What is the recommended treatment for cellulitis?

Treatment of Cellulitis

For uncomplicated cellulitis, treatment should begin promptly with antibiotics effective against typical Gram-positive pathogens, especially beta-hemolytic streptococci and Staphylococcus aureus, with oral beta-lactams such as amoxicillin-clavulanate being the first-line therapy for 5-10 days. 1

First-Line Antibiotic Therapy

Mild to Moderate Uncomplicated Cellulitis

• First choice: Oral beta-lactams (if MRSA is not prevalent in your area)
  • Amoxicillin-clavulanate (Augmentin) 1
  • Cephalexin 1
• Duration: 5-6 days is as effective as longer courses (5-10 days) for uncomplicated cases 1, 2

Alternative Options (for penicillin allergies or when beta-lactams are not appropriate)

• Clindamycin 600 mg orally three times daily 1
• Macrolides (though resistance is increasing) 3
• Lincosamides (though resistance is increasing) 3

When to Suspect MRSA

If MRSA is suspected (based on local prevalence, previous MRSA infection, or purulent drainage), consider:

• Clindamycin 600 mg orally three times daily 1
• TMP-SMX plus a beta-lactam (e.g., amoxicillin) 1
• Doxycycline or minocycline (not for children <8 years) 1
• Linezolid 600 mg twice daily 1, 4

Severe Cellulitis Requiring IV Therapy

For more severe infections requiring parenteral therapy:

• Vancomycin (for MRSA coverage) 3, 1
• Linezolid 600 mg IV twice daily 1, 4
• Clindamycin 600 mg IV three times daily 1
• Tedizolid 200 mg once daily for 6 days (as an alternative to linezolid) 5

Follow-Up and Monitoring

• Daily follow-up until definite improvement is noted 1
• Evaluate for possible abscess formation that may require drainage 1
• Look for signs of deeper infection or necrotizing fasciitis (severe pain, rapid progression, crepitus, systemic toxicity) 1

Special Considerations

Complex Abscesses

• For abscesses with significant cellulitis, incision and drainage plus antibiotic therapy is recommended 3
• Empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria may be needed for complex abscesses 3

Recurrent Cellulitis

• Identify and treat predisposing conditions (edema, obesity, eczema, venous insufficiency, local trauma) 1
• Consider prophylactic antibiotics for patients with 3-4 episodes per year despite treatment of predisposing factors 1
• In severe recurrent cases, a "pill in pocket" approach with oral antibiotics like tedizolid may be considered 6

Adjunctive Therapies

• Consider systemic corticosteroids in select adult patients to hasten resolution (contraindicated in diabetics and pregnant women) 1
• Reduce underlying edema through elevation, compression stockings, and diuretic therapy if appropriate 1
• Anti-inflammatory agents (like ibuprofen) may help hasten resolution of inflammation when added to antibiotic therapy 7

Common Pitfalls and Caveats

• Avoid using TMP-SMX alone for non-purulent cellulitis as it has poor activity against streptococci 1
• Tetracyclines should not be used in children under 8 years of age 1
• Fluoroquinolones have been approved for uncomplicated cellulitis but are not adequate for MRSA infections 3
• Obtain cultures from abscesses and purulent drainage to guide therapy, especially in cases not responding to initial treatment 1
• Be aware of pseudocellulitis conditions that can mimic cellulitis (venous stasis dermatitis, contact dermatitis, eczema, lymphedema) 8

Remember that prompt treatment is essential to prevent complications, and the choice of antibiotic should be guided by local resistance patterns and patient-specific factors such as allergies and comorbidities.