed and up to date taking into account local sensitivity patterns as well as regional and national guidelines. - Promoting and monitoring compliance with these guidelines. - Monitoring the use (quantity and quality) of antimicrobial agents within the Trust with the antimicrobial pharmacist. - Monitoring, in conjunction with the ambulatory care team, the rates of healthcare acquired infections (e.g. line infections and cases of Clostridium difficile infection). 4.4 Ambulatory care nursing team and the Gateshead Intermediate care team are responsible for:- - Ensuring that the patient concerned is suitable for OPAT treatment and meets the criteria set out in these guidelines. - Arranging for appropriate intravenous access to be inserted. - Arranging for / delivering the appropriate antibiotic therapy in a timely fashion. - Monitoring clinical response. - Discussing with the relevant clinical or microbiology team in the event of signs of treatment failure or any clinical concerns. - Monitoring for complications of treatment (including healthcare acquired infections). 4.5 Pharmacy staff: Are responsible for:- - Providing the necessary IV and oral antibiotics. - Monitoring antibiotic prescribing and alerting medical staff or the Microbiology team to discordant prescriptions. 5. Definitions Outpatient parenteral antimicrobial therapy (OPAT): Is a method for delivering intravenous antimicrobials in the community or outpatient setting, as an alternative to inpatient care. Antimicrobial stewardship: An organisational approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. This encompasses all activities intended to improve patient outcomes from infection while Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 6

7 minimising negative consequences such as healthcare associated infections and limiting the development of bacterial resistance. 6. Main body of the policy 6.1 Service Outline The service will be available to all patients registered with a Gateshead GP who meet the referral criteria for treatment of non-complicated cellulitis according to Eron s Class I or II (Appendix 1) in the community. The decision to treat the patient in the community will be made by the diagnosing clinician in primary or secondary care, including the Walk in Centre and Accident and Emergency Departments. The Gateshead Intermediate Care Team (GICT) will continue to be the community nursing team administering the treatment and the service will still be available 24 hours a day, 7 days a week. It is expected that the aims of the service will remain the same: Improve access to care closer to home Reduce avoidable non-elective hospital admissions Reduce the risk of healthcare associated infections associated Reduce the risk of loss of independence Improve patient partnership relationships Deliver cost savings for the whole health and social care economy 6.2 Service Description The Gateshead Intermediate Care Team (GICT) will provide a community based service to a clearly defined group of patients who are suffering from Eron s Class I or II cellulitis, in their own homes. If the patient meets the referral criteria for this service, they are referred to GICT by the appropriate clinician using the identified referral documentation. Referrals to GICT should be made by phone to the team coordinator, and backed up by the relevant referral documentation, which is to be faxed. The team will accept referrals for adults over the age of 18 and will carry out a routine risk assessment and the referring GP should alert the team of any known risk factors upon referral. Referral forms can be self-populated by the clinical system. Please indicate on the referral form the routine bloods, swabs and investigations that GICT are to carry out at the time of cannulation, which are dependent upon the drug treatment. The GP will flag any anomalies with the blood or swab results for necessary action/treatment to be taken by the GICT. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 7

8 During OOH periods (Friday Sunday) the nursing team will check patient blood results and liaise with the GP OOH service as necessary to ensure seamless care 24/7, 7 days a week. Patients should be given their prescription, information leaflet and drug treatment card identifying the relevant drug prescribed for the patient; they can then share this with the team when they visit. GICT will contact the patient within four hours of receipt of referral to confirm with the patient a suitable timescale for first contact and treatment to commence. Drugs will be supplied either by the hospital pharmacy team or QE facilities dependent upon whether patients are stepping down from secondary care or stepping up from primary care. For the patients referred via GP or GATDOC, GICT keep a stock of IV antibiotics at Bensham Hospital. The team take the required dose out for each individual visit. Drugs will be prescribed by the referring clinician and administered under an agreed drug protocol. While the patient is undergoing IV therapy they will remain the clinical responsibility of the referring clinician, but the drugs will be administered by the GICT. During treatment the patient will be regularly monitored by the GICT. The team will liaise with the referring clinical teams, highlighting if the patient is not responding to treatment; or if the patient has responded and needs to be transferred to oral antibiotics. The decision to move from IV to oral antibiotics will be made by the patient s referring clinician in liaison with the GICT. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 8

