Special Considerations for Cellulitis with Lymphedema: When to Use Compression with Infection
See images of cellulitis after breast cancer in NE Journal http://www.nejm.org/doi/full/10.1056/NEJMicm065836
1) The illness can become very severe very quickly: it is advised that people with lymphedema have antibiotics on hand to start at the first sign of redness, warmth, fever, pain and then seek appropriate medical care
2) The infecting organism can be unusual: recently a woman grew group B strep, usually associated with immunosuppression
3) Stagnant lymphatic fluid functions like an abscess: abscesses require drainage and cellulitis with lymphedema requires gentle compression to remove the infected fluid
4) Compression in lymphedema associated cellulitis: the "common belief" is to avoid all compression and manual lymphatic drainage. A literature search did not reveal any studies to support that belief, the only literature addressing compression and MLD in cellulitis associated with lymphedema comes from the International Best Practices Guidelines. The literature search did again confirm that infection harms lymphatics so prompt and successful treatment is crucial.
5) Knowledge of bandaging is CRUCIAL: sleeves and night garments are unlikely to fit in the acute phase of lymphedema associated cellulitis, and only multilayered bandaging will allow the gentle and accurate compression to assist in the resolution of the infection without over-compressing and inhibiting antibiotics to reach the area.
Outfield states: I'm back in a sleeve today, after wrapping most of the week. My sleeve didn't fit when I first tried after the redness receded. I only know how to wrap because I insisted on learning back when I was first diagnosed, and that was because I had read about it here and on the SUSO site. My CLT didn't think I'd need to do it. She thought a sleeve and a night garment would be enough for me (which they generally are). I think she was a little annoyed to teach me. But if I didn't know how to do it myself, I'd be waiting until sometime next month to get in for an appointment and I'd still be too swollen for my sleeve.
One patient reports being hospitalized for 12 days with cellulitis in her leg. In spite of using several antibiotics, nothing was working. A surgeon who was called in examined her leg and told the nurses to wrap it, but neither the nurses nor the physical therapist would wrap it, fearing the infection would spread up the leg. When the surgeon returned the following day he wrapped it himself with four bandages. That worked where the other interventions had failed, and the patient was released to go home with a PICC line the following day.
From the International Best Practices Guideline:
- Commence antibiotics as soon as possible , taking into account swab results and bacterial sensitivities when appropriate
- During bed rest, elevate the limb, administer appropriate analgesia (eg paracetamol or NSAID), and increase fluid intake
- Avoid SLD (self MLD) and MLD (by therapist)
- If tolerated, continue compression at a reduced level or switch from compression garments to reduced pressure MLLB (multilayered bandaging)
- Avoid long periods without compression Recommence usual compression and levels of activity once pain and inflammation are sufficiently reduced for the patient to tolerate
- Educate patient/carer - symptoms, when to seek medical attention, risk factors, antibiotics 'in case', prophylaxis if indicated
So, this is the best scientific advice/evidence we seem to have: avoid MLD in the acute phase, but resume light compression ASAP, and MLD can be resumed when the acute phase of infection is over.