From the Guidelines
Treatment for lower limb cellulitis typically involves antibiotics, elevation of the affected limb, and supportive care, with the goal of reducing morbidity, mortality, and improving quality of life. For mild to moderate cases, oral antibiotics such as cefadroxil 500mg twice daily, cephalexin 500mg four times daily, or amoxicillin-clavulanate 875/125mg twice daily for 5-10 days are recommended, as they target the common causative bacteria (streptococci and staphylococci) 1.
Key Considerations
- Elevation of the affected limb above heart level whenever possible to reduce swelling, as recommended by the Infectious Diseases Society of America 1.
- Pain management with acetaminophen or NSAIDs is often helpful, and patients should mark the border of the redness with a pen to monitor progression or improvement.
- Adequate hydration and rest are important for recovery, and compression stockings should be avoided during active infection but may be beneficial after resolution to prevent recurrence, especially in patients with chronic edema or venous insufficiency.
- Identifying and treating predisposing conditions, such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities, is crucial in managing lower limb cellulitis, as emphasized by the 2014 update by the Infectious Diseases Society of America 1.
Severe Cases
For more severe cases or those with systemic symptoms, intravenous antibiotics may be necessary, such as cefazolin 1-2g every 8 hours or vancomycin 15-20mg/kg every 12 hours if MRSA is suspected, as recommended by the 2018 WSES/SIS-E consensus conference 1.
Duration of Treatment
The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period, as stated in the practice guidelines for the diagnosis and management of skin and soft tissue infections 1.
Prevention of Recurrence
Administration of prophylactic antibiotics, such as oral penicillin or erythromycin, should be considered in patients who have 3-4 episodes of cellulitis per year despite attempts to treat or control predisposing factors, as suggested by the Infectious Diseases Society of America 1.
From the FDA Drug Label
The usual dose recommendations are as follows: Adult Patients Clinical IndicationDosage Serious infections due to susceptible strains of streptococci (including S pneumoniae) and staphylococci-septicemia, empyema, pneumonia, pericarditis, endocarditis and meningitis 5 to 24 million units/day
DOSAGE AND ADMINISTRATION The penicillinase-resistant penicillins are available for oral administration and for intramuscular and intravenous injection.
The treatment for lower limb cellulitis is not explicitly stated in the provided drug labels. However, based on the information provided for serious infections due to susceptible strains of streptococci, the dose of benzylpenicillin (IV) is 5 to 24 million units/day. For mild to moderate infections, the dose of flucloxacillin (PO) is 125 mg every 6 hours or 250 mg every 6 hours for severe infections.
- Benzylpenicillin (IV): 5 to 24 million units/day
- Flucloxacillin (PO): 125 mg every 6 hours or 250 mg every 6 hours 2 3
From the Research
Treatment Options for Lower Limb Cellulitis
- The treatment of lower limb cellulitis typically involves the use of antibiotics, with the goal of covering Streptococcus and methicillin-sensitive Staphylococcus aureus 4.
- A study comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis found no significant difference in improvement at day 5 between the two groups 5.
- Another study investigated the use of short-course intravenous antibiotic therapy for the treatment of lower limb cellulitis, but was unable to determine the noninferiority of this approach due to challenges with recruitment and misdiagnosis 6.
- The use of cycloidal vibration therapy in combination with standard treatment has been shown to reduce treatment times for lower limb cellulitis in a small randomized controlled trial 7.
Antibiotic Usage
- A retrospective study of patients with lower limb cellulitis found that the most commonly used antibiotics were cloxacillin and other penicillins, followed by cephalosporins 8.
- The mean number of antibiotics given for one episode of cellulitis was 1.7, highlighting the need for careful consideration of antibiotic usage in the treatment of this condition 8.
Duration of Treatment
- A review of cellulitis recommends that treatment should initially be for 5 days, with extension if symptoms are not improved 4.
- A study comparing short-course intravenous antibiotic therapy with longer courses of treatment found that the mean duration of intravenous antibiotics in the short-course group was 25.5 hours, while the longer course group received a mean of 78 hours of intravenous antibiotics 6.