9 6.3 Diagnosis of cellulitis Figure 1: Gateshead s Non-Complicated Cellulitis Pathway: Secondary care Diagnose cellulitis Identify suitability for community IV antibiotics (inclusion/exclusion criteria) Patient clinically stable Discuss community pathway with patient Prescribe drugs in accordance with recommended treatment completion of Administration of community injectable medicines form, include blood testing (as required) Decide on intravenous device for discharge: Cannula: hours for short term access or Mid-line: Used for 1-6 weeks or longer for short-to intermediate-term. Telephone Intermediate Care Team Co-ordinator: Telephone Intermediate Care Team co-ordinator ensures referral meets criteria for acceptance Yes No Time of next dose discussed with referrer. Patient discharged with intravenous antibiotics & administration of community injectable medicine form & a photograph of the cellulitis. Date agreed date for review at ACC Gateshead Intermediate Care (GIC) team home visit Discuss care to gain consent, complete comprehensive assessment, note any allergies. Daily VIP score, weekly line care depending on intravenous device insitu. Administer drugs prescribed Daily observations >EWS score Obtain any routine investigations necessary (blood/swabs) if necessary, dependent upon drug prescribed > ACC to follow up results on review. Provide patient information leaflet with contact details Schedule next visits until review at ACC Re-cannulate as required Advise referrer that patient stepping down needs to stay in hospital. Team capacity may require the ward to re-refer the following day or as advised by GIC team to assist patient discharge. Shared care with ACC if unable to complete visits requested, due to team activity Responsive to treatment Discuss with referrer within 48 hours to plan further care and oral switch On-going review Planned and unplanned according to patient s needs Deterioration Discuss with referrer if appropriate or admit directly to hospital Discharge Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 9

10 Figure 2: Gateshead s Non-Complicated Cellulitis Pathway: Primary care GP diagnosis of cellulitis & exclusion of DVT. Identify suitability for community IV antibiotics (inclusion/exclusion criteria) Patient clinically stable Discuss community pathway with patient Prescribe drugs in accordance with recommended treatment completion of Community Cellulitis Pathway Document on GIN access. Telephone Intermediate Care Team Co-ordinator: Telephone Intermediate Care Team co-ordinator ensures referral meets criteria for acceptance Yes No Gateshead Intermediate Care (GIC) team to contact the patient with 4 hours of receipt of referral to confirm estimated time of first visit at home address. Date agreed date for review with GP Intermediate Care Team home visit Discuss care to gain consent, complete comprehensive assessment, note any allergies. The team supply intravenous antibiotic prescribed dose to each visit (team supplies kept at Bensham Hospital from GHNT pharmacy) Decide on intravenous device for treatment Cannula: hours for short term access or Mid-line: Used for 1-6 weeks or longer for short-to intermediate-term. Photograph taken of cellulitis for patient records & reviews on first visit. Baseline bloods taken on first visit : CRP LFT, FBC, U&E s Daily VIP score, weekly line care depending on intravenous device insitu. Administer drugs prescribed Daily observations >EWS score Provide patient information leaflet with contact details Schedule next visits Re-cannulate as required Repeat bloods and photograph within hours Virtual review with GP as may need to continue on intravenous antibiotics or convert to orals Responsive to treatment Discuss with referrer within 48 hours to plan further care and oral switch On-going review Planned and unplanned according to patient s needs Deterioration Discuss with referrer if appropriate or admit directly to hospital If stepping up advise referrer to discuss patient with ambulatory care unit. Shared care with ACC if unable to complete visits requested, due to team activity Clindamycin mg mg oral QDS (Penicillin allergic) is an option for patient who can swallow medications Caution: Avoid Clindamycin in patient s at high risk of C.difficile infection Discharge Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 10

