Cellulitis Treatment: Addressing Ongoing Pain and Swelling

Questions about the treatment of cellulitis?

Hello Doctor: My mother experienced redness, swelling, and pain in her foot dorsum at night in late November, accompanied by fever.
Therefore, she went to the emergency department for evaluation.
Although there were no wounds, the doctor suspected cellulitis and arranged for her to be hospitalized, administering antibiotic treatment.
Three days later, the doctor informed us that her blood test results showed improvement, but the redness and pain in her foot dorsum had not subsided.
However, since my mother reported that her mobility was not significantly affected, the doctor agreed to discharge her and prescribed oral antibiotics for her to take as directed.
After returning home, the redness and pain in her foot dorsum did not improve.
During the week following her discharge, my mother continued to follow up with the doctor.
Due to the persistent redness and pain, the doctor changed her oral antibiotics twice.
During her third follow-up visit, since the redness and pain continued and the doctor mentioned that no bacteria could be cultured, they suspected other underlying issues and arranged for her to be hospitalized again, consulting a cardiologist to check for vascular problems.
After a week of hospitalization and a CT scan, the cardiologist confirmed that her blood vessels were normal and showed signs of normal aging.
However, the CT scan suggested a possible bone infection, which the infectious disease specialist disagreed with.
Another CT scan is scheduled.
Treatment has been ongoing for nearly three weeks, but my mother's foot dorsum remains red, swollen, and painful, and she is still hospitalized.
For the past week, we have been unable to consult with the infectious disease specialist, causing my mother significant anxiety.
We are unsure how long this treatment and hospitalization might take or if there are other avenues to explore.
We kindly ask for your advice.
Thank you.

HAN, 40~49 year old female. Ask Date: 2022/12/08

Dr. Hong Yuanbin reply Internal Medicine

Hello, in patients with compromised immunity or poor blood circulation, cellulitis can indeed be difficult to resolve.
It is usually necessary to confirm whether there is pus formation or bone infection.
Based on your description, a CT scan has already been performed, which should reveal any pus.
As for a potential bone infection, a bone scan can be considered for confirmation.
Regardless, antibiotic treatment should remain the primary approach, and some individuals may require treatment for 4 to 6 weeks before recovery.
Thank you for your question.

Reply Date: 2022/12/08

More Info

Cellulitis, or蜂窩性組織炎, is a common bacterial skin infection that can lead to significant pain, swelling, and redness. It often occurs when bacteria enter the skin through a cut or break, although in some cases, no obvious entry point is identified. Your mother's case, where she experienced persistent pain and swelling despite antibiotic treatment, raises several important considerations.

Firstly, it is crucial to understand that cellulitis can sometimes be caused by resistant bacteria, particularly if the initial antibiotics prescribed were not effective against the specific strain of bacteria involved. This could explain why your mother’s symptoms have not improved despite multiple changes in her antibiotic regimen. In cases where standard treatments fail, healthcare providers may consider a broader spectrum of antibiotics or even intravenous (IV) antibiotics, especially if the infection is severe or if there is a risk of complications.

Additionally, the persistence of symptoms could indicate that there are other underlying issues contributing to her condition. For example, conditions such as venous insufficiency, lymphedema, or even deep vein thrombosis (DVT) can mimic or exacerbate the symptoms of cellulitis. Given that the cardiology team has ruled out significant vascular issues, it may be worthwhile to explore other potential causes of her symptoms, including autoimmune conditions or even non-infectious inflammatory processes.

The imaging studies, such as CT scans, are essential in evaluating the extent of the infection and determining if there is any underlying bone involvement (osteomyelitis) or abscess formation that may require surgical intervention. If the imaging suggests that the bone is infected, this would necessitate a different treatment approach, potentially including surgical drainage and targeted antibiotics.

In terms of managing ongoing pain and swelling, supportive care is critical. This may include:
1. Elevation: Keeping the affected limb elevated can help reduce swelling.

2. Compression: Using compression bandages may assist in managing swelling, but this should be done cautiously and under medical supervision.

3. Pain Management: Over-the-counter pain relievers such as acetaminophen or ibuprofen can help alleviate discomfort. However, it is essential to consult with her healthcare provider before starting any new medications.

4. Physical Therapy: Once the acute infection is under control, physical therapy may help improve mobility and strength in the affected limb.

Given that your mother has been hospitalized for an extended period without significant improvement, it is crucial to maintain open communication with her healthcare team. If you are unable to reach the infectious disease specialist, consider asking for a case manager or patient advocate within the hospital to help facilitate communication. It may also be beneficial to seek a second opinion from another infectious disease specialist if her condition does not improve.

In summary, while cellulitis can often be effectively treated with antibiotics, persistent symptoms warrant a thorough reevaluation of the diagnosis and treatment plan. It is essential to consider all potential underlying causes and to ensure that your mother receives comprehensive care tailored to her specific needs. Keeping a detailed record of her symptoms, treatments, and responses can be invaluable in guiding her healthcare team in making informed decisions moving forward.

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