What is the recommended treatment for cheek cellulitis?

Treatment of Cheek Cellulitis

For typical nonpurulent cheek cellulitis, treat with a beta-lactam antibiotic such as cephalexin 500 mg orally every 6 hours or dicloxacillin 250-500 mg every 6 hours for 5 days, as this provides excellent coverage against streptococci and methicillin-sensitive S. aureus, which are the causative organisms in 96% of cases. 1

First-Line Antibiotic Selection

Beta-lactam monotherapy is the standard of care for uncomplicated cheek cellulitis. 1 The most appropriate oral agents include:

• Cephalexin 500 mg every 6 hours (preferred first-line option) 1, 2
• Dicloxacillin 250-500 mg every 6 hours 1, 2
• Amoxicillin (appropriate alternative) 1
• Amoxicillin-clavulanate 875/125 mg twice daily (reasonable choice, particularly for bite-associated cellulitis) 1, 2

These agents successfully treat cellulitis in 96% of patients, confirming that MRSA coverage is usually unnecessary for typical facial cellulitis. 1, 3

Treatment Duration

Treat for 5 days if clinical improvement occurs; extend only if symptoms have not improved within this timeframe. 1, 4, 2 Five-day courses are as effective as 10-day courses for uncomplicated cellulitis. 1, 4

When to Add MRSA Coverage

MRSA is an uncommon cause of typical cheek cellulitis and routine coverage is unnecessary. 1, 2 However, add MRSA-active antibiotics when specific risk factors are present: 1, 2

• Penetrating trauma or injection drug use 1, 2
• Purulent drainage or exudate 1, 2
• Evidence of MRSA infection elsewhere or known nasal MRSA colonization 1, 2
• Systemic inflammatory response syndrome (SIRS): fever >38°C, tachycardia >90 bpm, hypotension, or altered mental status 1, 2

If MRSA coverage is needed, use: 1, 2

• Clindamycin 300-450 mg orally every 6 hours (covers both streptococci and MRSA, avoiding need for combination therapy) 1, 2
• Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 DS tablets twice daily PLUS a beta-lactam (cephalexin or amoxicillin) 1, 2
• Doxycycline 100 mg twice daily PLUS a beta-lactam 1, 5

Severe Infections Requiring Hospitalization

Hospitalize patients with: 1, 2

• Signs of systemic toxicity (fever, hypotension, tachycardia, altered mental status) 1, 2
• Rapid progression or suspected necrotizing fasciitis 1
• Severe immunocompromise or neutropenia 1
• Failure of outpatient treatment after 24-48 hours 1

For severe cellulitis with systemic toxicity, use broad-spectrum combination therapy: 1

• Vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 3.375-4.5 g IV every 6 hours 1
• Alternative: Linezolid 600 mg IV twice daily plus piperacillin-tazobactam 1

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema and inflammatory substances 1, 4, 2
• Treat predisposing conditions such as tinea pedis, venous insufficiency, eczema, or chronic edema 1, 4, 2
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adults, though evidence is limited 1, 4

Critical Pitfalls to Avoid

• Do not routinely add MRSA coverage for typical nonpurulent cheek cellulitis without specific risk factors, as this represents overtreatment 1, 2
• Do not use doxycycline or TMP-SMX as monotherapy for typical cellulitis, as their activity against beta-hemolytic streptococci is unreliable 1, 5
• Do not extend treatment beyond 5 days automatically; only extend if clinical improvement has not occurred 1, 4
• Reassess within 24-48 hours to verify clinical response, as treatment failure rates of 21% have been reported with some regimens 1, 6

Special Considerations for Penicillin Allergy

For penicillin-allergic patients, clindamycin 300-450 mg orally every 6 hours is the preferred option, as 99.5% of S. pyogenes strains remain susceptible. 2