11 GP or medical practitioner will carry out clinical assessment; including risk factors and full patient history to establish diagnosis using Eron s classification system (Appendix 1). Clinical features of cellulitis are: Acute and progressive onset of red, painful, hot, swollen and tender skin with possible blister or bullae formation, usually unilateral Fever, malaise, shivering and rigors may precede or accompany the skin changes Spreading lymphangitis in severe cases Cause usually identifiable (such as laceration, burn, bite, leg ulceration, eczema) Differential diagnosis are identified below: Varicose eczema DVT Acute gout Common Rare Gangrene Carcinoma Erisipeloides Necrotising fasciitis Acute lipopsclerosis Vasculitis Pyoderma gangrenosum Patient assessment to include the following: Erythematous edges should be marked with indelible ink pen to allow subsequent clinical assessment of progress by the GIC team Temperature Blood pressure Heart Rate Respiration Rate Oxygen Saturation on air Patient weight if available FBC/U&E/LFT/CRP/Glucose/INR and routine swab if skin is broken or blistering [if this hasn t been by the GP then instructions should be given to the GIC team so that they can obtain the specimens during the initial visit] Patients suitable and unsuitable for the pathway are identified below: Suitable Adults with uncomplicated cellulitis Any patient who, on assessment, can be safely treated at home Unsuitable IV drug users Facial/ periorbital cellulitis Pregnancy/breastfeeding Known or suspected colonisation/infection with MRSA Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1

12 Whether to prescribe oral or intravenous antibiotics will be a matter of clinical judgement. Home IV antibiotic treatment should be considered for patients with: Marked cellulitis (more than mild localised but not extensive) Mild systemic features (e.g. flu-like symptoms, malaise) but not unwell Stable co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection. Cellulitis not improved on oral therapy. 6.4 Cellulitis Treatment Pathway Following diagnosis of cellulitis patients suitable for the pathway should be referred to the GIC team for treatment in the community. Treatment options depending upon individual patient circumstances are outlined below: No allergies or other contraindications NOTE RE: Penicillin allergy: If history of severe, type 1 or anaphylactic reaction to Penicillin AVOID Ceftriaxone (cross reactivity %). If allergy history is of non-severe or late onset rash: Administer Ceftriaxone with caution. Allergic to Cephalosporins or Type 1 anaphylactic Penicillin allergy Low risk of C.difficile infection Ceftriaxone IV* 1-2g once daily * Under 80kg 1g, over 80kg 2g OD Review the morning after the second dose to decide whether to continue OR switch to oral therapy Oral switch after 48/72 hours to Flucloxacillin 1g 6 hourly (to complete a 7 day course) or Doxycycline (200mg once a day) if Penicillin allergic. Patients should be seen twice daily to monitor wellbeing even though administration is once daily. Clindamycin PO 600mg 6 hourly (Complete a 7 day course then review) OR Teicoplanin IV 800mg Stat dose followed by 400mg once daily OR CDI within past 12 months or living in nursing home or otherwise deemed at high risk of CDI Teicoplanin IV 800mg Stat dose followed by 400mg once daily OR Linezolid** PO 600mg twice daily Oral switch after 48/72 hours to Flucloxacillin 1g 6 hourly (Complete 7 day course then review). Linezolid** PO 600mg twice daily ** Check for contra-indications and interactions. NOTE that Linezolid should NOT be given concurrently with antidepressants such as SSRIs and MAOIs. NB Daptomycin can be considered in the following circumstances but should only be administered in secondary care non response to treatment after 3 days worsening cellulitis spreading beyond marked borders signs of systemic illness Concurrent Statins should be withheld whilst on Daptomycin and a baseline CK should be checked with the CK then repeated at day 3 and then once weekly thereafter. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 12

