What is the recommended management of cellulitis in pregnancy?

Management of Cellulitis in Pregnancy

First-Line Antibiotic Selection

Pregnant women with cellulitis should be treated with a penicillinase-resistant penicillin (dicloxacillin) or first-generation cephalosporin (cephalexin) as first-line therapy, avoiding TMP-SMX (especially in third trimester) and tetracyclines entirely. 1

Oral Therapy for Uncomplicated Cases

• Cephalexin 500 mg orally four times daily for 5 days is the preferred first-line agent, providing excellent coverage against β-hemolytic streptococci and methicillin-sensitive Staphylococcus aureus 1, 2
• Dicloxacillin 500 mg orally four times daily is an equally effective alternative 1, 2, 3
• Clindamycin 300-450 mg orally three times daily is the best option for penicillin-allergic pregnant patients, as it covers both streptococci and MRSA while avoiding pregnancy contraindications 1, 2

Pregnancy-Specific Contraindications

• TMP-SMX is pregnancy category C/D and absolutely contraindicated in the third trimester due to risks of kernicterus and neural tube defects 1
• Tetracyclines (doxycycline, minocycline) are pregnancy category D and should never be used due to effects on fetal bone and tooth development 1
• Macrolides have increasing resistance among group A streptococci and are not first-line 1, 3

Treatment Duration

Five days of antibiotic therapy is as effective as 10 days for uncomplicated cellulitis in pregnancy, with extension only if symptoms have not improved 1, 2, 3

Severe or Complicated Cellulitis Requiring Hospitalization

Indications for Parenteral Therapy

• Systemic inflammatory response syndrome or signs of systemic toxicity 1, 3
• Rapidly progressive infection despite oral antibiotics 1
• Multiple sites of infection or extensive disease 1
• Inability to tolerate oral medications 1, 3
• Failed outpatient therapy 3, 4

Parenteral Antibiotic Options

• Nafcillin or cefazolin 1-2 g IV every 8 hours are the preferred agents for severe cellulitis requiring hospitalization 1, 3
• Vancomycin 15-20 mg/kg/dose IV every 8-12 hours for penicillin-allergic patients or when MRSA coverage is needed 1
• Clindamycin 600 mg IV three times daily provides coverage for both streptococci and MRSA 1

MRSA Coverage Considerations

MRSA is an unusual cause of typical cellulitis and routine coverage is unnecessary in pregnancy, but specific risk factors warrant empiric MRSA therapy 2, 3, 5

When to Add MRSA Coverage

• Penetrating trauma or injection drug use 1, 2, 5
• Purulent drainage or associated abscess 1, 2
• Evidence of MRSA infection at another site 2, 3
• Known nasal colonization with MRSA 2
• Failed initial β-lactam therapy 1

MRSA-Active Regimens Safe in Pregnancy

• Clindamycin alone covers both streptococci and MRSA 1, 2
• Vancomycin IV for severe infections requiring hospitalization 1
• Linezolid is more expensive but effective if other options fail 1

Surgical Management in Pregnancy

Incision and drainage under local anesthesia is the primary treatment for abscesses and should not be delayed in pregnant patients, as antibiotics alone are insufficient 2, 6, 4

Approach to Surgical Intervention

• Local anesthesia is preferred to avoid fetal exposure to general anesthesia 6, 4
• Prompt drainage of affected fascial spaces prevents airway compromise and systemic spread 4
• Removal of causative tooth in odontogenic infections is essential 6, 7
• Multidisciplinary management with obstetrics is critical for monitoring fetal well-being 4, 7

Adjunctive Measures

Essential Non-Pharmacologic Interventions

• Elevation of the affected extremity promotes gravity drainage of edema and inflammatory substances 2, 3
• Identify and treat predisposing conditions such as tinea pedis (toe web spaces), venous stasis, or dental infections 1, 2, 3, 6, 7
• Examine interdigital toe spaces in lower extremity cellulitis, as streptococci often colonize macerated areas 1, 3

Corticosteroids in Pregnancy

• Systemic corticosteroids (prednisolone 30 mg tapering over 8 days) may hasten resolution in non-diabetic patients, though evidence in pregnancy is limited 1
• Consider only in severe cases after weighing maternal benefit against potential fetal risks 1, 8

Maternal-Fetal Monitoring

Cervicofacial cellulitis in pregnancy carries significant risks of preterm labor, stillbirth, and maternal mortality if not aggressively managed 6, 4, 7

Critical Monitoring Parameters

• Close obstetric monitoring for signs of preterm labor, especially in third trimester 6, 4
• Fetal heart rate monitoring during hospitalization 4
• Duration of hospital stay correlates with number of fascial spaces involved 4
• Maternal mortality and stillbirth have been reported with delayed or inadequate treatment 7

Common Pitfalls to Avoid

• Do not use TMP-SMX in third trimester or tetracyclines at any point in pregnancy due to serious fetal risks 1
• Do not routinely add MRSA coverage for typical cellulitis without specific risk factors 2, 3, 5
• Do not treat abscesses with antibiotics alone—incision and drainage is mandatory 2
• Do not delay surgical intervention in severe cervicofacial cellulitis due to pregnancy status, as maternal and fetal outcomes worsen with delay 4, 7
• Do not fail to examine toe web spaces in lower extremity cellulitis, as this leads to recurrent infection 1, 3
• Do not treat longer than 5 days for uncomplicated cases, as extended courses provide no additional benefit 1, 2, 3