CELLULITIS
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Have recently seen a 55 y/o wf  who had bypass surgery  some years ago, with
vein grafts taken from both legs. Has had(by her count) 19 episodes of
cellulitis of the right leg(never the left), 5 requiring hospitalization. Has
used Lamisil for tinea pedis propylaxis and most recent episode was treated
with Duricef and Floxyl and is resolving. Erythromycin causes GI problems,
and she has no allergies. Would appreciate suggestions as to which antibiotic
would  be best for long-term prophylaxis. Thanks in advance.

Harold Rehbein
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Does she have an underlying stasis which gives entry? Sorry I can't help
with which antibiotic is best for prophylaxis-I would call an I.D. person
for that one.   

Diane Thaler
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Edema prophylaxis might be important. I'm convinced that edema is t he most
important predisposing factor to cellulitis.  I use lots of ace bandages and
Jobst stockings in patients who've had venous insults like CABG or clots.

Guy Webster
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Interesting: patient had bilateral saphenous grafts taken and now
has recurrent cellulitis.  I teach the residents about this 
phenomenon: Dermatosis Locus Minoris Resistentiae; something
I read somewhere but can't find a reference.  
"Is There Anybody Out There" that knows a reference for this
most fascinating phenomenon, and one of the 'fun' and 
mysterious things seen in Derm.  (I love this Specialty)

Re:  Antibiotics for Cellulitis
IMHO (in my humble opinion) would recommend:
	Daily cleansing with chlorhexidine gluconate soln mixed in
		Cetaphil as well as bacterial C&S of anterior nares,
		sacral crease, and crural areas looking for Strep/Staph
		(I don't remember you stating the 'germ' incriminated
		in the cellulitis)
	Bactroban to anterior nares qid X 2 weeks then BID  for another
		8 weeks: if remains clear, would use prophylactically
		BID on Saturdays & Sundays.
	Consider either Azithromycin for 4-6 weeks then qod X 2-3 
		months or even something like minocycline or a
		quinolone (blocking name).
		In this area of least resistance, I would hope the chlorhexidine
		would 'sterilize' the skin allowing you to taper the ABX
		with time.
	Don't forget about orthostasis as a cause for decreased 
		resistance: rec foot excercises to work the muscular
		pump, etc.

Patrick R. Carrington
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