13 N.B. If cellulitis follows a bite injury, please refer to main antibiotic policy for antibiotic recommendations. IV Antibiotics for the service are supplied directly to the GIC team by QEF / QE Pharmacy Department. GPs do not need to issue an FP10 prescription for these antibiotics. The Drug Therapy Record will act as administration record. A standard FP10 will need to be issued when patients are transferred to oral antibiotics. Please refer to Appendix 3 for monitoring and general drug advice. DVT Prophylaxis In addition to IV antibiotics, prophylactic Tinzaparin should be considered in ALL patients receiving treatment for significant cellulitis with IV antibiotics in the community Hour Clinical Review All patients should be reviewed by either the GICT, General Practitioner or Ambulatory care medical team around 48 hours into their treatment. Follow up arrangements should be agreed at the outset of treatment. As soon as clinically appropriate, an Intravenous to oral switch of antibiotics should be considered based on the following criteria:- Pyrexia settling Erythema settling Falling inflammatory markers (if available) Any co-morbidities stabilised Review by clinician (telephone/ face to face consultation depending on clinical circumstances) Erythema may increase during the first hours of treatment. Consider IV antibiotics if further deterioration or if the person develops any of the features requiring hospital admission. When patients are suitable for switch to oral antibiotics, switch to the oral antibiotics specified in the section 6.6. If patients are slow to respond, it may not be appropriate to switch to oral at 48hrs, continued assessment on a daily basis will need to be carried out to determine if a longer course is required and for how long. 6.6 Management of patients suitable for oral antibiotics Patients will be suitable for oral antibiotics if the following criteria apply:- No systemic features No uncontrolled co-morbidities Cellulitis is localised Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 13

14 Antibiotic Choice Generally a 7 day course but up to 14 days may be required in slow to respond infections First line Oral Flucloxacillin 500mg-1g QDS Penicillin allergy Oral Doxycycline 200mg OD (or Oral Clarithromycin 500mg BD) Mild facial cellulitis: Oral Co-amoxiclav 500/125 mg TDS for 7 days. However if the patient is frail and elderly or there are signs of peri-orbital cellulitis it may be best to discuss with a microbiologist and consider referral to hospital. If the cellulitis has followed an animal or human bit or the wound contaminated by water, broader spectrum antibiotics may be required so please discuss with a microbiologist. 6.7 Management of Healthcare Associated Infections The list below outlines advice for GP and GICT to minimise the risk of C. difficile in the community: Nurse and GP to liaise following patients first symptoms of diarrhoea Test for C difficile and treat according to local guidelines if positive Review all antibiotic treatment if applicable Do not prescribe anti-motility medication 6.8 Evaluation of this Pathway 7. Training The following monitoring arrangements will be put in place to ensure the pathway is operating as planned: Cellulitis activity data will be collected and monitored to inform the key metrics below: Number of referrals to A&E, Ambulatory Care Unit by GPs Number of admissions from GP s Number of referrals to GICT by GPs Number of patients stepped down to GICT by secondary care departments Number of inappropriate referrals to GICT Number of patients switched to oral medication within 72 hours Any evidence of patients on the pathway who have developed C difficile infection Any evidence of line infections Number and range of antibiotics prescribed Identify the number of practices operating the pathway This policy will be made available on the trust intranet. All staff involved with the management of cellulitis should familiarise themselves with this policy. Formal training will Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 14

15 be carried out at regular intervals. The details of this policy will be discussed at a Newcastle Gateshead CCG GP time out session. 8. Diversity and inclusion The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act Monitoring compliance with the policy Standard/process/issue All antibiotics should be prescribed in accordance with these guidelines All antibiotic prescriptions should have a review documented in the medical notes within 72 hours of prescription Record ALL line infections and cases of C.difficile infection Monitoring and audit Lead Tool Frequency Reporting Arrangement Ambulatory care and GIC team supported by Microbiology Consultants / Antimicrobial pharmacist Ambulatory care and GIC team supported by Microbiology Consultants / Antimicrobial pharmacist Ambulatory care / GIC team. Audit tool to be developed Audit / CQUIN mandatory data collection form Patient database Quarterly Antimicrobial steering group Quarterly Antimicrobial steering group Continuous monitoring Antimicrobial steering group 10. Consultation and review All stakeholders have been involved with the development of this policy. It will be kept under continuous review with formal a formal review conducted in 2 years time. 11. Implementation of the policy An will be sent out to all stakeholders at the point that this policy comes into effect. Details of the new policy will also be disseminated verbally amongst staff. 12. Associated documentation (Policies and Appendices) Appendix 1 Eron s Classification of Severity of Cellulitis Appendix 3 Antibiotic monitoring recommendations Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 15

