Treatment of Toe Cellulitis in a Low-Risk Patient
For this 58-year-old patient with uncomplicated toe cellulitis and no risk factors, prescribe cephalexin 500 mg orally four times daily for 5 days, targeting streptococci as the primary pathogen. 1, 2
Antibiotic Selection
First-line therapy should be cephalexin 500 mg orally four times daily, which provides excellent coverage against streptococci—the predominant pathogen in typical, non-purulent cellulitis 1, 2. Alternative first-line options include:
- Penicillin 250-500 mg orally four times daily 1, 2
- Amoxicillin (dose per standard guidelines) 1
- Dicloxacillin 500 mg orally four times daily 3, 1
For penicillin-allergic patients, clindamycin 300-450 mg orally three to four times daily is the preferred alternative 1, 2.
Duration of Treatment
Treat for 5 days initially, then extend treatment only if the infection has not improved within this timeframe 1, 2. This represents current guideline recommendations from the Infectious Diseases Society of America and American College of Physicians 1.
MRSA Coverage Is NOT Indicated
Do not add MRSA coverage for this patient. MRSA is an unusual cause of typical cellulitis and treatment is unnecessary unless specific risk factors are present 1. Consider MRSA coverage only if:
- Penetrating trauma is present 1, 2
- Purulent drainage exists 1, 2
- Concurrent MRSA infection elsewhere 1, 2
- History of injection drug use 1
Research evidence supports this approach: a randomized controlled trial demonstrated that adding trimethoprim-sulfamethoxazole to cephalexin provided no benefit for uncomplicated cellulitis (85% cure rate vs 82% with cephalexin alone, p=0.66) 4. A larger trial confirmed these findings in the per-protocol analysis (83.5% vs 85.5%, p=0.50) 5.
Essential Adjunctive Measures
Elevate the affected toe to promote gravity drainage of edema and inflammatory substances 1, 2. This is a critical component of treatment that should not be overlooked.
Examine and treat interdigital toe spaces carefully to eradicate colonization with pathogens 1. Tinea pedis and other toe web abnormalities are common predisposing factors 2, 6.
Monitoring and Follow-Up
Reassess the patient within 2-5 days to ensure clinical improvement 3. Primary indicators of improvement include:
- Resolution of local erythema, warmth, and tenderness 3
- Reduction in swelling 3
- Absence of fever or systemic symptoms 3
If no improvement occurs within 5 days, extend antibiotic therapy and reconsider the diagnosis 1. Common cellulitis mimics include venous insufficiency, eczema, deep vein thrombosis, and gout 6.
When to Hospitalize
This patient does not require hospitalization based on the clinical presentation. Hospitalization criteria include 1, 2:
- Systemic inflammatory response syndrome (SIRS) 1, 2
- Altered mental status or hemodynamic instability 1, 2
- Concern for deeper or necrotizing infection 1, 2
- Severely immunocompromised state 1, 2
- Outpatient treatment failure 1, 2
Common Pitfalls to Avoid
Do not automatically prescribe MRSA-active antibiotics without specific risk factors—this represents overtreatment and contributes to antibiotic resistance 1. The normal WBC count and absence of purulent drainage in this patient further support streptococcal etiology 1.
Do not ignore predisposing factors such as trauma, edema, or toe web abnormalities, as failure to address these can lead to recurrent infections despite appropriate antibiotic therapy 1, 2.
Do not extend treatment beyond 5 days if clinical improvement has occurred—unnecessary prolonged antibiotic courses increase adverse effects without additional benefit 1.