What is the treatment for breast cellulitis?

Treatment of Breast Cellulitis

For breast cellulitis, first-line treatment should be oral cephalexin 500 mg 3-4 times daily or amoxicillin-clavulanate 875/125 mg twice daily for 5-6 days, with extension if symptoms do not improve. 1

Antibiotic Selection

The treatment approach should follow these guidelines:

1. First-line antibiotics (targeting Streptococcus and methicillin-sensitive S. aureus):

   • Cephalexin 500 mg 3-4 times daily for 5-6 days 1
   • Amoxicillin-clavulanate 875/125 mg twice daily for 5-6 days 1
   • Clindamycin 300-450 mg orally three times daily for 5-6 days (for penicillin-allergic patients) 1

2. For patients requiring IV therapy:

   • Cefazolin 1g every 8 hours IV for 5-6 days 1
   • Consider hospitalization for patients with systemic inflammatory response syndrome, altered mental status, hemodynamic instability, or failure of outpatient treatment 1

3. Consider MRSA coverage when:

   • Patient has prior MRSA infection
   • Recent hospitalization
   • Antibiotic use in past 3 months
   • Close contact with MRSA-infected individuals
   • Patient is in a high-risk group (athletes, children, prisoners, military recruits, residents of long-term care facilities, IV drug users) 1, 2

Special Considerations for Breast Cellulitis

Breast cellulitis has some unique characteristics, particularly following breast conservation therapy for cancer:

• Breast cellulitis following breast conservation therapy may represent a shift from the traditional upper extremity cellulitis seen after mastectomy with axillary lymph node dissection 3
• Fluid collections at the surgical lumpectomy site increase risk (83% of cases) 3
• Risk may increase following follow-up mammograms 3

For implant-based breast reconstruction cases with cellulitis:

• Oral fluoroquinolones (e.g., ciprofloxacin, levofloxacin) may be considered as first-line treatment based on institutional microbiological data 4
• If oral antibiotics fail, consider IV options like gentamicin plus vancomycin 4

Treatment Duration and Follow-up

• Standard duration is 5-6 days for uncomplicated cellulitis 1
• Extend treatment if symptoms do not improve after initial course 2
• Monitor for visible improvement in local signs (decreased erythema, swelling, tenderness) 1
• Ensure patient is afebrile for at least 24 hours without antipyretics before discontinuing treatment 1

Prevention of Complications and Recurrence

• Address predisposing factors to minimize risk of recurrence 2
• For patients with 3-4 episodes per year despite treatment of predisposing factors, consider prophylactic antibiotics:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks
  • Intramuscular benzathine penicillin every 2-4 weeks 1

When to Consider Alternative Diagnoses

• Failure to improve with appropriate first-line antibiotics should prompt consideration for:
  • Resistant organisms
  • Secondary conditions that mimic cellulitis
  • Underlying complicating conditions (immunosuppression, chronic liver disease, chronic kidney disease) 2

Pitfalls to Avoid

• Failing to recognize MRSA risk factors when selecting empiric therapy
• Treating for insufficient duration when symptoms persist
• Not addressing underlying predisposing factors, leading to recurrence
• Overlooking the possibility of an abscess requiring drainage (consider point-of-care ultrasound in unclear cases) 5
• Not recognizing the unique characteristics of breast cellulitis following breast conservation therapy or reconstruction 4, 3