Patient assessment in the OPAT setting

This gentleman presented with a red, painful leg. He was referred to me as a clinical nurse specialist for assessment and suitability for OPAT by his general practitioner.

After confirming the history of the presenting complaint, past medical history, drug history, and allergies, I carry out a general assessment to check for signs of systemic infection. This includes temperature, blood pressure, heart rate, and pulse oximetry. I now strip the dressing from the leg and can immediately see the leg is swollen, red, and there is blistering in the posterior aspect of the lower leg. There has been some skin peeling, which is typical with a streptococcal skin infection. That is looking good. All this part here is great. You’ve had cellulitis before, haven’t you? Uh-huh, yeah. That’s all right. Yeah, so all this part here– that’s all a bit drying out. I think that one will burst.

That’s all looking good. I have taken my gloves off to few for temperature difference between the two legs. I think your infection marker has come down. Right. The entire lower leg from knee to foot is assessed. And an obvious heat difference is noted in the left leg.

It is very important to check for tinea pedis. And both feet should be checked. You can see just on this what causes the athlete’s foot. That’s a source of infection in there. So make sure you keep putting your treatment on that. After assessing the patients with bare hands, I carry out hand hygiene before dressing the leg. I wouldn’t normally apply a dressing, but the patient has concerns about leakage on his clothes. So I advise him to remove the dressing once he gets home. In summary, there is significant heat, swelling, and erythema to the left leg, with associated tinea pedis, but no signs of sepsis or systemic infection.

Therefore, from my assessment, the patient requires intravenous therapy, which, in our practice, is IV ceftriaxone, 2 grammes once daily. In light of tinea pedis, I have advised a topical antifungal, for example, miconazole. I will reassess daily. And when reduction in heat, swelling, and erythema is noted, I will switch to an appropriate oral antibiotic. On average, we find we can switch from IV to oral therapy after three to four days. In our practice, we supply either oral flucloxacillin or oral clindamycin for five days and will review again on completion of oral therapy.