What is the treatment for severe lower extremity cellulitis?

From the Guidelines

Severe leg cellulitis requires prompt medical treatment, typically with intravenous antibiotics in a hospital setting, with a recommended duration of 5-14 days, depending on clinical response, as stated in the guidelines by the Infectious Diseases Society of America 1. The standard treatment involves broad-spectrum antibiotics such as ceftriaxone (1-2g IV daily), vancomycin (15-20mg/kg IV every 12 hours), or piperacillin-tazobactam (4.5g IV every 6-8 hours) for 5-14 days, depending on clinical response. Some key points to consider in the treatment of severe leg cellulitis include:

• The choice of antibiotics should target common causative bacteria including Streptococcus and Staphylococcus species, with coverage adjusted based on local resistance patterns and patient risk factors 1.
• Alongside antibiotics, treatment includes elevation of the affected leg above heart level to reduce swelling, pain management with acetaminophen or NSAIDs, and proper wound care if skin breaks are present.
• Adequate hydration and monitoring for complications like abscess formation or sepsis are essential.
• Follow-up within 48-72 hours of starting treatment is important to ensure the infection is responding appropriately.
• For empirical coverage of CA-MRSA in outpatients with SSTI, oral antibiotic options include clindamycin, trimethoprim-sulfamethoxazole, a tetracycline, and linezolid, as recommended by the Infectious Diseases Society of America 1. It is also important to note that cultures from abscesses and other purulent SSTIs are recommended in patients treated with antibiotic therapy, patients with severe local infection or signs of systemic illness, patients who have not responded adequately to initial treatment, and if there is concern for a cluster or outbreak 1.

From the FDA Drug Label

1. 3 Skin and Skin Structure Infections Piperacillin and Tazobactam for Injection is indicated in adults for the treatment of uncomplicated and complicated skin and skin structure infections, including cellulitis, cutaneous abscesses and ischemic/diabetic foot infections caused by beta-lactamase producing isolates of Staphylococcus aureus. The treatment for severe leg cellulitis may include piperacillin-tazobactam (IV), as it is indicated for the treatment of complicated skin and skin structure infections, including cellulitis, in adults 2.

• Key points:
  • Piperacillin-tazobactam is effective against beta-lactamase producing isolates of Staphylococcus aureus.
  • The usual total daily dosage of piperacillin and tazobactam for adult patients with indications other than nosocomial pneumonia is 3.375 grams every six hours.
  • The usual duration of piperacillin and tazobactam treatment is from 7 to 10 days. Alternatively, linezolid (PO) may also be considered for the treatment of complicated skin and skin structure infections, including cellulitis, as it has been shown to be effective in clinical trials 3.
• Key points:
  • Linezolid is effective against Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus (MRSA).
  • The recommended dosage of linezolid for adult patients is 600 mg every 12 hours.
  • The cure rates in clinically evaluable patients with complicated skin and skin structure infections were 90% in linezolid-treated patients and 85% in oxacillin-treated patients.

From the Research

Treatment Options for Severe Leg Cellulitis

• The treatment of severe leg cellulitis typically involves the use of antibiotics, with the choice of antibiotic depending on the severity of the infection and the presence of any underlying conditions 4, 5.
• Studies have shown that antibiotics with activity against community-associated methicillin-resistant Staphylococcus aureus (MRSA), such as trimethoprim-sulfamethoxazole and clindamycin, are effective in treating cellulitis 5.
• The route of antibiotic administration, whether intravenous (IV) or oral (PO), may also play a role in the treatment of cellulitis, with some studies suggesting that IV therapy may be preferred in more severe cases 6.
• The duration of antibiotic therapy is also an important consideration, with some studies suggesting that a shorter course of treatment may be just as effective as a longer course 6.

Evidence-Based Guidelines

• The development of evidence-based care pathways for cellulitis has been shown to improve process, clinical, and cost outcomes 7.
• These pathways typically involve the use of narrow-spectrum antibiotics, unless there is a high suspicion of MRSA or other resistant organisms 4, 7.
• The use of broad-spectrum antibiotics should be reserved for cases where there is a high suspicion of resistant organisms or where the patient has failed to respond to narrow-spectrum antibiotics 4, 7.

Key Considerations

• The diagnosis and management of cellulitis should be based on the best available evidence, taking into account the severity of the infection, the presence of any underlying conditions, and the likelihood of resistant organisms 8.
• Community nurses and other healthcare professionals should be aware of the evidence base for the diagnosis and treatment of cellulitis and should be involved in the development and implementation of evidence-based care pathways 8.