What is the treatment for severe cellulitis?

From the Guidelines

Severe cellulitis requires prompt medical treatment, typically with intravenous antibiotics in a hospital setting, to reduce morbidity, mortality, and improve quality of life. The first-line treatment usually involves broad-spectrum antibiotics such as vancomycin (15-20 mg/kg every 12 hours), piperacillin-tazobactam (4.5g every 6-8 hours), or ceftriaxone (1-2g daily) plus metronidazole (500mg every 8 hours) for 5-14 days, depending on clinical response, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• Hospitalization is necessary to monitor for complications like sepsis or necrotizing fasciitis.
• The affected limb should be elevated to reduce swelling, and pain management with acetaminophen or NSAIDs is recommended.
• Once improvement occurs, typically after 2-3 days of IV therapy, patients may transition to oral antibiotics like amoxicillin-clavulanate (875/125mg twice daily), cephalexin (500mg four times daily), or clindamycin (300-450mg four times daily) for a total treatment duration of 10-14 days.
• Any underlying wounds should be cleaned and dressed appropriately.
• Patients with diabetes or immunocompromised conditions require closer monitoring and possibly longer treatment.

Additional Recommendations

• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.
• In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection 1.
• Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability 1.

Evidence-Based 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 1. In cases of uncomplicated cellulitis, a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days 2. Therapy for typical cases of cellulitis should include an antibiotic active against streptococci, and many clinicians choose an agent that is also effective against S. aureus 3. Vancomycin plus either piperacillin-tazobactam or imipenem-meropenem is recommended as a reasonable empiric regimen for severe infection 1. Severe cellulitis warrants urgent treatment because the infection can spread rapidly through tissue planes, potentially leading to tissue death, bacteremia, or septic shock if left untreated.

From the FDA Drug Label

The two trials were similar in design but differed in patient characteristics, including history of diabetes and peripheral vascular disease. There were a total of 534 adult patients treated with daptomycin for injection and 558 treated with comparator in the two trials. The efficacy endpoints in both trials were the clinical success rates in the intent-to-treat (ITT) population and in the clinically evaluable (CE) population. The success rates by pathogen for microbiologically evaluable patients are presented in Table 16 Pediatric Patients (1 to 17 Years of Age) with cSSSI The cSSSI pediatric trial was a single prospective multi-center, randomized, comparative trial A total of 396 pediatric patients aged 1 to 17 years with cSSSI caused by Gram positive pathogens were enrolled into the study.

The treatment for severe cellulitis is not explicitly stated in the provided drug labels. However, based on the information provided, daptomycin and tedizolid are used to treat complicated skin and skin structure infections (cSSSI), which may include cellulitis.

• The dosage of daptomycin for adults with cSSSI is 4 mg/kg IV q24h 4.
• The dosage of tedizolid for adults with ABSSSI is 200 mg once daily for 6 days 5. It is essential to note that the treatment for severe cellulitis should be determined by a healthcare professional, considering the severity of the infection, patient characteristics, and other factors.

From the Research

Treatment Options for Severe Cellulitis

• The treatment for severe cellulitis can involve various antibiotic regimens, with the choice of antibiotic and route of administration depending on the severity of the condition and patient factors 6, 7, 8, 9, 10.
• A "pill in pocket" approach with oral tedizolid has been proposed as a unique treatment approach for preventing severe cellulitis, reducing the need for recurrent hospitalizations and healthcare costs 6.
• Once-daily intravenous cefazolin plus oral probenecid has been shown to be equivalent to once-daily intravenous ceftriaxone plus oral placebo for the treatment of moderate-to-severe cellulitis in adults 7.
• Twice-daily cefazolin 2 g intravenously is a convenient and effective option for home-based treatment of patients with cellulitis, with clinical efficacy comparable to other treatment regimens 8.
• The route of antibiotic administration (intravenous vs oral) and duration of treatment may not be associated with clinical outcome, with some studies suggesting that oral therapy can be as effective as intravenous therapy 9, 10.

Antibiotic Choices

• Macrolides/streptogramins have been found to be more effective than penicillin antibiotics for the treatment of cellulitis 10.
• Cephalosporins have been shown to be effective, but there is no difference in treatment effect between different generations of cephalosporins 10.
• The use of long-term oral antibiotics has been advocated to prevent recurrent cellulitis episodes, but the choice of antibiotic and duration of treatment should be individualized based on patient factors and severity of the condition 6, 10.

Treatment Duration and Route of Administration

• The optimal duration of antibiotic treatment for cellulitis is unclear, with some studies suggesting that a course length of > 5 days may not result in additional benefit 9.
• The route of antibiotic administration (intravenous vs oral) may not be associated with clinical outcome, with oral therapy being a viable option for patients with cellulitis 9, 10.