What is the recommended management for leg cellulitis?

Management of Leg Cellulitis

For non-purulent leg cellulitis, a 5-6 day course of antibiotics active against streptococci is recommended as first-line therapy, with extension if the infection has not improved within this time period. 1, 2

Antibiotic Selection

• First-line therapy should target streptococci, which are the most common causative organisms in typical cellulitis 1, 3

• Recommended oral antibiotics include:

  • Penicillin or amoxicillin 2
  • Dicloxacillin or cephalexin (500 mg four times daily) 2
  • Amoxicillin-clavulanate 2
  • Clindamycin (for penicillin-allergic patients) 1, 2

• MRSA coverage is generally unnecessary for typical cellulitis and should only be considered in specific situations 1, 2:

  • Cellulitis associated with penetrating trauma 1
  • Evidence of MRSA infection elsewhere 2
  • Purulent drainage 2
  • History of injection drug use 2

Duration of Therapy

• A 5-6 day course of antibiotics is sufficient for uncomplicated cellulitis 1, 2
• Treatment should be extended if the infection has not improved within the initial 5-day period 1, 2
• The 2019 NICE guideline recommends a course of 5-7 days 1

Adjunctive Measures

• Elevation of the affected area is essential to promote gravity drainage of edema and inflammatory substances 1, 2

• Identify and treat predisposing conditions 1:

  • Tinea pedis or other toe web abnormalities 2
  • Venous insufficiency 2
  • Lymphedema 2
  • Prior trauma to the area 2

• Systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients to reduce inflammation and hasten resolution 1, 2

• Anti-inflammatory therapy may help speed resolution of cellulitis-related inflammation 4

Hospitalization Criteria

• Consider hospitalization for patients with 2:
  • Systemic inflammatory response syndrome
  • Altered mental status
  • Hemodynamic instability
  • Concern for deeper or necrotizing infection
  • Poor adherence to therapy
  • Immunocompromise
  • Failure of outpatient treatment

Prevention of Recurrence

• For patients with frequent episodes (3-4 episodes per year), consider prophylactic antibiotics 1, 5:

  • Oral penicillin or erythromycin twice daily for 4-52 weeks 1
  • Intramuscular benzathine penicillin every 2-4 weeks 1

• Prophylactic penicillin has been shown to reduce recurrence rates during the treatment period, with the protective effect diminishing once therapy is stopped 5

• Prophylactic antibiotics are most beneficial in patients without predisposing factors 6

• Address underlying conditions that predispose to recurrence 1, 7:

  • Treat tinea pedis 2
  • Manage venous insufficiency and lymphedema 2, 7
  • Address obesity if present 1

Common Pitfalls to Avoid

• Don't extend treatment unnecessarily beyond 5-6 days if clinical improvement has occurred 1, 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 1, 2