From the Guidelines
Cellulitis management should prioritize a 5- to 6-day course of antibiotics active against streptococci, as recommended by the most recent guidelines 1. The management of cellulitis involves several key components, including:
- Antibiotic therapy: The primary goal is to target common skin pathogens, primarily Streptococcus and Staphylococcus species.
- For mild to moderate uncomplicated cellulitis, oral antibiotics are appropriate, with options including cephalexin, clindamycin, or doxycycline if MRSA is suspected.
- For severe infections or those with systemic symptoms, intravenous antibiotics are necessary, typically cefazolin or vancomycin for MRSA concerns.
- Beyond antibiotics, elevating the affected limb reduces edema and pain, while marking the infection's border helps monitor progression.
- Adequate pain management with acetaminophen or NSAIDs is important.
- Patients should be advised to seek immediate medical attention if fever develops, the redness expands beyond the marked border, or if they develop increasing pain or systemic symptoms. The most recent guidelines from the American College of Physicians 1 recommend a 5- to 6-day course of antibiotics for nonpurulent cellulitis, which is consistent with the Infectious Diseases Society of America's 2014 guidelines 1. However, the 2021 guidelines provide more specific guidance on the duration of treatment, making them the most relevant and up-to-date recommendation for managing cellulitis.
From the Research
Management of Cellulitis
The management of cellulitis typically involves the use of antibiotics, with the goal of targeting the underlying causative pathogens.
- Most patients can be treated as outpatients with oral antibiotics, such as dicloxacillin or cephalexin, when methicillin-resistant Staphylococcus aureus is not a concern 2.
- For non-purulent, uncomplicated cases of cellulitis, targeted coverage of β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 3.
Antibiotic Treatment Duration
The duration of antibiotic treatment for cellulitis can vary, with some studies suggesting that shorter courses of therapy may be effective.
- A randomized, double-blind, placebo-controlled trial found that 5 days of levofloxacin therapy was as effective as 10 days of therapy for patients with uncomplicated cellulitis 4.
- A pilot randomized controlled trial comparing high-dose (1000 mg) to standard-dose (500 mg) cephalexin for outpatient management of cellulitis found that high-dose cephalexin had fewer treatment failures, but with a higher proportion of minor adverse effects 5.
Combination Therapy
Some studies have investigated the use of combination antibiotic and anti-inflammatory therapy for the management of cellulitis.
- A pilot study found that the addition of oral nonsteroidal anti-inflammatory therapy to antibiotic treatment hastened resolution of cellulitis-related inflammation, with significant shortening of the time to regression of inflammation and complete resolution of cellulitis 6.