What is the recommended treatment for nasal cellulitis caused by Staphylococcus (Staph) coagulase-negative bacteria?

Treatment of Nasal Cellulitis Caused by Coagulase-Negative Staphylococci

For nasal cellulitis caused by coagulase-negative staphylococci (CoNS), the recommended first-line treatment is clindamycin 300-450 mg orally three times daily or 600 mg IV three times daily for 5-6 days.

Antibiotic Selection

First-line options:

• Clindamycin: 300-450 mg orally three times daily or 600 mg IV three times daily 1
  • Provides excellent coverage for both CoNS and potential beta-hemolytic streptococci
  • Achieves adequate levels in nasal secretions to eliminate staphylococci 2

Alternative options (if clindamycin cannot be used):

• Linezolid: 600 mg orally/IV twice daily 2, 1
• Vancomycin: 15-20 mg/kg IV every 8-12 hours (for severe infections) 1, 3
• Trimethoprim-sulfamethoxazole (TMP-SMX) plus a beta-lactam 1

Duration of Therapy

• 5-6 days is sufficient for uncomplicated nasal cellulitis 2
• Consider extending treatment if infection has not improved after 5 days 2
• For severe or complicated infections, treatment may need to be extended to 7-14 days 2

Additional Management

1. Incision and drainage if there is a purulent collection or abscess formation 2, 1
2. Elevation of the affected area to promote drainage of edema and inflammatory substances 1
3. Wound care:
   • Keep draining wounds covered with clean, dry bandages
   • Maintain good personal hygiene with regular handwashing 2

Special Considerations

Antibiotic Resistance

• CoNS strains have shown high resistance to penicillin, oxacillin, and erythromycin 4
• Medium resistance to tetracycline, ciprofloxacin, and trimethoprim/sulfamethoxazole 4
• Low resistance to rifampicin, ceftizoxime, and gentamicin 4
• 100% sensitivity has been reported to vancomycin and cefotaxime 5

For Recurrent Infections

• Identify and treat predisposing conditions 2
• Consider decolonization strategies:
  • Nasal decolonization with mupirocin twice daily for 5-10 days 2
  • Topical body decolonization with chlorhexidine for 5-14 days 2
• For patients with 3-4 episodes per year, consider prophylactic antibiotics:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks 2
  • Intramuscular benzathine penicillin every 2-4 weeks 2

Monitoring and Follow-up

• Monitor for improvement within 48-72 hours of initiating treatment
• Watch for signs of treatment failure:
  • Increasing erythema, edema, or pain
  • Development of systemic symptoms (fever, tachycardia)
• For clindamycin therapy, monitor for diarrhea and potential C. difficile infection 1

Pitfalls and Caveats

1. Don't overlook nasal examination: Occult nasal infections can be the source of aggressive ascending facial and orbital cellulitis 6
2. Don't underdose antibiotics: Inadequate dosing is associated with clinical failure 1
3. Don't miss MRSA: While CoNS is the focus, consider MRSA coverage if risk factors are present (prior MRSA infection, recent hospitalization, recent antibiotics) 7
4. Don't forget to culture: Obtain cultures before starting antibiotics to guide therapy, especially in severe or non-responsive cases 2

By following these guidelines, most cases of nasal cellulitis caused by coagulase-negative staphylococci can be effectively managed with a short course of appropriate antibiotics, with clindamycin being the preferred first-line agent.