Antibiotic Treatment for Scrotal Cellulitis
For scrotal cellulitis, first-line treatment should be a 5-6 day course of antibiotics active against beta-hemolytic streptococci, which are the primary causative organisms, with consideration for adding Staphylococcus aureus coverage depending on risk factors. 1, 2
First-Line Treatment Options
For typical scrotal cellulitis without complications, use antibiotics targeting streptococci for 5-6 days: 1, 2
- Penicillin
- Amoxicillin
- Dicloxacillin
- Cephalexin (first-generation cephalosporin)
For patients with penicillin allergy, alternative options include: 2
- Clindamycin
- Erythromycin
Treatment Algorithm Based on Severity
Mild to Moderate Scrotal Cellulitis
- Oral antibiotics active against streptococci for 5-6 days 1, 2
- Elevate the affected area to promote drainage of edema 2
- Monitor for improvement within 48 hours 2
Severe or High-Risk Scrotal Cellulitis
Consider broader coverage including MRSA if any of these risk factors are present: 1, 2
- Penetrating trauma
- Evidence of MRSA elsewhere
- Nasal colonization with MRSA
- Injection drug use
- Systemic inflammatory response syndrome
- Purulent drainage
Treatment options for severe cases include: 2
- Vancomycin
- Linezolid
- Clindamycin (if local MRSA susceptibility rates are high)
- TMP-SMX plus a beta-lactam (for combined streptococcal and MRSA coverage)
Special Considerations
- Scrotal cellulitis is primarily caused by beta-hemolytic streptococci, often without a discernible entry point 3, 4
- Rapid fluid accumulation between fascial planes can lead to intense swelling and potential skin devascularization if not promptly treated 3
- For rapidly progressive scrotal cellulitis, especially with significant swelling, surgical consultation may be necessary to assess need for decompression 3
- In cases with no improvement after 5 days, consider extending treatment duration 1, 2
- In pediatric cases of scrotal cellulitis, broader coverage may be necessary if standard regimens fail 5
Common Pitfalls to Avoid
- Failure to examine for predisposing conditions like interdigital fissures or scaling 2
- Not elevating the affected area, which can delay improvement 2
- Inadequate treatment duration when clinical improvement is not evident after 5 days 1, 2
- Missing MRSA coverage when risk factors are present 2
- Overlooking the need for surgical evaluation in cases with significant swelling or signs of tissue compromise 3