What are the guidelines for managing cellulitis?

From the Guidelines

Cellulitis should be treated with a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care. For mild, uncomplicated cellulitis, oral antibiotics such as cephalexin, dicloxacillin, or clindamycin are recommended 1. The choice of antibiotic should be based on the severity of the infection, the presence of risk factors for MRSA, and the patient's ability to tolerate oral medications.

Key Considerations

• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.
• Patients should be monitored for signs of improvement or worsening of the infection, and antibiotic therapy should be adjusted as needed.
• Underlying conditions like diabetes, venous insufficiency, or lymphedema should be addressed to prevent recurrence.

Antibiotic Options

• For mild, uncomplicated cellulitis, oral cephalexin 500mg four times daily for 5-6 days is a recommended option 1.
• Alternatives include dicloxacillin 500mg four times daily, clindamycin 300-450mg three times daily (for penicillin-allergic patients), or doxycycline 100mg twice daily.
• For moderate infections or those with risk factors for MRSA, consider trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily.

Severe Cellulitis

• Severe cellulitis requires intravenous therapy with cefazolin 1-2g every 8 hours, vancomycin 15-20mg/kg every 12 hours (for MRSA concerns), or clindamycin 600-900mg every 8 hours.
• Patients with severe cellulitis should be closely monitored for signs of improvement or worsening of the infection, and antibiotic therapy should be adjusted as needed.

Patient Education

• Patients should be educated on the importance of completing the full course of antibiotic therapy, even if symptoms improve before completion.
• Patients should also be instructed on how to monitor for signs of worsening infection, such as increasing pain, redness, or swelling, and to seek medical attention if these symptoms occur.

From the Research

Guidelines for Managing Cellulitis

The management of cellulitis involves the use of antibiotics, with the goal of achieving clinical response and preventing treatment failure. The following guidelines are based on the available evidence:

• Duration of Antibiotic Therapy: A study published in 2004 2 found that 5 days of therapy with levofloxacin was as effective as 10 days of therapy for patients with uncomplicated cellulitis.
• Empiric Outpatient Therapy: A study published in 2010 3 found that trimethoprim-sulfamethoxazole and clindamycin were effective empiric treatments for outpatients with cellulitis, particularly in areas with a high prevalence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections.
• Time to Clinical Response: A systematic review and meta-analysis published in 2022 4 found that the mean time to clinical response was 1.68 days, with a 50% reduction in pain and severity score by day 5, and a 30-50% reduction in edema by day 2-4.
• Comparative Effectiveness of Antibiotics: A randomized controlled trial published in 2013 5 found that the addition of trimethoprim-sulfamethoxazole to cephalexin did not improve outcomes for patients with uncomplicated cellulitis without abscesses.
• Antimicrobial Activity against CA-MRSA: A review published in 2013 6 found that CA-MRSA plays a minor role in nonpurulent cellulitis, and that initial treatment should be primarily directed at β-hemolytic streptococci.

Key Considerations

When managing cellulitis, the following key considerations should be taken into account:

• The use of antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, may be preferred in areas with a high prevalence of MRSA infections 3.
• The duration of antibiotic therapy should be individualized based on the patient's response to treatment, with a minimum of 5 days of therapy recommended for uncomplicated cellulitis 2.
• Clinical response should be reassessed at 2-4 days, with adjustments to treatment made as needed 4.