Lymphoedema in Wales - Mixing Oedema and Infection

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Lymphoedema in Wales - Mixing Oedema and Infection Melanie Thomas Karen Morgan 5/6/2014

1 Lymphoedema in Wales - Mixing Oedema and Infection Melanie Thomas Karen Morgan 5/6/ National Clinical Lead Lymphoedema National Education & Research Lymphoedema Specialist

2 Lymphoedema: Photographs are the property ABM Lymphoedema Service permission is needed for publication 5/6/2014 2

3 Incidence- Cancer Breast cancer 28% with RT 37%. Gynae cancer 30-75% Urological cancer 20-95% Skin cancers- melanoma 25% Head and Neck 50%

4 Non- Cancer Incidence Trauma & Tissue damage- burns, VV surgery, Wounds, Venous Disease Infection- repeated cellulitis

5 Lymphoedema Treatment No Medication-hands on, skin care, massage, exercise, healthy weight, advice, support, encouragement, bandaging and compression garments Melanie Thomas PMU

6 Cost of Not Treating Pprimary lymphoedema House bound Immobile Carers 3 times daily Admitted to hospital 6 times in last 12 months with Cellulitis averaging 60 days. ( 20,000) Melanie Lewis 5/6/2014 6

7 Patient Journey 10 Wasted Years Numerous appointments District nurses with GP for infections and pain Referred to consultant dermatologist Vascular surgeon Orthopaedics Plastic surgery Palliative care Tissue viability nurse Palliative care nurse Physiotherapy Occupational therapy Dietetics Chiropody Social work Counselling Not forgetting numerous hospital admissions for Cellulitis 5/6/2014 7

8 Difference in Two Weeks Treatment Melanie Lewis 5/6/2014 Melanie Lewis Melanie Lewis 8

9 The Cost Savings of Appropriate Treatment Melanie Lewis In 1 year inappropriate Rx cost 10,000 Treated 23 times in Lymphoedema Clinic 5/6/2014 Melanie Lewis 9

10 Wasted Resources Delayed discharge Length of stays in hospital Waiting lists Wasted prescriptions Support staff contacts

11 Cost to The State 25% time off work, 8% unable to work Current All Wales Caseload 8500 In Wales up to 2225 people might take time off work 680 may have ceased to work

12 Cellulitis Audit Figures 46% developed Cellulitis episodes prior treatment. Post lymphoedema management 9% Of patients hospitalised with 3+ infective episodes prior rx, only 10% have relapsed since treatment. Saving the NHS 135,000.

13 The Strategy.. First published July 2009 for comments and final version December pages 8 chapters 101 references 10 recommendations 25 key actions with time scales Document available from 5/6/

14 Strategy Recommendations Implement lymphoedema education and training packages, aimed at all levels of staff...reducing associated risks like cellulitis Develop evidence based cellulitis care pathways and implemented use across all health care settings Carry out an audit of lymphoedema patients gaining access to assessment, treatment, cellulitis, and prevention schemes.

15 Agored Cymru Lymphedema Education AWMMG National Lymphoedema Formulary Auditing/ Research effects of lymphoedema and cellulitis all Wales basis All Wales Antimicrobial Guidance

Infections- Cellulitis CONSENSUS DOCUMENT Patients

cellulitis and many suffer recurrent episodes.

recurrent cellulitis in patients with lymphoedema

17 Infections- Cellulitis CONSENSUS DOCUMENT Patients with lymphoedema are at high risk of developing cellulitis and many suffer recurrent episodes. A consensus on the management of cellulitis and recurrent cellulitis in patients with lymphoedema is available FREE to download on the BLS website homepage at Photographs are the property of ABM UHB Lymphoedema Service permission is needed for publication

18 Size of the Problem of Cellulitis (Also known as Erysipelas or Lymphangitis) This disabling and painful condition occurs as both a precursor of lymphoedema and as a complication 29% of lymphoedema/ chronic oedema patients develop cellulitis (underestimation) 27% of that group admitted to hospital for IV Huge costs to patient and the NHS -Cox(2006)

19 WG Lymphoedema Strategy 2009 Cellulitis Cellulitis is both a cause and a complication of Lymphoedema. The occurrence of Lymphoedema varies between 10% and 19% amongst cases of Cellulitis 50% of patients with Lymphoedema experiencing at least one bout of cellulitis In a study of 176 patients admitted to hospital with cellulitis, lymphoedema was found to be a major risk factor and was present in 18% of cases One paper identifies cellulitis as a complication in 20-30% of lymphoedemas.

