From the Guidelines
The treatment for cellulitis should include an antibiotic active against streptococci, with a recommended duration of antimicrobial therapy of 5 days, but treatment should be extended if the infection has not improved within this time period 1.
Key Considerations
- For typical cases of cellulitis without systemic signs of infection, an antimicrobial agent active against streptococci is recommended, such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin 1.
- In cases of uncomplicated cellulitis, a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days 1.
- Patients with systemic signs of infection, facial involvement, or compromised immune systems may require hospitalization with intravenous antibiotics such as vancomycin, ceftriaxone, or piperacillin-tazobactam 1.
Management Strategies
- Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.
- Outpatient therapy is recommended for patients who do not have systemic signs of infection, altered mental status, or hemodynamic instability 1.
- Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended, but may be considered in patients with specific risk factors, such as malignancy on chemotherapy, neutropenia, or severe cell-mediated immunodeficiency 1.
From the Research
Cellulitis Treatment
- The treatment of cellulitis should initially cover Streptococcus and methicillin-sensitive S. aureus, with expansion for methicillin-resistant S. aureus (MRSA) in cases of cellulitis associated with specific risk factors 2.
- Five days of treatment is sufficient with extension if symptoms are not improved 2, 3.
- Antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy for outpatients with cellulitis in the community-associated MRSA-prevalent setting 4.
- Treatment for cellulitis typically involves a penicillin or cephalosporin, and treatment of abscesses is incision and drainage 5.
- Weight-based dosing of antibiotics such as clindamycin and trimethoprim/sulfamethoxazole is associated with better outcomes in cellulitis 6.
Antibiotic Options
- Trimethoprim-sulfamethoxazole has a higher treatment success rate than cephalexin for empiric therapy of cellulitis 4.
- Clindamycin has a higher success rate than cephalexin in patients with culture-confirmed MRSA infections, moderately severe cellulitis, and obesity 4.
- Levofloxacin is effective for the treatment of uncomplicated cellulitis, with a 5-day course being as effective as a 10-day course 3.
Management
- The history and physical examination are helpful in differentiating cellulitis and abscess in many cases, and point-of-care ultrasound can be a useful tool in unclear cases 5.
- Most patients with cellulitis can be managed as outpatients 5.
- Inadequate dosing of antibiotics is independently associated with clinical failure in patients hospitalized with cellulitis 6.