What is the recommended treatment for weeping cellulitis?

Treatment of Weeping Cellulitis

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

Antibiotic Selection

For Typical Non-Purulent Cellulitis:

• First-line therapy: β-lactam antibiotics active against streptococci
  • Penicillin
  • Amoxicillin
  • Dicloxacillin
  • Cephalexin
  • Amoxicillin-clavulanate
  • Clindamycin (alternative for penicillin-allergic patients)

For Purulent or Weeping Cellulitis:

• Consider coverage for both streptococci and S. aureus (including MRSA in specific risk situations)
• Options include:
  • Clindamycin alone 1
  • TMP-SMX or doxycycline plus a β-lactam (penicillin, cephalexin, or amoxicillin) 1
  • Linezolid alone (for more severe cases) 1

Duration of Therapy

• 5-6 days is sufficient for uncomplicated cellulitis 1
• Extend treatment if infection has not improved after the initial course 1

Severity-Based Treatment Approach

Mild Cellulitis (Outpatient):

• Oral antibiotics active against streptococci
• Elevation of affected area to reduce edema
• Treatment of predisposing conditions (tinea pedis, venous eczema)

Moderate to Severe Cellulitis:

• Consider hospitalization for:
  • Systemic inflammatory response syndrome (SIRS)
  • Altered mental status
  • Hemodynamic instability
  • Concern for deeper or necrotizing infection
  • Failed outpatient treatment 1
• IV antibiotics: vancomycin, daptomycin, linezolid, or telavancin 1

Special Considerations for Weeping Cellulitis

• Obtain cultures of exudate to guide therapy, especially if initial treatment fails 1
• Ensure adequate wound care and moisture management
• Consider MRSA coverage if:
  • Associated with penetrating trauma
  • Evidence of MRSA infection elsewhere
  • Nasal colonization with MRSA
  • Injection drug use
  • SIRS present 1

Adjunctive Measures

• Elevation of affected area to promote drainage of edema 1
• Treatment of predisposing conditions (tinea pedis, trauma, venous eczema) 1
• Systemic corticosteroids (prednisone 40 mg daily for 7 days) may be considered in non-diabetic adults 1

Common Pitfalls to Avoid

1. Overuse of broad-spectrum antibiotics - Studies show no benefit over narrow-spectrum options for uncomplicated cellulitis 2
2. Failure to address underlying conditions - Treating predisposing factors is essential to prevent recurrence 1
3. Inadequate follow-up - Ensure clinical improvement within 48-72 hours; if not improving, consider alternative diagnoses or resistant organisms 3
4. Missing atypical pathogens - Consider unusual organisms if standard therapy fails 4
5. Unnecessary prolonged therapy - 5 days is as effective as longer courses if clinical improvement occurs 1

Prevention of Recurrence

• Identify and treat predisposing conditions (edema, obesity, venous insufficiency, tinea pedis) 1
• Consider prophylactic antibiotics for patients with 3-4 episodes per year 1