20 Cellulitis Untreated cellulitis leads to tissue damage which in turn damages the initial lymphatic s that increases the risk of further cellulitis attacks Most episodes are believed to be caused by Group A Streptococci infection. However, microbiologists consider Staph aureus to be the cause in some patients

21 Cellulitis Guidelines Management At Home Home care First line Allergic to penicillin Acute Amoxicillin Erythromycin cellulitis 500mg 8hourly 500mg 6 hourly QDS OR TDS Evidence of Staph Clarithromycin aureus Folliculitis 500mg In addition or 12 hourly BD Alternative Flucloxacillin 500mg 6hourly QDS Second line comment Clindamycin NO LESS THAN 14 days 300mg 6 hourly QDS course May need up to 1-2 months

22 Cellulitis Guidelines of Management in Hospital Hospital First line Allergic to penicillin Second line comment Amoxicillin IV Clindamycin Clindamycin Switch to Acute iv 1.2g 6 Amoxicillin cellulitis 2g 8 hourly IV 600mg OR 6 hourly Benzylpenicill in g 6hourly OR Flucloxacillio n IV 2g 6hourly hourly 500mg 8 hourly when temp and Inflammati on resolved

23 Cellulitis Prophylaxis for Recurrent Cellulitis 2 or more attacks per year First line Allergic to penicillin Second line Penicillin V 500mg once a day (daily) However needs 1g if weight over 75kg Erythromycin Clarithromycin After 1 500mg once 250mg daily is once daily recommend is an ed alternative comment year half dose of penicillin to 250mg daily

24 Flucloxacillin Vs Amoxicillins Both antibiotics are effective against Group A beta haemolytic streptococci however, amoxicillin needs a lower inhibitory concentration Evidence suggests that amoxicillin has a better tissue penetration than Flucloxacillin Patients seem to tolerate Amoxicillin better than Flucloxacillin e.g. gastrointestinal disorders No resistance to either antibiotic has been observed, therefore no advantage to either drug Although the consensus group favours AMOXICILLIN as the first line oral antibiotic for treating cellulitis in Lymphoedema, Flucloxacillin is considered to be an acceptable alternative. However experience in the Lymphoedema clinical field has shown Amoxicillin to be the first choice

25 ABMUHB All Wales policy - Primary care Antimicrobial guidelines within ABMUHB. Patients with lymphoedema/chronic oedema presenting with cellulitis may require antibiotics for 14 days or longer (see Lymphoedema Guideline). ALL patients with lymphoedema/chronic oedema and cellulitis should be referred to the Lymphoedema Service. A referral form is available via COIN. Advice is also available over the telephone Mon Fri 8am 4.30pm. pg 31

27 Education Empower patients Early referral to services Emergency Admission Pathway Prevention All Wales Cellulitis Guidance

28 References Department of Health (2009) Hospital Episodes Statistics, Primary diagnosis DoH, London. Dupuy A, Benchikhi H, Roujeau JC. et al.(1999) Risk factors for erysipelas of the leg cellulitis: case-control study. BMJ Jun; 318(7198): International consensus Best Practice for the management of Lymphoedema document: 5.pdf

29 References Halpern J, Holder R, Langford NJ (2008) Ethnicity and other risk factors for acute lower limb cellulitis: a UKbased prospective case control study. Br J Dermatol 143 (1): Patch II Trial Prophylactic antibiotics for the prevention of cellulitis( Erysipelas) of the lower leg: result of the UK Dermatology Clinical Trials Network s Patch II Trial. (2012)British Journal of Dermatology pp Sheehan D, (2012) Wound Care Management of a patient with stage III Lymphoedema. Rehabilitation Nursing Vol 37, No4 July August 2012.

30 References Vaillant L. Gironet N (2002)[Infectious complications of lymphedema]. Revue de Medecine Interne Jun; 23 Suppl 3:403s-407s. Welsh Government A Strategy for Lymphoedema in Wales wales.gov.uk/topics/health/publications/.../strategies/lymphoedema. Wingfield C (2008) Cellulitis : reduction of associated hospital admissions. Dermatological Nurs 7 (2):

Cellulitis: a practical guide

Cellulitis: a practical guide Dr John Day Consultant in Infectious Diseases & General Medicine Southend University Hospital NHS Foundation Trust 77 yr old retired civil servant A&E presentation c/o rigors