16 Appendix 1: Eron s Classification of Severity of Cellulitis Eron s Severity Classification System to aid diagnosis, treatment and admission decisions. Once a diagnosis of lower limb cellulitis has been made a decision should be made as to admission and treatment options according to the following classification systems. Class 1 Community Treatment Patients have no signs of systemic toxicity, have no uncontrolled co-morbidities and can usually be managed with oral antimicrobials. Class II Community Treatment Patients are either systemically ill or systemically well but with a comorbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection. Class III Hospital Admission Patients may have a significant systemic upset such as acute confusion, tachycardia, tachypnoea and hypotension or may have unstable co-morbidities that may interfere with a response to therapy or have a limb threatening infection due to vascular compromise. Class IV Hospital Admission Patients have sepsis syndrome or severe life threatening infection such as necrotizing fasciitis. Clinical findings alone are usually adequate for diagnosing cellulitis, particularly in non-toxic immunocompetent patients. Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 16

17 Appendix 2: Primary Care Community Cellulitis Referral Form In-patient Request for Community Administration of Injectable Medicines Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 17

18 Appendix 3 Antibiotic monitoring recommendations Antibiotic Renal / Hepatic dose changes: Refer to BNF Monitoring required Baseline bloods Teicoplanin Renal FBC U&E LFT Ongoing monitoring FBC and U&E Day 3 then weekly LFT weekly General advice Plasma serum concentration monitoring may be required in elderly patients and in deep seated staphylococcal infection including bone and joint infection (discuss with a microbiologist). Risk of thrombocytopenia, neutropenia, renal and hepatic impairment Risk of auditory dysfunction during prolonged treatment in renal impairment or when used in combination with other nephrotoxic or neurotoxic drugs Daptomycin Renal & severe hepatic CK FBC U&E LFT Weekly CK*, FBC, U&E and LFT * CK levels more frequently if >5 times upper limit of normal pre-treatment, or if egfr <80mL/min/1.73m 2 Statins (and myopathy associated drugs) should be withheld during treatment Creatinine kinase (CK) monitoring required at baseline and weekly (or more frequently if CK >5 times upper limit of normal pretreatment, or if egfr <80mL/min/1.73m 2 ) Myalgia, muscle weakness and myositis may occur uncommonly, Rhabdomyolysis is very rare. In the event of unexplained muscle pain, tenderness, weakness or cramps during treatment check CK then discuss with Microbiologist Discontinue if unexplained muscular symptoms and CK raised markedly Linezolid Renal & severe hepatic FBC LFT Weekly FBC and LFT Linezolid is a reversible non-selective MAO inhibitor, see BNF appendix 1 for interactions with MAOI s (e.g. SSRIs, Tricyclic and other antidepressants such as Citalopram, Mirtazapine, Paroxetine, Sertraline, Fluoxetine, Escitalopram, Venlafaxine etc.). Please discuss with a Microbiologist if on any of these drugs) Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 18

19 Risk of haematopoietic disorders and myelosuppression (thrombocytopenia, anaemia, leucopenia and pancytopenia) and hepatitis, particularly in the elderly and following prolonged courses. If significant myelosuppression occurs, treatment should be stopped. Treatment courses should be limited to LESS THAN DAYS unless specifically advised or discussed with a Microbiologist Close monitoring is required in prolonged (>10 days) therapy; patients with pre-existing myelosuppression or who are receiving drugs that may affect FBC and renal impairment Visual impairment (severe optic neuropathy) can occur rarely (usually after >28 days therapy). If patients experience visual impairment (including blurred vision, visual field defect, changes in visual acuity and colour vision) seek medical / ophthalmology review Flucloxacillin / Ceftriaxone Renal & hepatic FBC Clotting U&E LFT Weekly FBC, clotting, U&E and LFT FBC, platelets and prolongation of prothrombin time monitoring required Can cause hepatic impairment (especially high dose Flucloxacillin) Risk of C.difficile infection. If loose stools develop seek medical review Clindamycin FBC LFT Weekly FBC and LFT Risk of C.difficile infection. If loose stools develop, stop antibiotic & seek medical review References: British National Formulary: Version 72, September 2016 March 2017 Summary of Product Characteristics ( Gateshead Cellulitis Pathway 2017: Primary, Community and Acute Care v1 19