Protocol for Patients Presenting with Abscess, Cellulitis, Furuncle, or Carbuncle
Any patient presenting with an area of tenderness, redness, swel ing, or pain
Danger signs present -immediate evaluation by a physician -address predisposing/ immunocompromising conditions Screen danger signs/symptoms
-systemic signs: temperature >38.0, heart rate
-for patients with penicil in al ergy or
-diabetes, malnutrition, HIV, renal failure, CHF, or
(crepitation or bul ae), use Penicil in 3
-history of not moving for long periods of times
-involvement of the face or hands, perineum, near
-large pain to touch outside the area of redness
-bul ae, ulcers, hemorrhage, or peeling of skin
-crepitation (gas formation under the skin)
-size of abscess beyond the typical experience
abscess-consider anticoagulation if clinical y consistent with DVT-24 hour observation
Treat Furuncle Treat Cellulitis/Erysipelas Treat Abscess or Carbuncle Incision and Drainage Preferred Penicillin Allergic (no immediate hypersensitivity) Penicillin Allergic (immediate hypersensitivity) Adapted from J Am Board Fam Pract 2004;17:S23–31. Pubmed ID: 15575027Clin Infect Dis 2005; 41:1373-1406. PMID: 16231249; Can Fam Phys 2007; 53(10): 1680-4 PMID: 17934031Notes (typically do not need to be printed out at the clinic; just for reference and documentation)We group these skin infections together owing to common/similar presentation. We are developing additional protocols for other soft tissue infections such as impetigo, necrotizing infections, and bite wounds.
Abscesses do not typically require antibiotics. Having cellulitis around an abscess does not require treatment in the absence of either fever, toxic appearance, or immunocompromise, al of which were screened out in the protocol. The exceptions would be: 1. if it's huge and extending (say, >10 cm, although there isn't a formal cut-off). 2. if the abscess can't be drained well. There is anecdotal evidence, which has led to widespread use in our setting, that, owing to the difficulties with patient fol ow-up and wound hygiene, abscesses should be treated with antibiotics. We currently do not do so, as there is no evidence for it, and wil focus on patient education and fol ow-up through community health workers to prevent adverse outcomes. However, we will be careful y documenting outcomes and may adjust as necessary.
Ciprofloxacin should not be used for cellulitis. Not only is it less studied (more in abscess than in cellulitis), but even if it works it should be spared b/c of its low genetic barrier to resistance, particularly when the other choices are adequate and wel established. Although quinolones have convenient dosing, microbial susceptibility won't last long. Quinolones also should be used with extreme care in an area with TB.
Injecting lidocaine into an abscess is not appropriate. It's painful and ineffective. Rather, it is necessary to inject into tissue where the nerves are, not into a tight pocket of pus which: 1) becomes tense with pain; 2) isn't where the nerves are; 3) would make the lido incredibly diluted by pus anyways. A field bloc is not painful, requires only one to two injections, only the first of which is felt, produces much less pain. To quote from a surgery book on local for abscesses: "Injection into the abscess cavity is ineffective and can exacerbate discomfort by increasing the intracavitary pressure." This is also the recommended procedure from the WHO Essential surgical care.
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