What are the treatment guidelines for cellulitis?

Wound Care Instructions for Cellulitis

For cellulitis treatment, use cephalexin 500 mg 3-4 times daily for 5-6 days as first-line therapy, with clindamycin or trimethoprim-sulfamethoxazole as alternatives in areas with high MRSA prevalence. 1

Antibiotic Selection

First-Line Options:

• Cephalexin: 500 mg 3-4 times daily for 5-6 days 1
  • Targets β-hemolytic Streptococcus and methicillin-sensitive S. aureus
  • Consider higher dosing (1000 mg four times daily) in severe cases 2

Alternative Options (especially for MRSA concerns):

• Clindamycin: 300-450 mg orally three times daily for 5-6 days 1

  • Effective against MRSA and anaerobes
  • Higher success rates than cephalexin in MRSA infections, obese patients, and moderate-severity cellulitis 3

• Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets twice daily 1

  • Significantly higher overall treatment success rate compared to cephalexin (91% vs 74%) in MRSA-prevalent settings 3
  • Caution: Less effective coverage against streptococci 1

Wound Care Instructions

1. Cleansing:

   • Gently clean the affected area with mild soap and warm water
   • Pat dry thoroughly with a clean towel
   • Avoid scrubbing or aggressive cleaning that could damage skin

2. Elevation:

   • Elevate the affected limb above heart level when possible
   • Reduces edema and improves circulation

3. Dressings:

   • Apply sterile, non-adherent dressings if skin is broken
   • Change dressings daily or when soiled
   • Keep the area clean and dry

4. Monitoring:

   • Mark the border of erythema with a pen to track progression/resolution
   • Assess for improvement within 72 hours of starting therapy 1
   • Seek immediate medical attention if:
     • Spreading redness beyond marked borders
     • Increasing pain, swelling, or warmth
     • Development of fever or systemic symptoms
     • Appearance of pus or drainage

Special Considerations

MRSA Risk Assessment:

Consider MRSA-active antibiotics (TMP-SMX or clindamycin) if patient has:

• Prior MRSA infections
• Injection drug use
• Recent hospitalization
• Athlete status
• Residence in long-term care facility 1, 4

Treatment Duration:

• Standard duration: 5-7 days 1
• Extended duration may be needed for:
  • Elderly patients
  • Diabetic patients
  • Patients with bacteremia
  • No improvement after 5-7 days 1

Adjunctive Therapy:

• Consider adding ibuprofen 400 mg every 6 hours for 5 days to hasten resolution
  • One study showed 82.8% of patients had regression of inflammation within 1-2 days with anti-inflammatory treatment versus only 9.1% with antibiotics alone 5

Treatment Failure Considerations

If no improvement within 72 hours:

1. Reassess diagnosis - consider alternative conditions that mimic cellulitis 4
2. Consider resistant organisms - switch to MRSA-active antibiotics if not already using 1, 3
3. Evaluate for abscess formation - surgical drainage is essential if present 1
4. Consider hospitalization for:
   • Deeper or necrotizing infection concerns
   • Poor adherence to therapy
   • Severely immunocompromised patients
   • Failed outpatient treatment 1

Prevention of Recurrence

• Maintain good hand hygiene
• Keep skin clean and dry
• Promptly treat minor skin breaks
• Daily change of socks and careful drying between toes after showers
• Address predisposing factors (e.g., edema, tinea pedis) 1, 4