I had a question come up at a patient I was wondering if you could answer.
Stove pipe edema to both legs and currently being treated with cefazolin for a ‘cellulitis’.
This 81-year-old female has had increasing difficulty to cope at home related to osteoarthritis of bilateral knees and marked lymphedema, bilateral lower extremities. She has had no falls to date. She is walker dependent with mobilization but is very limited in her ability to navigate her home environment, which is a one-level facility. She does have the assistance of private healthcare and home care nursing. We attempted to mitigate her edema in her lower extremities with supportive dressings but presently she is not able to get into her bed and is now having to sleep in a reclining chair at night. She is able to navigate to the washroom and to food supplies. She had been in hospital recently with reduction in lymphedema by pressure support dressings with some improvement but has been disabled due to the arthritis in bilateral knees and tends to sit more at home, without the supportive care, tends to collect fluid in her lower extremities and become more immobilized. There is no overt history of congestive heart failure. She does have chronic renal failure with low GFR in the low 30s. She also has a chronic pain syndrome, treated with baseline long-acting narcotics. She avoids NSAIDs due to the renal failure and due to the lymphedema with fluid collection. She has had previous steroid injections into the knee joints with minimal effect. We have discussed Synvisc injections to mitigate her knee pain. She also has a history of psoriatic arthritis but to date has rejected use of hydroxyquine due to previous rash. She is on low dose steroids to attempt to reduce any inflammatory arthritis.
Unable to see the legs as they were well wrapped. No cultures.
Being a bilateral ‘cellulitis’ thinking antibiotics are probably not required, but wondering what the best way to approach the patient with severe edema and ‘cellulitis’. If the physician insists on antibiotics, would a set length of therapy be the best method? (10-14 days?)
This is a tough one. It is very likely that no infection is present at all but it impossible to be definitive. The physician is into “drawing at straws” territory so may naturally be defensive. I think this is the sort of situation where a conciliatory approach is appropriate – “I am on your side” but being clear that there is considerable diagnostic uncertainty so that a finite course is very rational. I would suggest seven days and if that hasn’t helped it goes a long way to ruling out infection.
The next time the situation arises the diagnostic uncertainty will be further to the forefront and avoidance of antibiotic more likely.
I am happy to intervene but it is likely not a good idea as you would then be viewed as a “tattle tale” and not a thoughtful ally connected to a “wise sage”.