What is the recommended antibiotic regimen for burn cellulitis?

Antibiotic Treatment for Burn Cellulitis

For burn cellulitis, intravenous vancomycin is the recommended first-line treatment for hospitalized patients, with alternatives including linezolid, daptomycin, telavancin, or clindamycin depending on local resistance patterns and patient factors. 1

Classification and Initial Assessment

When evaluating burn cellulitis, determine:

1. Severity classification:

   • Mild: Localized erythema without systemic symptoms
   • Moderate: More extensive erythema with systemic signs (fever, leukocytosis)
   • Severe: Rapidly progressing infection, signs of sepsis, or in immunocompromised patients

2. Purulent vs. non-purulent:

   • Purulent: Associated with drainage or exudate
   • Non-purulent: No drainage or exudate

Antibiotic Treatment Algorithm

For Hospitalized Patients with Burn Cellulitis (Complicated SSTI)

First-line therapy (7-14 days, individualized based on clinical response):

• Intravenous vancomycin (15-20 mg/kg/dose every 8-12 hours) (A-I) 1

Alternative options:

• Linezolid 600 mg IV/PO twice daily (A-I)
• Daptomycin 4 mg/kg/dose IV once daily (A-I)
• Telavancin 10 mg/kg/dose IV once daily (A-I)
• Clindamycin 600 mg IV/PO three times daily (A-III)

For Outpatient Treatment (Mild to Moderate Burn Cellulitis)

For purulent cellulitis (empiric MRSA coverage):

• Clindamycin 300-450 mg PO three times daily (A-II)
• Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 DS tablets twice daily (A-II)
• Doxycycline 100 mg PO twice daily (A-II) (not for children <8 years)
• Linezolid 600 mg PO twice daily (A-II)

For non-purulent cellulitis (streptococcal coverage):

• Beta-lactam (e.g., cephalexin 500 mg PO four times daily) (A-II)
• If no response to beta-lactam or systemic toxicity present, add MRSA coverage

Special Considerations

Pediatric Patients

• For hospitalized children: Vancomycin is recommended (A-II) 1
• Alternative for stable children: Clindamycin 10-13 mg/kg/dose IV every 6-8 hours if local resistance is low (<10%) (A-II)
• Linezolid dosing: 10 mg/kg/dose PO/IV every 8 hours for children <12 years; 600 mg PO/IV twice daily for children >12 years (A-II)
• Avoid tetracyclines in children <8 years of age (A-II)

Continuous Infusion Option

Continuous-infusion oxacillin has shown effectiveness in burn cellulitis with 73% success rate and faster resolution of leukocytosis compared to other antibiotics 2. However, this approach is not mentioned in current guidelines and should be considered only in specific settings with appropriate monitoring.

Monitoring and Follow-up

1. Obtain cultures from purulent drainage before starting antibiotics
2. Monitor for clinical response within 48-72 hours:
   • Resolution of fever
   • Improvement in erythema and induration
   • Normalization of white blood cell count
3. Switch to oral therapy when clinically improving and able to tolerate oral medications
4. Duration of therapy: 7-14 days for complicated infections; 5-10 days for uncomplicated infections 1

Common Pitfalls to Avoid

1. Failure to obtain cultures in severe infections or when MRSA is suspected
2. Inadequate coverage for both streptococci and MRSA in burn wound infections
3. Delayed surgical debridement when indicated for deeper infections
4. Using rifampin as monotherapy or adjunctive therapy (not recommended) (A-III)
5. Prolonged IV therapy when oral options would be effective

Prevention of Recurrent Infections

For patients with recurrent infections:

• Keep wounds covered with clean, dry bandages
• Maintain good personal hygiene
• Consider decolonization with intranasal mupirocin and chlorhexidine washes for 5 days if recurrent S. aureus infections 1

The evidence strongly supports empiric MRSA coverage for burn wound cellulitis given the high prevalence of MRSA in burn units and the potential for serious complications if treatment is delayed or inadequate 3.