What is the treatment for scrotum cellulitis?

Treatment of Scrotal Cellulitis

Scrotal cellulitis should be treated with penicillin or amoxicillin for 5 days as first-line therapy, targeting the predominant causative organism, beta-hemolytic Streptococcus. 1, 2

Pathogen and Clinical Context

• Beta-hemolytic Streptococcus is the primary pathogen in scrotal cellulitis, typically without an identifiable portal of entry. 2
• Staphylococcus aureus is less commonly involved unless there is penetrating trauma, purulent drainage, or an underlying abscess. 1
• MRSA coverage is not routinely indicated for typical scrotal cellulitis unless specific risk factors are present (penetrating trauma, injection drug use, MRSA colonization elsewhere, or systemic inflammatory response syndrome). 1

First-Line Antibiotic Selection

Oral Therapy (Mild to Moderate Cases)

• Penicillin or amoxicillin are the preferred first-line agents for typical scrotal cellulitis. 1
• Alternative oral options include cephalexin, dicloxacillin, or amoxicillin-clavulanate. 1
• For penicillin-allergic patients, clindamycin is the preferred alternative with 99.5% susceptibility against streptococci. 1

Parenteral Therapy (Severe Cases)

• Intravenous penicillin remains first-line for severe streptococcal cellulitis requiring hospitalization. 1
• Consider vancomycin or linezolid plus piperacillin-tazobactam for severely compromised patients with systemic toxicity or concern for polymicrobial infection. 1

Treatment Duration

• Standard duration is 5 days, with extension only if clinical improvement has not occurred by day 5. 1
• This shorter course (5-7 days) is as effective as 10-day regimens when clinical improvement is evident. 1

Hospitalization Criteria

Admit patients with any of the following:

• Systemic inflammatory response syndrome (fever, tachycardia, hypotension, leukocytosis). 1
• Altered mental status or hemodynamic instability. 1
• Concern for deeper or necrotizing infection (Fournier's gangrene). 1
• Severe immunocompromise or failure of outpatient therapy. 1

Critical Surgical Considerations

• Immediate surgical decompression with linear incisions is required if fluid accumulates rapidly between Colles' and Buck's fascia, as failure to decompress can lead to skin devascularization and gangrene. 2
• Prompt surgical consultation is mandatory for aggressive infections with systemic toxicity or suspicion of necrotizing fasciitis. 1
• If gangrene develops, radical debridement of necrotic tissue plus a wide margin of adjacent inflamed skin must be performed. 2

Adjunctive Measures

• Elevation of the affected area promotes gravity drainage of edema and inflammatory substances, hastening improvement. 1
• Identify and treat predisposing conditions such as tinea pedis, trauma, obesity, or venous insufficiency to reduce recurrence risk. 1

Common Pitfalls to Avoid

• Do not empirically cover MRSA in typical scrotal cellulitis without specific risk factors—beta-lactam monotherapy is appropriate. 1
• Avoid fluoroquinolones as first-line therapy due to inadequate streptococcal coverage. 3
• Do not delay surgical consultation if there is rapid progression, severe pain out of proportion to examination findings, or crepitus suggesting necrotizing infection. 1, 2
• Blood cultures are unnecessary for typical cases but should be obtained if systemic features are present (high fever, hypotension) or in immunocompromised patients. 1