Cellulitis: A Patient's 21-Day Struggle with Infection

Q: Cellulitis: A Patient's 21-Day Struggle with Infection

Dear readers： 1. If the knee is still swollen and round, rehabilitation exercises can be performed at the bedside or on a chair to improve circulation and reduce edema. 2. The goal is to keep the C-reactive protein (CRP) level below 1. Sometimes it may tak

Cellulitis, hospitalized for 11 days... on the 21st day... still suffering?

Dear Dr.
Liao,
The patient does not have liver disease or diabetes and has sinusitis.
The bacteria causing the infection and the substances they have been exposed to cannot be determined.
The patient is a freight driver from Hsinchu.

The physician (including nurses) should pay attention to whether the treatment medications cover the potentially infectious bacteria, but the physician has not provided answers.
Since admission, blood tests have been conducted three times, and a tissue biopsy was performed, but no bacteria were cultured (for about 10 days).
Until the blood test on October 25, which was conducted just 2-3 days after the previous one (with a weekend in between), the source of the infection was identified, but the physician did not specify which culture yielded the pathogen.

On October 25, the patient had a fever and underwent blood tests in the afternoon.
On October 28, the infectious disease physician prescribed a medication to be administered every 4 hours, totaling 6 injections per day (I do not know which medication it is) for one week.
The first injection was given at midnight on October 29, and the last injection was administered at 4 PM on November 5.
During this period, the patient's temperature spiked above 38 degrees Celsius.
On November 4, the orthopedic doctor noted that there was "serous fluid" at the wound site.
On November 5, the surgeon stated that it was not a concern, as the body would naturally absorb it, and indicated that after the infectious disease treatment (6 times a day for one week), if the patient does not have a fever for 2 days while on oral medication, they can be discharged.
My questions are as follows:
1.
The patient's calf and thigh swelling has slightly decreased, but the knee remains swollen and round (the knee joint is not visible).
The patient can get out of bed to use the restroom but experiences pain in the knee and cannot extend it.
Will continuing oral medication really lead to gradual improvement, or is there a risk of a "flare-up"?
2.
The surgeon indicated that the infection index for cellulitis is 6, while a normal person is below 1.
3.
The orthopedic doctor mentioned the presence of serous fluid, while the surgeon said it would be naturally absorbed.
If it can be naturally absorbed, why did the orthopedic doctor bring it up? If the patient cannot absorb it naturally, will there be a risk of "worsening" again?
4.
Given the above conditions, is it considered cured if the patient can be discharged after 2 days of oral medication without fever?
5.
The patient was initially under the care of the infectious disease specialist, but after surgery, the care shifted to the surgeon, who consulted with both the orthopedic and infectious disease specialists.
However, the three doctors have never been present together in the ward, and their statements have been inconsistent.
Thank you very much for your response.
I feel helpless and heartbroken as a family member, and I am exhausted.
Sincerely,
A weary family member

Baozi, 40~49 year old female. Ask Date: 2013/11/05

Dr. Liao Zhongxin reply Internal Medicine

Dear readers:
1.
If the knee is still swollen and round, rehabilitation exercises can be performed at the bedside or on a chair to improve circulation and reduce edema.

2.
The goal is to keep the C-reactive protein (CRP) level below 1.
Sometimes it may take a bit longer to gradually decrease; if it remains elevated, further investigation is necessary.

3.
The orthopedic specialist mentioned there is fluid accumulation, while the surgeon stated it will be reabsorbed naturally.
In some cases, sterile drainage may still be required, and immediate suturing of the wound may not be appropriate.

4.
If the patient has not had a fever for two days while on oral medication, they can be discharged.
However, being discharged with oral medication does not mean the patient is fully healed; it may simply be due to prolonged hospitalization to avoid healthcare-associated infections or to consider psychological factors.
The patient can continue follow-up care in the outpatient setting to address any wound issues.

5.
The three doctors have never been in the ward together, and their opinions are inconsistent.
Asking the same question to a hundred people may yield a hundred different perspectives, reflecting differing positions.
It may be beneficial to request integrated care from the hospital and involve family members in the discussion.

Thank you!

Reply Date: 2013/11/05

More Info

Dear Patient's Family,
I understand that you are going through a very challenging time with your loved one's health, and I appreciate your detailed questions regarding the management of cellulitis and the associated complications. Let’s address your concerns one by one.

1. Swelling and Pain in the Knee: It is common for cellulitis to cause significant swelling and discomfort in the affected area. The fact that the swelling in the thigh and calf has slightly decreased is a positive sign, indicating that the treatment may be effective. However, persistent swelling in the knee, along with pain and difficulty in extending the leg, suggests that there may still be inflammation or fluid accumulation. It is essential to monitor this closely. If the oral medications prescribed after the intravenous treatment are effective, you should see continued improvement. However, if the swelling worsens or new symptoms arise, it is crucial to seek medical attention promptly.

2. Infection Index: The infection index you mentioned (6) being above the normal range (1 or below) indicates that there is still an active infection or inflammation present. This is not uncommon in cases of cellulitis, especially if the infection was severe or if there are underlying factors contributing to the prolonged recovery. Continuous monitoring of these levels is important to ensure they trend downward as treatment progresses.

3. Fluid Accumulation: The presence of "blood water" or seroma as noted by the orthopedic surgeon can be concerning. While it is true that the body can sometimes absorb this fluid naturally, there are instances where it may require intervention if it does not resolve on its own. If the fluid accumulation is significant or if it becomes infected, it could lead to further complications. The orthopedic surgeon’s mention of this is likely a precautionary measure, and it is essential to keep an eye on the situation. If the swelling does not decrease or if there are signs of infection (such as increased redness, warmth, or fever), further evaluation may be necessary.

4. Discharge and Recovery: The recommendation to discharge your loved one after two days without fever is generally based on clinical guidelines. However, it is crucial to ensure that the patient is stable and that the infection is adequately controlled. Discharge does not necessarily mean complete recovery, and follow-up care is vital. It is advisable to have a clear plan for monitoring and managing any ongoing symptoms after discharge.

5. Coordination of Care: It is understandable to feel frustrated with the lack of consistent communication among the healthcare providers. In complex cases like cellulitis, especially when multiple specialties are involved, it is crucial for the care team to communicate effectively. If you feel that there is a lack of clarity or consistency in the information provided, do not hesitate to ask for a care conference or a meeting with the involved physicians. This can help ensure that everyone is on the same page regarding the treatment plan and expectations.

In summary, while there are positive signs in your loved one’s recovery, it is essential to remain vigilant and proactive in managing any ongoing symptoms or concerns. Regular follow-ups with the healthcare team, clear communication, and monitoring for any changes in condition will be key to ensuring a successful recovery.

Thank you for your patience and for advocating for your loved one’s health. Please do not hesitate to reach out to the medical team with any further questions or concerns.

Best wishes for a smooth recovery.

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