Treatment of Scrotal Cellulitis
For scrotal cellulitis, initiate empiric broad-spectrum antibiotic therapy covering Gram-positive, Gram-negative, and anaerobic bacteria, using a combination such as vancomycin plus piperacillin-tazobactam or a carbapenem (imipenem/meropenem). 1
Rationale for Combination Therapy
The scrotal region is considered a complex anatomical site requiring broader coverage than typical cellulitis:
Scrotal and perineal infections require coverage beyond typical streptococci and staphylococci because these areas harbor polymicrobial flora including anaerobes and Gram-negative organisms 1
Complex abscesses in perineal regions necessitate empiric broad-spectrum coverage targeting Gram-positive, Gram-negative, and anaerobic bacteria, particularly when systemic signs are present or in immunocompromised patients 1
Recommended Antibiotic Combinations
First-Line Regimen:
- Vancomycin PLUS piperacillin-tazobactam provides comprehensive coverage for MRSA, streptococci, Gram-negatives, and anaerobes 1, 2
Alternative Regimen:
- Vancomycin PLUS imipenem or meropenem for severely compromised patients or when broader Gram-negative coverage is needed 2
MRSA Coverage Considerations
MRSA coverage is essential in scrotal cellulitis due to several high-risk factors:
- Perineal location increases risk of MRSA involvement 1
- Penetrating trauma or purulent drainage warrants MRSA coverage 1, 2
- Options for MRSA coverage include vancomycin, daptomycin, linezolid, or telavancin 1, 2
Surgical Evaluation
Prompt surgical consultation is critical because:
- Perianal and perirectal abscesses require surgical drainage and cannot be treated with antibiotics alone 1
- Undrained abscesses can expand into adjacent spaces and progress to systemic infection 1
- Source control through incision and drainage is mandatory when abscess formation is present 1
Common Pitfalls to Avoid
- Never treat scrotal/perineal cellulitis with beta-lactam monotherapy alone as this misses anaerobic and Gram-negative coverage 1
- Do not delay surgical evaluation if there is fluctuance, induration beyond simple cellulitis borders, or systemic signs 1
- Avoid assuming simple cellulitis in the scrotal region—always consider complex infection requiring broader coverage 1