What is the recommended antibiotic for cellulitis of the toe?

Recommended Antibiotic for Cellulitis of the Toe

For typical non-purulent cellulitis of the toe, an antibiotic active against streptococci such as cephalexin (500 mg four times daily) or penicillin is recommended as first-line therapy for 5 days. 1

First-Line Treatment Options

• Cephalexin 500 mg orally four times daily for 5 days is the preferred first-line treatment for uncomplicated cellulitis of the toe, as it provides excellent coverage against streptococci, which are the most common causative pathogens 1
• Penicillin (250-500 mg orally four times daily) is an alternative first-line option that effectively targets streptococci 1
• Treatment should be extended beyond 5 days if the infection has not improved within this time period 1

Alternative Options for Penicillin-Allergic Patients

• Clindamycin 300-450 mg orally four times daily for 5 days is the preferred treatment for patients with penicillin or cephalosporin allergies 2
• For patients unable to tolerate clindamycin, alternative options include trimethoprim-sulfamethoxazole or doxycycline, though these have less reliable activity against streptococci 2

When to Consider MRSA Coverage

• MRSA is an unusual cause of typical cellulitis and treatment for this organism is usually unnecessary 1

• Consider MRSA coverage only if the cellulitis is associated with:

  • Penetrating trauma, especially from illicit drug use 1
  • Purulent drainage 1
  • Concurrent evidence of MRSA infection elsewhere 1
  • Nasal colonization with MRSA 1
  • Systemic inflammatory response syndrome (SIRS) 1

• If MRSA coverage is needed, options include:

  • Clindamycin alone 1
  • Combination therapy with either trimethoprim-sulfamethoxazole or doxycycline plus a β-lactam (penicillin, cephalexin, or amoxicillin) 1

Treatment Duration

• A 5-day course of antibiotic therapy is as effective as a 10-day course for uncomplicated cellulitis if clinical improvement occurs within the first 5 days 3
• Extend treatment if the infection has not improved within 5 days 1, 2

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 1, 2
• Treatment of predisposing conditions such as tinea pedis, trauma, or venous eczema 1, 2
• Careful examination of interdigital toe spaces to identify and treat fissuring, scaling, or maceration that may harbor pathogens 1

Hospitalization Criteria

• Consider hospitalization if there is:
  • Concern for deeper or necrotizing infection 1
  • Poor adherence to therapy 1
  • Severely immunocompromised patient 1
  • Failure of outpatient treatment 1
  • Systemic inflammatory response syndrome (SIRS) 1
  • Altered mental status or hemodynamic instability 1

Prevention of Recurrent Cellulitis

• Identify and treat predisposing conditions such as edema, obesity, venous insufficiency, and toe web abnormalities 1, 4
• For patients with 3-4 episodes per year despite addressing predisposing factors, consider prophylactic antibiotics such as oral penicillin or erythromycin twice daily 2, 4

Common Pitfalls to Avoid

• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1
• A recent double-blind study showed that a combination of trimethoprim-sulfamethoxazole plus cephalexin was no more efficacious than cephalexin alone in pure cellulitis 1, 5
• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 1, 3