What is the recommended treatment for labial cellulitis?

Treatment of Labial Cellulitis

For labial cellulitis, a 5-day course of antibiotics active against streptococci is the recommended first-line treatment, with extension if the infection has not improved within this time period. 1

Diagnostic Approach

• Cultures of blood or cutaneous aspirates are not routinely recommended for typical cases of labial cellulitis 1
• Blood cultures should be considered in patients with:
  • Malignancy on chemotherapy
  • Neutropenia
  • Severe cell-mediated immunodeficiency
  • Systemic signs of infection (high fever, hypotension) 1

Antibiotic Treatment

First-line Treatment (Mild Cellulitis):

• Oral antibiotics active against streptococci:
  • Penicillin
  • Amoxicillin
  • Dicloxacillin
  • Cephalexin
  • Clindamycin 1

Duration:

• 5 days of antimicrobial therapy is sufficient for uncomplicated cellulitis 1
• Treatment should be extended if infection has not improved within 5 days 1

For Moderate to Severe Cellulitis:

• With systemic signs of infection: Add coverage for methicillin-susceptible S. aureus (MSSA) 1
• For patients with risk factors for MRSA (penetrating trauma, evidence of MRSA elsewhere, nasal colonization with MRSA, injection drug use, purulent drainage): Add coverage for MRSA 1
  • Options include: vancomycin, daptomycin, linezolid (IV) or doxycycline, clindamycin, or SMX-TMP (oral) 1

Special Considerations

MRSA Coverage

• MRSA is an unusual cause of typical cellulitis 1
• If coverage for both streptococci and MRSA is desired for oral therapy:
  • Clindamycin alone, or
  • Combination of either SMX-TMP or doxycycline with a β-lactam (penicillin, cephalexin, or amoxicillin) 1

Adjunctive Measures

• Elevation of the affected area to promote drainage of edema 1
• Treatment of predisposing factors such as edema or underlying cutaneous disorders 1
• Systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients to hasten resolution 1, 2

Hospitalization Criteria

Hospitalization is recommended if:

• There is concern for deeper or necrotizing infection
• Patient has poor adherence to therapy
• Infection is in a severely immunocompromised patient
• Outpatient treatment is failing
• Patient has SIRS, altered mental status, or hemodynamic instability 1

Prevention of Recurrence

• Identify and treat predisposing conditions such as edema, obesity, eczema, and venous insufficiency 1
• For patients with 3-4 episodes per year despite addressing predisposing factors, consider prophylactic antibiotics:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks, or
  • Intramuscular benzathine penicillin every 2-4 weeks 1

Common Pitfalls

1. Treating for MRSA unnecessarily in typical cellulitis cases where streptococci are the predominant pathogens 1
2. Using overly broad-spectrum antibiotics when narrower options would suffice 3
3. Continuing antibiotics for longer than necessary (5 days is typically sufficient for uncomplicated cases) 1
4. Failing to elevate the affected area, which can delay improvement 1
5. Not addressing underlying predisposing factors, which increases risk of recurrence 1

Remember that labial cellulitis, like other forms of cellulitis, is primarily caused by streptococci, and treatment should be targeted accordingly unless specific risk factors for other pathogens are present.