What is the recommended treatment for cellulitis?

Treatment of Cellulitis

The recommended first-line treatment for uncomplicated cellulitis is a 5-day course of antibiotics active against streptococci, such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin. 1, 2

Antibiotic Selection

• For uncomplicated, non-purulent cellulitis, use antibiotics active against streptococci (penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin) 1, 2
• For moderate infections with systemic signs, consider coverage for both streptococci and methicillin-susceptible S. aureus (MSSA) 1
• MRSA is an unusual cause of typical cellulitis and coverage is unnecessary in uncomplicated cases 1
• Consider MRSA coverage only in specific situations:
  • Cellulitis associated with penetrating trauma 1, 2
  • Purulent drainage 1, 2
  • Evidence of MRSA infection elsewhere 1, 2
  • History of injection drug use 2

Duration of Therapy

• A 5-day course of antimicrobial therapy is as effective as a 10-day course if clinical improvement has occurred by day 5 1, 3
• Extend treatment if infection has not improved within the initial 5-day period 2

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema and inflammatory substances 1, 2
• Identify and treat predisposing conditions:
  • Tinea pedis 1, 2
  • Trauma 1, 2
  • Venous eczema 1
  • Venous insufficiency 2
• Consider systemic corticosteroids in non-diabetic adult patients to reduce inflammation and hasten resolution 1, 2, 4

Treatment Setting

• Outpatient therapy is appropriate for patients without:

  • Systemic inflammatory response syndrome (SIRS) 1, 2
  • Altered mental status 1, 2
  • Hemodynamic instability 1, 2

• Hospitalization is recommended if:

  • Concern for deeper or necrotizing infection 1, 2
  • Poor adherence to therapy 1, 2
  • Infection in a severely immunocompromised patient 1, 2
  • Failure of outpatient treatment 1, 2

Prevention of Recurrence

• Identify and treat predisposing conditions such as:

  • Edema 1
  • Obesity 1
  • Eczema 1
  • Venous insufficiency 1, 2
  • Toe web abnormalities 1, 2

• For patients with 3-4 episodes of cellulitis per year despite treatment of predisposing factors, consider prophylactic antibiotics such as:

  • Oral penicillin 1, 2
  • Erythromycin 2
  • Intramuscular benzathine penicillin 2

Special Considerations for Preseptal Cellulitis

• Similar antibiotic recommendations apply (streptococcal coverage) 5
• Identify and treat predisposing factors, such as sinusitis 5

Common Pitfalls to Avoid

• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 2
• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1, 2
• Don't forget to examine interdigital toe spaces in lower-extremity cellulitis 2
• Don't overlook the importance of elevating the affected area, especially in patients with venous insufficiency or lymphedema 2