What is the treatment for cellulitis with eschar formation?

Treatment of Cellulitis with Eschar Formation

The treatment of cellulitis with eschar formation requires surgical debridement of the eschar down to a clean ulcer base, followed by appropriate antibiotic therapy targeting the likely pathogens. 1

Initial Management

Eschar Management

• Eschar must be debrided to:
  • Allow proper assessment of the wound
  • Remove necrotic tissue that harbors bacteria
  • Improve antibiotic penetration
  • Facilitate wound healing 1

Assessment for Secondary Infection

• Evaluate for secondary bacterial infection before initiating treatment
• Look for:
  • Increased erythema around eschar
  • Purulent drainage
  • Systemic signs of infection (fever, elevated white blood cell count)
  • Lymphangitic streaking 1, 2

Antibiotic Therapy

Empiric Antibiotic Selection

• For non-severe infections:

  • Amoxicillin-clavulanate 875/125 mg twice daily orally for 5-7 days 2
  • Clindamycin (if penicillin allergic) with caution in renal impairment 2

• For moderate to severe infections:

  • Piperacillin-tazobactam 3.375 grams IV every 6 hours (total daily dose 13.5 grams) for 7-10 days 3
  • Adjust dose in renal impairment 3

• For suspected MRSA:

  • Add appropriate MRSA coverage based on local resistance patterns 2

Duration of Treatment

• Uncomplicated skin infections: 5-7 days
• If slow response: extend to 7-10 days 2
• Severe infections with eschar may require longer treatment courses

Special Considerations

Burn-Related Eschar

• Burn wound infections with eschar are typically polymicrobial
• Initial colonization with Gram-positive bacteria from patient's skin flora
• Rapid colonization by Gram-negative bacteria within a week
• Consider early surgical excision of eschar to decrease invasive infection risk 1

Pressure Ulcers with Eschar

• Typically polymicrobial infections including:
  • Aerobes: S. aureus, Enterococcus spp., P. mirabilis, E. coli, Pseudomonas spp.
  • Anaerobes: Peptococcus spp., B. fragilis, C. perfringens
• Combination of surgical debridement and antibiotics is required 1

Monitoring and Follow-up

• Reassess within 48-72 hours to evaluate response to treatment
• Monitor for:
  • Abscess formation (fluctuance, persistent fever despite antibiotics)
  • Signs of worsening infection or systemic involvement 2

Indications for Hospital Admission

• Systemic inflammatory response syndrome (SIRS)
• Altered mental status
• Hemodynamic instability
• Concern for deeper or necrotizing infection
• Poor adherence to therapy
• Severe immunocompromise
• Failure of outpatient treatment 2

Adjunctive Measures

• Elevation of affected area to reduce edema
• Treatment of predisposing factors (edema, underlying skin disorders)
• Systemic corticosteroids may be considered in non-diabetic adult patients (prednisone 40 mg daily for 7 days) 2

Common Pitfalls to Avoid

• Failing to debride eschar, which can harbor bacteria and impede antibiotic penetration
• Not considering unusual causes of cellulitis with eschar (e.g., anthrax, scrub typhus) in patients with relevant exposure history 4, 5
• Inadequate assessment of infection severity leading to inappropriate antibiotic selection
• Failing to extend treatment duration when infection has not improved after initial course
• Not addressing underlying predisposing factors 2