What is the recommended management for a case of cellulitis?

Management of Cellulitis

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

Antibiotic Selection

First-Line Therapy

• For uncomplicated cellulitis, oral antibiotics active against streptococci should be used, including penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin 3, 1, 2
• A 5-day course of antimicrobial therapy is as effective as a 10-day course if clinical improvement has occurred by day 5 3, 2
• Treatment should be extended if the infection has not improved within the initial 5-day period 1, 2

When to Consider MRSA Coverage

• MRSA is an unusual cause of typical cellulitis - a study showed that treatment with β-lactams was successful in 96% of patients 3
• Consider MRSA coverage only in specific situations:
  • Cellulitis associated with penetrating trauma 3, 2
  • Evidence of MRSA infection elsewhere 3, 2
  • Purulent drainage 3, 2
  • History of injection drug use 3, 2
• Options for MRSA coverage include:
  • Intravenous options: vancomycin, daptomycin, linezolid, or telavancin 3
  • Oral options: clindamycin alone or combination of SMX-TMP or doxycycline with a β-lactam 3, 2

Parenteral Therapy

• Indicated for severely ill patients or those unable to tolerate oral medications 3
• Reasonable choices include:
  • Penicillinase-resistant penicillin such as nafcillin 3
  • First-generation cephalosporin such as cefazolin 3
  • For patients with life-threatening penicillin allergies: clindamycin or vancomycin 3

Adjunctive Measures

• Elevation of the affected area is crucial to promote gravity drainage of edema and inflammatory substances 3, 2
• Identify and treat predisposing conditions that may have contributed to the infection:
  • Tinea pedis 3, 2
  • Venous insufficiency 3, 2
  • Lymphedema 3, 2
  • Prior trauma to the area 3, 2
• Systemic corticosteroids may be considered in non-diabetic adult patients to reduce inflammation and hasten resolution 3, 1, 2
  • In one randomized trial, prednisolone (starting with 30 mg) as an 8-day tapering course shortened healing time, treatment time with IV antibiotics, and hospital stay by 1 day 3

Hospitalization Criteria

• Consider hospitalization for patients with:
  • Severe infections with systemic inflammatory response syndrome 1, 2
  • Altered mental status 1, 2
  • Hemodynamic instability 1, 2
  • Concern for deeper or necrotizing infection 1, 2
  • Poor adherence to therapy 2
  • Immunocompromise 2
  • Failure of outpatient treatment 2

Management of Recurrent Cellulitis

• Recurrent cellulitis affects up to 47% of patients after the first episode 4
• For patients with frequent episodes, consider prophylactic antibiotics:
  • Oral penicillin 1, 2
  • Erythromycin 1, 2
  • Intramuscular benzathine penicillin 1, 2
• Each attack of cellulitis causes lymphatic inflammation and possibly permanent damage, which can lead to lymphedema and increased risk of recurrence 3, 4
• Address underlying conditions that predispose to recurrence:
  • Treat interdigital maceration and tinea pedis 3, 2
  • Keep skin well hydrated with emollients to avoid dryness and cracking 3
  • Reduce underlying edema through elevation and compression therapy 3, 2

Common Pitfalls to Avoid

• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 2, 5
• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 3, 2
• Don't forget to examine interdigital toe spaces in lower-extremity cellulitis, as treating fissuring or maceration may reduce recurrence 2, 6
• Don't overlook the importance of elevating the affected area, especially in patients with venous insufficiency or lymphedema 3, 2
• Don't miss alternative diagnoses that can mimic cellulitis - venous insufficiency, eczema, deep vein thrombosis, and gout are frequently mistaken for cellulitis 6, 7