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    A 32-year-old woman with diabetes presents with a 3 days history of erythema, warmth, edema and pain of her forearm

    By   ·  1 minute read

    A 32-year-old woman with diabetes presents with a 3 days history of erythema, warmth, edema and pain of her right forearm. Examination shows that she is afebrile with normal vital signs and has a slightly edematous area of erythema with indistinct borders on her medial forearm, extending to the posterior side of the upper arm, but not to the hand, and with no areas of fluctuance or induration. She has full active and passive range of motion, and normal sensation and pulses. She denies any insect bites. 

    image (68)

    How should she be managed?

    • One time dose of IM penicillin followed by an outpatient course with amoxicillin
    • Outpatient management with cephalexin or clindamycin and close follow-up
    • Outpatient management with a 14 day course of erythromycin, then re-evaluation
    • Inpatient admission, IV antibiotic therapy with ciprofloxacin
    The correct answer is:

    Outpatient management with cephalexin or clindamycin and close follow-up

     

    This patient can be managed as an outpatient for her uncomplicated cellulitis. Emerging antibiotic resistance must be considered in selecting the antibiotic, as well as the risk of community acquired methicillin-resistant staphylococcus aureus (CA-MRSA).

    In this case, the absence of purulence points towards streptococcal species or simple staphylococus aureus. Simple, nonpurulent cellulitis can initially be treated with cephalexin or clindamycin; development of purulence would raise the concern for CA-MRSA.

    Close followup, within 24-48 hours, is recommended for cellulitis, especially in the setting of diabetes, both as healing will be impaired and her glucose control might worsen. Osteolmyelitis is unlikely with this presentation.

    Reference:

    Palin DJ. Skin Infections (Chapter 129. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. 2018

     

    This question appears in Med-Challenger Emergency Nurse Practitioner Exam Review with CME

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