From the Guidelines
Leg cellulitis should be managed with a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care. This approach is supported by the American College of Physicians' best practice advice 1. The diagnosis of leg cellulitis is typically made through clinical examination, looking for signs such as redness, warmth, swelling, and tenderness of the affected area, often accompanied by fever and elevated white blood cell count.
Key Considerations in Management
- For mild cases, oral antibiotics such as cephalexin, dicloxacillin, or clindamycin are appropriate 1.
- For severe cases or those with systemic symptoms, intravenous antibiotics like cefazolin or vancomycin may be necessary 1.
- If MRSA is suspected, coverage with trimethoprim-sulfamethoxazole, doxycycline, or linezolid should be considered 1.
- Elevation of the affected limb, pain management, and proper wound care are essential supportive measures.
- Patients should be educated to monitor progression, stay hydrated, and seek immediate medical attention if fever develops, redness extends beyond the marked line, or symptoms worsen despite 48 hours of antibiotics.
Duration of Antibiotic Therapy
The recommended duration of antimicrobial therapy for leg cellulitis is 5 days, but treatment should be extended if the infection has not improved within this time period 1. This recommendation is based on the most recent guidelines and evidence, prioritizing the reduction of morbidity, mortality, and improvement of quality of life for patients with leg cellulitis.
Special Considerations
- Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended but may be considered in specific cases such as malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites 1.
- In severely compromised patients, broad-spectrum antimicrobial coverage may be considered, with vancomycin plus either piperacillin-tazobactam or imipenem-meropenem as a reasonable empiric regimen for severe infections 1.
From the Research
Diagnosis of Leg Cellulitis
- Leg cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma 2.
- The condition classically presents with erythema, swelling, warmth, and tenderness over the affected area 2.
- A broad differential diagnosis is necessary, as other dermatologic diseases such as venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis can present with similar findings 2, 3.
- History, local characteristics of the affected area, systemic signs, laboratory tests, and skin biopsy can be helpful in confirming the correct diagnosis 2.
Management of Leg Cellulitis
- Most patients can be treated as outpatients with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern 2.
- In areas with a high prevalence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections, antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy for outpatients with cellulitis 4.
- The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 3.
- Community nurses play a crucial role in caring for people who are at risk of cellulitis, and it is essential that they are aware of the evidence base for diagnosis and treatment of lower leg cellulitis 5.